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Lindsay R, Kalifa A, Kuziek J, Kabbouche M, Hershey AD, Orr SL. The safety and efficacy of onabotulinumtoxinA injections for children and adolescents with chronic migraine: A systematic review and meta-analysis. Headache 2024. [PMID: 39129275 DOI: 10.1111/head.14798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 06/14/2024] [Accepted: 06/19/2024] [Indexed: 08/13/2024]
Abstract
OBJECTIVE To qualitatively and quantitatively summarize the evidence for the use of onabotulinumtoxinA injections in children and adolescents with migraine. BACKGROUND There are limited evidence-based treatment options for youth with migraine, especially youth with chronic migraine (CM). OnabotulinumtoxinA injections are an established evidence-based treatment for adults with CM. While several studies have assessed their safety and efficacy among adolescents with CM, there are no published systematic reviews summarizing the pediatric evidence. METHODS We carried out a systematic review, reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis, aiming to identify studies that included five or more children and adolescents aged ≤18 years with a diagnosis of migraine, who were treated with ≥50 units (U) of onabotulinumtoxinA and had outcomes assessed ≥4 weeks after one or more injection cycle. Both observational studies and randomized controlled trials (RCTs) were eligible for inclusion. Two investigators independently carried out the first (titles and abstracts) and second (full text) screening stages, as well as data extraction and quality appraisal. The American Academy of Neurology risk of bias grading scheme was used to assess study risk of bias. Studies with adequate data were pooled using random effects meta-analyses, and Hedge's g standardized mean differences with 95% confidence intervals (CIs) were generated to estimate the effect sizes of the continuous outcomes included. Studies lacking data required for meta-analysis were summarized qualitatively. RESULTS We screened 634 studies and included 14 studies comprising 491 participants, of whom 489 had CM. Two studies were RCTs, 12 were observational uncontrolled studies, and all but one study included only youth with CM. Five Class IV observational uncontrolled studies were amenable to pooling in meta-analyses. After a mean of 2-2.6 injection cycles, headache frequency was shown to decrease significantly after treatment with onabotulinumtoxinA (Hedge's g = 0.97, 95% CI 0.58-1.35; p < 0.0001), as did severity (Hedge's g = 1.24, 95% CI 0.55-1.94; p = 0.0005), with both estimates having a large effect size magnitude. A Class I parallel-group RCT of one injection series (155 U, 74 U, or placebo), powered to detect a change in 4 headache days per month, did not find outcome differences between the active and placebo treatment arms. A Class IV crossover RCT showed superiority of active (155 U) versus placebo injections. The remaining Class IV observational studies that were excluded from the meta-analyses all showed improved outcomes with onabotulinumtoxinA injections over time. No serious adverse events related to treatment occurred. CONCLUSION OnabotulinumtoxinA injections have established safety for use in children and adolescents with CM and are likely effective in reducing headache frequency and severity over time. However, in the absence of an adequately powered parallel-group RCT assessing the efficacy of multiple injection cycles, it remains unclear if this intervention is superior to placebo.
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Affiliation(s)
- Rebecca Lindsay
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amira Kalifa
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan Kuziek
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marielle Kabbouche
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics and Neurology, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Andrew D Hershey
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics and Neurology, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Serena L Orr
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Mavridi A, Redmond A, Archontakis-Barakakis P, Bogdanova-Mihaylova P, Deligianni CI, Mitsikostas DD, Mavridis T. Onabotulinumtoxina in the Prevention of Migraine in Pediatric Population: A Systematic Review. Toxins (Basel) 2024; 16:295. [PMID: 39057935 PMCID: PMC11281299 DOI: 10.3390/toxins16070295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/26/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
Migraine is a leading cause of disability worldwide, yet it remains underrecognized and undertreated, especially in the pediatric and adolescent population. Chronic migraine occurs approximately in 1% of children and adolescents requiring preventive treatment. Topiramate is the only FDA-approved preventative treatment for children older than 12 years of age, but there is conflicting evidence regarding its efficacy. OnabotulinumtoxinA is a known and approved treatment for the management of chronic migraine in people older than 18 years. Several studies examine its role in the pediatric population with positive results; however, the clear-cut benefit is still unclear. OnabotulinumtoxinA seems not only to improve disability scores (PedMIDAS) but also to improve the quality, characteristics, and frequency of migraines in the said population. This systematic review aims to summarize the evidence on the efficacy, dosing, administration, long-term outcomes, and safety of onabotulinumtoxinA in pediatric and adolescent migraine. Eighteen studies met the eligibility criteria and were included in this review. The mean monthly migraine days (MMDs), decreased from of 21.2 days per month to 10.7 after treatment. The reported treatment-related adverse effects were mild and primarily injection site related and ranged from 0% to 47.0%. Thus, this review provides compelling evidence suggesting that OnabotulinumtoxinA may represent a safe and effective preventive treatment option for pediatric migraine.
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Affiliation(s)
- Artemis Mavridi
- First Department of Pediatrics, School of Medicine, “Aghia Sofia” Children’s Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Aine Redmond
- Department of Neurology, Tallaght University Hospital, D24 NR0A Dublin, Ireland; (A.R.); (P.B.-M.)
| | | | | | - Christina I. Deligianni
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
- Neurology Department, Athens Naval Hospital, Deinokratous 70, 11521 Athens, Greece
| | - Dimos D. Mitsikostas
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Theodoros Mavridis
- Department of Neurology, Tallaght University Hospital, D24 NR0A Dublin, Ireland; (A.R.); (P.B.-M.)
