Practice Parameter: Pharmacological treatment of migraine headache in children and adolescents: Report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society

Effectiveness of Lidocaine Infusion Versus Valproate Infusion for Pediatric Status Migrainosus

OBJECTIVE

To compare the efficacy (as measured by time to resolution of pain) and safety of valproate infusion and lidocaine infusion in the treatment of pediatric status migrainosus.

METHODS

We conducted a single-center retrospective cohort study from March 2014 to June 2021 evaluating children and adolescents who received a lidocaine or sodium valproate infusion for the treatment of status migrainosus. During the study period, lidocaine infusion was exclusively used before March 2016, whereas sodium valproate infusion was exclusively used afterward.

RESULTS

A total of 31 patients received lidocaine and 63 received sodium valproate infusion. Patients in the lidocaine group achieved significantly faster control of pain with median hours to pain free of 11.7 (interquartile range, 3.8-32.3) hours compared with 43.4 (interquartile range 13.8-68.7) hours in the valproate group (P = .002). At discharge, 21 of 31 (67.7%) of patients receiving lidocaine were pain-free compared with 26 of 59 (44.1%) of patients receiving valproate (P = .03). There were significantly more infusion interruptions of valproate compared with lidocaine for various patient-related factors (16/63, 25.4% vs 1/31, 3.2%; P = .009). More adverse effects were observed with valproate (42/63, 67%) compared with lidocaine (1/31, 3.2%; P < .001). The significant difference in hours to pain control persisted after adjustment for sex, race, age, BMI, presence of comorbidities, and pain score at admission. All patients in both groups completed the infusions and were discharged from the hospital.

CONCLUSIONS

Intravenous lidocaine infusion is associated with superior pain control and a better safety profile compared with intravenous sodium valproate infusion in status migrainosus.

Bioactive Ingredients from Dairy-Based Lactic Acid Bacterial Fermentations for Functional Food Production and Their Health Effects

Lactic acid bacteria are traditionally applied in a variety of fermented food products, and they have the ability to produce a wide range of bioactive ingredients during fermentation, including vitamins, bacteriocins, bioactive peptides, and bioactive compounds. The bioactivity and health benefits associated with these ingredients have garnered interest in applications in the functional dairy market and have relevance both as components produced in situ and as functional additives. This review provides a brief description of the regulations regarding the functional food market in the European Union, as well as an overview of some of the functional dairy products currently available in the Irish and European markets. A better understanding of the production of these ingredients excreted by lactic acid bacteria can further drive the development and innovation of the continuously growing functional food market.

Neuromodulation in Pediatric Migraine using Repetitive Neuromuscular Magnetic Stimulation: A Feasibility Study

Migraine has a relevant impact on pediatric health. Non-pharmacological modalities for its management are urgently needed. This study assessed the safety, feasibility, acceptance, and efficacy of repetitive neuromuscular magnetic stimulation (rNMS) in pediatric migraine. A total of 13 patients with migraine, ≥6 headache days during baseline, and ≥1 myofascial trigger point in the upper trapezius muscles (UTM) received six rNMS sessions within 3 weeks. Headache frequency, intensity, and medication intake were monitored using headache calendars; headache-related impairment and quality of life were measured using PedMIDAS and KINDL questionnaires. Muscular involvement was assessed using pressure pain thresholds (PPT). Adherence yielded 100%. In 82% of all rNMS sessions, no side effects occurred. All participants would recommend rNMS and would repeat it. Headache frequency, medication intake, and PedMIDAS scores decreased from baseline to follow-up (FU), trending towards statistical significance (p = 0.089; p = 0.081, p = 0.055). A total of 7 patients were classified as responders, with a ≥25% relative reduction in headache frequency. PPT above the UTM significantly increased from pre- to post-assessment, which sustained until FU (p = 0.015 and 0.026, respectively). rNMS was safe, feasible, well-accepted, and beneficial on the muscular level. The potential to reduce headache-related symptoms together with PPT changes of the targeted UTM may underscore the interplay of peripheral and central mechanisms conceptualized within the trigemino-cervical complex.

Quality of life in children suffering from headaches: a systematic literature review

BACKGROUND

Headaches are the most common complaints among pediatric populations. Determining the cause and appropriate treatment for headaches may be challenging and costly, and the impact of headaches on the lives of patients and their families is not well understood.

OBJECTIVE

A systematic literature review was conducted to examine what PROMs are currently used, and to identify quality of life (QoL) concepts important to children suffering from headaches and any known determinants of QoL.

METHODS

Embase, Medline, Web of Science, CINAHL, EBSCOhost, PsychINFO, Cochrane CENTRAL and Google Scholar were searched from their inception through to June 2021. Studies investigating QoL, using a validated outcome measure in pediatric patients with headaches, were included. Relevant studies were identified through title and abstract screening and full text review by two independent reviewers. A citation review of included studies was performed. QoL concepts were extracted from the outcome measures that were used in each study to develop a preliminary conceptual model of QoL in children suffering from headaches. Determinants of QoL were also identified and categorized.

RESULTS

A total of 5421 studies were identified in the search. Title and abstract screening resulted in the exclusion of 5006 studies. Among the 415 studies included for full text review, 56 were eligible for final analysis. A citation review resulted in the addition of five studies. Most studies were conducted in high-income countries and included a patient-sample accordingly (n = 45 studies). Sixteen different PROMs were identified in the included studies, of which the PedsQL was used the most often (n = 38 studies). The most common health concepts reported were physical functioning (n = 113 items), social and psychological wellbeing (N = 117, n = 91 resp.). Twenty-five unique determinants of QoL were extracted from the included studies.

CONCLUSION

There is a need for a condition-specific PROM to facilitate the measurement of QoL outcomes in the pediatric headache population. A conceptual model was developed based on the findings from the health concepts. Findings from this review could be used for future qualitative interviews with pediatric patients with headaches to elicit and refine important QoL concepts.

The Efficacy of Different Triptans for the Treatment of Acute Headache in Pediatric Migraine: A Systematic Review

BACKGROUND

Serotonin receptors 5-HT1B and 5-HT1D in the cerebral arteries are activated by the 5-hydroxytryptophan agonists (triptans) to relieve the discomfort associated with migraines. Even though triptans are often used to treat acute migraines, there is some debate over their effectiveness.

OBJECTIVE

Our systematic review aimed to evaluate the effectiveness of triptans for acute treatment of migraine in young individuals.

METHODS

Utilizing the databases of Google Scholar, Cochrane Library, and PubMed, a literature search was conducted, and all papers published till July 2022 were included. This systematic review was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. In addition to the Boolean operators AND, OR, and NOT, the following descriptive terms were also used: "Triptans," "Pediatric Migraine," "Migraine disorders," "Headache," "Children," and "Adolescent."

