DHE Infusion Coupled With Adjunctive Care Successful in Refractory Pediatric Migraine

Mark Connelly, PhD, clinical psychologist, and director of research, developmental and behavioral sciences, Childrens Mercy Kansas City, and professor of pediatrics, Missouri Kansas City School of Medicine

Mark Connelly, PhD

Study results in a pediatric population with refractory migraine suggest that a combination of outpatient dihydroergotamine (DHE) infusion with multidisciplinary adjunctive care can be an effective treatment option for these patients.

All told, headache intensity (P <.0001) and headache frequency (P = .012) were statistically significantly reduced through the course of the study period, including a 27% reduction in the proportion of patients reporting continuous headache, lowered from 0.91 to 0.66 (P = .009).

The retrospective chart review, dubbed the comprehensive aggressive migraine protocol (CAMP) was led by Mark Connelly, PhD, clinical psychologist, and director of research, developmental and behavioral sciences, Children’s Mercy Kansas City, and professor of pediatrics, Missouri Kansas City School of Medicine. It included 36 patients aged 11 to 18 years, assessed for 5 days of outpatient DHE infusion and 3 months of follow-up.

“Overall, this study suggests that a combination of up to 5 days of intravenous DHE and multidisciplinary nonpharmacological care provided to children/adolescents in an outpatient environment in most cases safely improves headaches and functioning up to 3 months,” Connelly and colleagues wrote. They noted that additional research is still needed, preferably using prospective design for a longer period and larger sample size. As well, “inclusion of a comparator condition is needed to better establish relative benefits and cost-effectiveness of the protocol.”

The CAMP medication protocol included weight-based DHE dosing up to 1 mg/mL BID infused over 30 minutes in 50 mL of saline for 5 days, as well as adjunctive services which included training in relaxation skills (97%; n = 35), social work assessment with school reintegration support (97%; n = 35), psychology assessment (94%; n = 34), and therapeutic massage (78%; n = 28). A small proportion (58%; n = 21) of patients received aromatherapy.

Headache intensity declined from a mean of 5.8 (±2.5) to 2.4 (±2.7) during treatment and remained significantly improved over the course of the 3&#8208;month follow&#8208;up. Similarly, the frequency decreased by a mean of 1.5 days per week from a mean of 6.7 (±1.0) to 5.2 (±2.7) through the follow&#8208;up.

Over that same 3-month follow&#8208;up period, Connelly and colleagues observed a reduction in school days missed per month from a median of 4.5 (mean, 11.0 [±12.1]) to 0 (mean, 2.8 [±7.6]; P = .001). As well, relative to the baseline Pediatric Migraine Disability Assessment (PedMIDAS) score of 25.0 (±20.4), there was a significant improvement through 3-month follow-up to 6.7 (±12.5; P = .002).

There also were reductions in headache&#8208;related visits per month to the emergency department (from 0.2 [±0.3] to 0.1 [±0.2]; P = .010) and medical providers (from 0.2 [±0.2] to 0.1 [± 0.2]; P = 0002).

Connelly and colleagues noted that adverse events (AEs) were common, though typically minor and transient. Discontinuation of CAMP prior to 5 days occurred in 16 cases, due to early complete headache cessation (n = 8), patient/family preference (n = 6), or AEs (n = 2).

“Unique to our study was the observation of relatively sustained benefits in headache frequency, intensity, and impairment through 3-months following the outpatient treatment protocol,” the investigators wrote. “On average, we observed a 30% to 76% improvement over a 3-month period in the headache and functioning outcomes evaluated for this study. Improved headache outcomes also were associated with reduced headache-related medical and ED visits over this same time period. The additional ancillary interdisciplinary services received during CAMP may have in part contributed to these overall sustained improvements.”

REFERENCE

Connelly M, Sekhon S, Stephens D, Boorigie M, Bickel J. Enhancing Outpatient Dihydroergotamine Infusion With Interdisciplinary Care to Treat Refractory Pediatric Migraine: Preliminary Outcomes From the Comprehensive Aggressive Migraine Protocol (“CAMP”). Headache. Published online October 18, 2019. Accessed November 8, 2019. doi: 10.1111/head.13685.