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
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Gómez-Dabó L, Caronna E, Mas-de-les-Valls R, Gallardo VJ, Alpuente A, Torres-Ferrus M, Pozo-Rosich P. Effectiveness and Safety of OnabotulinumtoxinA in Adolescent Patients with Chronic Migraine. Toxins (Basel) 2024; 16:221. [PMID: 38787073 PMCID: PMC11126010 DOI: 10.3390/toxins16050221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/06/2024] [Accepted: 05/09/2024] [Indexed: 05/25/2024] Open
Abstract
Chronic migraine (CM) significantly affects underage individuals. The study objectives are (1) to analyze the effectiveness and safety of onabotulinumtoxinA (BTX-A) in adolescents with CM; (2) to review the literature on BTX-A use in the pediatric population. This prospective observational study included patients under 18 years old with CM treated with BTX-A (PREEMPT protocol) as compassionate use. Demographic, efficacy (monthly headache days-MHD; monthly migraine days-MMD; acute medication days/month-AMDM) and side effect data were collected. A ≥ 50% reduction in MHD was considered as a response. Effectiveness and safety were analyzed at 6 and 12 months. A systematic review of the use of BTX-A in children/adolescents was conducted in July 2023. In total, 20 patients were included (median age 15 years [14.75-17], 70% (14/20) females). The median basal frequencies were 28.8 [20-28] MHD, 18 [10-28] MMD and 10 [7.5-21.2] AMDM. Compared with baseline, at 6 months (n = 20), 11 patients (55%) were responders, with a median reduction in MHD of -20 days/month (p = 0.001). At 12 months (n = 14), eight patients (57.1%) were responders, with a median reduction in MHD of -17.5 days/month (p = 0.002). No adverse effects were reported. The literature search showed similar results. Our data supports the concept that BTX-A is effective, well tolerated, and safe in adolescents with CM resistant to oral preventatives.
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Affiliation(s)
- Laura Gómez-Dabó
- Headache Clinic, Neurology Department, Vall d’Hebron Hospital, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (L.G.-D.); (E.C.); (A.A.); (M.T.-F.)
- Headache and Neurological Pain Research Group, Vall d’Hebron Institut de Recerca (VHIR), Department of Medicine, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (R.M.-d.-l.-V.); (V.J.G.)
| | - Edoardo Caronna
- Headache Clinic, Neurology Department, Vall d’Hebron Hospital, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (L.G.-D.); (E.C.); (A.A.); (M.T.-F.)
- Headache and Neurological Pain Research Group, Vall d’Hebron Institut de Recerca (VHIR), Department of Medicine, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (R.M.-d.-l.-V.); (V.J.G.)
| | - Rut Mas-de-les-Valls
- Headache and Neurological Pain Research Group, Vall d’Hebron Institut de Recerca (VHIR), Department of Medicine, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (R.M.-d.-l.-V.); (V.J.G.)
| | - Víctor J. Gallardo
- Headache and Neurological Pain Research Group, Vall d’Hebron Institut de Recerca (VHIR), Department of Medicine, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (R.M.-d.-l.-V.); (V.J.G.)
| | - Alicia Alpuente
- Headache Clinic, Neurology Department, Vall d’Hebron Hospital, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (L.G.-D.); (E.C.); (A.A.); (M.T.-F.)
- Headache and Neurological Pain Research Group, Vall d’Hebron Institut de Recerca (VHIR), Department of Medicine, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (R.M.-d.-l.-V.); (V.J.G.)
| | - Marta Torres-Ferrus
- Headache Clinic, Neurology Department, Vall d’Hebron Hospital, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (L.G.-D.); (E.C.); (A.A.); (M.T.-F.)
- Headache and Neurological Pain Research Group, Vall d’Hebron Institut de Recerca (VHIR), Department of Medicine, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (R.M.-d.-l.-V.); (V.J.G.)
| | - Patricia Pozo-Rosich
- Headache Clinic, Neurology Department, Vall d’Hebron Hospital, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (L.G.-D.); (E.C.); (A.A.); (M.T.-F.)
- Headache and Neurological Pain Research Group, Vall d’Hebron Institut de Recerca (VHIR), Department of Medicine, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (R.M.-d.-l.-V.); (V.J.G.)
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Akbar A, Ford J, Tripathi S. The Use of Botulinum Toxin Type A in Medically Refractory Pediatric Patients With Chronic Daily Headaches and Its Impact on the Quality of Life. J Child Neurol 2024; 39:55-60. [PMID: 38351705 DOI: 10.1177/08830738241227061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
Background: Chronic migraine in children has been a challenging condition to treat, prompting the investigation of alternative therapies. This retrospective single-center chart review aimed to evaluate the efficacy and safety of Botox injections for managing chronic migraine in children. Methods: The study included children with chronic daily headaches and chronic migraine who were medically refractory to previous treatments at OSF Healthcare/Illinois Neurological Institute, Peoria, between 2015 and 2021. Botox injections were administered quarterly following a specific protocol. Data were obtained from electronic medical records by manual review. Results: Twenty-four patients met the inclusion criteria (median age 15.4 years, 87% female). Comorbidities included depression (41.6%) and sleep disturbances (33.2%). Prior to Botox treatment, patients had been tried on a median number of 5 (interquartile range [IQR] 4, 7) medications. Botox injections resulted in a significant reduction in headache frequency, with a mean difference (6 months vs pretreatment) in the Headache Impact Test (HIT 3) scores of -19.6 (95% CI -24.8, -14.3), P < .001, and mean difference in the Migraine Disability Assessment (MIDAS) scores of -50.8 (95% CI -62.6, -39.0, P < .001). Subjective improvements included mood enhancement (13/24, 54.2%) and improved concentration (12/24, 50%). Treatment-related side effects were reported by 5/24 (20%) of patients and were mostly mild to moderate. Conclusions: Botox injections offer a promising therapeutic option for managing chronic migraine in children who have not responded to traditional medications. Future controlled trials and long-term follow-up studies are needed to further evaluate Botox treatment's benefits and adverse effects in children with chronic migraine.