RESULTS

A total of 1047 studies were identified, and 25 articles were finally included in the study. 17 of them were RCTs while the remaining were non-randomized trials. Most studies recruited participants aged between 12-17 years. Among 25 studies, 7 reported sumatriptan use, 3 assessed a combination of sumatriptan and naproxen, 4 were on almotriptan, 1 on eletriptan, 6 on rizatriptan, and 4 on zolmitriptan use.

CONCLUSION

We found that rizatriptan (good tolerability profile with a dose of 5 mg) and sumatriptan (nasal spray, 10 mg and 20 mg) had higher efficiency as compared to other triptans. Regardless of type or dose, all triptans are generally well tolerated by patients, but a few adverse effects such as light-headedness (sumatriptan), nasopharyngitis, and, muscular spasms (sumatriptan/ naproxen), somnolence, and dry mouth (rizatriptan), and dizziness (zolmitriptan group) were reported with the triptans.

Off-Label Cyproheptadine in Children and Adolescents: Psychiatric Comorbidities, Interacting Variables, Safety, and Risks of Hepatotoxicity

Cyproheptadine is a widely prescribed first-generation antihistamine, and due to its unique chemical structure, it has a popular off-label choice for a range of clinical conditions. Its efficacy is widely debated in the literature, but there are reports of hepatotoxicity as a rare adverse effect. Its benefits in migraine prophylaxis and appetite stimulation also underscore a highly overlapping clinical pathway that requires additional assessment and evaluation. The evidence suggests a baseline metabolic profile before initiation and assessment for co-occurring mental health conditions may improve overall response with evidence-based mental health interventions.

Beyond pain control: Outcome and treatment preferences in pediatric migraine

OBJECTIVE

The objective of this study was to describe treatment preferences and perceived quality of existing outcome measures among children and adolescents with migraine and their caregivers.

BACKGROUND

Across disciplines, there is increasing recognition of the value of direct input from stakeholders. Little empirical work has been done to determine what outcomes matter most to pediatric patients with migraine and their caregivers.

METHODS

In this qualitative study, we recruited participants from the multicenter, prospective Pediatric Migraine Registry. We used stratified purposive sampling to recruit children and adolescents of varied ages and headache frequency. Patients with migraine and their caregivers completed semistructured interviews targeting treatment preferences and perceived quality of existing outcome measures. Emergent themes and subthemes were identified using conventional content analysis.

RESULTS

Thirty dyads of children/adolescents and their caregivers were enrolled and completed 59 interviews (n = 29 children/adolescent interviews and n = 30 caregiver interviews). Three themes emerged. (1) Symptom relief: Looking beyond headache resolution: Participants described the value of outcomes in addition to pain relief, including a reduction in migraine intensity and improvement in non-pain symptoms. (2) Trade-offs between side effects and relief: Participants described cost-benefit analyses that can occur with headache treatment and acknowledged the impact of drug side effects on daily life and medication adherence. (3) Child-centered treatment: Participants described medication attributes salient to the pediatric context, including age-appropriate routes of administration and adequate safety data.

CONCLUSIONS

Children, adolescents, and caregivers impacted by migraine value outcomes in addition to traditionally studied migraine endpoints. Participants valued decreased pain severity, even in the absence of pain resolution. Participants also prioritized the absence of side effects and key medication attributes, including fast onset and age-appropriate routes of administration. These results highlight an opportunity to design patient-centered clinical trials, develop drugs, and support product labeling that align with the outcomes valued most by children and adolescents with migraine and their caregivers.

Acute Care and Treatment of Migraine

OBJECTIVE

Migraine is a chronic neurological disease involving the brain and its vasculature, typically characterized by recurrent attacks of moderate or severe throbbing headache, accompanied by sensitivity to light and sound, and associated with nausea, vomiting, and inability to move due to worsening of pain. About 30% of migraineurs have some type of aura, most often visual. Migraine attacks, if untreated or suboptimally treated, usually result in significant disability, requiring bed rest and resulting in poor quality of life. Increased frequency of attacks and overuse of acute care medication are significant risks for chronification, resulting in the transformation of episodic migraine into chronic migraine. We aim to review most acute care treatments for migraine.

METHODS

Current treatment options for migraine attacks were reviewed from the selected literature and combined with our clinical experience.

RESULTS

Current acute treatment options for migraine attacks include over-the-counter analgesics, at times combined with caffeine, nonsteroidal anti-inflammatory medications, opioids, and migraine-specific medications such as triptans and ergots. In the near future, we will probably have 3 gepants (small-molecule calcitonin gene-related peptide [CGRP] receptor antagonists). The first one was just approved in the United States. A ditan acting as a stimulator of 5-HT1F receptors, was also just approved by the FDA. Stimulation of the trigeminal, vagal, occipital, and even upper arm peripheral nerves through electrical nerve stimulation devices and magnetic stimulation devices are available as alternative, nondrug treatment options. Several devices have already been FDA-allowed for treatment in the United States and/or approved elsewhere, and others will follow soon. Behavioral medicine techniques such as biofeedback training and mindfulness have been available for some time and are often helpful.

CONCLUSION

A wide variety of acute care options to treat migraine are available, and others will soon be and will herein be described in further detail. Some medications have been approved by regulatory authorities in countries other than the United States, and some devices have been given a CE Mark in Europe.

Trajectory of treatment response in the child and adolescent migraine prevention (CHAMP) study: A randomized clinical trial

OBJECTIVE

Identify preventive medication treatment response trajectories among youth participating in the Childhood and Adolescent Migraine Prevention study.

METHODS

Data were evaluated from 328 youth (ages 8-17). Childhood and Adolescent Migraine Prevention study participants completed headache diaries during a 28-day baseline period and a 168-day active treatment period during which youth took amitriptyline, topiramate, or placebo. Daily headache occurrence trajectories were established across baseline and active treatment periods using longitudinal hierarchical linear modeling. We tested potential treatment group differences. We also compared final models to trajectory findings from a clinical trial of cognitive behavioral therapy plus amitriptyline for youth with chronic migraine to test for reproducibility.

RESULTS

Daily headache occurrence showed stability across baseline. Active treatment models revealed decreases in headache frequency that were most notable early in the trial period. Baseline and active treatment models did not differ by treatment group and replicated trajectory cognitive behavioral therapy plus amitriptyline trial findings.

CONCLUSIONS

Replicating headache frequency trajectories across clinical trials provides strong evidence that youth can improve quickly. Given no effect for medication, we need to better understand what drives this clinically meaningful improvement. Results also suggest an expected trajectory of treatment response for use in designing and determining endpoints for future clinical trials.Trial Registration. ClinicalTrials.gov Identifier: NCT01581281.

