Guest: Deanna Duggan, DNP, APRN, CPNP-PC, PMHS, AQH

View the recording from our Migraine Clinician Masterclass, developed in partnership with IVPN Neuropsychiatry. In this webinar, we hear from Deanna Duggan, DNP, APRN, CPNP-PC, PMHS, AQH, who talks about the Management of Pediatric Migraine. Please note that this video is intended for healthcare providers.

TRANSCRIPT

Deanna Duggan, DNP, APRN, CPNP-PC, PMHS, AQH: Thank you for the invitation and I’m honored to be speaking to you all. I hope that the information that we discuss today will help benefit you as clinicians, particularly being on the front lines of health care when seeing children and adolescents with complaints of headache. 

I have no financial disclosures, although some pharmacological treatments mentioned in this presentation are off label and not approved by the United States Food and Drug Administration for use in the pediatric population. 

I’m not going to read through the learning objectives for the sake of time. However, I will mention some specific migraine-related symptoms that we see in the pediatric population that are a bit different as compared to adults, and taking those into account, individualizing a migraine management plan that can be utilized to help kids for both acute and preventive treatment. 

To start, we know that there are over 100 different headache types that are classified by the International Headache Society, and this link is included on this slide if you had an interest to peruse them. For the sake of pediatrics, we’re mostly going to focus on primary headache type and migraine. But when you first encounter a patient that has a new chief complaint of headache, we need to consider either primary or secondary headache types.

This is a bit of an overwhelming slide, but this is really just a snapshot of some of the more common headache types that are seen, that are described in the International Headache Classification. Part one are primary headache types, including tension-type headache, which are the most common type of headache that most individuals experience in their lifetime, and secondly migraine, which is the most disabling headache type worldwide. There are, even in kids and adolescents, there are kids that suffer from chronic migraine or status migrainosus, which is a migraine lasting longer than 72 hours in duration.

Highlighted on this slide, though, are cyclical vomiting syndrome, abdominal migraine, and other headache types that are specific to pediatrics. So, even with cyclic vomiting syndrome and abdominal migraine, typically those patients, they can present very young, and they don’t have any complaint or behavior associated with headache. Instead, they have bouts of acute gastrointestinal disturbances.

Typically, they’re worked up thoroughly by gastrointestinal primary care colleagues before they come to us in neurology to help solidify our diagnosis. There’s usually sometimes a hunch that they may have abdominal migraine, but these are all syndromes that may be associated with migraine, with the thought that, as children, there’s a lot of rapid growth. 

Specifically, we know there’s the most rapid amount of growth in the brain from birth to three years of age. We have seen and diagnosed toddlers as young as two years of age or even younger with some of these episodic syndromes, and as they continue to grow, sometimes these episodic syndromes will evolve into more of a classic style migraine. 

Now, thinking also about the secondary headaches or part two. If you have a headache that occurred directly as a result of an instigating either injury or illness, then they are considered secondary headaches. But what’s really intriguing is you can certainly have two or three different headache types in the same child or individual at the same time.

You can have, for example, a child who had episodic migraines, but then they experience a concussion, and now they have a secondary headache attributed to head or neck trauma, and then that secondary headache can, in turn, exacerbate the primary headache. The point of this slide is just to give you information that there are specific criteria out there per the International Headache Society, and it really is helpful for us so that we can arrive at the most accurate and comprehensive diagnosis. 

So, what is a migraine? We know it’s an inherited neurologic disorder characterized by sensory, autonomic, vestibular, cognitive, and gastrointestinal symptoms. It’s not just severe head pain. And I try to emphasize that there is a known genetic predisposition because there’s a lot of families, especially when they have a younger child with migraines, who are understandably concerned about the prognosis and potential underlying pathology that may be harmful, and so we really want to explain as much as can to families and set up expectations about what is a migraine. It is a chronic neurologic disorder, and our efforts are aimed to try to help reduce the frequency and severity of their migraine attacks over time.

So, what we know about prevalence of migraines in general is that one billion individuals worldwide experience migraines, and of those, one in five are women. There’s definitely more of a burden that’s seen in women as compared to men. However, one in eleven children experience migraines. And what is known is that half of adults who experience migraines began to develop migraines in childhood. 

With regard to incidence, what we’ve typically seen anecdotally and clinically is reflected in this graph from 2019, where we typically see the mean age of onset of migraine around eight years of age for boys, although certainly it can be much younger, and then around nine years of age for girls. What we also see is that typically the closer that girls approach puberty, the closer they get to puberty, then that’s when we typically see the migraines begin. 

