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Chatterjee JH, Blume HK. Triptans in the Acute Migraine Management of Children and Adolescents: An Update. Curr Pain Headache Rep 2024:10.1007/s11916-024-01213-x. [PMID: 38581536 DOI: 10.1007/s11916-024-01213-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE OF REVIEW To summarize recent findings regarding triptan use in the acute treatment of pediatric migraine. RECENT FINDINGS Prevalence of pediatric migraine is rising. The American Headache Society and American Academy of Neurology updated guidelines to provide evidence-based recommendations for the treatment of acute migraine in youth. In the setting of a dearth of new randomized controlled trials (RCTs), we review current guidelines, triptan use in the emergency department, and an era of secondary analyses. Measuring the efficacy of triptans in pediatric migraine has been challenged by high placebo response rates. Secondary analyses, combining data from multiple RCTs, support that triptans are safe and effective in the treatment of migraine. Triptans are a vital tool and the only FDA-approved migraine-specific treatment available in pediatrics. There is a need for further studies and funding support in pediatric headache medicine.
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Affiliation(s)
- Jessica Hauser Chatterjee
- University of Washington School of Medicine, Department of Neurology, Division of Child Neurology and Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, USA.
| | - Heidi K Blume
- Child Neurology, Seattle Children's Hospital, 4800 Sand Point Way NE, MB 7.420 Box 5371, Seattle, WA, 98105, USA
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Hauser Chatterjee J, Hartford EA, Law E, Barry D, Blume H. Sumatriptan as a First-Line Treatment for Headache in the Pediatric Emergency Department. Pediatr Neurol 2023; 142:68-75. [PMID: 36958085 DOI: 10.1016/j.pediatrneurol.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/23/2022] [Accepted: 01/29/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Headache is a common presenting condition for patients seen in the pediatric emergency department (ED). Intranasal (IN) sumatriptan is a well-tolerated and safe abortive treatment for migraine headache, but it is infrequently administered in pediatric EDs. In this study we characterize an ED migraine pathway that uses IN sumatriptan as a first-line treatment. METHODS We performed retrospective chart analysis from a single center, reviewing a cohort of patients treated on an ED migraine pathway between October 2016 and February 2020. We reviewed patient demographics, clinical characteristics, treatment patterns, change in pain scores, sumatriptan prescriptions at discharge, length of stay (LOS), ED charges, and unexpected return visits. RESULTS A total of 558 patients (aged six to 21 years, 66% female) were included in this study. Overall, the median pretreatment pain score was 7 (interquartile range [IQR]: 5 to 8) and the median post-treatment pain score was 2 (IQR: 0 to 4). Forty-eight percent of patients received IN sumatriptan in the ED, and 36% of those who received sumatriptan were prescribed oral sumatriptan at discharge. When intravenous (IV) access was obtained for headache management, this was associated with a significantly longer LOS and higher ED charges. CONCLUSIONS IN sumatriptan shows promise as a feasible and potentially effective first-line treatment for pediatric migraine in the ED that could reduce the need for IV therapies, shorten LOS, and lower ED charges. Further research is needed to determine the efficacy of IN sumatriptan relative to other common first-line therapies used to treat pediatric migraine in the ED.
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Affiliation(s)
- Jessica Hauser Chatterjee
- Division of Child Neurology, Department of Neurology, University of Washington School of Medicine and the Seattle Children's Research Institute, Center for Integrative Brain Research, Seattle, Washington.
| | - Emily A Hartford
- Department of Pediatric Emergency Medicine, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Emily Law
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington; Center for Child Health, Behavior & Development, Seattle Children's Research Institute, Seattle, Washington
| | - Dwight Barry
- Clinical Analytics, Seattle Children's Hospital, Seattle, Washington
| | - Heidi Blume
- Division of Child Neurology, Department of Neurology, University of Washington School of Medicine and the Seattle Children's Research Institute, Center for Integrative Brain Research, Seattle, Washington
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Abstract
Migraine is a common, chronic, disorder that is typically characterized by recurrent disabling attacks of headache and accompanying symptoms, including aura. The aetiology is multifactorial with rare monogenic variants. Depression, epilepsy, stroke and myocardial infarction are comorbid diseases. Spreading depolarization probably causes aura and possibly also triggers trigeminal sensory activation, the underlying mechanism for the headache. Despite earlier beliefs, vasodilation is only a secondary phenomenon and vasoconstriction is not essential for antimigraine efficacy. Management includes analgesics or NSAIDs for mild attacks, and, for moderate or severe attacks, triptans or 5HT1B/1D receptor agonists. Because of cardiovascular safety concerns, unreliable efficacy and tolerability issues, use of ergots to abort attacks has nearly vanished in most countries. CGRP receptor antagonists (gepants) and lasmiditan, a selective 5HT1F receptor agonist, have emerged as effective acute treatments. Intramuscular onabotulinumtoxinA may be helpful in chronic migraine (migraine on ≥15 days per month) and monoclonal antibodies targeting CGRP or its receptor, as well as two gepants, have proven effective and well tolerated for the preventive treatment of migraine. Several neuromodulation modalities have been approved for acute and/or preventive migraine treatment. The emergence of new treatment targets and therapies illustrates the bright future for migraine management.
