Improving the Identification and Treatment of Pediatric Migraine

Karl Doghramji, MD, FAASM, DFAPA

Christina Szperka, MD, MSCE

Since May 2018, the clinical care of migraine has experienced drastic change in terms of therapeutic approaches. Several novel agents and devices completed their treks through the development pipeline and made their way into the hands of clinicians, which, alongside improving awareness, has better allowed them to manage the almost 40 million Americans with the disease.¹

Although, there are still lingering challenges. One is refractory disease, but another that is perhaps less often discussed—and less often identified—is the pediatric population. According to the Migraine Research Foundation, up to 28% of adolescents between the ages of 15-19 years are affected by migraine, and 50% of those with migraine experience their first attack before the age of 12 years.²

Christina Szperka, MD, MSCE, who is the director of the Pediatric Headache Program at Children's Hospital of Philadelphia, is all too familiar with the challenges of treating younger kids with migraine. In a conversation with NeurologyLive^®, she offered up her perspective on the current state of clinical care and awareness for pediatric migraine, and provided her insight into the changes the landscape of treatment has undergone and their effect on pediatric care.

NeurologyLive^®: As someone who focuses on pediatric migraine care, how would you describe the overall landscape?

Christina Szperka, MD, MSCE: When I think about the landscape of pediatric migraine, I think the first and most important thing is to realize that it's often underrecognized. About 9% of children have migraine, and that means that it's typically a little bit less common in younger children and increases in frequency with adolescents. It's a really common problem. People think about common problems and children, and think about something like asthma, but they don't necessarily recognize migraine. Migraine actually causes a tremendous amount of disability—it contributes to missed days of school for children; it contributes to the problem of what's called presenteeism, where you go to school but you're really not there mentally. It really can cause a lot of trouble for kids.

I think the most important thing, when I think about the overall landscape, honestly, is making sure that we increase recognition because we're not going to improve treatment nor going to help those kids to get through that day and minimize a disability unless we recognize the problem for what it is.

How much of the migraine population is ultimately pediatric patients and how can they be better identified?

As I said, it's about 9% of kids. Again, a little bit less among the younger ones and a little bit more among the older. As we think about that, there have been a lot of different ideas on how we can improve diagnosis. There was even an interesting project that was done a couple of years ago, working primarly with school nurses—because kids who have a headache go to the school nurse—and they essentially then pair that with some education to send a note home to say, “Please bring your child to your pediatrician so that they can actually evaluate the headaches.”

In our own quality improvement work, many years ago, we tried to work with pediatricians in our network to ask what we can do to help. What we learned was that, most of the time, if this comes up, it comes up in the setting of a well-child check, where they are already trying to squeeze a huge amount of care into a really short amount of time. We already asked our general pediatricians do a huge amount of care, and so figuring out ways to get children to come to attention, and maybe bring it up in the well-child check, but maybe also give them the permission to then say, “Okay, let's have another visit about this, let's think about this. What else can we do?” There's also often a lot of wait time, right? Parents may come and say, “I'm really worried about my child having something serious.” With a proper history, you can often rule out if there's anything more sinister going on and make the diagnosis of migraine, but you have to have the time to do that, you have to have the tools to do that, and you have to know what to ask and how to do it.

In terms of the parents and patients, is migraine something they know to look out for, or is patient/parent awareness not at that level?

There's a lot more awareness now than there was when the parents of my patients were children. Oftentimes, families will come and say, “I have a history of headache, or my spouse has a history of headache,” or something like that. But they will often express that there is more recognition of the problem now, whereas they may have suffered for several years as a child not knowing and with no one knowing what to do.

There's a lot more public awareness, there's obviously more awareness within individual families, and that's passed on. I think there's also been, over the past several years, increasing awareness as a result of advocacy. There have been several organizations—the American Migraine Foundation; CHAMP, the Coalition for Headache and Migraine Patients; Miles for Migraine; and quite frankly, some of the pharma companies, in their public advertisements on television—that have essentially brought the word migraine to people and brought it out into public awareness. There's been a lot more discussion about it, and I think that, in turn, makes people recognize, “Oh, this is something I can actually go to the doctor and talk to them about.”

When it comes to the actual care process, are there any major differences or things that the physician community should be aware of in terms of treating kids versus treating adults with migraine?

First, in the area of diagnosis, children's migraines may act a little bit differently. Typically, the official criteria for migraine in adults requires that we often think of headaches as one-sided, typically 4 hours in duration. Children's headaches may be bilateral, and they may be shorter in duration. Sometimes children don't necessarily report that they're bothered by light or sound, but you can figure it out from their behavior, right? If they want their siblings to be quiet, or they run away to a dark room, things like that, where you can just get a bit more from the observation—there may be some slight differences. There's also a lower frequency of aura in children, and it sort of evolves as they age. Otherwise, in many ways, the headache feels similar, right? It's a bad headache that's disabling and typically, for the vast majority of patients, it comes and goes. You have periods of time with no headache, you have a bad headache that has those features, and it goes away.

There certainly are certain red flags. We worry about things like the headaches getting much worse, or getting really frequent really quickly, or very explosive-onset headache, waking that child from sleep in the middle of the night—things like that are much more worrisome. Although, sometimes they are honestly still migraine. But we're more suspicious of another cause if that happens.