And compared to other common pediatric disorders, migraine carries a heavy burden. I think this slide definitely opened my eyes to, as compared to ADHD and asthma and even ear infections, thinking about a pediatrician or any provider working in primary care, that you’re going to encounter the chief complaint of headache and migraine quite a bit, even in children. 

And because of that, migraines, we know how the frequency, the prevalence in kids, unfortunately, the consequences of migraine, that it does impact their school performance. And so with regard to attendance, because if they’re just not able to attend school, if they need to arrive late or leave early, we see a large impact on school attendance because of migraine. 

And then also with school-reported problems, and this is perhaps a bit vague, but consider this; when a child needs to ask the teacher to be excused to go to the school nurse because of the headache, or perhaps they just lay their head down. It’s also hard for them sometimes to learn. Imagine having a headache, even if it’s not severe, but a moderate headache and trying to learn a new math equation or how to plug in a formula. You’re not going to be, the kids aren’t at 100%. And so there’s struggles with their school performance related to the migraine. And then also, unfortunately, that may lead to the necessity for them to repeat a grade. 

So pathophysiology of migraine, just in brief. We don’t have a complete understanding of everything involved that’s going on inside the brain during a migraine attack. But what we do know is that there is activation of the trigeminal nucleus caudalis, thalamus, hypothalamus, and cortex. And there’s several neurotransmitters and neuropeptides, for example, calcitonin gene-related peptide, neurokinin-1, that are produced in the trigeminal ganglion. And this is known to play a role in the modulation of pain transmission and vascular tone.

So data from studies that are recent support the impression that a presensitized state exists in the peripheral nervous systems of individuals with migraines. So this explains why even when you’re not in the middle of a migraine attack, even with kids, that they can still have light sensitivity and noise sensitivity or osmophobia. 

And during the phases of a migraine attack, there is an anatomical correlation of what’s going on during these phases of an attack. So with the prodrome or premonitory symptoms, this is a hypothalamic event. And initially, before the pain begins, a child can experience fatigue, yawning, mood changes, and food cravings.

Not all children or individuals with migraines experience an aura. But if they were to experience an aura, then we would see that either before the onset of pain or after the onset of the head pain. And with the aura specifically, this is a cortical event referred to as cortical spreading depression. So the cortex changes that are happening in the occipital lobe would result in a visual aura, in the parietal areas, sensory aura, and in temporal areas would result in a language symptom related to the aura. 

And with the headache phase at the onset of the pain, this is when we have trigeminal nucleus caudalis to trigeminal ganglia activation and then followed by after the headache attack has resolved, there’s still a postdrome. And this can last 24 to 48 hours. And this is the cortex and brainstem in recovery where there’s still some residual fatigue, cognitive changes, perhaps neck stiffness. 

So pertaining to auras, just briefly mentioned in the last slide, prevalence of auras in children is estimated to occur between 15 to 30% of children with auras. And auras may last 5 to 60 minutes. And the reason that this is delineated from 5 to 60 minutes is that an aura, especially any kind of sensory change that lasts less than five minutes, that may raise clinical suspicion for another neurologic issue, such as seizure. But typically, we see auras last from 5 to 60 minutes. And within that timeframe, there can be a succession of auras, but this is a bit reassuring to us that this is fitting within the international headache classification. 

Also, aura may occur before or during the headache, as mentioned previously, but it can also occur without a headache. So you can have an aura without the headache whatsoever.  But those kids we usually typically follow fairly closely over time. 

Of the auras, visual aura is the most common aura, but kids can also report, for example, paresthesias to their extremities, even involving perhaps a cheek, their tongue, speech, language, or even motor deficits. But with auras that are migraine related, we know that they’re fully reversible. When the headache attack is resolved, so the aura should have resolved as well. 

With specific mention of blurred vision, there are some individuals who report blurred vision during a migraine attack, but without any other positive or negative features of a visual aura. Generalized blurred vision on its own is not necessarily considered or indicated as aura.

So what’s the difference between a migraine and tension-type headaches? Since we’re looking at, these are the top two most commonly reported headaches in pediatrics. The big differences that I hope to help you draw your attention to with highlighted is migraines are moderate to severe in intensity, whereas tension-type headaches are mild and moderate. As far as the location of the pain, according to the international classification as mentioned here, kids may report pain, even adults, unilateral or bilateral.

