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Objective: This observational study aimed to: (i) describe and explore preliminary psychometric properties of a multidimensional sleep health composite score in adolescent females with frequent migraine; and (ii) examine associations between the composite score, headache characteristics, and emotional health. Background: Sleep health is a multidimensional construct comprised of various dimensions of sleep and circadian functioning, including Regularity, Satisfaction, Alertness, Timing, Efficiency, and Duration (Ru‐SATED framework). The Ru‐SATED sleep health composite score may provide a holistic perspective of sleep among adolescents with frequent migraine in the context of neurobiological and psychosocial impacts on sleep unique to this developmental period. Methods: In all, 60 female adolescents (aged 12–18 years) with high‐frequency episodic or chronic migraine completed wrist‐worn actigraphy for 10 days and concurrent daily electronic surveys assessing headache, sleep, and emotional health. A sleep health composite score was derived from empirically supported "healthy" versus "unhealthy" ratings on the six Ru‐SATED sleep dimensions. Results: Half of participants (27/54 [50%]) had a composite score ≥4 (i.e., at least four of the six dimensions rated as poor). Convergent validity of the composite score was acceptable (rs = 0.30–0.56, all p < 0.05). Internal consistency among the dimensions was low (α = 0.45). Multivariate multiple regression models indicated that worse sleep health was associated with greater headache‐related disability (B = 0.71, p = 0.018) and anxiety (B = 0.59, p = 0.010), and trended toward significance for sadness (B = 0.35, p = 0.052). The composite score was not significantly associated with headache frequency or severity. Conclusions: A multidimensional sleep health composite score may provide an alternative, more comprehensive picture of sleep disturbance among adolescent females with frequent migraine. Larger studies are needed to examine psychometric properties more rigorously and further explore the composite score as a potentially unique predictor of headache outcomes. [ABSTRACT FROM AUTHOR]

Objective: We aimed to determine if T2‐weighted hyperintense white matter lesions (WMLs) on brain magnetic resonance imaging (MRI) occur more frequently in pediatric patients with migraine and other primary headache disorders compared to the general pediatric population. Background: Small foci of T2 hyperintensity in the white matter are frequently identified on brain MRI during the workup of pediatric headache. Such lesions have been reported to be more common among adults with migraine versus adults without migraine; however, this association has not been well established in the pediatric population. Methods: We performed a retrospective cross‐sectional single‐center study of electronic medical records and radiologic studies, examining pediatric patients from 3 to 18 years old who underwent brain MRI between 2016 and 2021. Patients with existing intracranial disease or abnormalities were excluded. Patients with reports of headache were categorized. Imaging was reviewed to determine the number and location of WMLs. Headache‐associated disability scores (Pediatric Migraine Disability Assessment) were noted, when available. Results: Brain MRI of 248 patients with a diagnosis of headache (144 with migraine, 42 with non‐migraine primary headache, and 62 with headache that could not be further classified) and 490 controls were reviewed. WMLs were encountered commonly among all study participants, with a prevalence of 40.5% (17/42) to 54.1% (265/490). There was no statistically significant difference comparing the number of lesions between each of the headache groups and the control group: migraine group versus control group median [interquartile range (IQR)], 0 [0–3] versus 1 [0–4], incidence rate ratio [95% confidence interval (CI)], 0.99 [0.69–1.44], p = 0.989, non‐migraine headache group versus control group median [IQR], 0 [0–3] versus 1 [0–4], 0.71 [0.46–1.31], p = 0.156, headache not otherwise specified group versus control group median [IQR], 0 [0–4] versus 1 [0–4], 0.77 [0.45–1.31], p = 0.291. There was no significant correlation between headache‐associated disability and the number of WMLs (0.07 [−0.30 to 0.17], rho [95% CI]). Conclusion: T2 hyperintense WMLs are common within the pediatric population and are not encountered more frequently in pediatric patients with migraine or other primary headache disorders. Thus, such lesions are presumably incidental and unlikely related to headache history. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy and safety of zolmitriptan nasal spray (ZNS) in the acute treatment of migraine headache in patients aged 6 to 11 years. Background: Triptans have demonstrated efficacy in adults, but pediatric studies of these agents have largely failed and there are few triptan options for these patients. Because lack of response to 1 triptan does not necessarily preclude response to an alternate triptan, additional triptan options for pediatric patients are desirable. Methods: This Phase 3, randomized, double‐blind, placebo‐controlled, multicenter crossover trial with an open‐label extension enrolled patients aged 6 to 11 years with a diagnosis of migraine for ≥6 months and ≥16 headache‐free days/month (N = 373). After a run‐in period to eliminate placebo responders, 186 patients were randomized within their body weight stratum to ZNS followed by matching placebo, or placebo followed by matching ZNS. Patients <50 kg who were randomly allocated to ZNS were randomized to 5:1 to ZNS 2.5 or 1.0 mg; those ≥50 kg were randomized 5:1 to ZNS 5.0 or 2.5 mg. Patients had 6 weeks to treat 1 moderate to severe migraine headache and then crossed over to the alternate arm, during which they had 6 weeks to treat a second migraine attack. Patients could participate in a subsequent 6‐month outpatient open‐label extension. The primary efficacy endpoint was pain‐free status at 2 h in patients treated with the high dose from each stratum. Results: The trial was terminated early due to slow enrollment. Three hundred patients (mean age, 9 years) entered the placebo run‐in period and 186 entered the double‐blind period. Pain‐free status at 2 h postdose was achieved by 45/133 (33.8%) and 30/128 (23.4%) of patients who received high‐dose ZNS and placebo, respectively (p = 0.0777; odds ratio [OR] 1.51; 95% confidence interval [CI] 0.96, 2.38). Several secondary endpoints achieved statistical significance. There were few treatment‐related adverse events and none led to discontinuation. ZNS retained efficacy and demonstrated a consistent safety profile throughout the 6‐month open‐label extension. Conclusion: The effect of high‐dose ZNS on the primary endpoint of pain‐free status at 2 h did not achieve statistical significance. ZNS was safe and well tolerated in this pediatric population. [ABSTRACT FROM AUTHOR]