Then, when we move on to treatment, we generally think about treating pediatric migraine in 3 different pieces. First, is that we think about lifestyle habits and things like that. So, are the children getting consistent sleep? Are they able to eat consistently through the day and hydrate? To be honest with you, there's actually less evidence behind a lot of those recommendations than we would like. I think that's an area of that will be important over the next several years, to try to clarify what in those recommendations are actually important. For example, if the child isn't getting enough sleep because the parent works an evening shift and gets home late and things like that, telling them, “You must get more sleep,” is not going to fix the problem, right? I think we have to be really careful about figuring out what's really crucial, and then how we help families make those changes so that they are realistic, and we're not just being dogmatic and saying, “You must do this.”

Generally speaking, as we think about it, it's often helpful to keep a really consistent schedule of hydration, eating, sleeping. Exercise can be really important. Just sort of general, good, light, good, healthy habits. We generally recommend those things for pretty much everybody. If somebody comes in really worried about something serious, we'll do investigations, but also, we've got to make sure that they're on a consistent schedule to try to minimize the problem from the get-go.

We think about acute therapies for anybody who's having a bad headache, even if they are at relatively low frequency. We had new guidelines published in 2019, and it really clearly spells out that, essentially, there's evidence for anti-inflammatory medications, like ibuprofen, as first line for pretty much everyone. Then definitely triptans in adolescents—one is actually FDA-approved down to the age of 6 years. So we can use both anti-inflammatories and migraine-specific medications in the vast majority of kids, and they are often very effective. There are several different meds that you can try if one doesn't quite work. You can switch within class, but they're often effective in helping. It's important though, to get them in early. That's where the partnering the schools comes in. I mentioned asthma earlier. There was a group from the American Headache Society, where we worked to build pediatric version of a migraine action plan to be able to send a message to school nurses. It essentially looks just like the asthma action plan—intentionally—so that they have something to follow. If the child comes into their office with a headache, it was meant to be something that they're already familiar with.

Then, when we think about then sort of a third piece of treatment is preventive therapies. In that, we essentially get pulled in when we have a child who has more frequent headaches. If they're having headaches at least once a week where they're causing a lot of disability, then we think about using preventive therapies. We used to say preventive medications, but there have been a lot of different and interesting innovations in the past several years. So I would say it's a little bit broader now, and I would say therapies, because sometimes we'll be using things like vitamins. Now, we're even thinking about devices. It's not just pills all the time anymore.

For you, what has been the impact of these new therapies? Is there research ongoing that's looking into these things in younger patients?

The landscape is very much changing. The new therapies are generally FDA-approved for 18 years and older. Things like the CGRP antibodies and ditans are FDA approved for 18 and older—so adults only. There are isolated times where we will use them off-label in older teenagers, but typically, that's not the standard. There are trials ongoing of essentially all of those new medications, in different phases. Some of them, obviously, started a couple of years ago, and some of them are about to start in various phases now. I think that's really exciting because there's a whole lot of work being done in the space, and a whole lot of emphasis on coming up with some new things that might be helpful.

The devices have an interesting story because the there's been almost, it seems to me, a shift in that the bar for devices was always a little bit different. But now, essentially, they've been able to extend the indication for some of the devices to 12 years and older, just based on either small, or in some cases, no studies. Essentially, just to say it's safe, it's should theoretically work. For some of the different devices, there were full studies, and for others there weren't. That has enabled us to essentially be permitted to use those devices on-label for adolescents. Insurance coverage is different story. The insurance will say, “Well, it isn't necessarily proven to some degree.” Sometimes the devices haven't undergone the same degree of study that the medications have, and so it doesn't mean we'll get them covered by insurance, but it does mean that we are reading them, theoretically, on label.

One of the important lessons as we think about all of these studies now is also to reflect on what we've learned thus far. A few years ago, the Childhood Adolescent Migraine Prevention Study, CHAMPS, that came out with the results, was amitriptyline versus topiramate versus placebo. As you may remember, essentially, all 3 arms performed equally well. So about two-thirds of kids in all 3 are arms got better—which was huge because it meant many kids are getting better, which is consistent with what we see in clinical care. Great for clinical care, hard for a study, because it did not essentially prove that those medications were better than placebo. There's a whole lot of discussion about why. Was it just that the being in a study essentially helped kids to have an expectation of benefit, and that helps them to get better? I think it's really important, as we think about the studies that we're doing now, that, to some degree, honestly, we run the risk of repeating that same thing. It may or may not demonstrate in the end that there is superiority of these new therapies if we're still testing them in a similar trial design. I am excited that we are moving on and we're doing all these studies now. But I'm also a little bit cautious because I think that lack of benefit over placebo in a study, quite frankly, does not mean in my mind that it's not still a really good thing in clinical care, or that it's not still a good tool I could use in clinical care. Navigating the piece of, “How do I take the trials and work with it in real life?” is tricky.

Transcript edited for clarity.

REFERENCES
1. Robbins M. Migraine – Where We Are and Where We Are Going. American Migraine Foundation website. Published January 1, 2015. Accessed December 22, 2021. https://americanmigrainefoundation.org/resource-library/migraine-where-we-are-and-where-we-are-going/
2. Migraine Facts. Migraine Research Foundation website. Updated 2021. Accessed December 22, 2021. https://migraineresearchfoundation.org/about-migraine/migraine-facts/