Evaluating Pediatric Migraine Options Uncovers Challenges
No medications were associated with improved quality of life or reduced headache duration.
No currently available medications improve quality of life or reduce headache duration in pediatric migraine, according to the results of a network meta-analysis published in JAMA Network Open,1 although topiramate and pregabalin demonstrated a reduction in headache frequency and intensity.
No medications were associated with improved quality of life or reduced headache duration.| Image credit: Yevhen - stock.adobe.com
While adult migraineurs have numerous options for both prevention and pain management, pediatric patients with migraine have notably fewer options. Current first-line therapeutic options for acute management include acetaminophen, ibuprofen, and other nonsteroidal anti-inflammatory drugs; triptans can be used in adolescents, and combination therapies—such as sumatriptan and naproxen—have also demonstrated promise in adolescents.
There is limited evidence available for prophylactic treatment of pediatric migraines, with off-label use of preventive medications a common practice. In the current study, researchers conducted a network meta-analysis to evaluate existing efficacy, safety, and acceptability data of pediatric prophylactic treatments for migraine.
A total of 45 clinical trials, inclusive of 3771 participants, were included in the review and meta-analysis. Of these, 37 studies were available to evaluate the efficacy of medications in reducing migraine frequency in a total of 2617 patients. When compared with placebo, pregabalin, topiramate with vitamin D3, flunarizine, levetiracetam, riboflavin, cinnarizine, topiramate, and amitriptyline (ratio of means [RoM], 0.38, 0.44, 0.46, 0.47, 0.50, 0.64, 0.70, and 0.73, respectively) were significantly associated with a lower migraine frequency. Based on network estimates, pregabalin led to a 62% reduction in migraine frequency.
READ MORE: Managing Medication Overuse Headache in Chronic Migraine
In 29 studies including 2801 patients, participants reported a 50% or higher responder rate. Four medications—flunarizine and a-lipoic acid, flunarizine, pregabalin, and cinnarizine—showed significant effect size vs placebo (RR, 8.73, 4.0, 1.88, and 1.46, respectively).
Nineteen studies reported on headache intensity. Within these studies, results showed that propranolol and cinnarizine, pregabalin, valproate, levetiracetam, and cinnarizine had a significant effect size on the reduction of prospective migraine intensity (RoM, 0.45, 0.57, 0.60, 0.62, and 0.64, respectively). In the 17 studies, inclusive of 15 treatments, that evaluated headache duration, no preventive medications were associated with a reduction in migraine duration.
In the 13 studies with quantitative data assessing quality of life and disability, no treatments were associated with a significant reduction in disability, or with an improvement in quality of life.
A total of 30 studies, and 2486 patients, reported adverse events. Of these, 365 reported mild adverse events and 24 patients discontinued due to serious adverse events. Amitriptyline, topiramate, and valproate (RR, 3.81, 4.34, and 5.93, respectively) were associated with significantly higher risks of adverse events vs placebo.
Study limitations include potential differences in baseline values for some outcomes, small study populations of fewer than 100 patients for some medications, and substantial heterogeneity for doses, treatment formats, and reporting methods.
“This study underscores the potential benefits of combination therapies, particularly those involving vitamin supplementation,” the researchers concluded, noting however that these treatments “did not improve quality of life or reduce the duration of migraine attacks.” Future research must develop more comprehensive therapeutic strategies for this patient population.
READ MORE: Pain Management Resource Center