Evidence-Based Protocols in Child Neurology

Medical care has become more complex as the scientific method has expanded medical knowledge. Medicine is also now practiced across different medical systems of varying complexity, and creating standard treatment guidelines is one way of establishing uniform treatment across these systems. The creation of guidelines ensures the delivery of quality medical care and improved patient outcomes. Evidence-based medicine is the application of scientific research to produce these treatment guidelines. This article shall focus on the current treatment guidelines used for inpatient pediatric neurology.

Evaluation of the Etiology, Clinical Presentation, Findings and Prophylaxis of Children with Headache

Objectives:

A headache is prevalent in childhood and constitutes a significant part of outpatient applications. This study aimed to evaluate the results of etiology, clinical features, examination results, prophylactic treatment and follow-up in patients with a headache.

Methods:

Between January 2017 and December 2018, the files of the patients with the complaint of headache were reviewed retrospectively in this study. A headache was classified according to the International Headache Society (IHS) criteria.

Results:

In this study, 350 patients aged between 3-17 years old and the mean age of 11.2±2.7 with a headache were included; 212 (60.6%) of them was female and 138 (39.4%) of them was male. The rate of a primary headache was higher in females than in males (p=0.004). The headache causes were a migraine in 51.1%, tension-type headache in 32.3%, secondary in 13.4%, and not classified in 3.1%. The mean age of the patients with a primary headache was significantly higher than patients with a secondary headache (p<0.001). The most common trigger factor was insomnia (52.7%). Abnormal physical/neurological signs and symptoms were detected in 17 (9.49%) patients. Cranial magnetic resonance imaging (MRI) examination was performed in 121 (34.5%) patients. Abnormal findings were found in 35 (28.9%) of these. In this study, 33 patients underwent electroencephalography (EEG); none of the had an epileptiform abnormality. Flunarizine (23.2%) and cyproheptadine (7.5%) were the most administered prophylactic treatments. It was observed that all patients who had prophylaxis and who had come to control had a significant decrease in headaches.

Conclusion:

The cause of childhood headaches is mostly migraine and tension-type headache. As long as there is no abnormality in the history and neurological examination, neuroimaging studies are not required in the routine evaluation of patients with a headache. Prophylactic treatment increases the quality of life in selected cases.

Retrospective Observational Study on Riboflavin Prophylaxis in Child and Adolescent Migraine

BACKGROUND

We evaluated the efficacy of riboflavin in pediatric migraineurs.

METHODS

A retrospective observational study was performed on 42 patients (aged six to 18 years) with migraine who were evaluated from January to December 2019 at Dell Children's Medical Center in Austin, Texas. Weight-based dosing of riboflavin was recommended for migraine prevention. Descriptive statistics were used to study the population demographics. Nonparametric tests were used for inferential statistics to study the effect of riboflavin on headache frequency, intensity, and duration.

RESULTS

Patients treated with riboflavin had a significant reduction in headache days per month (frequency) at the first follow-up visit at 2 to 4 months (T1) (11.07 ± 10.52 days) compared with the baseline T0 (21.90 ± 9.85 days); P < 0.001 in regard to the primary outcome in 42 patients (mean age, 13.38 ± 3.38). Mean headache intensity decreased from 8.85 (±6.41; T0) to 2.30 (±2.51; T1); P < 0.001 on a 0 to 10 scale. The headache duration also reduced significantly from 18.23 ± 17.07 hours (T0) to 10.18 ± 10.49 hours (T1); P = 0.001. There was a positive correlation between riboflavin efficacy and reduced use of acute medications (r_s = 0.304; P = 0.05). Riboflavin was useful in reducing the frequency and intensity in two patients with new daily persistent headache.

CONCLUSIONS

Patients treated with riboflavin had a reduction in headache frequency, use of acute medications, and days of school missed. Riboflavin prophylaxis also reduced migraine intensity and duration. Riboflavin is recommended as a safe, inexpensive, and effective nutraceutical in the treatment of pediatric migraine.

Acute Treatment of Pediatric Migraine: A Review of the Updated Guidelines

The purpose of the Research to Practice column is to review and critique current research articles that directly affect the practice of the advanced practice nurse (APN) in the emergency department. This review examines the findings of M. from their article, "Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society." The authors completed an extensive literature review and created eight recommendations for the acute treatment of pediatric migraine focusing on medication selection, dosing, patient education, and patient counseling. By applying the evidence-based guidelines presented in this study, the urgent care or emergency department APN can confidently recognize and treat acute migraine symptoms and reduce patient risks from unnecessary testing and overuse of acute migraine medications.

An Open-Label Study Evaluating the Pharmacokinetics and Safety of Diclofenac Potassium for Oral Solution for the Acute Treatment of MWA or MWoA in Pediatric Participants

OBJECTIVE

To evaluate the pharmacokinetics, safety, and tolerability of a single 50-mg oral dose of diclofenac potassium for oral solution (OS) in a pediatric cohort with a diagnosis of episodic migraine; the 3-month safety trial following an outpatient dosing period was also evaluated.

BACKGROUND

Children and adolescents often experience migraine pain that is poorly controlled, which may affect their emotional and psychological well-being. Diclofenac potassium for OS is approved for the treatment of migraine with aura (MWA) or migraine without aura (MWoA) in adults 18 years of age or older. It is formulated in a soluble buffered powder that provides more rapid absorption than the tablet formulations of diclofenac potassium. In a randomized, double-blind, crossover trial, more adult patients were pain-free at 2 hours post-dose following treatment with diclofenac potassium for OS than those who received the diclofenac tablet formulation or placebo.

METHODS

This was a Phase 4 open-label study that took place at 2 US sites. Participants 12-17 years of age with a diagnosis of episodic MWA or MWoA for ≥3 months and ≤14 headaches per month were enrolled in the study. Participants received one 50-mg dose of diclofenac potassium for OS under fasted conditions on day 1. Blood samples were collected for PK analysis within 15 minutes pre-dose and at 5, 10, 15, 20, 30, 40, and 60 minutes post-dose, and at 2, 4, and 6 hours post-dose. Safety evaluations were performed after the initial dose and at the end of study on day 90; adverse events were monitored throughout the study. After completing the PK assessments, participants were given a 3-month supply (27 packets) of diclofenac potassium for OS (50-mg doses) for their migraine attacks. Participants were advised to take diclofenac potassium for OS at the onset of a migraine. They were told to take no more than 2 doses daily and not to use it more than 3 days/week.

