Pediatric Migraine Research Updates: Prevention, Treatment, Diagnosis
As little as we know about migraine generally, we know even less about migraine among children. Although two migraine treatment medications are FDA approved for the pediatric population (rizatriptan & almotriptan), we don't know enough about which, if any, medications for prevention or treatment are effective for children. Two studies reviewing existing research attempt to shed some light on this issue. There is also new research about a tool for diagnosing children with migraine that seems to be effective.
Pediatric Migraine Prevention
Researchers at the Medical College of Wisconsin in Milwaukee examining existing studies found only trazodone and topamirate were better than placebo at reducing the frequency of migraine attacks among the children studied. Interestingly, children responded incredibly favorably to placebo treatments. The susceptibility of children to the placebo effect is well recognized. This reinforces the need to perform double blind studies on all research populations, including children, and to follow International Headache Society standards when designing research studies.
Despite exhaustive attempts to find studies about preventive medications for children with migraine, the researchers were only able to find 21 to include in their review. This statistic highlights the desperate need for not only more research into migraine generally, but specifically among the pediatric population.
In an editorial accompanying the study, Marco Arruda, MD, PhD, of the Glia Institute in Sao Paulo, Brazil, said he's not as concerned about whether children are helped by the medications or the placebo effect specifically as long as some improvement can be made in their migraine patterns that improves their quality of life and ability to function. He also pointed out that just because no evidence has been found at this time showing these medications are effective does not mean they aren't effective. It simply means we don't yet know.
There are some lingering unanswered questions about this review. Were the children given therapeutic doses of the preventive medications? Do we even know what a therapeutic dose of any of these medications would be for children of a particular age? Was the so-called placebo effect actually attributable to effective education about headache disorders and coping skills? Finally, how would the results have differed if more than just one study of preventive medications involved children with chronic migraine? Clearly we need more research studies that examine the efficacy of preventive medications in children with chronic migraine.
Pediatric Migraine Treatment
In conducting a review of seven sets of triptan efficacy and trial data submitted to the FDA, researchers found an extremely high placebo rate among child migraineurs. Medications represented in studies including in the review included: sumatriptan nasal spray (Imitrex) and zolmatriptan (Zomig), eletriptan (Relpax), almotriptan (Axert) and rizatriptan (Maxalt) tablets. The placebo rate ranged from 53% to 57.5%.
To try to reduce the impact of the placebo effect the researchers excluded children reporting early relief from placebo from the rest of the study. This reduced the placebo rate by 6% and brought the efficacy rate in that drug, rizatriptan, to 30.6%.
Worth also noting is that in giving its stamp of approval the FDA has determined there was sufficient evidence of efficacy for the use of two triptans to treat children with migraine: rizatriptan (Maxalt) and almotriptan (Axert). Both were included in this review.
Pediatric Migraine Diagnosis
Finally, researchers at the National Institutes of Mental Health have determined that the Diagnostic Interview of Headache Syndromes - Child Version (DIHS-C) is a useful tool for diagnosing children with headache disorders according to the International Headache Society classification system, the gold standard.
When used by medical staff other than a doctor, the tool was able to match the diagnosis of a neurologist 98% of the time.
The lead study author suggests the tool could be used by a doctor's staff to make an initial assessment, allowing the doctor to use his or her limited time with the patient more efficiently.
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