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Vukovic AA, Hariharan S, Caruso MC, Zellner SM, Kabbouche M, Porter SC, Murtagh-Kurowski E. Standardized Headache Therapy in the Pediatric Emergency Department Using Improvement Methodology. Pediatr Qual Saf 2021; 6:e443. [PMID: 34345756 DOI: 10.1097/pq9.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/16/2021] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Primary headache is a common cause of pediatric emergency department (PED) visits. Without published guidelines to direct treatment options, various strategies lacking evidence are often employed. This study aims to standardize primary headache treatment in the PED by promoting evidence-based therapies, reducing nonstandard abortive therapies, and introducing dihydroergotamine (DHE) into practice. Methods: A multidisciplinary team developed key drivers, created a clinical care algorithm, and updated electronic medical record order sets. Outcome measures included the percentage of patients receiving evidence-based therapies, nonstandard abortive therapies, DHE given after failed first-line therapies, and overall PED length of stay. Process measures included the percent of eligible patients with the order set usage and medications received within 90 minutes. Balancing measures included hospital admissions and returns to the PED within 72 hours. Annotated control charts depicted results over time. Results: We collected data from July 2017 to December 2019. The percent of patients receiving evidence-based therapies increased from 69% to 73%. The percent of patients receiving nonstandard abortive therapies decreased from 2.5% to 0.6%. The percent of patients receiving DHE after failed first-line therapies increased from 0% to 37.2%. No untoward effects on process or balancing measures occurred, with sustained improvement for 14 months. Conclusion: Standardization efforts for patients with primary headaches led to improved use of evidence-based therapies and reduced nonstandard abortive therapies. This methodology also led to improved DHE use for migraine headache resistant to first-line therapies. We accomplished these results without increasing length of stay, admission, or return visits.
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AMINI L, YAGHINI O, GHAZAVI M, ASLANI N. L-carnitine versus Propranolol for pediatric migraine prophylaxis. Iran J Child Neurol 2021; 15:77-86. [PMID: 36213159 PMCID: PMC9376025 DOI: 10.22037/ijcn.v15i2.25558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 06/16/2020] [Indexed: 11/21/2022]
Abstract
Objective Carnitine plays a significant role in fatty acid transportation in mitochondria and has been shown to have a prophylactic effect on adult migraine. The aim of this randomized controlled trial was to compare and evaluate the effects of L-carnitine supplementation versus propranolol in the prevention of pediatric migraine. Materials & Methods A total of 60 pediatric patients with episodic migraine were randomly allocated to 2 independent groups to receive either 50 mg/kg/day L-carnitine or 1 mg/kg/day propranolol as a prophylactic drug. Frequency, severity, and duration of migraine attacks and headache disability based on the Pediatric Migraine Disability Assessment Score (PedMIDAS) were studied at the baseline and after 2, 4, and 12 weeks. Results A total of 56 patients were evaluated in the study: 23 girls (41%) and 33 boys (59%) with a mean age of 9.7 ± 2.1 years. Frequency of migraine headaches per month reduced from 11.4 ± 7.1 to 5.34 ± 2.4 in the L-carnitine group and from 10.7 ± 6.2 to 4.96 ± 3.9 in the propranolol group by the end of the study. Headache severity score was also reduced from 19.38 ± 14 to 2.88 ± 7.4 and from 12.92 ± 13 to 0.82 ± 1.3 in the L-carnitine and propranolol groups, respectively. We found a significant decrease in frequency, severity, and duration of headache attacks in both groups (P < 0.01). No significant difference was observed between the efficacies of the 2 drugs.This study concluded that L-carnitine supplementation can play a prophylactic role in the management of pediatric migraine.
