Special Populations in Neurology: Pediatric Migraine

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A Q&A WITH ALISON ALFORD, MD

Dr Heidi Moawad interviews Dr Alison Alford, a neurologist who specializes in pediatric headache medicine. She currently runs her own practice, Pediatric Headache Center of Richmond, in Richmond, VA.

Heidi Moawad, MD (HM): What are the challenges you face when it comes to pediatric migraine?

Alison Alford, MD (AA): One of the most difficult tasks, as you would imagine, is taking a history. I have some very little ones who have a difficult time describing the quality of their headaches. Describing symptoms is difficult enough for an adult. Treatments can be a very big hurdle. There is very little research in children and very few medication options that are approved for under aged 18 years. There is a lot involved in getting what our patients need.

HM: What are the criteria you use when deciding if a child is a good candidate for this treatment?

AA: I typically offer it to patients who have a high burden of frequency. I really prefer not to prescribe daily medications if I can avoid it. SPG blocks are minimally invasive and can sometimes provide up to months of relief with one block; they can also build on themselves and provide months of relief with a few weeks of therapy. If we can treat with just a rescue, then we don't necessarily need a SPG. Sometimes, however, we use it to break an intractable migraine as well, which can avoid IV therapy sometimes too.

HM: How did the children respond to the treatment?

AA: Most children respond very well and rapidly to the treatment. Sometimes within minutes. It can provide relief anywhere from 3 hours to 3 months. One of my patients got 9 months of relief and one, a year. Typically, I see anywhere from 2 to 6 weeks of relief with one block with peak around a month. Additionally, in two cases, treatment helped joint pain related Ehlers-Dahlos Syndrome and Complex Regional Pain Syndrome.

HM: How often do children typically need to repeat treatment and what are the signs that treatment effects were wearing off?

AA: I typically tell patients to call when they feel the next headache coming on and we can decide if we are at a time to do another. The two cases where it helped more generalized pain required 2 to 3 times a week (which ended up being unsustainable). They both had their symptoms return once the blocks stopped.

HM: How many pediatric migraines have you treated with SPG blocks?

AA: We have done at least a thousand procedures at this time. See the video of Dr Alford demonstrating the SPG block procedure, courtesy of WLKR CoastLive, here.