But in my experience with kids, typically when you ask them to localize their pain, where does your head hurt the most, usually the younger kids will point directly to the midline of their forehead or bi-temporal areas. It’s usually not until later on in adolescence or late teens to where maybe the pain kind of migrates and becomes more unilateral. Whereas with tension headaches, the headaches can be bilateral. Also a lot of times kids will describe it as holocephalic. 

A migraine has a throbbing quality of the pain. But in kids, sometimes, especially if they’re very young or they’re not able to verbalize the description of the characteristics of the pain, when we ask them, what does it feel like when your head hurts? Can you describe it? Sometimes they’ll say it feels like a hammer is pounding in my head, which has been helpful for us. 

Thinking about young, young kids too, especially if kids are nonverbal, for example, with autism spectrum disorders, then we may have to infer from their behavior what their activity level was prior to, and then after the onset of the attack, what changed? Did they stop what they’re doing? Did they develop facial pallor? Did they lie down? Did they vomit and fall asleep? 

Considering how long of a duration a migraine attack must be for kids to qualify as a migraine per the criteria, the attacks need to last at least two hours. We also consider the amount of time if they were to stop their activity, lie down, and fall asleep, even while they’re asleep, we don’t assume that their migraine attack is resolved. We assume, actually, the opposite. They’re probably sleeping through the pain. We consider that when the child is asleep, that that is included into the duration of the migraine attack. 

One of the main symptoms involved with migraine that’s a giveaway is nausea or vomiting. With tension-type headache, absolutely no nausea or vomiting can be experienced by the child. Automatically, with the presence of nausea or vomiting, tension-type headache is excluded per the criteria. 

Then for migraine, sensitivity to light and noise, whereas with tension-type headache, the child cannot experience no more than one of photophobia or phonophobia.

Now with triggers, I mentioned before that I typically try to educate families that the cause of migraine, and it may be a bit simplistic to explain it this way, but I think it can really help them understand the concept. There’s the genetic predisposition. It’s intrinsic. But triggers exist inside and outside the body that can certainly serve as catalysts to set off and bring about an exacerbation of migraines.

Stress is number one, either physical or behavioral. There’s times of the school year where we see a lot more stress built up than others typically. Usually, as kids get ready towards the end of a term with final exams, projects due, in combination with any other extracurricular activities or athletics that they might be involved in, it just becomes a cumulative overload, so to speak, and the stressors can be a strong trigger. Also, inadequate sleep, prolonged or strenuous exercise for very competitive athletes, fasting, dehydration, all of these things listed. 

Last but not least, and this is not an exclusive list, there are a lot of dietary triggers out there, and it’s sometimes not always easy to identify an obvious trigger. For example, I had one patient who told me that every time they ate pizza from a certain grocery store that their family bought it from, that pepperoni on that pizza triggered a migraine, but they could eat pepperoni pizza from a different restaurant and they were fine. So it’s really rare for families to be able to identify the trigger that specific. 

But the take-home message is not everybody’s triggers are the same, and moderation is key, and if you start to notice a pattern, then it perhaps may be a migraine trigger. For example, MSG, which are additives in a lot of the junk foods, also chocolate, aged vegetables or fruits, things of that nature. 

And being that we are on the front lines, seeing patients in clinical settings, a lot of times with kids and their parents, there’s a lot of heightened anxiety about are we really sure that this is what it is? And as clinicians, we try to reassure the families if we have ruled out that we’re not dealing with another disorder, their neurologic exam is normal, and also the characteristics of the headache and the headache pattern are reassuring.

So consider the presentation pattern. So reassuring patterns are acute recurrent. So there’s, for example, a nine-year-old female who, she experiences four to five migraine attacks per month, and in between her headaches, she’s completely at 100% baseline. Her activity level is normal, she’s thriving in school. But during the migraines, certainly they are affecting her.

And then also chronic, nonprogressive where there are kids, it’s unfortunate where they actually experience chronic daily unremitting headaches for an extended amount of time, months to years, but that specific headache intensity on a regular, on an average daily level and also their associated symptoms, may fluctuate a bit, but it’s pretty much remained stable. Those are reassuring patterns. 

Although we have strategies for both, they’re not alarming, whereas worrisome patterns are, as demonstrated on this slide, when you have acute thunderclap, a chronic progressive headache, or you have a drastic change and an escalation that raises concern, any kind of drastic change in pattern as well that warrants further evaluation.