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Affiliation(s)
- Laya AMINI
- Department of Pediatrics, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid YAGHINI
- Pediatric Neurology, Child Growth and Development Research center, Research Institute for Primordial Prevention of Noncommunicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadreza GHAZAVI
- Pediatric Neurology, Child Growth and Development Research center, Research Institute for Primordial Prevention of Noncommunicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nahid ASLANI
- Department of Pediatrics, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Costa FM, Ferreira IP, Mascarenhas IF, Alves CF, Bento VA, Loureiro HC. Diagnosis and Treatment of Headache in a Pediatric Emergency Department. Pediatr Emerg Care 2020; 36:571-4. [PMID: 33105467 DOI: 10.1097/PEC.0000000000002284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aims of the study were (1) to analyze the etiology and clinical management of headaches in children in the emergency department and (2) to analyze the treatment used in children diagnosed with headaches and with migraines. METHODS Retrospective study of all the patients who were admitted to the pediatric emergency department of Hospital Professor Doutor Fernando Fonseca, Lisbon, in 2014, with a chief complaint of headaches or the primary discharge diagnosis was headache/migraine. RESULTS Headache related cases represented 3.8% of all the visits, a total of 2354 subjects. The median age was 10 years and 52.6% were female. The most frequent diagnoses were as follow: headaches (21.3%), upper respiratory infections (18.4%), and migraines (6.1%). There were 4 cases of meningitis, 6,5% of all patients underwent computed tomography which was mostly requested in school-age children and adolescents. The average time from the first medical observation until discharge was 85 minutes. Fifty-five percent did not take any pain relief medication, 17.2% took acetaminophen, and 11.1% took ibuprofen. Patients who received ondansetron had less revisits (P = 0.000). Subjects with mild-moderate pain treated with acetaminophen or no medication had more revisits (P = 0.000). CONCLUSIONS Secondary benign headaches were the most common and very rarely headache as a symptom was associated with life-threatening situations. Antiemetics seem to be efficient ally in the treatment of primary headaches, but it is important to consider alternative pharmacological regimes in patients who present with higher pain scores.
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Sheridan DC, Dhatt S, Narayan K, Lin A, Fu R, Meckler GD. Effectiveness of Emergency Department Treatment of Pediatric Headache and Relation to Rebound Headache. Pediatr Emerg Care 2020; 36:e720-5. [PMID: 31929393 DOI: 10.1097/PEC.0000000000002027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to assess the association between the degree of headache relief obtained in the pediatric emergency department (PED) with abortive treatment and unscheduled return visits to the PED for a recurrent or persistent headache within 72 hours. METHODS This was a retrospective observational study with 369 patients, all younger than 18 years, who presented to the PED with a primary complaint of either a headache or migraine. Patient and visit details were collected from the medical chart, along with presenting and discharge pain score. Percent pain reduction at discharge was determined through the following calculation: (Presenting Pain Score - Discharge Pain Score)/Presenting Pain Score. Associations were assessed using multivariable logistic regression. RESULTS No significant association was found between the percent pain reduction and return to the PED (P = 0.49). Mean presenting pain score at the index visit was statistically higher for those who ended up returning to the PED versus those who did not (8.1 vs 7.4; P = 0.02). A trend toward increase in return visits was seen among patients who had a headache duration greater than 3 days (odds ratio, 1.99) and patients who experienced less than 50% pain reduction in the PED (odds ratio, 1.77). CONCLUSIONS Complete resolution in the PED may not be necessary, given the lack of association between the degree of pain relief and revisit rates. Perhaps, the goal should be to achieve at least 50% pain reduction before discharge.
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Turner AL, Shandley S, Miller E, Perry MS, Ryals B. Intranasal Ketamine for Abortive Migraine Therapy in Pediatric Patients: A Single-Center Review. Pediatr Neurol 2020; 104:46-53. [PMID: 31902550 DOI: 10.1016/j.pediatrneurol.2019.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 10/16/2019] [Accepted: 10/27/2019] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Adrian L Turner
- Department of Pharmacy, Cook Children's Medical Center, Fort Worth, Texas; Jane and John Justin Neurosciences Center, Cook Children's Medical Center, Fort Worth, Texas.
| | - Sabrina Shandley
- Jane and John Justin Neurosciences Center, Cook Children's Medical Center, Fort Worth, Texas; Research Administration Office, Cook Children's Medical Center, Fort Worth, Texas
| | - Ean Miller
- Department of Pharmacy, Cook Children's Medical Center, Fort Worth, Texas
| | - M Scott Perry
- Jane and John Justin Neurosciences Center, Cook Children's Medical Center, Fort Worth, Texas
| | - Brian Ryals
- Jane and John Justin Neurosciences Center, Cook Children's Medical Center, Fort Worth, Texas
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Abstract
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.
