Pediatric Migraine: A Lot More to Learn
Ten percent of U.S. children under the age of 18 have Migraine. Despite this, relatively little is known about pediatric Migraine. With few FDA-approved treatments, doctors who treat these children may prescribe off-label treatments commonly used to treat adults with Migraine.
Yet kids aren’t miniature adults. Their bodies and brains are still developing, so their response to treatment may be different, and they are more likely to experience side effects. Their response to treatment may also be influenced by developmental and environmental factors to a greater degree than adults.
Let’s take a look at some of the recent discoveries about pediatric Migraine. Many of the findings don’t match the results of similar studies involving adult patients. Clearly, we have a lot more to learn.
Symptoms and diagnosis
- Pediatric Migraine isn’t the same as adult Migraine. The symptoms of pediatric Migraine don’t fit the ICHD-3 diagnostic criteria.
- When a child presents in the ER with a headache, half the time, the diagnosis is “non-specific headache disorder.” A new algorithm has been developed to improve diagnostic accuracy. It has been tested for reliability and validity at pediatric Migraine and headache centers. The challenge now is to implement this algorithm at emergency rooms and primary care clinics around the country.
- Most often children report that pain feels “tightening,” while adolescents and young adults report a “throbbing” sensation.
- Bilateral pain is present in 75 percent of children, 60 percent of adolescents, and 85 percent of young adults.
- Autonomic symptoms of nausea, vertigo, feeling light-headed, sleep disorders are more common in children and adolescents.
- Only one triptan, rizatriptan (Maxalt), is approved for children as young as six years old.
- Three others, almotriptan (Axert), zolmitriptan nasal spray (Zomig), and sumatriptan/naproxen (Treximet) are approved for children ages 12 and up.
- Triptans do not work for 35 percent of children and adolescents with chronic Migraine.
- One study found that dihydroergotamine nasal spray (Migranal) was moderately effective.
- Topiramate (Topamax) is approved to prevent Migraine in children 12 years and older.
- Amitriptyline is most commonly prescribed.
- A study published in the January, 2017 issue of The New England Journal of Medicine reported that placebo treatment is more effective than either topiramate or amitriptyline.
- That same study found that children were more likely to experience intolerable side effects.
- A March, 2016 study published in Headache found that amitriptyline plus cognitive behavioral therapy was more effective than amitriptyline alone.
- Over one-third of parents and pediatric patients state that their primary treatment goal is to “stop headaches.”
- Most are only willing to tolerate minimal side effects, yet expect maximum benefits from treatment. Studies are needed on newer non-oral treatments to determine their safety and effectiveness for children.
- This expectation is at odds with the medically acceptable success rate of a 50 percent reduction in severity and/or frequency. Managing treatment expectations is essential for treatment compliance and satisfaction.
- Kids with anxiety are more likely to accept a referral for cognitive behavioral therapy. Otherwise, children may downplay the social and emotional impact of Migraine. Both parents and children may be reluctant to seek therapy as part of their Migraine treatment plan.
- Improving sleep hygiene is an effective strategy for improving pediatric Migraine management.
- A new questionnaire, The Sleep Inventory for Pediatric Headache was developed in 2016 to identify sleep problems that may affect Migraine severity and frequency.
- When parents experience anxiety, depression, or distress related to their child’s Migraine symptoms, kids experience poorer treatment outcomes.
- Successful treatment may involve disease education and behavioral therapy for the entire family.
So much more to learn
In a June 2017 interview with the American Headache Society, Peter Goadsby, M.D., explained, “It is critical that we find better ways to help children and adolescents living with the disabling impact of Migraine during the most formative years of their lives. While data presented at the AHS Annual Scientific Meeting further illuminate our understanding of pediatric Migraine, it also shows that current benchmarks used to diagnose and treat this patient population are insufficient.”
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