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Affiliation(s)
- Asra Akbar
- Division of Pediatric Neurology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Jenna Ford
- Advanced Practice Nurse, Illinois Neurological Institute, Peoria, IL, USA
| | - Sandeep Tripathi
- Division of Pediatric Critical Care, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
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Karian V, Morton H, Schefter ZJ, Smith A, Rogan H, Morse B, LeBel A. OnabotulinumtoxinA for Pediatric Migraine. Pain Manag Nurs 2023; 24:610-616. [PMID: 37183070 DOI: 10.1016/j.pmn.2023.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/08/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Migraine is a painful, prevalent, and problematic condition among children. Children need access to safe and effective treatment options to alleviate the impact of this chronic condition on their wellbeing. CLINICAL IMPLICATIONS Nurses have a crucial role in supporting patient access to BTX-A. Given the results of this and other studies demonstrating the safety and efficacy of BTX-A in children, nurses can support policy change for health plans to fund this intervention for pediatric migraineurs. Allowing children to receive the safe and effective BTX-A injections will lessen the already significant impact of chronic migraine on their physical, emotional and mental health. Nurses can also play a key role in providing education to patients regarding safe administration of BTX-A for migraine. AIM The objective of this study was to define the experiences, effects, and clinical response of children to onabotulinumtoxinA (BTX-A) for migraine prevention. METHODS Clinical documentation for patients aged 13-17 years presenting for BTX-A treatment for chronic migraine between 2016-2022 in a community-based specialty clinic within a large, urban, pediatric academic medical center were included. A series of one-way repeated measures (analysis of variance [ANOVA]) were conducted to compare headache frequency, severity, and duration at baseline, and following first and second injections of BTX-A. RESULTS Of 32 eligible participants, administration of BTX-A demonstrated a decrease in headache frequency and severity. Participants reported nearly seven fewer headache days per month. Participants reported neck stiffness, fever or flu-like symptoms, fatigue, and worsening pain following BTX-A administration. CONCLUSIONS Pediatric migraineurs need therapies that are safe, effective, and accessible. BTX-A was a safe and effective treatment for migraine among the children included in this study.
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Affiliation(s)
- Victoria Karian
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Hannah Morton
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Zoë J Schefter
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Allison Smith
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Hannah Rogan
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Brenna Morse
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; School of Nursing, MGH Institute of Health Professions, Boston, Massachusetts.
| | - Alyssa LeBel
- Pediatric Headache Program, Division of Pain Medicine, Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
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VanderPluym JH, Victorio MCC, Oakley CB, Rastogi RG, Orr SL. Beyond the Guidelines: A Narrative Review of Treatments on the Horizon for Migraine in Children and Adolescents. Neurology 2023; 101:788-797. [PMID: 37604658 PMCID: PMC10634646 DOI: 10.1212/wnl.0000000000207677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 06/06/2023] [Indexed: 08/23/2023] Open
Abstract
Migraine is common in children and adolescents and can cause significant disability. There are relatively limited evidence-based treatment options available, especially when compared with treatment of migraine in adults. The Pediatric Research Equity Act requires the study of a new drug or biologic in pediatric populations. As such it is mandatory that the newest migraine treatment options available for adults be evaluated in children and adolescents. It will take years before results from clinical trials in pediatric patients become available. In the meantime, there is eagerness among clinicians to seek out the existing evidence that may help provide clarity on utilization of the newer migraine therapies in children and adolescents because many of the currently available, guideline-recommended treatments do not provide benefit for all patients. In this narrative review, the literature regarding onabotulinumtoxinA, neuromodulatory devices, calcitonin gene-related peptide (CGRP) monoclonal antibodies, 5-hydroxytryptamine (1F) agonists (i.e., ditans), and CGRP small-molecule receptor antagonists (i.e., gepants) for the treatment of migraine in children and adolescents will be summarized.
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Affiliation(s)
- Juliana H VanderPluym
- From the Department of Neurology (J.H.V.), Mayo Clinic, Scottsdale, AZ; Division of Neurology (M.C.C.V.), NeuroDevelopmental Science Center, Akron Children's Hospital, OH; Department of Neurology (C.B.O.), Johns Hopkins University School of Medicine, Baltimore, MD; Division of Neurology (R.G.R.), Barrow Neurological Institute at Phoenix Children's Hospital, AZ; Department of Child Health and Neurology (R.G.R.), University of Arizona College of Medicine-Phoenix; Departments of Pediatrics (S.L.O.), Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta; and Department of Neurology (S.L.O.), Alberta Children's Hospital, Calgary, Canada.
