Search

Objective: Understand health resource, medication use, and cost of adults with chronic migraine who received guideline‐recommended onabotulinumtoxinA (botulinum toxin) treatment frequency and then continued or reduced/stopped. Background: Botulinum toxin may be a beneficial treatment for chronic migraine; the trajectory of health resources utilization among those with continued or reduced/stopped use is unclear. Methods: A retrospective population‐based cohort study utilizing administrative data from Alberta, Canada (2012–2020), was performed. A cohort of adults who received ≥5 botulinum toxin treatment cycles for chronic migraine over 18 months (6‐month run‐in; 1‐year pre‐index period) were grouped into those who (1) continued use (≥3 treatments/year), or (2) stopped or reduced use (stopped for 6 months then received 0 or 1–2 treatments/year, respectively) over a 1‐year post‐index period. Health resources and medication use were described, and pre–post costs were assessed. A second cohort that received ≥3 treatments/year immediately followed by 1 year of stopped or reduced use was considered in sensitivity analysis. Results: Pre–post health resource, medication use, and costs were similar among those with continued use (n = 3336). Among those who stopped or reduced use (n = 1099; 756 stopped, 343 reduced), health resource, medication use, and costs were lower in the post‐ (total median per‐person cost [IQR]: all‐cause $4851 [$8090]; migraine‐related $835 [$1915]) versus pre‐ (all‐cause $6096 [$7207]; migraine‐related $2995 [$1950]) index period (estimated cost ratios [95% CI]: total all‐cause 0.86 [0.79, 0.95]; total migraine‐related 0.44 [0.40, 0.48]). In the second cohort (n = 3763), return to continued use (≥3 treatments/year) occurred in up to 70.4% in those with reduced use. Conclusions: Of adults treated with botulinum toxin for chronic migraine, 75.2% had continued use, stable health resource and medication use, and costs over a 2 year period. In those that stopped/reduced use, the observed lower health resource and migraine medication use may indicate improved symptom control, but the resumption of guideline‐recommended treatment intervals after reduced use was common. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to assess the efficacy and safety of a common monotherapy (intravenous [iv] metoclopramide) compared to a combination strategy (adding iv ketorolac to metoclopramide) in children presenting for acute treatment of migraine headache in the emergency department (ED). Methods: Children aged 5–17 years presenting for acute treatment of migraine headache at two pediatric EDs were enrolled in a double‐blind randomized controlled trial. Children were randomly assigned to receive iv metoclopramide 0.2 mg/kg) and placebo or iv metoclopramide (0.2 mg/kg) and ketorolac (0.5 mg/kg). The primary outcome was a mean change in pain from baseline to 120 min via a 100 mm Visual Analog Scale (VAS). Follow‐up was conducted 24‐h after discharge. Results: Fifty‐three children were randomized and included in the analysis (monotherapy group [metoclopramide + placebo], n = 27; and ketorolac group [metoclopramide + ketorolac], n = 26); mean age was 12.9 ± 2.7 years and baseline pain severity on VAS was 67.3 ± 2.7 mm. The mean change in pain intensity at 120 min was −44 mm (SD: 24; 95% confidence interval [CI]: 32–57) for the monotherapy group and −36 mm (SD: 24; 95% CI: 23–49) for the ketorolac group, with a mean difference between groups of 8 mm (95% CI: −9–25; p = 0.360). Seventeen percent of the children (9/53; 95% CI: 7–27%) were pain‐free at discharge. There was no difference in headache recurrence or adverse events between groups. Conclusions: The approach of combining iv metoclopramide with ketorolac failed to improve pain scores in children presenting for acute treatment of migraine headache in the ED compared to metoclopramide monotherapy. Most patients were discharged with residual pain. Further comparative studies are needed to test alternative ED treatments for migraine in children or adolescents. [ABSTRACT FROM AUTHOR]