Objective: As a post‐approval commitment, this dose‐ranging study was undertaken to evaluate efficacy and safety of onabotulinumtoxinA in adolescents. Background: In adolescents, migraine is often undiagnosed or misdiagnosed and can present unique management challenges. OnabotulinumtoxinA was approved for prevention of chronic migraine (CM) in adults in 2010. Methods: This multicenter, double‐blind, parallel‐group, randomized trial assessed a single treatment of onabotulinumtoxinA (155 U or 74 U) vs placebo (intramuscular saline) administered via the recommended fixed‐dose fixed site paradigm in adolescents with CM aged 12 to <18 years. The primary efficacy measure was change in frequency of headache days from baseline at week 12; other measures included change in frequency of headache days at weeks 4 and 8 and change in frequency of severe headache days. Safety and tolerability were assessed. Results: Of 125 randomized patients (onabotulinumtoxinA 155 U, n = 45; onabotulinumtoxinA 74 U, n = 43; placebo, n = 37), all were included in the primary efficacy analysis, and 115 (92.0%) completed the study. Lack of efficacy was the primary reason for discontinuing (n = 4; 3.2%); no patients discontinued because of adverse events. All treatments reduced frequency of headache days at week 12, with no significant differences between treatments. The mean (95% confidence interval) changes from baseline in the frequency of headache days during the 28‐day period ending at week 12 (primary endpoint) were −6.3 (−8.5, −4.2), −6.4 (−8.8, −4.0), and −6.8 (−9.6, −4.1) days in the onabotulinumtoxinA 155 U, onabotulinumtoxinA 74 U, and placebo groups, respectively (P ≥.474). All treatments reduced frequency of severe headache days and were well‐tolerated; serious adverse events (n = 3) were considered unrelated to treatment and resolved without sequelae. The most commonly reported treatment‐emergent adverse events were neck pain (n = 8), upper respiratory tract infection (n = 7), migraine, and nasopharyngitis (n = 5 each). Conclusion: Although this study did not meet its efficacy endpoints, onabotulinumtoxinA was well tolerated in this adolescent population. Given previous data demonstrating the benefits of onabotulinumtoxinA in adults with CM, additional studies with design modifications, including adequate statistical power, to assess the efficacy of multiple treatment cycles of onabotulinumtoxinA for CM prevention in adolescents may be informative. [ABSTRACT FROM AUTHOR]