RESULTS

Twenty-five participants completed the study; 84% were females and 96% were white or Caucasian, with a mean age of 15.5 years and a mean weight of 63.1 kg. Diclofenac was rapidly absorbed with a median time to maximum concentration of 15 minutes and a mean peak plasma concentration of 1412 (±846.2) ng/mL. Diclofenac had a half-life of 66.8 (±9.2) minutes. The mean area under the concentration-time curve from zero to the last measurable time point was 82,920.0 (±25,327.6) minutes × ng/mL, and the mean area under the concentration-time curve from time zero to infinity was 84,388.8 (±25,993.6) minutes × ng/mL. Participants took the study drug an average of 10 times over 79 days, with an overall total drug exposure of 506 mg. No deaths or discontinuations due to an AE were reported during the study. The most frequently reported treatment emergent adverse events were arthralgia and motion sickness, each of which occurred in 2 (8%) of the participants.

CONCLUSIONS

Diclofenac potassium for OS exhibited a favorable pharmacokinetic and safety profile in 12- to 17-year-old patients with a diagnosis of episodic MWA or MWoA.

Effectiveness of low-dose riboflavin as a prophylactic agent in pediatric migraine

BACKGROUND

Riboflavin may prevent migraine episodes; however, there is limited evidence of its effectiveness in pediatric populations. This study investigated the effectiveness of riboflavin and clinical predictors of response in children with migraines.

METHODS

We retrospectively reviewed data from 68 Japanese children with migraines, of whom 52 also exhibited another type of headache. Patients received 10 or 40 mg/day of riboflavin. We evaluated the average migraine frequency per month as a baseline and after 3 months of riboflavin therapy to determine the effectiveness and clinical predictors of response.

RESULTS

The frequency of migraine episodes was significantly lower at 3 months than at baseline (median, [interquartile range], 5.2 (3-7) vs. 4.0 (2-5); p < 0.01). Twenty-five patients (36.7%) showed 50% or greater reduction in episode frequency (responders), while 18 (26.5%) showed a 25%-50% reduction. We compared responders (n = 25) and non-responders (n = 43) and found no significant differences in sex, familial history, riboflavin dose, migraine type (i.e., presence or absence of aura), age at headache onset, or age at consultation. However, non-responders were more likely to have co-morbid non-migraine headaches (odds ratio, 4.11; 95% confidence interval [CI], 1.27-13.33; p = 0.02); this variable was also significant in a multivariate analysis (adjusted odds ratio, 3.8; 95% CI, 1.16-12.6; p = 0.03). Of the co-morbid headache types, only tension headaches were significant (odds ratio, 0.176; 95% CI, 0.04-0.73; p = 0.013). No adverse effects of riboflavin were identified.

CONCLUSIONS

Low-dose riboflavin is safe and modestly effective for migraines in children. It may be especially beneficial for children without other co-morbid headache types.

Assessment of the genotoxic potential of a migraine-specific drug by comet and cytokinesis-block micronucleus assays

Background: Eletriptan is a migraine-specific drug-containing the triptan group. In terms of drug safety, the present study aimed to investigate the genotoxic potential of eletriptan.Research design & methods: We conducted our study by using the cytokinesis-block micronucleus cytome (CBMN) assay, a comprehensive method for measuring micronucleus formation, and a sensitive method for detecting DNA-strand breaks. In the assay, cytokinesis-block proliferation index and the frequency of micronuclei were evaluated in lymphocytes treated with three different concentrations (1, 10 and 25 µg/ml) of eletriptan for 48 hours. In comet assays, DNA damage was evaluated in leucocytes treated with three different concentrations (1, 10 and 25 µg/ml) of eletriptan for an hour.Results: Eletriptan did not induce cytotoxicity nor any increased micronuclei frequencies. While the comet parameters % DNA in tail, tail moment, and the olive moment was found to be significantly increased at 10 and 25 µg/ml, the cytokinesis-block proliferation index values were not.Conclusion: These findings suggest that eletriptan is non-cytotoxic but potentially weakly genotoxic at higher concentrations (10 and 25 µg/ml).

Intranasal Ketamine for Abortive Migraine Therapy in Pediatric Patients: A Single-Center Review

BACKGROUND

Ketamine has recently emerged as a promising therapeutic alternative for abortive migraine therapy, likely secondary to N-methyl-d-aspartate antagonism. Most reports examine adults and the intravenous route. Fewer utilize intranasal administration or pediatric populations. Given the limited evidence for intranasal ketamine in pediatric migraine populations, we retrospectively reviewed our experience to further characterize safety and efficacy of intranasal ketamine in this population.

METHODS

A retrospective review in a free-standing, pediatric medical center was performed examining the utilization of intranasal ketamine at 0.1 to 0.2 mg/kg/dose up to five doses in pediatric migraineurs. Pain scores (scale = 0 to 10) were recorded at baseline and after each dose. Response was characterized as pain score reduction to 0 to -3 and/or reduction of at least 50%.

RESULTS

Twenty-five encounters (25 of 34; 73.5%) were responders (mean pain score reduction of -7.2 from admission to treatment completion). Overall pain reduction from admission to discharge in the entire study population was 66.1%. Side effects were mild and transient.

CONCLUSIONS

Our experience with intranasal ketamine has promising outcomes in both pain relief and side effect minimization. When other therapeutic options are unavailable, practitioners should consider intranasal ketamine.

Evaluation and Treatment of Primary Headaches in Adolescents

Headache is a common episodic and chronic pain syndrome in adolescents. Evaluation of headaches in primary care requires a comprehensive assessment including lifestyle behaviors and physical examination, as well as an understanding of when to pursue appropriate testing. Primary headache disorders seen in adolescents include migraine and tension-type headache. Pharmacologic management for primary headache includes both acute and prophylactic treatment strategies.

Development of a Prospective Real-World Data Clinical Registry of Children and Adolescents With Migraine

OBJECTIVE

To develop a multicenter, multistakeholder, prospective clinical registry of children and adolescents with migraine to support the collection of real-world data of sufficient quality to support regulatory submissions and provide site-based infrastructure support for future clinical trials.

BACKGROUND

As new migraine treatments come to market, pediatric efficacy and safety trials of these agents are needed. A clinical registry is an ideal regulatory strategy to provide both real-world data and site infrastructure to execute these trials.

DESIGN

Multicenter, multistakeholder, prospective real-world data clinical registry of children and adolescents, 4-17 years of age, diagnosed with migraine with or without aura. Participants will be followed for up to 12 months at 3-month intervals, with interval recording of clinical data at study sites and self-reported data via mobile health application, as well as biobanking. We developed electronic case report forms that incorporated routinely collected clinical data with National Institute of Neurological Disorders and Stroke Headache Common Data Elements (Version 2.0). All data are captured in a 21 CFR Part 11 - compliant electronic data capture system - augmented by a real-time, web-based, and customizable data visualization platform. We engaged vendors to provide ancillary biobanking, patient data entry, and data visualization services.