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Affiliation(s)
- Suzy Mascaro Walter
- West Virginia University School of Nursing, 64 Medical Center Drive, Morgantown, WV 26505, USA.
| | - Christine Banvard-Fox
- Department of Pediatrics, Division of Adolescent Medicine, WVU Medicine, West Virginia University, 6040 University Town Center Drive, Morgantown, WV 26501, USA
| | - Courtney Cundiff
- Department of Emergency Medicine, WVU Medicine, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26505, USA
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Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskauer SJ, Giza CC, Joseph M, Broomand C, Weissman B, Gordon W, Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duhaime AC, Putukian M, Holshouser B, Paulk D, Wade SL, Herring SA, Halstead M, Keenan HT, Choe M, Christian CW, Guskiewicz K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWitt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman R, Getchius T, Gronseth G, Donnell Z, O'Connor RE, Timmons SD. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr 2018; 172:e182853. [PMID: 30193284 PMCID: PMC7006878 DOI: 10.1001/jamapediatrics.2018.2853] [Citation(s) in RCA: 285] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. Objective To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. Evidence Review The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. Findings The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Conclusions and Relevance This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.
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Affiliation(s)
| | | | - Kelly Sarmiento
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Matthew J Breiding
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Tamara M Haegerich
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Gerard A Gioia
- Children's National Health System, George Washington University School of Medicine, Washington, DC
| | | | | | - Stacy J Suskauer
- Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher C Giza
- The University of California, Los Angeles (UCLA) Steve Tisch BrainSPORT Program, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles
| | | | - Catherine Broomand
- Center for Neuropsychological Services, Kaiser Permanente, Roseville, California
| | | | - Wayne Gordon
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Karen McAvoy
- Rocky Mountain Hospital for Children, Denver, Colorado
| | - Linda Ewing-Cobbs
- Children's Learning Institute, Department of Pediatrics, University of Texas (UT) Health Science Center at Houston
| | | | - Margot Putukian
- University Health Services, Princeton University, Princeton, New Jersey
| | | | | | - Shari L Wade
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - Meeryo Choe
- The University of California, Los Angeles (UCLA) Steve Tisch BrainSPORT Program, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles
| | - Cindy W Christian
- Children's Hospital of Philadelphia, Raymond and Ruth Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - P B Raksin
- John H. Stroger, Jr Hospital of Cook County (formerly Cook County Hospital), Chicago, Illinois
| | - Andrew Gregory
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Anne Mucha
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | - H Gerry Taylor
- Nationwide Children's Hospital Research Institute, Columbus, Ohio
| | - James M Callahan
- Children's Hospital of Philadelphia, Raymond and Ruth Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - John DeWitt
- Jameson Crane Sports Medicine Institute, School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus
| | - Michael W Collins
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | | | - John Ragheb
- Nicklaus Children's Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Theodore J Spinks
- Department of Pediatric Neurosurgery, St Joseph's Children's Hospital, Tampa, Florida
| | | | | | | | | | - Tom Getchius
- American Academy of Neurology, Minneapolis, Minnesota
| | | | - Zoe Donnell
- Social Marketing Group, ICF, Rockville, Maryland
| | | | - Shelly D Timmons
- Penn State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
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11
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Abstract
OBJECTIVES Headache remains a frequent complaint for children presenting to a pediatric emergency department (ED). Typical treatments include oral or intravenous medications, but do not always relieve pain. An alternative intervention is auricular acupuncture. It has been shown to be effective in the treatment of migraines in adults. The objective of this study was to evaluate the utility and adverse effects of auricular acupuncture in the treatment of pediatric migraines in the ED. METHODS This was a prospective, interventional, cohort study of patients 8 to 18 years of age. Efficacious ear points were located by needle contact or electrical point finder with attention to 2 migraine lines on the ear. ASP gold semipermanent ear needles were placed in the efficacious points and patients were monitored for 15 minutes. The primary outcome was the change in preintervention and postintervention pain scores using a numerical self-reported pain visual analog scale (VAS). RESULTS Nineteen patients elected to enroll in the study. The mean change in the VAS scores was both clinically and statistically significant at 7.03 (interquartile range, 6-8.5) with a P value of less than 0.001. Two patients elected to withdraw from the study secondary to incomplete resolution of migraine pain despite improvement in VAS scores. There were no known adverse events. CONCLUSIONS With all subjects showing improvement or resolution of migraine headache, this pilot study introduces an alternative intervention to pediatric migraine management. Further studies are needed to evaluate the duration of symptom resolution and comparative effectiveness; auricular acupuncture seems to be a valid alternative.