| | - M Cristina C Victorio
- From the Department of Neurology (J.H.V.), Mayo Clinic, Scottsdale, AZ; Division of Neurology (M.C.C.V.), NeuroDevelopmental Science Center, Akron Children's Hospital, OH; Department of Neurology (C.B.O.), Johns Hopkins University School of Medicine, Baltimore, MD; Division of Neurology (R.G.R.), Barrow Neurological Institute at Phoenix Children's Hospital, AZ; Department of Child Health and Neurology (R.G.R.), University of Arizona College of Medicine-Phoenix; Departments of Pediatrics (S.L.O.), Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta; and Department of Neurology (S.L.O.), Alberta Children's Hospital, Calgary, Canada
| | - Christopher B Oakley
- From the Department of Neurology (J.H.V.), Mayo Clinic, Scottsdale, AZ; Division of Neurology (M.C.C.V.), NeuroDevelopmental Science Center, Akron Children's Hospital, OH; Department of Neurology (C.B.O.), Johns Hopkins University School of Medicine, Baltimore, MD; Division of Neurology (R.G.R.), Barrow Neurological Institute at Phoenix Children's Hospital, AZ; Department of Child Health and Neurology (R.G.R.), University of Arizona College of Medicine-Phoenix; Departments of Pediatrics (S.L.O.), Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta; and Department of Neurology (S.L.O.), Alberta Children's Hospital, Calgary, Canada
| | - Reena G Rastogi
- From the Department of Neurology (J.H.V.), Mayo Clinic, Scottsdale, AZ; Division of Neurology (M.C.C.V.), NeuroDevelopmental Science Center, Akron Children's Hospital, OH; Department of Neurology (C.B.O.), Johns Hopkins University School of Medicine, Baltimore, MD; Division of Neurology (R.G.R.), Barrow Neurological Institute at Phoenix Children's Hospital, AZ; Department of Child Health and Neurology (R.G.R.), University of Arizona College of Medicine-Phoenix; Departments of Pediatrics (S.L.O.), Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta; and Department of Neurology (S.L.O.), Alberta Children's Hospital, Calgary, Canada
| | - Serena L Orr
- From the Department of Neurology (J.H.V.), Mayo Clinic, Scottsdale, AZ; Division of Neurology (M.C.C.V.), NeuroDevelopmental Science Center, Akron Children's Hospital, OH; Department of Neurology (C.B.O.), Johns Hopkins University School of Medicine, Baltimore, MD; Division of Neurology (R.G.R.), Barrow Neurological Institute at Phoenix Children's Hospital, AZ; Department of Child Health and Neurology (R.G.R.), University of Arizona College of Medicine-Phoenix; Departments of Pediatrics (S.L.O.), Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta; and Department of Neurology (S.L.O.), Alberta Children's Hospital, Calgary, Canada
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Rastogi RG, Hastriter EV, Evans RL, Bassal F, Hickman C, Karnik KT, Little R, Lewis KS. Advances in the Acute and Preventive Treatment of Pediatric Migraine. Curr Pain Headache Rep 2023; 27:521-529. [PMID: 37561313 DOI: 10.1007/s11916-023-01157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE OF REVIEW Headaches are common in children and adolescents. Treatments for debilitating migraine are often not FDA approved or lack evidence of efficacy for children. This narrative review looks at the evidence for acute and preventative pharmacologic and non-pharmacologic treatment of pediatric migraine, as well as reviewing any recent or ongoing clinical trials. RECENT FINDINGS Studies have been published on pharmacological treatments for headache, as well as non-pharmacological treatments. Recent findings in pediatric migraine using onabotulinumtoxinA, calcitonin gene related peptide antagonists, interventional procedures, and devices are reviewed. Pharmacologic as well as non-pharmacologic approaches for the prevention and treatment of migraine show safety and efficacy data that is promising. These treatments should be incorporated in a multi-modal approach to the management of pediatric migraine. Continued studies, prospective and randomized, are needed to further assess these newer treatments for migraine in the pediatric setting.
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Affiliation(s)
- Reena Gogia Rastogi
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA.
| | - Eric Vance Hastriter
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Rachel L Evans
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Frederick Bassal
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Carolyn Hickman
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Kavitha T Karnik
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Robert Little
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Kara Stuart Lewis
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
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Papetti L, Frattale I, Ursitti F, Sforza G, Monte G, Ferilli MAN, Tarantino S, Proietti Checchi M, Valeriani M. Real Life Data on OnabotulinumtoxinA for Treatment of Chronic Migraine in Pediatric Age. J Clin Med 2023; 12:jcm12051802. [PMID: 36902596 PMCID: PMC10003637 DOI: 10.3390/jcm12051802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND The use of OnabotulinumtoxinA (OBT-A) for the treatment of chronic migraine (CM) in adults represents a therapy with the greatest efficacy and safety data. However, we have little evidence on the use of OBT-A in children or adolescents. The present study aims to describe the experience with OBT-A in the treatment of CM in adolescents in an Italian third-level headache center. METHODS The analysis included all patients under the age of 18 treated with OBT-A for CM at the Bambino Gesù Children's Hospital. All patients received OBT-A following the PREEMPT protocol. Subjects were classified as good responders if a greater than 50% reduction in the monthly frequency of attacks was observed, partial responders if the reduction was between 30 and 50%, and non-responders if it was <30%. RESULTS The treated population consisted of 37 females and 9 males with a mean age of 14.7 years. Before starting OBT-A, 58.7% of the subjects had attempted prophylactic therapy with other drugs. From OBT-A initiation to the last clinical observation, the mean duration of follow-up was 17.6 ± 13.7 SD (range: 1-48) months. The number of OBT-A injections were 3.4 ± 3 SD. Sixty eight percent of the subjects responded to treatment within the first three administrations of OBT-A. Proceeding with the number of administrations, a progressive improvement in frequency was further observed. CONCLUSIONS The use of OBT-A in pediatric age can have benefits in terms of reduction in the frequency and intensity of headache episodes. Furthermore, treatment with OBT-A has an excellent safety profile. These data support the use of OBT-A in the treatment of childhood migraine.
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Affiliation(s)
- Laura Papetti
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
- Correspondence: ; Tel.: +39-06-6859-2865
| | - Ilaria Frattale
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, 00165 Rome, Italy
| | - Fabiana Ursitti
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | - Giorgia Sforza
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | - Gabriele Monte
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | | | - Samuela Tarantino
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | | | - Massimiliano Valeriani
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
- Center for Sensory-Motor Interaction, Aalborg University, Fredrik Bajers Vej 7 D3, DK-9220 Aalborg, Denmark
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Peck J, Zeien J, Patel M, Cornett EM, Berger AA, Hasoon J, Kassem H, Jung JW, Ramírez GF, Fugueroa PC, Singhal NR, Song J, Kaye AM, Kaye AD, Koushik SS, Strand NH, Ganti L. Review of Interventional Therapies for Refractory Pediatric Migraine. Health Psychol Res 2023; 10:67853. [PMID: 36726476 PMCID: PMC9886171 DOI: 10.52965/001c.67853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
This is a review of the latest and seminal evidence in pediatric migraine. It covers the etiology and pathophysiology known today, and then will review treatment options, efficacy and safety, quality of data and indications. Though migraine is usually regarded as an infliction in adults, it is not uncommon in the pediatric population and affects up to 8% of children. Children may experience migraine differently than adults, and present not only with headache but also frequent gastrointestinal symptoms. They are frequently shorter in duration than in adults. Traditional migraine treatment in adults is less effective in children. In this population, adjunct therapies - such as interventional techniques - should be considered when traditional treatment fails, including Botulinum Toxin A (BTA) injections, peripheral nerve and ganglion blocks. BTA injections are FDA approved for migraine prophylaxis in adults, but currently not in children; however, recent evidence shows efficacy and safety in pediatric migraine management. Nerve blocks stop nociceptive afferent fibers through injection of local anesthetics, and it may be associated with the local injection of corticosteroids. Although more common in adults, recent data suggests they are safe and effective in children and adolescents. Blocking the sphenopalatine ganglion can be achieved through nasal approach, and achieves a similar action by blocking the entire ganglion. Interventional techniques may provide a key component in the alleviation of this otherwise debilitating chronic migraine pain. Though most studies have been performed in adults, new studies provide encouraging results for treatment in children.