RESULTS

We used an iterative and highly collaborative multistakeholder approach to design and implement a streamlined registry protocol with input from all participating US sites. At each design and implementation step, we received input from therapeutic area experts, the US Food and Drug Administration (FDA), the National Institutes of Health, patient and parent advocates, health technology partners, drug developers, and site-based clinical investigators. The registry is governed by a multistakeholder steering committee with representation from sites, industry partners, patient advocates, and a member from the FDA (non-voting with respect to steering committee matters). The multistakeholder and site-driven approach to registry design and execution was highly efficient and resulted in the first patient enrolled within 6 months of concept development.

CONCLUSIONS

By ensuring regulatory compliant implementation of the registry, we created both a source of real-world data and a multisite platform for the conduct of future clinical trials that can be submitted to regulatory authorities to support inclusion of pediatric data in approved drug labeling. A highly collaborative approach with broad stakeholder engagement at all stages of the registry development was a key to our operational success.

Evaluation of the Neurological Complaints during Pregnancy and Postpartum

BACKGROUND

Pregnancy and postpartum are critical periods for patients with neurological complications. In this study, we aimed to evaluate the clinical characteristics and outcome of pregnant women with neurological conditions.

MATERIALS AND METHODS

This cross-sectional study reviewed pregnant women with neurological signs and symptoms, who were registered in the Medical Care Monitoring Center (MCMC) database of Shiraz University of Medical Sciences 2013-15. A questionnaire was designed to record each patient's information including demographic variables, past medical history, clinical presentation, obstetric profile, and fetal/maternal outcomes.

RESULTS

Totally, 332 mothers were registered in the database. The main neurological complaints in our population were headache, seizure, unilateral neurological symptoms, multiple sclerosis, neuromuscular disorder, and brain tumor. More than half of the patients (54%) experienced headache during the pregnancy and postpartum period.

CONCLUSION

Evaluating the neurological disorders separately, based on the time of symptom onset indicates the importance of follow-up of mothers during peripartum. Our findings suggest that decisions for pregnancy in women with neurological disorders should be based on risks outweighing for the mother and the fetus, particularly regarding the pharmacological side effects.

Pediatric Migraine: An Update

This article outlines key features of diagnosis and treatment of migraine in children and adolescents. It emphasizes techniques that can be used by clinicians to optimize history taking in this population, as well as recognition of episodic conditions that may be associated with migraine and present in childhood. Acute treatment strategies include use of over-the-counter analgesics and triptan medications that have been approved by the US Food and Drug Administration for use in children and adolescents. Preventive treatment approach includes lifestyle modifications, behavioral strategies, and consideration of preventive medications with the lowest side effect profiles.

Flunarizine as prophylaxis for episodic migraine: a systematic review with meta-analysis

Based on few clinical trials, flunarizine is considered a first-line prophylactic treatment for migraine in several guidelines. In this meta-analysis, we examined the pooled evidence for its effectiveness, tolerability, and safety. Prospective randomized controlled trials of flunarizine as a prophylaxis against migraine were identified from a systematic literature search, and risk of bias was assessed for all included studies. Reduction in mean attack frequency was estimated by calculating the mean difference (MD), and a series of secondary outcomes-including adverse events (AEs)-were also analyzed. The database search yielded 879 unique records. Twenty-five studies were included in data synthesis. We scored 31/175 risk of bias items as "high," with attrition as the most frequent bias. A pooled analysis estimated that flunarizine reduces the headache frequency by 0.4 attacks per 4 weeks compared with placebo (5 trials, 249 participants: MD -0.44; 95% confidence interval -0.61 to -0.26). Analysis also revealed that the effectiveness of flunarizine prophylaxis is comparable with that of propranolol (7 trials, 1151 participants, MD -0.08; 95% confidence interval -0.34 to 0.18). Flunarizine also seems to be effective in children. The most frequent AEs were sedation and weight increase. Meta-analyses were robust and homogenous, although several of the included trials potentially suffered from high risk of bias. Unfortunately, reporting of AEs was inconsistent and limited. In conclusion, pooled analysis of data from partially outdated trials shows that 10-mg flunarizine per day is effective and well tolerated in treating episodic migraine-supporting current guideline recommendations.

Modern approaches to diagnostics and treatment of migraine in children

This article reviews modern approaches to diagnostics and treatment of a very common and simultaneously underestimated and often maltreated disorder in children. It is fallacious management of migraine masked behind the diagnoses such as autonomic vessel dysfunction and vascular headache here in Ukraine. This is a tremendous problem and it should be solved with appropriate information spread across the medical community. Up-to-date classification according to the International Headache Society, diagnostic criteria, differential diagnosis, investigation and treatment strategies are presented in the article. All supported data are com-pliant with guidelines of developed countries with evidence-based medicine (US, Canada, Great Britain, Japan, Australia, New Zealand) enhanced with new trials and approved methods. Migraine management is a rapidly evolving concept, where major changes were done during recent years (transcranial Deep Brain Stimulation, vagus stimulation, CGRP-receptor mono-clonal antibodies). Considering disorder incidence and its impact on life quality and the existence of options for alleviating symptoms, this information is important for physicians who work with children, especially for general practitioners, pediatrics, pediatric and adult neurologists.

Treatment of migraine attacks and prevention of migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology

In collaboration with some of the leading headache centres in Germany, Switzerland and Austria, we have established new guidelines for the treatment of migraine attacks and the prevention of migraine. A thorough literature research of the last 10 years has been the basis of the current recommendations. At the beginning, we present therapeutic novelties, followed by a summary of all recommendations. After an introduction, we cover topics like drug therapy and practical experience, non-effective medication, migraine prevention, interventional methods, non-medicational and psychological methods for prevention and therapies without proof of efficacy.

Cognitive Behavioral Therapy for Pediatric Headache and Migraine: Why to Prescribe and What New Research Is Critical for Advancing Integrated Biobehavioral Care

PURPOSE OF REVIEW

To highlight current evidence supporting the prescription of cognitive behavioral therapy (CBT) as part of first-line preventive treatment for children and adolescents with headache and discuss a research strategy aimed at: (1) understanding how and why CBT works, and (2) developing effective and efficient approaches for integrating CBT into headache specialty, neurology, and primary care settings.

RECENT FINDINGS

Although preventive medications for pediatric headache and migraine are commonly prescribed, recent meta-analyses and an NIH-funded, multi-center clinical trial suggests that the effect of pill-taking therapies may be mostly due to a placebo effect. These findings have led to greater consideration of prescription of non-pharmacological therapies as first-line interventions (either alone or in combination with pill-based therapy). A literature that extends back to the 1980s and includes recent clinical trials and meta-analyses demonstrates that CBT decreases headache frequency and related disability in youth with headache and migraine and has a favorable benefit to risk profile with almost no negative side effects.