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Faber AJ, Lagman-Bartolome AM, Rajapakse T. Drugs for the acute treatment of migraine in children and adolescents. Paediatr Child Health 2017; 22:454-458. [PMID: 29479263 DOI: 10.1093/pch/pxx170] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
| | | | - Thilinie Rajapakse
- Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta
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13
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Wilcox SL, Ludwick AM, Lebel A, Borsook D. Age- and sex-related differences in the presentation of paediatric migraine: A retrospective cohort study. Cephalalgia 2017; 38:1107-1118. [PMID: 28766966 DOI: 10.1177/0333102417722570] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction Although migraine is a common headache complaint in children and adolescents there remains a significant gap in understanding the unique aspects of the disease in these age groups and their evolution with development. The aim of this retrospective cohort study was to identify migraine features that are influenced by age and sex. Methods The headache characteristics of 359 paediatric patients with a clinical diagnosis of migraine from a tertiary paediatric headache clinic were assessed. Patients retrospectively reported headache characteristics during a structured intake interview and clinical exam. Headache characteristics, description and associated symptoms were compared between children (age ≤ 12 years) and adolescents (age > 12 years), and between male and female migraineurs. Results Several migraine features differed significantly with age and/or sex, including: (i) a marked change from a 1:1 sex ratio in children to a 2:1 predominance of girls in adolescents; (ii) a higher frequency of headache attacks per month in adolescents and female migraineurs; (iii) a higher proportion of adolescents endorsed a 'throbbing' pain quality; (iv) a higher proportion of children reporting nausea and vomiting; and (v) a higher proportion of adolescents, particularly female migraineurs, had a diagnosis of a co-morbid anxiety. Conclusion The presentation of migraine, both in terms of its headache characteristics and associated symptoms, appear to vary as a function of age and sex. Given that migraine symptoms have a neural basis, it is not surprising that during the key period of neurodevelopment from childhood to adolescence this may impact their presentation.
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Affiliation(s)
- Sophie Louise Wilcox
- 1 Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Allison Marra Ludwick
- 1 Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alyssa Lebel
- 2 Pediatric Headache Program, Department of Anesthesiology, Perioperative, and Pain Medicine & Department of Neurology, Boston Children's Hospital, Waltham, MA, USA
| | - David Borsook
- 1 Center for Pain and the Brain, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,2 Pediatric Headache Program, Department of Anesthesiology, Perioperative, and Pain Medicine & Department of Neurology, Boston Children's Hospital, Waltham, MA, USA
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14
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Affiliation(s)
- Kon-Hee Lee
- Department of Pediatrics, Kangnam Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Korea
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15
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Abstract
OPINION STATEMENT While the diagnosis of migraine in children is generally straightforward, treatment can seem complex with a number of medication choices, many of which are used "off label." Patients with intermittent migraines can often be managed with ibuprofen or naproxen taken as needed. Unfortunately, by the time that children present to our practice, they have often tried these medications without improvement. Triptans are frequently prescribed to these patients with good success. It is important to make the patient aware of the possible associated serotonergic reactions. If the patient is having more than one headache per week or the headaches are prolonged, prophylactic treatment is indicated. In our practice, the overwhelming majority of these patients will be treated with amitriptyline or topiramate. We generally allow side effect tolerability to guide our choice of medication. Cyproheptadine is often used in younger patients as it comes in a liquid form. There is evidence supporting the use of propranolol, though the potential worsening of underlying asthma symptoms may limit its use, and sodium valproate, which must be used with caution in female patients of childbearing age due to significant teratogenicity risks. Other prophylactic treatments with less robust evidence include the antiepileptic drugs gabapentin, zonisamide, and levetiracetam; calcium channel blockers such as verapamil and amlodipine; and the angiotensin receptor blocking agent candasartin (not available in the USA). Almost all patients in our practice are advised to take magnesium supplementation. Magnesium is a supplement with relatively few adverse effects and good evidence for improvement of migraine symptoms. We evaluate lifestyle issues and comorbidities in all our patients. Ignoring these will make successful treatment near impossible. Good sleep, adequate hydration, appropriate diet, and exercise are vitally important. Finally, most of our patients benefit from a psychology evaluation with cognitive behavioral therapy. Stress management and biofeedback are tremendously helpful in improving quality of life in migraineurs.