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Affiliation(s)
| | - Justin Zeien
- Department of AnesthesiologyUniversity of Arizona College of Medicine-Phoenix
| | - Megha Patel
- Department of AnesthesiologyUniversity of Arizona College of Medicine-Phoenix
| | - Elyse M. Cornett
- Department of AnesthesiologyLouisiana State University Shreveport
| | | | - Jamal Hasoon
- Department AnesthesiologyMount Sinai Medical Center
| | - Hisham Kassem
- Department AnesthesiologyCritical Care, and Pain Medicine, Beth Israel Deaconess Medical Center
| | | | | | - Paola Colon Fugueroa
- NeurologyHCA Florida Osceola Hospital & University of Central Florida College if Medicine
| | - Neil R. Singhal
- Valley Anesthesiology and Pain Consultants – Envision Physician Services
| | | | - Adam M. Kaye
- Department of Pharmacy PracticeThomas J. Long School of Pharmacy and Health Sciences, University of the Pacific
| | - Alan D. Kaye
- Department of AnesthesiologyLouisiana State University Shreveport
| | - Sarang S. Koushik
- Valleywise Health Medical Center, Creighton University School of Medicine
| | - Natalie H. Strand
- Department of Anesthesiology and Perioperative MedicineMayo Clinic Phoenix
| | - Latha Ganti
- Neurology and Emergency MedicineUniversity of Central Florida College of Medicine
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10
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Goenka A, Yu SG, George MC, Chikkannaiah M, MacDonald S, Stolfi A, Kumar G. Is Botox Right for Me: When to Assess the Efficacy of the Botox Injection for Chronic Migraine in Pediatric Population. Neuropediatrics 2022; 53:344-350. [PMID: 35453165 DOI: 10.1055/a-1832-9168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Botulinum toxin type A (BoNT-A) has shown to be a safe and effective treatment for children with chronic migraines. Our study was to assess the efficacy of the Onabotulinum toxin type A at different intervals after initiation of therapy. We conducted a retrospective and prospective analysis of 34 patients at a children's hospital where children received four rounds of the BoNT-A therapy for the treatment of chronic migraine. Among the 34 patients, 25 patients (age range: 13-21 years), who responded to the BoNT-A therapy, were included in the analysis. Patients received standard 31 injection, 155 unit's protocol. Patients were assessed every 3 months after their initial injection. Reasons for discontinuation of therapy were analyzed. After the first two BoNT-A sessions, significant improvement was observed with a decrease in headache frequency and intensity (p < 0.001). There was further reduction in headache frequency and intensity with the fourth round of BoNT-A therapy, with comparative analysis between the second and fourth round showing a p-value of <0.001. In terms of reduction of emergency room visits and hospitalization, a significant improvement was seen after the third round of BoNT-A therapy (p < 0.01). A significant decrease in the number of abortive and preventive medications was seen after the second round of BoNT-A therapy (p < 0.001). The efficacy of BoNT-A treatment in decreasing headache frequency, intensity, and the number of abortive and preventive medications can be assessed effectively after two treatment sessions. This trend continued to be observed with additional third and fourth sessions.
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Affiliation(s)
- Ajay Goenka
- Department of Neurology, Dayton Children Hospital, Wright State University Boonshoft School of Medicine, Dayton, Ohio, United States.,Department of Pediatrics, Wright State University, Boonshoft School of Medicine, Dayton, Ohio, United States
| | - Sarah G Yu
- Department of Pediatrics, Wright State University, Boonshoft School of Medicine, Dayton, Ohio, United States
| | - Monica C George
- Department of Pediatrics, Wright State University, Boonshoft School of Medicine, Dayton, Ohio, United States
| | - Mahesh Chikkannaiah
- Department of Neurology, Dayton Children Hospital, Wright State University Boonshoft School of Medicine, Dayton, Ohio, United States.,Department of Pediatrics, Wright State University, Boonshoft School of Medicine, Dayton, Ohio, United States
| | - Sarah MacDonald
- Department of Neurology, Dayton Children Hospital, Wright State University Boonshoft School of Medicine, Dayton, Ohio, United States
| | - Adrienne Stolfi
- Department of Pediatrics, Wright State University, Boonshoft School of Medicine, Dayton, Ohio, United States
| | - Gogi Kumar
- Department of Neurology, Dayton Children Hospital, Wright State University Boonshoft School of Medicine, Dayton, Ohio, United States.,Department of Pediatrics, Wright State University, Boonshoft School of Medicine, Dayton, Ohio, United States
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11
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Generalized Anxiety Disorder: A Predictor for Poor Responsiveness to Botulinum Toxin Type A Therapy for Pediatric Migraine. Pediatr Neurol 2022; 130:21-27. [PMID: 35305510 DOI: 10.1016/j.pediatrneurol.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/19/2021] [Accepted: 02/14/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND To assess the efficacy, safety, and predictors for poor responsiveness of botulinum toxin type A (BoNT-A) for chronic migraine in the adolescent and young adult population. METHODS A retrospective analysis of 56 patients who received BoNT-A for chronic migraine with an age range from 13 to 21 years was performed. Of 56 patients, 34 were enrolled in the study based on the inclusion criterion. Patients who received three dosages of BoNT-A were assessed at nine months from the first injection. Variables including age, body mass index, headache intensity, frequency, character, and side effects were assessed. The patients were divided into two groups based on response to BoNT-A therapy, responders and nonresponders. RESULTS Overall among the 34 patients enrolled in the study, the average headache frequency decreased from 18.6 of 28 to 9.9 of 28 days, P value, <0.001 from baseline. There was significant decrease in the average headache intensity, 8.1 to 4.3. Of 34 patients, 25 (73%) patients responded to treatment with decrease in headache frequency by ≥ 50% from the baseline. Among the nonresponder patients, a significant number of patients (six of nine, 67%) had generalized anxiety disorder with Generalized Anxiety Disorder-7 score greater than 15 versus the responder group (six of 25, 24%, P value 0.040). CONCLUSIONS BoNT-A remains a safe and effective therapy for adolescent and young adult patients with chronic migraines at nine months of follow-up. Generalized anxiety disorder with Generalized Anxiety Disorder-7 score greater than 15 can be a major predictor of poor response to this therapy.