Objective: To provide evidence‐based recommendations for the acute symptomatic treatment of children and adolescents with migraine. Methods: We performed a systematic review of the literature and rated risk of bias of included studies according to the American Academy of Neurology classification of evidence criteria. A multidisciplinary panel developed practice recommendations, integrating findings from the systematic review and following an Institute of Medicine‐compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence. Results: There is evidence to support the efficacy of the use of ibuprofen, acetaminophen (in children and adolescents), and triptans (mainly in adolescents) for the relief of migraine pain, although confidence in the evidence varies between agents. There is high confidence that adolescents receiving oral sumatriptan/naproxen and zolmitriptan nasal spray are more likely to be headache free at 2 hours than those receiving placebo. No acute treatments were effective for migraine‐related nausea or vomiting; some triptans were effective for migraine‐related phonophobia and photophobia. Recommendations: Recommendations for the treatment of acute migraine in children and adolescents focus on the importance of early treatment, choosing the route of administration best suited to the characteristics of the individual migraine attack, and providing counselling on lifestyle factors that can exacerbate migraine, including trigger avoidance and medication overuse. [ABSTRACT FROM AUTHOR]

An editorial is presented in which author discusses new guidelines of migraine. Topics discussed include information on guidelines from American Academy of Neurology (AAN) in collaboration with specialty societies has developed a growing number of evaluation and treatment guidelines; challenges of guideline development like finding strength of the evidence of efficacy; and use of the standardized approach of the guideline development.

Objective: To provide updated evidence‐based recommendations for migraine prevention using pharmacologic treatment with or without cognitive behavioral therapy in the pediatric population. Methods: The authors systematically reviewed literature from January 2003 to August 2017 and developed practice recommendations using the American Academy of Neurology 2011 process, as amended. Results: Fifteen class I‐III studies on migraine prevention in children in adolescents met inclusion criteria. There is insufficient evidence to determine if children and adolescents receiving divalproex, onabotulinumtoxinA, amitriptyline, nimodipine and flunarizine are more or less likely than those receiving placebo to have a reduction in headache frequency. Children with migraine receiving propranolol are possibly more likely than those receiving placebo to have an at least 50% reduction in headache frequency. Children and adolescents receiving topiramate and cinnarizine are probably more likely than those receiving placebo to have a decrease in headache frequency. Children with migraine receiving amitriptyline plus cognitive behavioral therapy are more likely than those receiving amitriptyline plus headache education to have a reduction in headache frequency. Recommendations The majority of randomized controlled trials studying the efficacy of preventive medications for pediatric migraine fail to demonstrate superiority to placebo. Recommendations for the prevention of migraine in children include counseling on lifestyle and behavioral factors that influence headache frequency, and assessment and management of comorbid disorders associated with headache persistence. Clinicians should engage in shared decision making with patients and caregivers regarding the use of preventive treatments for migraine, including discussion of the limitations in the evidence to support pharmacologic treatments. [ABSTRACT FROM AUTHOR]

The article focuses on development of the medical transfer packet for transition of care of the pediatric patient with headache. Topics include the roles that pediatric providers play in caring for adolescents and young adults (AYA) with chronic diseases is transition to adult care, the transition AYA with headache disorders to adult care there is a consensus statement from the American Academy of Neurology, and the neurologist's role in supporting transition of AYA with neurological disorders.

The article highlights information about an application form regarding Pediatric Migraine Action Plan (PedMAP).

Children and adolescents can experience significant disability from frequent migraine. A number of tools have been developed to help quantify the impact of migraine in this population. Many preventative medications used in adults are routinely used to prevent migraines in children, although there has been less rigorous study. This article reviews the indications and evidence for the use of migraine preventatives, such as antidepressants, antihypertensives, anticonvulsants, antihistamines, and botulinum toxin, in this population. [ABSTRACT FROM AUTHOR]

Objective To compare outcomes of pediatric migraine patients treated in an emergency department ( ED) before and after implementation of a standardized combination intravenous therapy regimen aimed toward improving and standardizing abortive migraine therapy. Background In a pediatric ED, migraines represent 8-18% of all headache visits. Despite this large number, no standard treatment for acute migraine therapy currently exists. Methods The study utilized a retrospective chart review of patients seeking acute migraine treatment at a tertiary care, pediatric ED from August 2006 to March 2010. Inclusion criteria were pediatric migraine patients as defined by International Headache Society guidelines. The comparison population received various migraine therapies based on attending practice preference. After October 2008, patients received standardized intravenous combination therapy involving a normal saline fluid bolus, ketorolac, prochlorperazine, and diphenhydramine. Occasionally, metoclopramide was substituted during prochlorperazine shortages. Reduction in headache pain score was the primary outcome. Secondary outcome measures included length of ED stay, hospital admission rate, and ED readmission rate within 48 hours. Results The study yielded 87 patients who received standardized combination therapy and 165 comparison patients. No significant difference in patient characteristics existed when evaluating patient demographics, outpatient medication use, and initial headache pain score. When compared with the non-standardized therapy population, the combination therapy patients revealed significant reductions in pain score (decrease of 5.3 vs 6.9, difference −1.6, 95% confidence interval −2.2 to −0.8, P < .001), length of ED stay (5.3 vs 4.4 hours, difference 0.9, 95% confidence interval 0.2-1.6, P = .008), and hospital admission rate (32% vs 3%, P < .001) without changes in ED return rate (7% vs 2%, P = .148). Conclusion Standardized combination therapy is effective for acute pediatric migraine therapy in the ED by significantly reducing headache pain scores, length of ED stay, and hospital admission rates. [ABSTRACT FROM AUTHOR]