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Affiliation(s)
- Kelsey Merison
- Division of Child Neurology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Howard Jacobs
- Division of Child Neurology, Ohio State University, Nationwide Children's Hospital, FB, Suite 4A.4-4814, 700 Children's Drive, Columbus, OH, 43205, USA.
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Bekan G, Tfelt-Hansen P. Is the Generally Held View That Intravenous Dihydroergotamine Is Effective in Migraine Based on Wrong "General Consensus" of One Trial? A Critical Review of the Trial and Subsequent Quotations. Headache 2016; 56:1482-1491. [PMID: 27595607 DOI: 10.1111/head.12904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/22/2016] [Accepted: 07/13/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The claim that parenteral dihydroergotamine (DHE) is effective in migraine is based on one randomized, placebo-controlled, crossover trial from 1986. The aim of this review was to critically evaluate the original article. It was also found to be of interest to review quotes concerning the results in the more than 100 articles subsequently referring to the article. METHODS The correctness of the stated effect of intravenous DHE in the randomized clinical trial (RCT) was first critically evaluated. Then, Google Scholar was searched for references to the article and these references were classified as to whether they judged the reported RCT as positive or negative. RESULTS The design of the RCT, with a crossover within one migraine attack, only allows evaluation of the results for the first period and the effect of DHE and placebo were quite comparable. About 151 references were found for the article in Google scholar. Among the 95 articles with a judgment on the efficacy of intravenous DHE in the RCT, 90 stated that DHE was effective or likely effective whereas only 5 articles stated that DHE was ineffective. CONCLUSIONS Despite a "negative" RCT, authors of subsequent articles on the efficacy of parenteral DHE overwhelmingly reported this RCT as "positive." This is probably due to the fact that the authors concluded in the abstract that DHE is effective, and to a kind of "wrong general consensus."
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Affiliation(s)
- Goran Bekan
- Department of Neurology, North Zealand Hospital in Hillerød, Hillerød, Denmark
| | - Peer Tfelt-Hansen
- Department of Neurology, Zealand University Hospital, Roskilde, Denmark.
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Abstract
OBJECTIVE The aim of the study was to evaluate the safety and efficacy of a standardized pediatric migraine practice guideline in the emergency department (ED). METHODS Migraine Clinical Practice Guideline (MCPG) was created in collaboration with the Division of Pediatric Neurology and Pediatric Emergency Medicine. The MCPG was established on evidence-based data and best practice after a review of the literature. The MCPG was implemented for patients with a known diagnosis of migraine headaches and a verbal numeric pain score (VPS) greater than 6 on a 0 to 10 scale. Patients received intravenous saline, ketorolac, diphenhydramine, and either metoclopramide or prochlorperazine. After 40 minutes, another VPS was obtained, and if no improvement, a repeat dose of metoclopramide or prochlorperazine was administered. If after 40 minutes and minimal pain relief occurred, a consult to neurology was made. A chart review of patients enrolled in the MCPG from April 2004 to April 2013 was conducted. We recorded demographic data, vital signs, ED length of stay, initial VPS, last recorded VPS, adverse events, and admission rate. Nonparametric statistics were performed. RESULTS A total of 533 charts were identified with a discharge diagnosis of migraine headache of which 266 were enrolled in the MCPG (179 females and 87 males). Mean (SD) age was 13.9 (3.1). Mean (SD) initial VPS was 7.8 (2.0). Mean (SD) discharge VPS was 2.1 (2.8), representing a 73% reduction of pain. Twenty patients (7.5%) were admitted for status migrainosus; mean (SD) age was 14.0 (3.5) years and mean (SD) VPS was 6.3 (2.8). Mean (SD) length of stay in ED was 283 (107) minutes. No adverse events were identified. CONCLUSIONS Our MCPG was clinically safe and effective in treating children with acute migraine headaches. Our data add to the dearth of existing published literature on migraine treatment protocols in the ED setting. We recommend additional prospective and comparative studies to further evaluate the effectiveness of our protocol in this patient population.