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12
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Botox (OnabotulinumtoxinA) for Treatment of Migraine Symptoms: A Systematic Review. Pain Res Manag 2022; 2022:3284446. [PMID: 35401888 PMCID: PMC8989603 DOI: 10.1155/2022/3284446] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 11/17/2022]
Abstract
Background. Migraine is one of the most common types of headache, and it is the second most common cause of neurological disorders, with an annual prevalence of about 15% of the population. This study aimed to evaluate the effect of BoNT-A on the duration and intensity of migraine attacks. In addition, we investigated the effective injection sites. Methods. According to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, we searched online databases, including Web of Science, PubMed, EMBASE, Scopus, Cochrane Library, ProQuest, ClinicalTrials.gov, and Google Scholar from 2011 to 2021. Results. A total of 24 articles were included in the study. The use of BoNT-A in individuals suffering from chronic migraine (CM) decreases the frequency of migraine attacks per month, pain intensity, medication use, emergency visits, and migraine-related disabilities. The BoNT-A was well tolerated and leads to improved performance and better quality of life (QoL). Overall, treatment with BoNT-A in adults with CM is beneficial. In addition, the use of BoNT-A in individuals with vestibular migraine (VM) reduces the frequency of migraines and brings about the improvement of disability status caused by migraine headaches. Meanwhile, the use of BoNT-A reduces the frequency of migraine attacks per month among individuals with chronic refractory migraine (CRM). Conclusions. The use of BoNT-A is a low-cost option for the treatment of various kinds of migraines, including chronic, episodic, unilateral, and vestibular types. BoNT-A can reduce the frequency of migraine attacks per month and diminish the severity of pain.
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13
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Abstract
Pediatric headache impacts up to 80% of children, many recurrently, by the time they are 15 years old. Preventing the progression of episodic to chronic headache results in less truancy, staying current with schoolwork and improves children's quality of life. Lifestyle choices can play an important role in headache treatment. Early effective treatment of episodic headache can prevent transformation into a chronic form. While details of a child's headache are critical for making a proper diagnosis; patient education is critical and effective rescue and preventive treatment strategies enable patients to focus on enjoying activities of daily living. Recognizing "red flags" that may suggest a serious underlying etiology is critical in the early stages of diagnosing and preparing to treat children with headaches. Finally directing patients to manage their headaches at home and when to proceed to an emergency department, urgent care or infusion unit can lower the economic burden of acute headache management.
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Affiliation(s)
- Debra M O'Donnell
- Pediatric Neurologist, Dayton Children's Hospital, Division of Neurology, OH, United States.
| | - Anastazia Agin
- Pediatrician and Headache Specialist, Dayton Children's Hospital, Division of Neurology, OH, United States
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14
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Alqahtani M, Barmherzig R, Lagman-Bartolome AM. Approach to Pediatric Intractable Migraine. Curr Neurol Neurosci Rep 2021; 21:38. [PMID: 34089140 DOI: 10.1007/s11910-021-01128-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Intractable migraine in children and adolescents is a significant cause of disability and decreased quality of life (QoL) in this population. Challenges include lack of unifying definition for intractable migraine, and limited data on best-practice management in this age group, with most current treatment pathways extrapolated from adult studies or expert consensus. RECENT FINDINGS A comprehensive approach in the evaluation and management of intractable migraine in this age group encompasses excluding secondary causes of headache; making an accurate diagnosis; identifying and appropriately managing modifiable risk factors; and initiating appropriate pharmacologic therapy to reduce disability, improve health-related quality of life, reduce risk of progression, and develop adaptive pain coping strategies. Several strategies for management of pediatric intractable migraine including use of acute medications, bridge therapy in outpatient setting, emerging therapies for preventive therapy, and a stepwise combination therapy for management of pediatric intractable migraine in emergency and inpatient setting are presented based on available clinical data, safety/tolerability, availability, cost-effectiveness, and expert consensus. This descriptive review of the available literature focuses on approach to therapy for acute intractable migraine in a pediatric population including outpatient, emergency department (ED), and inpatient management.
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Affiliation(s)
- Mohammed Alqahtani
- Division of Neurology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - Rebecca Barmherzig
- Pediatric Headache Program, Division of Neurology, Children's Hospital of Philadelphia (CHOP), 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Ana Marissa Lagman-Bartolome
- Division of Neurology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada. .,Centre for Headache, Women's College Hospital, University of Toronto, 76 Grenville Street, Toronto, Ontario, M5B1S2, Canada.