SUMMARY

CBT has been repeatedly demonstrated as effective in treating pediatric headache and migraine. As such, it should be considered as part of first-line preventive treatment for pediatric headache (either alone or in combination with a pill-based therapy). We need to better understand how this therapy works and what makes it distinct (if anything) from the placebo effect. What we need to achieve is empirical support for efficient access to this evidence-based treatment and clarity on how to match the intensity of non-pharmacological intervention to the needs of our patients at the time they present for care.

Safety and Efficacy of IV Lidocaine in the Treatment of Children and Adolescents With Status Migraine

OBJECTIVES

To evaluate the safety and efficacy of IV lidocaine in treating children and adolescents with status migraine.

DESIGN

Retrospective observational study.

SETTING

Single center PICU.

PATIENTS

Children and adolescents admitted with status migraine.

INTERVENTION

IV lidocaine.

MEASUREMENT AND MAIN RESULTS

Thirty-three lidocaine infusions were administered to 28 patients with status migraine. Two patients were excluded from analysis, leaving 31 infusions administered to 26 patients for analysis. Patients' ages ranged from 10 to 19 years with an average of 14.9 ± 2.4 years. Mean duration of hospitalization was 4.6 ± 1.5 days. Lidocaine was administered as a bolus (2.9 ± 0.18 mg/kg) in 80.6% (95% CI, 63.7-90.8%) of the patients, followed by an infusion, which was started at a mean rate of 1.29 ± 0.2 mg/kg/hr with mean maximum dose of 1.56 ± 0.27 mg/kg/hr. The highest lidocaine drip was 2.25 mg/kg/hr and lowest 1.125 mg/kg/hr. Lidocaine was interrupted in one patient secondary to side effects: chest pain and anxiety. On average, it took 16.3 ± 12.9 hours for 50% reduction in pain scores (range, 1.3-40.4 hr) and 19.3 ± 19.3 hours for complete resolution (0.8-72.1). 90.3% of cases (95% CI, 75.1-96.6%) experienced pain resolution with 51.6% (95% CI, 34.8-68%) encountering a relapse of pain. Mean pain scores at the time of discharge were 1 ± 1.6 (median, 0). Both mean reported highest and lowest scores dropped over the course of the 5 days from 5.1 ± 1.9 and 2.1 ± 2.4 on day 1 to 1.0 ± 1.4 and 0 on day 5 of therapy. One-way analysis by analysis of variance for high pain score by day was statistically significant with a p value of less than 0.01.

CONCLUSIONS

In the appropriate patient population, IV lidocaine may be a safe and effective treatment for children and adolescents with status migraine. Larger prospective studies need to be done not only to evaluate safety and efficacy but also the analgesic longevity of IV lidocaine post discharge.

Vertigo in children; a narrative review of the various causes and their management

Vertigo is a not an uncommon symptom in children, but often the treating doctors are unsure of the diagnosis and the management of these cases. This narrative review of the literature discusses the brief etiopathology, the clinical manifestations and the management algorithm of most of the conditions causing vertigo in children. The relevant information has been condensed into a table for the perusal of the readers, which would assist in the appropriate management of these children.

Differences in Pediatric Headache Prescription Patterns by Diagnosis

BACKGROUND

Few studies have reported prescription patterns for headache medication.

OBJECTIVE

The aim was to present the rates of specific medication prescribed to pediatric patients diagnosed with migraine, tension-type headache (TTH), and new daily persistent headache (NDPH), as well as differences in those prescription patterns by diagnosis, age, and gender.

PATIENTS AND METHODS

A query using the i2b2 platform yielded 14,591 patients [migraine 10,547 (72.3%); TTH 3200 (21.9%); NDPH 844 (5.8%)] seen over a 3-year period, who were aged 4-17 years at the time of their visit and diagnosed with migraine, TTH, or NDPH.

RESULTS

Sumatriptan was the most frequently prescribed medication for migraine followed by amitriptyline. The most frequently prescribed medication for both TTH and NDPH was amitriptyline, followed by sumatriptan in TTH and by topiramate in NDPH. Age and gender differences were also found in prescription patterns of each of the diagnoses. The differences in prescription patterns found between the diagnoses, as well as age and gender differences found within the diagnoses, are discussed.

CONCLUSIONS

A wide range of medications are prescribed to children and adolescents with headache, with most medications prescribed for off-label use. As these medications are not Food and Drug Administration (FDA) approved for use in children and adolescents with headache, there is a need for large scale, randomized controlled trials to assess the efficacy of these medications.

Migraine

Migraine is a chronic paroxysmal neurological disorder characterised by multiphase attacks of head pain and a myriad of neurological symptoms. The underlying genetic and biological underpinnings and neural networks involved are coming sharply into focus. This progress in the fundamental understanding of migraine has led to novel, mechanism-based and disease-specific therapeutics. In this Seminar, the clinical features and neurobiology of migraine are reviewed, evidence to support available treatment options is provided, and emerging drug, device, and biological therapies are discussed.

Prophylactic effect of riboflavin on pediatric migraine: a randomized, double-blind, placebo-controlled trial

Background and aim

Riboflavin may have an acceptable effect on migraine among children. This study was carried out to determine the prophylactic effect of riboflavin on migraine in children.

Methods

This randomized clinical trial study was performed at Shahid Beheshti Hospital in Kashan, Iran from December 2012 to February 2015. Ninety children with migraine were allocated randomly into 3 groups (placebo, low-dose and high-dose riboflavin). The outcomes (frequency, intensity and duration of headaches) were measured at baseline and 12 weeks of medication in each group, and the decrease of them were compared. SPSS software version 16 was used for analysis of the data. Descriptive statistics, Chi-square, Fisher's exact and t-test were used for statistical analyses.

Results

There was a significant decrease of migraine frequency (p=0.000) and mean duration (p=0.000) in the high-dose group compared with the placebo group. No significant reduction of frequency and mean duration of attacks were reported in the low-dose group compared to the placebo group (p=0.49 and p=0.69 respectively). There was no significant reduction of migraine intensity in the low-dose and high-dose groups compared to the placebo group (p=0.71 and p=0.74 respectively).

Conclusion

High-dose riboflavin is a safe, well tolerated, cost-effective method of prophylaxis for children with migraine.

Trial registration

The trial was registered at the Iranian Clinical Trial Registry with number IRCT2013020412361N1.

Funding

The study was supported by the Deputy of Research, Kashan University of Medical Sciences (grant number 91073).