With regard to red flags specific to children, this is a mnemonic that some of you may have come across in the past. We call it SNOOPY. With regard to what findings would cause us concern to really investigate for underlying pathology that would then result in a secondary headache, so any systemic symptoms, secondary risk factors like immune deficiencies, cancers. In kids, diabetes type 1. If their sugars are not adequately controlled, that can certainly exacerbate and potentiate headaches. Neurologic signs that are abnormal, papilledema, onset of the headache if it’s sudden, occipital and location. 

There’s a debate on this specifically with regard to if the pain is only occipital, if it’s isolated to the occipital area, especially in the pediatric population, we typically want to address the possibility of a cervicogenic headache or was there a history of injury because that location of the pain in and of itself isn’t entirely associated with migraine. You can, like I said earlier, have a combination of two or three headache types, but we would really want to do more thorough evaluation. 

A pattern change, precipitance, so Valsalva or position change specifically. Is the headache at its worst first thing in the morning when their head is still on the pillow and they open their eyes, is that when the pain is intense? Or they can’t tolerate coughing or bending over, we may have concern for increased intracranial hypertension. Also, with a young age, so any child younger than six years of age that has a concerning fulminant onset of headache, then this would definitely raise a red flag.

So clinical pearls for the clinician, when you’re faced with these red flags, you’re seeing these patients and you’re concerned, what is their disposition? What should you do? So for thunderclap headache or the worst headache of their life, they’ve never had a headache this bad before, then we send them to the EC. Also, if its intractable vomiting upon awakening, we send them to the emergency center. Any kind of abnormal neurologic finding, including fundoscopic exam, and then any concern specifically with regard to fever when we’re worried about a central nervous system infection, we send them directly to the emergency department for prompt evaluation. 

Yellow flags are, well, we’re concerned, but we’re comfortable that we may with close follow-up order an evaluation as an outpatient, specifically thinking about imaging or referrals to other providers, maybe ophthalmology. So a patient younger than six years of age, a new onset or new daily persistent headache, change in headache pattern. By the way, we saw and we had been seeing quite a bit even in adolescents with long COVID, where they had definitely what presented as what would have been a new daily persistent headache, although they had a temporal relation to acute COVID infection a few weeks prior to that. 

A side-locked headache, headache consistently waking a patient up from sleep, especially in the pediatric population, that is a concern, and then also positional headache or Valsalva induced.

So with regard to evaluation, there are diagnostics that we typically order to investigate what’s going on, specifically for any kind of anatomical abnormalities that may be a cause for a secondary headache. There are a variety of imaging options that are available, but that may depend on your location, what area you’re in, if you’re in a hospital-based clinic, or if you’re in a rural area where there’s not much available. So a brain MRI is preferred as first line where that really is going to reveal more as far as looking at the tissues, white matter, gray matter, and structures of the midbrain.

However, if there’s a concern for an acute bleed, if there’s been trauma, then a head CT, if that may be available first and much faster. 

But going back to the MRI, typically we order without contrast. And the reason is that magnets have, the technology of MRI has improved to the point where we typically don’t necessarily need to give gadolinium-containing compounds. There is a concern with gadolinium compounds, which is the contrast that’s used with MRI, is that there are still some trace amounts that can be, that have been found in tissues years later after administration. So just out of an abundance of caution, we avoid using contrast unless there is a known lesion that we need to check for interval changes.

Lumbar puncture, if there is a concern for intracranial hypertension or even low pressure, and also labs to evaluate for systemic illness and any other markers of inflammation, nutritional deficiencies, and metabolic screening. 

So, and there are some resources available to help and that have given guidance to the clinicians about trying to avoid unnecessary imaging exams. The consensus is that if there is a normal neurologic exam and there’s no atypical features and the headaches are consistent with migraines, typically neural imaging is not recommended, even in children, unless there’s some of those red or yellow flags or the SNOOPY mnemonic that make you have a clinical concern.

So now on to migraine management.

Briefly, let me just kind of mention, first and foremost, the foundation of our management plan really needs to involve making sure that kids are adequately hydrated, and this is just what we typically use to calculate maintenance fluid requirements. Kids are getting nutrition that’s good. The best way to get to nutrition is through the whole foods that we eat with dark green leafy vegetables and fruits, legumes.

However, sometimes kids are picky, and so we really need to sit down and kind of sort through what is their typical, what is their typical diet on a daily basis consisting of, gives us opportunities for counseling and encouragement. Also, routine exercise doesn’t necessarily have to be strenuous exercise, but exercise. Walking is great. If that’s baby step, then that’s one thing at a time that we can do to encourage them to exercise. Maintaining a regular sleep cycle and then managing stress.

