Amy A. Gelfand, MD, MAS reviewing
New guidelines highlight the current limits of evidence for migraine preventives in youth.
Sponsoring Organization: American Academy of Neurology (AAN)
Background and Objective
The AAN has issued new clinical practice guidelines on migraine preventive treatment (i.e., headache frequency lowering) in children and adolescents, updated from their guidelines published in 2004 (Neurology 2004; 63:2215). The authors conducted a systematic review of 15 trials. (The AAN concurrently published guidelines on acute migraine treatments; NEJM JW Neurol Nov 2019 and Neurology 2019; 93:487.)
Key Recommendations
- Topiramate is probably more effective than placebo at lowering headache frequency in children and adolescents.
- Propranolol is possibly more effective than placebo.
- Amitriptyline combined with cognitive-behavioral therapy is more effective than amitriptyline combined with headache education.
- Insufficient evidence is available to determine efficacy of amitriptyline (alone), nimodipine, onabotulinum toxin A, and extended-release divalproex sodium.
- The guideline authors recommend that clinicians counsel patients and families that lifestyle and behavioral factors may influence headache frequency, and educate them “to identify and modify migraine contributors that are potentially modifiable.” They recommend shared decision-making about whether to start a preventive and counseling about the efficacy and side effects of topiramate, propranolol, and amitriptyline plus cognitive-behavioral therapy.
What’s Changed
Topiramate and propranolol moved up in levels of evidence, from “insufficient evidence” and “recommendations cannot be made” in 2004 to “probably” and “possibly” more effective than placebo, respectively.
COMMENT
Potentially the most controversial recommendation in this guideline is the one that might appear most straightforward: that clinicians should discuss with patients and families the modification of so-called migraine contributors. Although the belief that weight loss and regular exercise, sleep, meals, and hydration can decrease migraine frequency is deeply ingrained in the minds of many clinicians, evidence for this is based predominantly on observational data, with only modest supporting experimental data. Encouraging behavioral changes may appear to have minimal downside but has potential to amplify migraine stigma, i.e., to risk assigning blame or responsibility to the patient for their migraine frequency based on their behavioral “choices.” Compared with adults, children and adolescents enjoy little control over their schedules. High school and middle school start times are often misaligned with adolescent circadian biology (Pediatrics 2014; 134:642; MMWR Morb Mortal Wkly Rep 2015; 64:809; J Clin Sleep Med 2016; 12:785), with consequences for sleep duration and for adiposity in adolescent girls (JAMA Pediatr 2019 Sep 16;. Also unclear is whether the target for behavior modification should be the patient and family unit or society itself. Particularly given the superiority of amitriptyline plus cognitive-behavioral therapy over “headache education” (JAMA 2013; 310:2622), clinicians should tread carefully and avoid blaming children and adolescents for having migraine, a terrible neurologic disease.