Pediatric Headache and Seizures

Headache and seizures are two of the most common complaints seen in the field of pediatric neurology with headache being number one. Both these conditions may coexist. Where the difficulty begins is when the symptoms are not clear cut in making a diagnosis, and conditions are possible as either an atypical seizure or migraine variant. What further complicates matters is the fact that there are many underlying neurologic conditions that carry with them a higher likelihood of developing both headaches and seizures, making each a distinct possibility when obtaining a history from a parent about unusual spells. Although differentiating between seizure and headache may not be easy, with a focused yet thorough history and appropriate use of investigative tools, it can be done. Coming to the correct diagnosis is only the start; once seizures and or headaches have been appropriately diagnosed then the real challenge begins and that is finding a way to successfully treat the headaches and seizures. Within pediatric neurology, the acute options tend to be more diagnosis specific whereas the prophylactic ones may overlap and treat both headaches and seizures. In the following review, we will discuss the epidemiology of pediatric headaches and seizures, the overlap between these 2 conditions in diagnosis, as well as how to tell them apart, and the treatment options and prognosis of both common neurologic disorders in children.

Treatment of acute migraine attacks in children with analgesics on the World Health Organization Essential Medicines List: A systematic review and GRADE evidence synthesis

Background The World Health Organization Essential Medicines List (WHO EML) contains two analgesics for treatment of acute migraine attacks in children, ibuprofen and paracetamol. Methods The Embase, CDSR, CENTRAL, DARE and MEDLINE databases were searched up to 18 April 2017. We analyzed randomized controlled trials (RCTs) and systematic reviews (SRs) that investigate the efficacy and safety of ibuprofen or paracetamol for treatment of acute migraine attacks in children. We conducted meta-analysis and assessments of evidence with GRADE, Cochrane risk of bias tool, and AMSTAR. Results Three RCTs (201 children) and 10 SRs on ibuprofen and/or paracetamol for acute migraine attacks in children were included. Meta-analysis indicated that ibuprofen was superior to placebo for pain-free at 2 h or pain relief at 2 h, without difference in adverse events. There were no differences between paracetamol and placebo, or ibuprofen and paracetamol. Ten SRs that analyzed various therapies for migraine in children were published between 2004 and 2016, with discordant conclusions. Conclusion Limited data from poor quality RCTs indicate that ibuprofen and paracetamol might be effective analgesics for treating migraine attacks in children. Inclusion of ibuprofen and paracetamol as antimigraine medicines for children in the WHO EML is supported by indirect evidence from studies in adults.

Factors Associated With Discharge After Initial Emergency Treatment of Pediatric Migraine

OBJECTIVE

Migraine treatment varies widely in the pediatric emergency department (ED). Factors associated with discharge after only initial emergency treatment were examined.

METHODS

A retrospective chart analysis was conducted on patients 6 to 18 years old who presented to the St. Louis Children's Hospital ED between January 1, 2008, and December 31, 2011, with a discharge diagnosis of migraine (n = 700 visits). Associations between patient characteristics, initial treatments, and rates of discharge after only initial treatment were examined using a generalized linear model and receiver operating characteristic curves.

RESULTS

If exclusively oral or intranasal (PO/IN) medications were given initially (n = 285), ibuprofen alone was associated with lower discharge rates compared with other PO/IN medication regimens (P < 0.05). The only other variable associated with discharge was arrival pain score (P < 0.05). When ibuprofen alone was administered, pain scores equal to or lower than 5/10 were associated with the greatest sensitivity and specificity for discharge. With administration of other PO/IN regimens, pain scores equal to or lower than 8/10 were associated with the greatest sensitivity and specificity for discharge. If intravenous (IV) medications were given initially (n = 415), ketorolac given with an antinausea medication was associated with higher discharge rates compared with independent administration of these medications (P < 0.05). Intravenous medications were associated with higher discharge rates compared with PO/IN medications (P < 0.001).

CONCLUSIONS

Arrival pain score may be used to help select initial migraine treatment in the pediatric ED. Initial use of PO/IN regimens including triptans or an antiemetic and concurrent administration of IV ketorolac with an antiemetic may be associated with higher rates of discharge after initial treatment alone.

Is topiramate effective for migraine prevention in patients less than 18 years of age? A meta-analysis of randomized controlled trials

Background

Mainly based on evidence of success in adults, various medications are commonly used to prevent pediatric migraines. Topiramate has been approved for migraine prevention in children as young as 12 years of age. In this meta-analysis, we aimed to assess the currently published data pertaining to the efficacy of topiramate for migraine prevention in patients less than 18 years of age.

Methods

We searched PubMed/Medline, Embase and the Cochrane Library (from inception to April 2017) for randomized controlled trials (RCTs) published in English. Two independent investigators performed data extraction and quality evaluation using the Cochrane Collaboration’s tool. The data extracted were analyzed by Review Manager 5.3 software.

Results

A total of four RCTs matching the inclusion criteria were included, with an aggregate of 465 patients. Of these patients, 329 were included in the topiramate group, and 136 were included in the placebo group. This meta-analysis revealed that compared with placebo, topiramate failed to decrease the number of patients experiencing a ≥ 50% relative reduction in headache frequency (n = 465, RR = 1.26, 95% CI = [0.94,1.67], Z = 1.55, P = 0.12) or the number of headache days (n = 465, MD = −0.77, 95% CI = [−2.31,0.76], Z = 0.99, P = 0.32) but did reduce PedMIDAS scores (n = 205, MD = −9.02, 95% CI = [−17.34, −0.70], Z = 2.13, P = 0.03). Higher rates of side effects and adverse events in the topiramate group than in the placebo group were observed in the included trials.

Conclusions

Topiramate may not achieve a more effective clinical trial endpoint than placebo in the prevention of migraines in patients less than 18 years of age, and topiramate may lead to more side effects or adverse events in the included patients.

Off-Label Prescribing for Children with Migraines in U.S. Ambulatory Care Settings

BACKGROUND

Migraines, Which Affect About 10% Of School-Age Children In The United States, Can Significantly Impair Quality Of Life. Despite Potential Disability, Many Children Do Not Receive Treatment Or Prophylaxis, Since Medications Specifically Approved For Children Are Significantly Less Than For Adults. There Is Also Controversy Surrounding The Apparent Widespread Practice Of Prescribing Off-Label Medications For Children With Migraines. However, Little Research Has Been Done To Identify Physician-Prescribing Patterns Of Migraine Medication For Children.

OBJECTIVE

To Investigate The Prevalence And Pattern Of Off-Label Prescribing For Children With Migraines.

