There is little evidence to support the efficacy of prophylactic pharmacologic treatments in pediatric migraine, according to a systematic review and network meta-analysis. "While not entirely surprising, as recent large trials, such as CHAMP study, also found no difference between pharmacological treatments and placebo in preventing migraines, the low level of evidence of superiority for pharmacological interventions over placebo for prophylactic treatment of pediatric migraine is striking, especially in the long run," Dr. Joe Kossowsky from Boston Children's Hospital and Harvard Medical School told Reuters Health by email. "This is in contrast to the relatively effective pharmacological interruptive treatments for acute pediatric migraine episodes." Treatment options for children and adolescents with migraine are largely based on adult studies, and pharmacologic interventions are often used off label. Several studies have suggested treatments that work in adults might not be effective in children. Dr. Kossowsky and colleagues conducted a network meta-analysis to compare and rank medications regarding acceptability, safety, and efficacy in the prophylactic treatment of migraine in children and adolescents. They identified 23 double-blind, parallel randomized controlled trials involving a total of 2,217 patients; the trials compared 13 pharmacologic treatments (beta-blockers, anticonvulsants, antidepressants, antihistamines, and calcium channel blockers) with each other or with placebo. In their analysis of 19 studies that provided sufficient data, only two treatments were significantly more effective than placebo in the short term: propranolol and topiramate, but the certainty of evidence was only low to moderate. None of the other pharmacologic interventions outperformed placebo, and there were no significant differences between the individual treatments, according to the report in JAMA Pediatrics. In the long-term analysis (up to 24 weeks), no treatment was significantly more effective than placebo for migraine prevention. There were no significant differences between prophylactic pharmacologic treatments and placebo in terms of acceptability (treatment discontinuation for any reason) or safety (treatment discontinuation due to adverse effects). "Prophylactic treatment of migraine should not consist primarily of a pharmacological intervention," Dr. Kossowsky said. "Focus should be given to non-pharmacological interventions (triggers, lifestyle, cognitive behavioral therapy/biofeedback/relaxation), which can be augmented by pharmacological interventions." "In any case, patients and their parents should be informed about the relatively low level of efficacy and risk of side effects, especially for long-term pharmacological prophylactic treatment," he said. "We are currently examining the effects of various genetic predispositions on medication efficacy in preventing migraine, which could hopefully allow for a more personalized medicine approach in the future and help us understand which patients could profit from pharmacological prophylactic treatments," Dr. Kossowsky added. Dr. Boris Zernikow from Children's and Adolescents' Hospital Datteln, Witten/Herdecke University, Datteln, North Rhine-Westphalia, who wrote an editorial related to this report, told Reuters Health by email, "Do not regularly prescribe drugs in order to attempt migraine prevention in children and adolescents!" "Preventive medication should only be considered if non-pharmacological preventive strategies have failed," he said. "However, children with severe cognitive impairments in whom non-pharmacological preventive strategies are difficult to implement and for whom it might be difficult to detect the beginning of a migraine attack may benefit from medication use." "Second, children who have very prolonged attacks with status migrainosus might benefit from preventive medication," Dr. Zernikow said. "A third possible indication for pharmacological preventive treatments are children and adolescents who develop severe migraine complications like persistent aura, migraine aura-triggered seizures, brainstem aura, or hemiplegia." —Will Boggs MD Source