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Teleanu RI, Vladacenco O, Teleanu DM, Epure DA. Treatment of Pediatric Migraine: a Review. Maedica (Bucur) 2016; 11:136-143. [PMID: 28461833 PMCID: PMC5394581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Migraine is a common, but often underdiagnosed complaint in children and the lack of studies regarding its treatment in this particularly population makes it harder to enlarge the choices of treatment. However, recent trials made it easier to utilize newer compounds that improve the outcome of the disease. We reviewed the treatment of pediatric migraine and divided therapeutic methods into two broad areas: treatment of the acute attack - used both in the emergency room and as home options and prophylactic agents. Not to be forgotten when talking about treating migraine in children and adolescents is the support therapies offered alongside the classical approach by teams formed by the pediatric neurologist, pediatrician, psychologist, support groups and the families of the patients.
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Affiliation(s)
- Raluca Ioana Teleanu
- Department of Pediatric Neurology, "Dr. Victor Gomoiu" Children's Hospital, Bucharest, Romania
| | - Oana Vladacenco
- Department of Pediatric Neurology, "Dr. Victor Gomoiu" Children's Hospital, Bucharest, Romania
| | | | - Diana Anamaria Epure
- Department of Pediatric Neurology, "Dr. Victor Gomoiu" Children's Hospital, Bucharest, Romania
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Gelfand AA, Fullerton HJ, Jacobson A, Sidney S, Goadsby PJ, Kurth T, Pressman A. Is migraine a risk factor for pediatric stroke? Cephalalgia 2015; 35:1252-60. [PMID: 25754176 DOI: 10.1177/0333102415576222] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 02/13/2015] [Indexed: 11/17/2022]
Abstract
IMPORTANCE Our understanding of risk factors for childhood stroke is incomplete. In adults, migraine with aura is associated with a two-fold increase in ischemic stroke risk. OBJECTIVE In this cohort study we examine the association between migraine and stroke among children in Kaiser Permanente Northern California (KPNC). DESIGN, SETTING, AND PARTICIPANTS Children ages 2-17 years who were members of KPNC for ≥6 months between 1997 and 2007 were included. Migraine cohort members had one or more of: an ICD-9 code for migraine, migraine listed as a significant health problem, or a prescription for a migraine-specific medication. The comparison group was children with no evidence of headache. MAIN OUTCOME MEASURES Main outcome measures included stroke incidence rates and incidence rate ratios (IR). RESULTS Among the 1,566,952 children within KPNC during the study period, 88,164 had migraine, and 1,323,142 had no evidence of headache. Eight migraineurs had a stroke (three (38%) hemorrhagic; five (63%) ischemic). Eighty strokes occurred in children without headache (53 (66%) hemorrhagic; 27 (34%) ischemic). The ischemic stroke incidence rate was 0.9/100,000 person-years in migraineurs vs. 0.4/100,000 person-years in those without headache; IR 2.0 (95% CI 0.8-5.2). A post-hoc analysis of adolescents (12-17 years) showed an increased risk of ischemic stroke among those with migraine; IR 3.4 (95% CI 1.2-9.5). The hemorrhagic stroke incidence rate was 0.5/100,000 person-years in migraineurs and 0.9/100,000 person-years in those without headache; IR 0.6 (95% CI 0.2-2.0). CONCLUSIONS There was no statistically significant increase in hemorrhagic or ischemic stroke risk in pediatric migraineurs in this cohort study. A post-hoc analysis found that ischemic stroke risk was significantly elevated in adolescents with migraine. Future studies should focus on identifying risk factors for ischemic stroke among adolescent migraineurs. Based on adult data, we recommend that migraine aura status should be studied as a possible risk factor for ischemic stroke among adolescent migraineurs.
