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ObjectiveTo provide updated evidence-based recommendations for migraine prevention using pharmacologic treatment with or without cognitive behavioral therapy in the pediatric population.MethodsThe authors systematically reviewed literature from January 2003 to August 2017 and developed practice recommendations using the American Academy of Neurology 2011 process, as amended.ResultsFifteen Class I–III studies on migraine prevention in children and adolescents met inclusion criteria. There is insufficient evidence to determine if children and adolescents receiving divalproex, onabotulinumtoxinA, amitriptyline, nimodipine, or flunarizine are more or less likely than those receiving placebo to have a reduction in headache frequency. Children with migraine receiving propranolol are possibly more likely than those receiving placebo to have an at least 50% reduction in headache frequency. Children and adolescents receiving topiramate and cinnarizine are probably more likely than those receiving placebo to have a decrease in headache frequency. Children with migraine receiving amitriptyline plus cognitive behavioral therapy are more likely than those receiving amitriptyline plus headache education to have a reduction in headache frequency.RecommendationsThe majority of randomized controlled trials studying the efficacy of preventive medications for pediatric migraine fail to demonstrate superiority to placebo. Recommendations for the prevention of migraine in children include counseling on lifestyle and behavioral factors that influence headache frequency and assessment and management of comorbid disorders associated with headache persistence. Clinicians should engage in shared decision-making with patients and caregivers regarding the use of preventive treatments for migraine, including discussion of the limitations in the evidence to support pharmacologic treatments.

Inhibitory pain modulation has been reported to be deficient in adults across different types of chronic pain, including migraine. To determine whether a similar phenomenon occurs in youth, we performed a quantitative sensory testing investigation in adolescents with migraine (N = 19). These patients were compared to healthy adolescents with (Fam-His; N = 20) or without (Healthy; N = 29) a family history of migraine (eg, first-degree relative with migraine). Subjects were first familiarized with the stimuli and visual analogue rating scales using graded noxious stimuli (0°C, 43-49°C range). These data were used to explore potential pain sensitivity differences between the groups. Pain inhibition was assessed by conditioned pain modulation (CPM), which used both suprathreshold heat pain (heat CPM) and pressure pain thresholds (pressure CPM) as the test stimuli before and during cold-water immersion (8°C). In response to the graded heat stimuli, Fam-His participants reported higher pain intensity ratings compared with patients with migraine, who in turn reported higher pain intensity ratings than the healthy controls (F = 3.6, [df = 2, 459], P = 0.027). For heat and pressure CPM, there was no significant group difference in the magnitude of CPM responses. Thus, adolescents with migraine and healthy adolescents have similar inhibitory pain modulation capability, despite having marked differences in pain sensitivity. Although Fam-His participants are asymptomatic, they demonstrate alterations in pain processing, which may serve as markers for prediction of migraine development.

Chronic pain in children is associated with significant negative impact on social, emotional, and school functioning. Previous studies on the impact of pain on children's functioning have primarily used mixed samples of pain conditions or single pain conditions (eg, headache and abdominal pain) with relatively small sample sizes. As a result, the similarities and differences in the impact of pain in subgroups of children with chronic pain have not been closely examined.To compare pain characteristics, quality of life, and emotional functioning among youth with pediatric chronic migraine (CM) and juvenile fibromyalgia (JFM).We combined data obtained during screening of patients for 2 relatively large intervention studies of youth (age range, 10 to 18 y) with CM (N=153) and JFM (N=151). Measures of pain intensity, quality of life (Pediatric Quality of Life; PedsQL, child and parent-proxy), depressive symptoms (Children's Depression Inventory), and anxiety symptoms (Adolescent Symptom Inventory-4-Anxiety subscale) were completed by youth and their parent. A multivariate analysis of covariance controlling for effects of age and sex was performed to examine differences in quality of life and emotional functioning between the CM and JFM groups.Youth with JFM had significantly higher anxiety and depressive symptoms, and lower quality of life in all domains. Among children with CM, overall functioning was higher but school functioning was a specific area of concern.Results indicate important differences in subgroups of pediatric pain patients and point to the need for more intensive multidisciplinary intervention for JFM patients.