Objective.— To examine the prevalence of obesity, the relationship between weight compared with headache frequency and disability, and effect of weight change on headache outcomes within a pediatric headache population. Background.— Headache and obesity are both common conditions in children and adults. Research in adults has suggested a relationship between the 2 conditions. This relationship has not yet been explored within a pediatric population. The effect of obesity and weight change on headache outcomes may have important implications for clinical care. Method.— Data on height, weight, age, and gender, as well as headache frequency and disability, were collected on 913 consecutive patients at 7 pediatric headache centers, the body mass index (BMI) calculated and the BMI percentile determined. The same data were collected on patients seen at 3- (n = 213) and 6-month (n = 174) follow-up for comparative analysis. Results.— The prevalence of overweight patients at initial visit did not significantly differ from the general pediatric population. BMI percentile was significantly correlated with headache frequency and disability at initial visit, although the correlations were relatively small. For children who were obese or at risk for overweight as initial visit, change in BMI was significantly positively correlated with change in headache frequency at 3- and 6-month follow-up. Conclusions.— Obesity is associated with headache frequency and disability in the pediatric headache population. For children who are overweight, weight loss can contribute to a reduction in headaches over time. Clinicians should consider child weight status in providing care for pediatric headache. [ABSTRACT FROM AUTHOR]

Objective.—To evaluate the sensitivity of the new International Classification of Headache Disorders-2nd edition (ICHD-II) criteria in the diagnosis of childhood migraine and to propose specific criteria for the diagnosis of childhood migraine. Background.—In 2004, ICHD-II was adopted by the International Headache Society. The prior version had been criticized for its lack of sensitivity in diagnosing childhood headaches. ICHD-II is felt to be an improvement as it provides for some differences between pediatric and adult migraine diagnosis in its footnotes, however, has yet to be validated. Clinically, it is the impression of many pediatric headache specialists that children's migraines are of shorter duration, tend to be bilateral rather than unilateral, and that children more often report either photophobia or phonophobia, rather than both. Methods.—The characteristics of headache in 260 patients, ages 18 and under, clinically diagnosed with migraine at two large pediatric headache centers were compiled using standard intake questionnaires. Inter-rater reliability in clinical diagnosis was determined by consensus of the clinical diagnosis. These data were analyzed applying the International Classification of Headache Disorders-1st edition (ICHD-I) and ICHD-II criteria for migraine to determine sensitivity of migraine diagnosis in comparison with clinical impression. Each headache characteristic in ICHD-II was analyzed individually to determine its effect on sensitivity of diagnosis. Results.—183/260 patients (70.4%) met ICHD-I criteria. 161/260 patients (61.9%) met the ICHD-II criteria with a 4- to 72-hour range. When the footnoted allowance of ICHD-II for short duration (2 hours) was utilized, 187/260 patients (71.9%) met criteria, while this improved to 192/260 patients (73.9%) with 1-hour duration. If duration was excluded, 210/260 patients (80.8%) met criteria. The most common reasons for patients not meeting the standard criteria were the requirement of unilateral location, headache duration and number of associated symptoms. Based on these observations, modified criteria were empirically derived and the sensitivity increased to 84.4%. Data were reanalyzed using the criteria of focal head pain, either bilateral or unilateral, shortened duration, and modified associated symptoms, which resulted in an improved sensitivity in migraine diagnosis of 84.4%. Conclusions.—Modification of ICHD-II criteria to include bilateral headache, headache duration of 1 to 72 hours, and nausea and/or vomiting plus two of five other associated symptoms (photophobia, phonophobia, difficulty thinking, lightheadedness, or fatigue), in addition to the usual description of moderate to severe pain of a throbbing or pulsating nature worsening or limiting physical activity, improved sensitivity of migraine diagnosis to 84.4%. [ABSTRACT FROM AUTHOR]