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Affiliation(s)
- Amy A Gelfand
- UCSF Headache Center, Department of Neurology, University of California San Francisco, USA Division of Child Neurology, UCSF, USA
| | | | - Alice Jacobson
- Sutter Health Research Development and Dissemination, USA Kaiser Permanente Northern California, Division of Research Oakland, USA
| | - Stephen Sidney
- Kaiser Permanente Northern California, Division of Research Oakland, USA
| | - Peter J Goadsby
- UCSF Headache Center, Department of Neurology, University of California San Francisco, USA NIHR-Wellcome Trust Clinical Research Facility, King's College London, UK
| | - Tobias Kurth
- Inserm Research Center for Epidemiology and Biostatistics (U897) - Team Neuroepidemiology, France University of Bordeaux, College of Health Sciences, France
| | - Alice Pressman
- Sutter Health Research Development and Dissemination, USA Kaiser Permanente Northern California, Division of Research Oakland, USA
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Pinchefsky E, Dubrovsky AS, Friedman D, Shevell M. Part II--Management of pediatric post-traumatic headaches. Pediatr Neurol 2015; 52:270-80. [PMID: 25499091 DOI: 10.1016/j.pediatrneurol.2014.10.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 10/09/2014] [Accepted: 10/09/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND Post-traumatic headache is one of the most common symptoms occurring after mild traumatic brain injury in children. METHODS This is an expert opinion-based two-part review on pediatric post-traumatic headaches. In part II, we focus on the medical management of post-traumatic headaches. There are no randomized controlled trials evaluating the efficacy of therapies specifically for pediatric post-traumatic headaches. Thus, the algorithm we propose has been extrapolated from the primary headache literature and small noncontrolled trials of post-traumatic headache. RESULTS Most post-traumatic headaches are migraine or tension type, and standard medications for these headache types are used. A multifaceted approach is needed to address all the possible causes of headache and any comorbid conditions that may delay recovery or alter treatment choices. For acute treatment, nonsteroidal anti-inflammatories can be used. If the headaches have migrainous features and nonsteroidal anti-inflammatories are not effective, triptans may be beneficial. Opioids are not indicated. Medication overuse should be avoided. For preventive treatments, some reports indicate that amitriptyline, gabapentin, or topiramate may be beneficial. Amitriptyline is a good choice because it can be used to treat both migraine and tension-type headaches. Nerve blocks, nutraceuticals (e.g. melatonin), and behavioral therapies may also be useful, and lifestyle factors, especially adequate sleep hygiene and strategies to cope with anxiety, should be emphasized. CONCLUSIONS Improved treatment of acute post-traumatic headache may reduce the likelihood of developing chronic headaches, which can be especially problematic to effectively manage and can be functionally debilitating.
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Affiliation(s)
- Elana Pinchefsky
- Division of Pediatric Neurology, Departments of Pediatrics and Neurology/Neurosurgery, Montreal Children's Hospital / McGill University Health Centre (MUHC), Montreal, Quebec, Canada
| | - Alexander Sasha Dubrovsky
- Department of Pediatric Emergency Medicine, Montreal Children's Hospital Trauma Centre, McGill University Health Centre, Montreal, Quebec, Canada
| | - Debbie Friedman
- Trauma Programs, Mild Traumatic Brain Injury Program, Concussion Clinic, Montreal, Quebec, Canada; Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), Department of Pediatrics, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Michael Shevell
- Department of Pediatrics, Departments of Pediatrics and Neurology/Neurosurgery, Montreal Children's Hospital Trauma Centre, McGill University Health Centre, Montreal, Quebec, Canada.
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Abstract
BACKGROUND AND OBJECTIVES Migraine headache is a common pediatric complaint among emergency department (ED) patients. There are limited trials on abortive therapies in the ED. The objective of this study was to apply a comparative effectiveness approach to investigate acute medication regimens for the prevention of ED revisits. METHODS Retrospective study using administrative data (Pediatric Health Information System) from 35 pediatric EDs (2009-2012). Children aged 7 to 18 years with a principal diagnosis of migraine headache were studied. The primary outcome was a revisit to the ED within 3 days for discharged patients. The primary analysis compared the treatment regimens and individual medications on the risk for revisit. RESULTS The study identified 32,124 children with migraine; 27,317 (85%) were discharged, and 5.5% had a return ED visit within 3 days. At the index visit, the most common medications included nonopioid analgesics (66%), dopamine antagonists (50%), diphenhydramine (33%), and ondansetron (21%). Triptans and opiate medications were administered infrequently (3% each). Children receiving metoclopramide had a 31% increased odds for an ED revisit within 3 days compared with prochlorperazine. Diphenhydramine with dopamine antagonists was associated with 27% increased odds of an ED revisit compared with dopamine antagonists alone. Children receiving ondansetron had similar revisit rates to those receiving dopamine antagonists. CONCLUSIONS The majority of children with migraines are successfully discharged from the ED and only 1 in 18 required a revisit within 3 days. Prochlorperazine appears to be superior to metoclopramide in preventing a revisit, and diphenhydramine use is associated with increased rates of return.
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Affiliation(s)
- Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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22
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Abstract
In this article, we hope to summarize current understanding of pediatric headache. We discuss epidemiology, genetics, classification, diagnosis, outpatient, emergency and inpatient treatment options, prevention strategies, and behavioral approaches. For each section, we end with a series of questions for future research and consideration.
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Affiliation(s)
- Samata Singhi
- Pediatric Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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