Objective (1) The primary objectives were (1) to assess the response to intravenous ( IV) fluid in children presenting to the ED with migraine and; (2) to assess the effect of treatment expectation on the response to I. Background Despite a lack of evidence for the practice, many emergency department ( ED) migraine treatment protocols include a bolus of IV fluid. This study assessed the overall response to IV fluid hydration and the effect of expected medication treatment on the pain response among children and adolescents with migraine in an urban ED. Methods A single-blind, randomized parallel arm trial of 10 mL/kg IV 0.9% sodium chloride for children and adolescents aged 5-17 years presenting to a pediatric ED with migraine. Patients were randomized into group A (no expectation of medication in combination with IV fluid) and group B (expectation that medication may be given simultaneously). All participants were treated with standard care following the 30-minute assessment. Results Forty-seven participants were randomized and 2 were excluded; mean age was 13.3 years and 31 (67.4%) were females. Demographics and baseline characteristics were similar between groups. Overall, there was no statistically significant difference for the primary outcome - change from baseline on the visual analog scale ( VAS) at 30 minutes with a mean change of −12.3 mm (standard deviation [ SD] 17.9) in group A and −12.7 mm ( SD 13.2) in group B ( P = .936). The standardized difference between the 2 means ( Cohen's d effect size) was low at 0.024 (95% confidence interval [ CI] −0.56 to 0.61). Overall, complete headache relief was observed in only 1 participant; 16 of 45 (35.6%; 95% CI 21.8 to 51.2) had a reduction in headache of 33% or more and 8 of 45 (17.8%; 95% CI 6.1 to 29.4%) had a minimum clinical significant difference of 30 mm or more on VAS with 4 in each group. Thirteen of 39 patients with follow-up data (33.3%; 95% CI 19.1 to 50.2%) reported a moderate or severe headache at the 24-hour follow up with no difference between groups; only 3 patients returned to the ED. One participant reported a minor IV-related adverse event. Conclusions The overall decrease in pain with IV fluid is small and clinically insignificant. Treatment expectation did not significantly influence headache relief at 30 minutes with IV fluid hydration in children or adolescents with migraine in the ED. The average relief of headache with IV fluid alone was small; however, a clinically meaningful response was observed in 17.8%. Recurrence of headache is common in 33% after ED discharge. [ABSTRACT FROM AUTHOR]

Objectives.—Evidence-based guidelines for the treatment of children with migraine are limited given the paucity of randomized controlled trials, especially in the emergency department (ED). Our objectives were to: (1) characterize the treatment of children with migraine in the ED; (2) determine whether treatment varies in pediatric versus mixed (pediatric and adult) EDs. Methods.—Children aged 5 to 17 years presenting to 4 regional emergency departments in Edmonton, Alberta, Canada during the 2003/2004 fiscal year with a diagnostic code of headache or migraine were selected. A standardized retrospective chart abstraction was performed and migraine or probable migraine cases were classified based on the International Classification of Headache Disorders II. Results.—Three hundred and eighty-two cases were identified of which 48.7% (n = 186/382) met sufficient criteria for migraine. No treatment was given in 44.2% (n = 169/382). Simple oral analgesics (23.3%; n = 89/182) and dopamine antagonists (metoclopramide and prochlorperazine; 20.7%; n = 79/182) were prescribed first-line most commonly. Opiate medications (5.5%), ketorolac (4.7%), dihydroergotamine (1%) were prescribed first-line infrequently. There was a significant difference in the management choices between pediatric and mixed adult/pediatric EDs (χ2= 19.695; df = 5; P= .001). The pediatric ED was more likely to prescribe a dopamine antagonist (12.9 vs 6.8%; P= .044) while the mixed adult/pediatric EDs were more likely to prescribe an opiate (28.1% vs 18.4%; P= .031). Children with migraine in all EDs were significantly more likely to receive drug therapy (68.3% vs 42.9%; P < .001) or a dopamine antagonist (32.3% vs 9.7%; P < .001). Polypharmacy (31.2%; n = 119/382) and neuroimaging (29.1%; n = 111/382) were common. Outcome was poorly documented overall. No adverse events were recorded. Conclusions.—Significant variation in practice in the management of acute headaches in children was observed between mixed population and pediatric-only emergency physicians in the same city. Most children do not receive any drug therapy. Children presenting to the pediatric ED were significantly more likely to receive a dopamine antagonist while opiates were prescribed more commonly in the mixed ED. More clinical trials are required in children to clarify areas of clinical uncertainty on which evidence-based practice guidelines can be formed. [ABSTRACT FROM AUTHOR]