So with acute care, looking at what do we have to offer children that have breakthrough migraine attacks? I like this slide. This is actually borrowed from the American Headache Society, where looking at, there’s kind of a small fire, medium fire, big fire.

So for a milder to moderate headache, we can start with trying an NSAID and then making sure, looking at, are there any triggers that are going on? Do they need to eat? Do they need to hydrate? Do they need to rest? Perhaps those interventions alone may stop the migraine from progressing. 

Whereas if the migraine is already moderate to severe, we may consider giving them a triptan either alone or in combination with an NSAID. And then when the migraines are at their worst, and specifically if they’re associated with nausea and vomiting, then we can also, in addition to triptan and NSAID, consider giving them a dopamine antagonist. 

So here is a list of American Headache Society guidelines in AAN, looking at the different triptans, NSAID. Now there’s, you can also have provider preference, but these actually do have FDA approval for children and adolescents younger than 18 years of age. Specifically, looking at zolmitriptan nasal spray, has an indication for six years and older, and rizatriptan, the dispersible tablet, also has indication for six years or older. The remainder of the triptans are approved for 12 years of age and older.

But as providers, if we can maybe perhaps switch triptans and consider others off label. And then these are the most common dopamine antagonists that we have available in the United States that we use to try to abort the severe migraine attack, especially if they are associated with vomiting or they’re persistent despite administration with NSAID with the triptan. 

The next slide is really just more of a comprehensive list of, there are triptans that we do sometimes use, again, off label. The benefit of frovatriptan and naratriptan is that they do have longer half-lives. So in instances where adolescents may have menstrual-related migraines or migraines that tend to just persist for days, those may be more beneficial to try. Again, that’s up to the discretion of the provider and disclosure to the family.

And with regard to triptans, as I briefly mentioned, they’re available nasal spray, dispersible tablet, or tablets that are swallowed whole. But typically when you’re prescribing these, there’s a rule of two. No matter what the formulation, you can take a second dose if needed after the first dose, but there needs to be a two-hour time frame of between the first and the second dose. And that’s pretty much true, that’s true of all triptans. And typically, no more than two doses in a 24-hour time frame. And we ideally encourage patients and families not to administer or give or take triptans any more than twice per week to avoid medication overuse or rebound headache. 

And just also a little note, being that we see a lot of kids that have comorbid anxiety and depression, and they may also be taking an SSRI or SNRI per psychiatry to manage those conditions. Oftentimes, when we prescribe triptans, there is a drug-drug interaction, kind of a pop-up box that may present to us to say, oh, there’s a risk of serotonin syndrome or serotonin toxicity.

But the American Headache Society has issued a position statement that says there’s really not enough available evidence to support the limited use of triptans, being that triptans are administered on an as-needed basis. Triptans are not prescribed to be taken daily. So being that it is used ideally as a sparing type of acute treatment, we typically will prescribe triptans even if the child is taking an SSRI or SNRI.

Common side effects to warn children of is with regard to triptans, particularly sumatriptan, is they can have tightness of the face, neck, and chest. They can feel hot. It can be really, for some, intolerable, and for others, it’s not bothersome at all. So we really ask the kids, how do you feel? Does it help you? Do the benefits outweigh the side effects? And so that’s what we take into consideration when we revisit and see them for follow-up. 

Contraindications to triptans is heart disease, cerebrovascular disease, rare migraine subtypes such as hemiplegic migraine or migraine with brainstem aura, and uncontrolled hypertension. 

So we typically formulate a migraine action plan or migraine management plan for kids to have at school. It’s helpful for the school nurses to have this so they can follow along, similar to an asthma action plan. So that we have a step one, again, with that stratified care, step two, and then step three if the migraine persists despite those initial interventions. And this is really helpful to have on file with the school, and hopefully it can help ameliorate some conflict that can happen with regard to the missed amount of school that they have and needing to miss class to treat the migraine itself.

So a few pearls for quick treatment. So if one triptan is tried and it’s not effective, we typically will switch and try another triptan. Once we’ve tried three separate triptans, what are the chances that a fourth triptan may be effective? It’s rather slim. So again, kind of at the discretion of maybe we need to think about a different combination of approach, thinking about adding, trying a different NSAID. And then if the migraines are quite chronic, especially if they’re near daily, a lot of times triptans just don’t, they are not effective and they won’t work well.

It’s not to say that they may not work later on, but until we have a good preventive plan in place, the acute plan may not be near as effective. And then please refer to a headache specialist if you feel that you’ve exhausted all options and let us help see if we can get a different plan in place to get their migraines better controlled, better effectively aborted.