METHODS

A Secondary Data Analysis Was Conducted Using The Pooled National Ambulatory Medical Care Survey (Namcs) 2011 And 2012. Patients Aged 17 Years Or Younger With A Migraine Diagnosis Were Included. A Series Of Weighted Descriptive Analyses Were Used To Estimate The Prevalence Of Migraine Drugs Prescribed During Pediatric Office Visits. A Weighted Logistic Regression Was Constructed To Compare The Prescribing Patterns Between Off-Label And Fda-Approved Medications. Analyses Used Sas 9.4 Methodology And Incorporated Sample Weights To Adjust For The Complex Sampling Design Employed By Namcs.

RESULTS

Of The 12.9 Million Outpatient Visits With A Migraine Diagnosis That Took Place Between 2010 And 2012, 1.2 Million Were Pediatric Visits. Females Accounted For Nearly Twice The Number Of Migraine Visits Than Males (66% Vs. 34%). Children Aged 12-17 Years Accounted For The Highest Frequency Of Visits (84%), Compared With Those Aged Under 12 Years (16%). 66.7% Of These Pediatric Patients Received At Least 1 Migraine Drug. Of These, Off-Label Medications Were Prescribed 1.5 Times More Than Fda-Approved Medications For Children (60.34% Vs. 39.65%). The Results Of Logistic Regression Showed A Significant Likelihood Of Prescribing Off-Label Medications Based On Physician Specialty, Patient Race, And Reason For Visit. Neurologists (Or = 0.028, P < 0.05) And Pediatricians (Or = 0.095, P < 0.05) Were Less Likely To Prescribe Off-Label Drugs Than General And Family Practitioners. Visits For Preventive Care (Or = 5.8, P < 0.05) And Flare-Ups From Chronic Migraines (Or = 5.0, P < 0.05) Were More Likely To Result In Off-Label Drug Prescriptions Than Visits For New Migraine Incidence.

CONCLUSIONS

This Study Provides Significant Real-World Evidence Of The Widespread Practice Of Prescribing Off-Label Drugs To Children With Migraines. Although Medical Literature Shows That Off-Label Prescribing May Not Be Harmful, There Is A Dearth Of Research And Practice Guidelines To Help Practitioners Uphold Safety Standards And Ensure The Prescription Of Age-Appropriate Medications To Children.

DISCLOSURES

No outside funding supported this study. The authors report no potential conflicts of interest relevant to this research. Lai and Ting contributed to study concept and design and collected the data, along with the other authors. Data interpretation was performed by Lai, Koh, Obi, Ho, and Ting. The manuscript was written and revised by Lai, Koh, and Ho, with assistance from Ting and Obi.

Flunarizine versus topiramate for chronic migraine prophylaxis: a randomized trial

OBJECTIVES

Chronic migraine (CM) is a prevalent and devastating disorder with limited therapeutic options. This study explored the efficacy of 10 mg/d flunarizine for CM prophylaxis as compared with 50 mg/d topiramate.

METHODS

We conducted a prospective, randomized, open-label, blinded-endpoint trial. Patients with CM were randomized to flunarizine and topiramate treatment. The primary outcomes assessed were the reductions in the total numbers of headache days and migraine days after 8 weeks of treatment. Secondary outcomes were reductions in the numbers of days of acute abortive medication intake and acute abortive medication tablets taken, and the 50% responder rate.

RESULTS

Sixty-two subjects were randomized (n=31/group). Patients treated with flunarizine showed significant reductions in the numbers of total headache days (-4.9 vs -2.3, P=.012) and migraine days (-4.3 vs -1.4, P=.001) compared with those treated with topiramate. Patients treated with flunarizine also showed significant reductions in the numbers of days of acute abortive medication intake (-2.3 vs -0.2, P=.005) and acute abortive medication tablets taken (-4.6 vs -0.5, P=.005) and had a higher 50% responder rate in terms of total headache days (58.6% vs 25.9%, P=.013) and migraine days (75.9% vs 29.6%, P=.001), compared with topiramate-treated patients. Flunarizine was generally well tolerated and had a safety profile comparable to that of topiramate.

CONCLUSIONS

Our results suggest that, in an 8-week study, 10 mg/d flunarizine is more effective than 50 mg/d topiramate for CM prophylaxis.

Childhood Headache: A Brief Review

Headaches are common in childhood and adolescence and can cause significant distress and disability for a child and their family. Providers need to be able to identify "red flags" for worrisome causes of secondary headaches and recognize typical primary headache characteristics to provide each patient with the best possible care to improve their quality of life and minimize disability. This article reviews the epidemiology of headaches in children, signs and symptoms of secondary headaches, definitions of some primary childhood headaches, and options for management of both acute and chronic pediatric migraine. [Pediatr Ann. 2017;46(4):e155-e165.].

Evidence and consensus recommendations for the pharmacological management of pain in India

Despite enormous progress in the field of pain management over the recent years, pain continues to be a highly prevalent medical condition worldwide. In the developing countries, pain is often an undertreated and neglected aspect of treatment. Awareness issues and several misconceptions associated with the use of analgesics, fear of adverse events - particularly with opioids and surgical methods of analgesia - are major factors contributing to suboptimal treatment of pain. Untreated pain, as a consequence, is associated with disability, loss of income, unemployment and considerable mortality; besides contributing majorly to the economic burden on the society and the health care system in general. Available guidelines suggest that a strategic treatment approach may be helpful for physicians in managing pain in real-world settings. The aim of this manuscript is to propose treatment recommendations for the management of different types of pain, based on the available evidence. Evidence search was performed by using MEDLINE (by PubMed) and Cochrane databases. The types of articles included in this review were based on randomized control studies, case-control or cohort studies, prospective and retrospective studies, systematic reviews, meta-analyses, clinical practice guidelines and evidence-based consensus recommendations. Articles were reviewed by a multidisciplinary expert panel and recommendations were developed. A stepwise treatment algorithm-based approach based on a careful diagnosis and evaluation of the underlying disease, associated comorbidities and type/duration of pain is proposed to assist general practitioners, physicians and pain specialists in clinical decision making.

Migraine with Aura or Sports-Related Concussion: Case Report, Pathophysiology, and Multidisciplinary Approach to Management

The evaluation and management of athletes presenting with clinical features of migraine headache with aura in the setting of sports-related head trauma is challenging. We present a case report of a 15-yr-old boy with a history of migraine with visual aura that developed acute visual disturbance and headache after a head injury during an ice hockey game. The patient underwent comprehensive assessment at a multidisciplinary concussion program, including neuro-ophthalmological examination, neurocognitive testing, and graded aerobic treadmill testing. Clinical history and multidisciplinary assessment was consistent with the diagnosis of coexisting sports-related concussion and migraine with brainstem aura. The authors discuss the pearls and pitfalls of managing patients who develop migraine headache with visual aura after sports-related head injury and the value of a comprehensive multidisciplinary approach to this unique patient population.