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15
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Santana L, Liu C. Experience of Botulinum Toxin A Injections for Chronic Migraine Headaches in a Pediatric Chronic Pain Clinic. J Pediatr Pharmacol Ther 2021; 26:151-156. [PMID: 33603578 DOI: 10.5863/1551-6776-26.2.151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Prevalence of chronic migraine in children can reach 7.7%, causing decreased school performance, difficulty with extracurricular activities (including sports, theater, or music), and changes in sleep and mood. Many studies confirm that botulinum toxin type A injections effectively alleviate chronic migraines in adults; however, the literature regarding children is sparse. This study aims to analyze the safety and effectiveness of botulinum type A injections in a group of pediatric patients diagnosed with chronic migraines in a pediatric pain clinic. METHODS In this retrospective (2013-2018) study, the effects of botulinum toxin type A injections were analyzed using data from 65 pediatric patients diagnosed with chronic migraines. The study group ranged from 11 to 18 years of age. A pediatric pain management physician administered the botulinum using the Phase 3 Research Evaluating Migraine Prophylaxis Therapy program protocol and followed the pain pattern. Dosages, tolerance, and side effects were measured. RESULTS In this study, 74% of the patients tried more than 6 medications before the injections. There was a decrease in the visual analog scale score of 5.2 ± 2.2 points upon 6-week follow-up. The mean amount of medication used was 173.2 ± 35 units, and patients received an average of 2.8 ± 1.1 units/kg. Adverse events include one patient who developed dizziness and another who had low-grade fevers with enlarged cervical lymph nodes; both resolved within few minutes. CONCLUSIONS This study supports the use of botulinum type A for chronic migraines in pediatric patients. Multicentered, randomized studies with larger population are needed to evaluate the long-term safety and efficacy of this therapy.
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16
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Abstract
AIMS To conduct a review of the literature on the use of botulinum toxin for the treatment of pediatric chronic migraine. METHODS A review of the literature was performed using EMBASE, PubMed, and Cochrane/Ovid. Using our inclusion and exclusion criteria, we targeted any study, published before April 2020, evaluating the efficacy of botulinum toxin in migraineurs younger than 18 years. RESULTS Seven studies were included: 2 retrospective analyses, 3 case series, a case report, and a randomized control trial. Studies included 1 to 125 patients, with the number of botulinum toxin treatments ranging from 1 to 11 treatments. The results of the randomized controlled trial showed nonsuperiority between placebo and botulinum toxin. Results of the other studies were generally favorable but were difficult to compare because of lack of standardization of botulinum toxin dosing, injection paradigm, frequency and duration of treatment, usage of accompanying prophylaxis, and variation in outcome measures across studies. There was low-quality evidence that botulinum toxin improved headache frequency and intensity, though some studies demonstrated efficacy in treatment with botulinum toxin. CONCLUSION This review is the first of its kind, updating the literature on the efficacy of botulinum toxin in pediatric patients. Given evidence of its utility in treating pediatric migraines, off-label use should be considered in certain cases. Further study is warranted to better characterize injection paradigms and patient selection because of the limited and inconsistent data available.
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Affiliation(s)
- Raymundo Marcelo
- 158147Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Brin Freund
- 158147Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Department of Neurology, 1501Johns Hopkins Hospital, Baltimore, MD, USA
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17
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Winner PK, Kabbouche M, Yonker M, Wangsadipura V, Lum A, Brin MF. A Randomized Trial to Evaluate OnabotulinumtoxinA for Prevention of Headaches in Adolescents With Chronic Migraine. Headache 2020; 60:564-575. [PMID: 32037549 PMCID: PMC7065250 DOI: 10.1111/head.13754] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE As a post-approval commitment, this dose-ranging study was undertaken to evaluate efficacy and safety of onabotulinumtoxinA in adolescents. BACKGROUND In adolescents, migraine is often undiagnosed or misdiagnosed and can present unique management challenges. OnabotulinumtoxinA was approved for prevention of chronic migraine (CM) in adults in 2010. METHODS This multicenter, double-blind, parallel-group, randomized trial assessed a single treatment of onabotulinumtoxinA (155 U or 74 U) vs placebo (intramuscular saline) administered via the recommended fixed-dose fixed site paradigm in adolescents with CM aged 12 to <18 years. The primary efficacy measure was change in frequency of headache days from baseline at week 12; other measures included change in frequency of headache days at weeks 4 and 8 and change in frequency of severe headache days. Safety and tolerability were assessed. RESULTS Of 125 randomized patients (onabotulinumtoxinA 155 U, n = 45; onabotulinumtoxinA 74 U, n = 43; placebo, n = 37), all were included in the primary efficacy analysis, and 115 (92.0%) completed the study. Lack of efficacy was the primary reason for discontinuing (n = 4; 3.2%); no patients discontinued because of adverse events. All treatments reduced frequency of headache days at week 12, with no significant differences between treatments. The mean (95% confidence interval) changes from baseline in the frequency of headache days during the 28-day period ending at week 12 (primary endpoint) were -6.3 (-8.5, -4.2), -6.4 (-8.8, -4.0), and -6.8 (-9.6, -4.1) days in the onabotulinumtoxinA 155 U, onabotulinumtoxinA 74 U, and placebo groups, respectively (P ≥ .474). All treatments reduced frequency of severe headache days and were well-tolerated; serious adverse events (n = 3) were considered unrelated to treatment and resolved without sequelae. The most commonly reported treatment-emergent adverse events were neck pain (n = 8), upper respiratory tract infection (n = 7), migraine, and nasopharyngitis (n = 5 each). CONCLUSION Although this study did not meet its efficacy endpoints, onabotulinumtoxinA was well tolerated in this adolescent population. Given previous data demonstrating the benefits of onabotulinumtoxinA in adults with CM, additional studies with design modifications, including adequate statistical power, to assess the efficacy of multiple treatment cycles of onabotulinumtoxinA for CM prevention in adolescents may be informative.
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Affiliation(s)
- Paul K. Winner
- Palm Beach Headache CenterPremiere Research Institute@Palm Beach NeurologyWest Palm BeachFLUSA
| | | | - Marcy Yonker
- University of Colorado School of Medicine/Children’s HospitalAuroraCOUSA
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18
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Abstract
Migraine is the most common acute and recurrent headache syndrome in children. This condition has unique clinical characteristics in the pediatric population, that can evolve with age, and significantly impact a child's quality of life, affecting their education, socialization, and family life. The purpose of this review is to describe the varied clinical features of migraine seen in children, and discuss potential treatment options for pediatric migraine, including chronic migraine. In many patients a multifaceted approach involving lifestyle changes, treatment of comorbid conditions, and pharmacological treatments are needed for optimal headache control. WHAT THIS PAPER ADDS: Migraine presents as various phenotypes in children, sometimes evolving as the child ages. An expanded range of treatment options exists for the challenging chronic migraine patient.