So when do we prescribe preventive therapy? When there’s frequent days of headache, it interferes with school activities, you may have a patient-parent preference to do so, and especially if they’re over, they’re too frequently taking acute medications. 

So nutraceuticals. I consider nutraceuticals as first line, but then it also depends on the fulminant nature of the headaches themselves. But a lot of families are willing to try nutraceuticals initially. Riboflavin has fairly good evidence to be of help. Magnesium is thought to have anti-inflammatory properties to it. Coenzyme Q10 also can be helpful. Melatonin, there’s a little bit of conflicting evidence as far as how effective it is at managing chronic migraine. However, it may be helpful for kids that have difficulty falling asleep, especially on school nights.

And just of note, Petasites or Butterbur root is no longer currently recommended for use as a preventive, although there was some supporting evidence that it could be helpful. But there is a naturally occurring element in the root that are phenylalkalinoids that can cause liver toxicity. And to be cautious, we don’t want to cause that kind of toxicity or liver damage in kids, so we’ve avoided it. It’s really difficult to detect how much of those PAs are in the root itself. There may be some manufacturers who can ensure that, but until we have more reassurance, we have abandoned recommending it for use in kids. 

With pharmaceuticals, topiramate in the United States is the only preventive medicine that has indication for use in children 12 years and older, whereas amitriptyline, propranolol, valproate, and cyproheptadine have been used for years, first line, as pharmaceutical agents to help manage migraines on a preventive basis. Really, we have to look at the other possible comorbid health factors that are going on with the child and make the best judgment that we can and discuss possible side effects and goals for treatment with the family regarding each medication. 

And also to mention, other strategies that can be very helpful, especially in tandem with pharmaceutical and nutraceutical treatments, are the biobehavioral approaches where biofeedback, cognitive behavioral therapy, clinical hypnosis, physical therapy, and acupuncture can be extremely helpful and, in some cases, are more helpful for the children as compared to several preventive medications that they’ve tried. So these strategies definitely need to be brought to the forefront of consideration when kids start to develop more frequent migraines or chronic migraines.

But returning back to the notion of the first-line pharmaceutical approaches that are used for prevention, there was a study that was conducted several years ago that looked at head-to-head the benefits, the efficacy of topiramate versus amitriptyline versus placebo in children over 24 weeks that had frequent to chronic migraines. And the findings were a bit surprising because neither topiramate nor amitriptyline had demonstrated any improvement over placebo. So what this tells us is that there’s really no one slam-dunk, surefire treatment approach as far as pharmaceuticals that’s going to be guaranteed to be efficacious.

What we have to do is consider each child on an individual basis, looking at their holistic health, and then considering all other possible treatment strategies that may be beneficial to them, and if we do select a pharmaceutical option, that we consider the side effects and how that may impact their health as well. 

So some tips. Set appropriate expectations. I wish we could bold highlight this and make this 60 font. Families need to understand that even though we are starting a preventive treatment plan, they’re still going to have breakthrough migraines.

There’s no cure that just because they’re going to start this medicine that doesn’t ensure that they’re never going to have breakthrough migraine attacks. And so the expectations need to be clear that we’re using this medicine to try to help slow down the progression of or reduce the frequency and intensity of, to improve quality of life. There are naturally always super responders. There are some kids, even adults, who try preventive, and it’s like they’ve got a completely different life, and they don’t remember the last time they had a breakthrough migraine. But that’s typically not the case, so we really want to set expectations.

We also want to be forthcoming about possible side effects, and by trying to mitigate those from being intolerable, we titrate slowly. And then the goal is eventually to, if we can get the migraine frequency stabilized, eventually over time try to wean off the medication. This isn’t a medicine that we intend for them to take forever or for the rest of their lives. 

So, if they are referred to headache specialists, there’s other treatment options that we can consider; CGRP antagonists, Botox injections per chronic migraine protocol, nerve blocks, and then what’s really promising is neuromodulation devices of how these have come available and have authorization for use in the United States for kids 12 years and older.

So, in summary, we want to make an accurate diagnosis, rule out secondary headache types, provide acute treatment with a management plan for school, also some preventive strategies, and then also consider behavioral, nutraceutical, and other medical managements in combination to reduce their disability. 

Thank you, and I’m happy to take any questions. I apologize for going over time.

*The contents of this video are intended for general informational purposes only and does not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. AMD and the speaker do not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.