Headaches and migraine occur frequently in children and adolescents and may have a significant impact on the child's and parents' lives. Recent advances in diagnosis, epidemiology, and treatment have improved the outcomes of children with headaches. This review summarizes some of these findings.Recent studies have revealed the increasing incidence of migraine and chronic migraine in the pediatric and adolescent age groups. These studies have also begun to identify comorbidities that may affect the impact over a lifetime. Limitations of the diagnosis of migraine have restricted some of these findings, but modifications to the criteria may assist with early recognition. Proper evaluation and treatment, including acute, preventive, and biobehavioral therapies, may need to be incorporated for optimal outcomes. Long-term outcomes may be determined by the underlying pathophysiology as well as early effective management.Migraine in children is increasingly being recognized as a problem. Early, effective treatment is available and may result in long-term benefit and prevent disease progression. Further research into childhood headaches should help reveal additional pathophysiological mechanisms and treatment options.

Objective: To review evidence on the pharmacologic treatment of the child with migraine headache.Methods: The authors reviewed, abstracted, and classified relevant literature. Recommendations were based on a four-tiered scheme of evidence classification. Treatment options were separated into medications for acute headache and preventive medications.Results: The authors identified and reviewed 166 articles. For acute treatment, five agents were reviewed. Sumatriptan nasal spray and ibuprofen are effective and are well tolerated vs placebo. Acetaminophen is probably effective and is well tolerated vs placebo. Rizatriptan and zolmitriptan were safe and well tolerated but were not superior to placebo. For preventive therapy, 12 agents were evaluated. Flunarizine is probably effective. The data concerning cyproheptadine, amitriptyline, divalproex sodium, topiramate, and levetiracetam were insufficient. Conflicting data were found concerning propranolol and trazodone. Pizotifen, nimodipine, and clonidine did not show efficacy.Conclusions: For children (>age 6 years), ibuprofen is effective and acetaminophen is probably effective and either can be considered for the acute treatment of migraine. For adolescents (>12 years of age), sumatriptan nasal spray is effective and should be considered for the acute treatment of migraine. For preventive therapy, flunarizine is probably effective and can be considered, but is not available in the United States. There are conflicting or insufficient data to make any other recommendations for the preventive therapy of migraine in children and adolescents. For a clinical problem so prevalent in children and adolescents, there is a disappointing lack of evidence from controlled, randomized, and masked trials.

Background: Chronic daily headaches (CDH) occur in >4% of the adult population. The criteria for CDH, however, are controversial. In children, the characterization of frequent headaches and CDH is limited. Methods: A Headache Center to characterize headaches in children (3 to 18 years old) was established. Over 34 months, 577 children have been evaluated. With use of a definition of ≥15 headaches per month, 200 (34.6%) children had CDH. Results: The average age at the first headache in these children was 9.3 ± 3.6 years, whereas the average age at presentation to the Headache Center was 12.5 ± 3.1 years. Sixty-eight percent were girls, 88% were Caucasian, and 11% were African American. Ninety-two percent clinically had migraine headaches, whereas 60.5% met the International Headache Society migraine criteria. The pain was pulsatile in 79%, 63.5% had nausea with or without vomiting, and 59.5% had photophobia and phonophobia. Three subcategories emerged, with 37% having frequent headaches but not daily, 43.5% having episodic daily headaches, and 19.5% having a continuous headache. Conclusion: The features of CDH in children most closely match those of migraine. A clear division of these children using frequency identifies three groups: frequent headaches (15 to 29), daily intermittent, and daily continuous. The daily continuous group is the most unique; however, the nature of these headaches continues to remain migrainous.

