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What to do when conventional treatment of headache fails in children

Presented by
Prof. Ishaq Abu-Arafeh, Royal Hospital for Children, Glasgow, UK
EHC 2022
Pharmacological and non-pharmacological options are limited for the treatment and prevention of migraine in children and adolescents. Prof. Ishaq Abu-Arafeh (Royal Hospital for Children, Glasgow, UK) gave an overview of existing and upcoming treatment options. The good news he shared is that paediatric studies of lasmiditan and gepants are now recruiting.

Migraine is common in children and adolescents (7–8%). It is refractory when there are ≥8 debilitating headache days a month for ≥6 consecutive months and all available prophylactic treatments failed. The reasons for failure can be inadequate assessment and inadequate pharmacotherapy and/or non-pharmacological treatment but also unrealistically high expectations.

The more frequent the migraine, the higher the impact on quality of life. There is a general lack of understanding of the biopsychosocial nature of migraine, it being a brain disease which is nonetheless highly influenced by factors such as poor sleep routine, an erratic meal pattern, and a sedentary lifestyle. It is important to advise on a healthy lifestyle and non-pharmacological treatment options.

An important risk factor is obesity, which occurs in about 25% of children with migraine. This relation seems to be bidirectional: obesity increases the risk of complex headaches, and children with migraine are at increased risk of obesity. Other important risk factors are other chronic pain disorders, as well as psychiatric comorbidity.

Pharmacological treatment should be tailored to the child's needs, disease profile, and migraine attack characteristics. The reasons specific medications have failed can often be found in the patient's history, according to Prof. Abu-Arafeh. For example, treatment can be delayed due to lack of access; and the medication, the dose, or the formulation can be inappropriate.

Options for acute treatment are very limited. The starting point and cornerstone is still paracetamol or ibuprofen. Second-line treatments include sumatriptan nasal spray; third-line options are sumatriptan nasal spray or tablet, sumatriptan/naproxen oral tablets, and zolmitriptan melting tablets or nasal spray. Additional options exist but none of them are evidence-based: chlorpromazine/prochlorperazine, domperidone, cyclizine, and ondansetron.

Prof. Abu-Arafeh stressed the importance of carefully selecting patients for preventive treatment. Preventive therapy should be used regularly for at least 4–6 weeks before efficacy can be evaluated. If successful, it can be used for 6–12 months and then be re-evaluated. However, the available options are limited and often inadequate. Propranolol can be given, and topiramate or amitriptyline are alternatives, but these last 2 treatments are not significantly more effective than placebo [2].

When all else fails, options that could be considered (but with little evidence to back them up) are greater occipital nerve (GON) block, botulinum toxin-A (which does not reduce the number of headache days in children but does improve quality of life), and transcranial neuromodulation.

For status migrainosus, the evidence for children is even more limited. Options are intranasal ketamine and dihydroergotamine infusion.

Trials that are currently recruiting children and adolescents are the PIONEER-Peds-1 and PIONEER-Peds-2 studies (lasmiditan), OASIS study (erenumab), and PROSPECT 1 and 2 studies and REJOIN study (both assessing eptinezumab).

    1. Abu-Arafeh I. What's next, when conventional treatment of refractory headache fails in children? SciSe 14, EHC 2022, 07–10 December, Vienna, Austria.
    2. Powers SW, et al. N Engl J Med 2017;376(2):115-24.


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