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Affiliation(s)
- Paul E Youssef
- Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Kenneth J Mack
- Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
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19
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Pearson R, Levyim D, Choe M, Taraman S, Langdon R. Survey of Child Neurologists on Management of Pediatric Post-traumatic Headache. J Child Neurol 2019; 34:739-747. [PMID: 31232148 DOI: 10.1177/0883073819856837] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Traumatic brain injury causes significant morbidity in youth, and headache is the most common postconcussive symptom. No established guidelines exist for pediatric post-traumatic headache management. We aimed to characterize common clinical practices of child neurologists. Of 95 practitioners who completed our survey, most evaluate <50 pediatric concussion patients per year, and 38.9% of practitioners consistently use International Classification of Headache Disorders criteria to diagnose post-traumatic headache. Most recommend nonsteroidal anti-inflammatory drugs as abortive therapy, though timing after injury and frequency of use varies, as does the time when providers begin prophylactic medications. Amitriptyline, topiramate, and vitamins/supplements are most commonly used for prophylaxis. Approach to rest and return to activities varies; one-third recommend rest for 1 to 3 days and then progressive return, consistent with current best practice. With no established guidelines for pediatric post-traumatic headache management, it is not surprising that practices vary considerably. Further studies are needed to define the best, evidence-based management for pediatric post-traumatic headache.
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Affiliation(s)
- Rachel Pearson
- 1 Children's Hospital Orange County, University of California-Irvine, Orange, CA, USA
| | - Desiree Levyim
- 1 Children's Hospital Orange County, University of California-Irvine, Orange, CA, USA
| | - Meeryo Choe
- 2 UCLA Steve Tisch BrainSPORT Program and UCLA Brain Injury Research Center, UCLA Mattel Children's Hospital, Los Angeles, CA, USA
| | - Sharief Taraman
- 1 Children's Hospital Orange County, University of California-Irvine, Orange, CA, USA
| | - Raquel Langdon
- 3 Children's National Medical Center, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
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20
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Ali SS, Bragin I, Rende E, Mejico L, Werner KE. Further Evidence that Onabotulinum Toxin is a Viable Treatment Option for Pediatric Chronic Migraine Patients. Cureus 2019; 11:e4343. [PMID: 31187008 PMCID: PMC6541167 DOI: 10.7759/cureus.4343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/28/2019] [Indexed: 12/30/2022] Open
Abstract
Introduction Chronic migraine is particularly devastating. It affects school work, extracurricular activities, and quality of life, including relationships with other family members, and can also influence the mental health of both the migraineurs and family members. According to the International Classification of Headache Disorders, 3rd edition (ICHD-3), chronic migraine is defined as 15 or more headache days per month for greater than three months, where at least on eight days per month, there are features of migraine headache. Although botulinum toxin type A (BoNTA) has been proven effective for treating chronic migraine in adults, little literature exists about its use in children. Here, we present the treatment response in children with chronic migraines treated with BoNTA at our institutions Duke and State University of New York (SUNY) Upstate. Method A retrospective analysis of 30 adolescent migraineurs who met ICHD-3 criteria for chronic migraine were treated with BoNTA injection according to the standardized adult protocol. Descriptive statistics and paired t-tests were performed. A total of 185 units of botulinum toxin were injected intramuscularly per patient, as in addition to the standard 31 sites for a total of 155 units, an additional 30 units were given in areas that were felt to provide further benefit. Results Participants (n=30) were 16.5 ± 1.83 years old. The headaches were precipitated by trauma in seven cases. All had failed standard pharmacotherapy, including amitriptyline and topiramate. An average of 2.47 ± 1.6 BoNTA injection cycles was performed. Migraine severity decreased significantly from 7.47 ± 1.89 on a 10-point scale to 4.34 ± 3.02 (p<.001). Additionally, headache frequency improved from 24.4 ± 7.49 painful days per month to 14.8 ± 12.52 painful days per month (p<.001). One patient developed nausea related to injections; all others tolerated it well, with no side effects. Discussion BoNTA injection was a safe and effective therapy for chronic migraine in our cohort of children recalcitrant to medical therapy. Further research with multi-centered, double-blinded, randomized, placebo-controlled trials is warranted to evaluate the long-term safety and efficacy in this population.
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Affiliation(s)
- Sameer S Ali
- Neurology, Veterans Affairs Connecticut Healthcare System, West Haven, USA
| | - Ilya Bragin
- Neurology, St. Lukes University Health Network, Bethlehem, USA
| | | | - Luis Mejico
- Neurology, State University of New York, Syracuse, USA
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21
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Connelly M, Sekhon S. Current perspectives on the development and treatment of chronic daily headache in children and adolescents. Pain Manag 2019; 9:175-189. [PMID: 30681030 DOI: 10.2217/pmt-2018-0057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Headache disorders subsumed under the term chronic daily headache (CDH), including chronic migraine, chronic tension-type headache and new daily persistent headache, affect up to 4% of the pediatric population and can be highly disabling and challenging to effectively treat. Although historically the knowledge base about this group of headache disorders in children primarily was derived from clinical observation and extrapolation from adult studies, over the past several years there have been important research findings relevant to the development and management of pediatric CDH that can help inform clinical practice. The intent of this paper is to provide a focused review on recent empirical work done on pediatric CDH and suggest avenues for future work.
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Affiliation(s)
- Mark Connelly
- Department of Pediatrics, Division of Developmental and Behavioral Sciences, Children's Mercy Hospitals & Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Subhjit Sekhon
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO 64110, USA
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