Lifestyle factors, long implicated in the onset and exacerbation of headache disorders in adults, have rarely been studied in adolescents. In this issue of Neurology ®, Robberstad and coworkers1 report a large, cross-sectional school-based study assessing the relationships of lifestyle factors to the prevalence and frequency of 3 headache types (migraine, tension-type headache, and “nonclassifiable headache”). Their study, conducted in a sample of 5,847 Norwegian adolescents, ranging in age from 13 to 18 years, examined the separate and combined effects of low physical activity, smoking, and being overweight. The study is a vital step toward a better understanding of lifestyle effects and the potential for behavioral interventions for adolescents with headache disorders. Negative lifestyle factors were surprisingly common, with low physical activity in 31%, smoking in 19%, and being overweight in 16% of this adolescent sample. When examined one at a time, each of these factors was associated with an increased prevalence of migraine, tension-type headache, and nonclassifiable headache in both boys and girls. The effects of each factor were similar in magnitude for each headache type. This lack of specificity for headache type raises the possibility that these lifestyle factors may be associated not just with headache but with all-cause pain. The authors also combined their lifestyle factors into a 4-point lifestyle status scale based on the number of negative factors present. The very poor …

Chronic daily headache (CDH) affects up to 4% of adults and between 1% and 2% of middle-school children.1 Children with CDH often have a history of episodic migraine or a family history of migraines. The headache characteristics in patients with CDH can vary between patients as well as within an individual patient. Their headaches may present as severe intermittent migraine attacks, intermittent low severity headaches, continuous headache pain, or as a combination of these headache types.2 This variation continues to make this condition remarkably challenging to understand and to treat. When the patient and his or her family are in the office, 3 main questions arise: why did this happen, how can we treat it, and when will it go away? Several studies have begun to address these questions, but these studies have often …

For adults, primary headaches have been associated with both socioeconomic and health factors. Oftentimes it is difficult to determine whether the socioeconomic component is a contributor to the impact of the headache or whether the headaches influence the socioeconomic status. For migraine this is complicated by the underlying genetic etiology and the separation of this genetic family history from the socioeconomic family history. Population-based epidemiology studies have attempted to sort out the degree of contribution of these multiple factors. In this issue of Neurology , Bigal et al. examine these roles in adolescents as part of the American Migraine Prevalence and Prevention (AMPP) study.1 Migraine is a common pain condition that significantly burdens an individual, his or her family, and society.2–4 Migraine frequently starts in childhood and adolescence; the prevalence increases and peaks in the most socioeconomic productive years for adults. This combination not only creates increased cost and utilization of medical services, but …

Primary chronic daily headaches (CDH) in adults have emerged as a public health priority in recent years because of their prevalence and substantial disability. Although numerous clinic-based studies are available, recent population studies have done much to define the natural history and risk factors for CDH in adults. The current issue of Neurology extends population-based work on CDH to adolescents with two important new studies.1,2 In the simplest terms, CDH is defined by the occurrence of 15 or more headache days per month. Defined in this way, CDH affects 4% of American adults3–5 and makes up a majority of patients seen in tertiary headache clinics.6–8 In children and adolescents, however, the prevalence of CDH appears to be lower.9,10 The most disabling form of CDH evolves from migraine and has been called transformed migraine (TM) or chronic migraine (CM). TM is defined by Silberstein-Lipton (S-L) criteria11 as a primary CDH disorder, linked to migraine by a current or prior history of migraine; this definition does not require a specific number of migraine attacks. In contrast, CM defined by the International Classification of Headache Disorders-2 (ICHD-2) requires 15 or more days per month of migraine without aura. Several additional types of CDH are also recognized. These include chronic tension-type headache (CTTH), new daily persistent headache (NDPH), and hemicrania continua (HC). Each of these is defined based …

Relaxation training and thermal biofeedback are promising treatments for pediatric headache.1-5⇓⇓⇓⇓ This study evaluated the effectiveness of an hour-long, biofeedback-assisted relaxation training (BART) session within the context of a multidisciplinary pediatric headache center. The objectives were to determine whether peripheral body temperature (PBT) changes obtained during the training session (T1) could be maintained when measured at the child’s subsequent follow-up clinic visit (T2), and to summarize headache perception and quality of life at T1 and T2. Twenty children consecutively referred for BART received standard multidisciplinary treatment and BART based on headache presentation and developmental status. The sample consisted of 10 girls and 10 boys, with a mean age of 11.6 years (SD = 2.2 years). The sample was predominantly white (95%). All children were clinically diagnosed with migraine, with 90% meeting International Headache Society criteria. The sample was representative of the general population of the headache center6 and those children referred …