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Acute Treatment of Migraine in Children and Adolescents PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Acute Treatment of Migraine in Children and Adolescents" by American Academy of Neurology.
This medical PowerPoint presentation talks about the efficacy of treatments for acute symptoms of migraine in children and adolescents.
Migraine headaches can be a debilitating condition for children and adolescents, affecting their school performance and quality of life. The treatment of migraine headaches in this population involves both acute and preventive strategies.
The acute treatment of migraine in children and adolescents typically involves the use of medication to relieve pain and associated symptoms. The commonly used medications include NSAIDs, Triptans, Antiemetics, Acetaminophen and Ergotamines etc.

Tags : Migraine in Children and Adolescents, Migraine headaches, NSAIDs, Triptans, Antiemetics, Acetaminophen Ergotamines, Child Neurology PowerPoint presentation, Neurology PowerPoint presentation

Published on : Mar 21, 2023 | Views : 594 | Downloads : 3

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Report by: The Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and The American Headache Society Practice Guideline Update: Acute Treatment of Migraine in Children and Adolescents Slide 1
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Slide 2 Practice Guideline Funding This practice guideline was developed with financial support from the American Academy of Neurology (AAN). Authors who serve or have served as AAN subcommittee members or as methodologists (M.O., Y.H.M., T.P., S.P., L.B., D.G., and N.L.) were reimbursed by the AAN for expenses related to travel to subcommittee meetings where drafts of manuscripts were reviewed. All authors on the panel were reimbursed by the AAN for expenses related to travel to in-person meetings.
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Slide 3 Sharing This Information The AAN develops these presentation slides as educational tools for neurologists and other health care practitioners. You may download and retain a single copy for your personal use. Please contact guidelines@aan.com to learn about options for sharing this content beyond your personal use.
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Slide 4 Presentation Objectives To present evidence on the efficacy of treatments for acute symptoms of migraine in children and adolescents To present practice recommendations for the acute symptomatic treatment of children and adolescents with migraine and behavioral changes that can be made to avoid migraine events or exacerbations
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Slide 5 Overview Introduction Clinical questions AAN guideline process Methods Conclusions Practice recommendations
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Slide 6 Introduction Diagnosis of primary headache disorders is based on clinical criteria specified in the International Classification of Headache Disorders, 3rd edition (International Headache Society).1 Management of migraine includes acute and preventive therapies as well as behavioral and lifestyle changes. Acute treatments must be carefully selected and individually tailored to a patient’s headache pattern, severity, and disability as well as the person’s expectations, needs, and goals of treatment. This practice guideline systematically assess all randomized controlled trials that evaluated acute migraine treatments in children and adolescents. This guideline updates a previous guideline published in 2004 on the treatment of migraine in children and adolescents.
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Slide 7 Clinical Questions The systematic review for this practice guideline addressed the following question: In children and adolescents with migraine, do acute self-administered treatments, compared with placebo, reduce headache pain and associated symptoms (nausea, vomiting, photophobia, and phonophobia) and maintain headache freedom?
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Slide 8 AAN Guideline Process* Clinical Questions Evidence Conclusions Recommendations *Guideline developed using the 2011 AAN Clinical Practice Guideline Process Manual, as amended.
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Literature Search/Review Rigorous, Comprehensive, Transparent Slide 9 Two databases (MEDLINE and Embase) were searched from December 1, 2003, to February 15, 2015. An updated search was conducted January 1, 2015, to August 25, 2017.
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AAN Classification of Evidence (2011) Therapeutic Scheme Slide 10 *Note that numbers I to iii in Class Ie are required for Class II in equivalence trials. If any one of the three is missing, the class is automatically downgraded to Class III.
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AAN Classification of Evidence (2011) Therapeutic Scheme Slide 11
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AAN Classification of Evidence (2011) Therapeutic Scheme Slide 12 **Objective outcome measurement: an outcome measure that is unlikely to be affected by an observer’s (patient, treating physician, investigator) expectation or bias (e.g., blood tests, administrative outcome data).
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Clinical Question: ConclusionsOutcome: Pain Response at 30 Minutes Slide 14 Abbreviations: NS=nasal spray; OT=oral tablet
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Clinical Question: ConclusionsOutcome: Pain Response at 1 Hour Slide 15 Abbreviations: NS=nasal spray; OT=oral tablet
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Clinical Question: ConclusionsOutcome: Pain Response at 2 Hours Slide 16 Abbreviations: NS=nasal spray; ODT=oral disintegrating tablet; OS=oral solution; OT=oral tablet
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Clinical Question: ConclusionsOutcome: Pain Free at 1 Hour Slide 17 Abbreviations: NS=nasal spray
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Clinical Question: ConclusionsOutcome: Pain Free at 2 Hours Slide 18 Abbreviations: NS=nasal spray; ODT=oral disintegrating tablet; OS=oral solution; OT=oral tablet
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Clinical Question: ConclusionsOutcome: Relief of Nausea at 2 Hours Slide 19 Abbreviations: NS=nasal spray; ODT=oral disintegrating tablet; OS=oral solution; OT=oral tablet
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Clinical Question: ConclusionsOutcome: Relief of Vomiting at 2 Hours Slide 20 Abbreviations: NS=nasal spray; ODT=oral disintegrating tablet
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Clinical Question: ConclusionsOutcome: Relief of Photophobia Slide 21 Abbreviations: NS=nasal spray; ODT=oral disintegrating tablet; OT=oral tablet
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Clinical Question: ConclusionsOutcome: Relief of Phonophobia at 30 Minutes Slide 22
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Practice RecommendationsEstablish a Specific Headache DiagnosisRecommendation 1:Rationale Slide 23 The appropriate care of a patient with headaches requires establishing a correct diagnosis. This affects our diagnostic approach, treatment, and prognosis. Patients with signs and symptoms of secondary headache, such as sudden change in headache, papilledema, focal deficits, and the additional presence of seizures, require further evaluation beyond a thorough history and physical examination. When migraine is diagnosed, tailored treatments may be considered that can result in improved outcomes.19 Diagnostic criteria for pediatric migraine include at least 5 headaches over the past year that last 2−72 hours when untreated, with 2 of 4 additional features (pulsatile quality, unilateral, worsening with activity or limiting activity, moderate to severe in intensity), and association with at least nausea, vomiting, photophobia, or phonophobia. These associated symptoms can be inferred by family report of the child’s activities. The time a child sleeps can be considered part of the headache duration. Auras typically occur in about one third of older children and adolescents and precede the headache by 5−60 minutes.1
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Practice Recommendations Slide 24
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Practice RecommendationsAcute Migraine Treatment Recommendation 2:Rationale Slide 25 Migraine treatment should aim to achieve fast, complete pain relief, with minimum side effects. Associated symptoms like nausea, vomiting, photophobia, and phonophobia should also be addressed. In adults, early treatment of migraine (within less than 1 hour of headache onset) improves pain-free rates.20 Improved efficacy with early treatment is likely to be seen in children and adolescents as well. Many children and adolescents use and benefit from nonprescription oral analgesics like acetaminophen, ibuprofen, and naproxen.21 Triptans are less commonly prescribed in children than in adults, and only almotriptan (for patients aged 12 years and older), rizatriptan (for patients aged 6–17 years), sumatriptan/naproxen (for patients aged 12 years and older), and zolmitriptan NS (for patients aged 12 years and older) are approved by the Food and Drug Administration (FDA) for use in children. Ergots and oral naproxen alone have not been studied in children.
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Practice Recommendations Slide 26
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Practice RecommendationsAcute Migraine TreatmentRecommendation 3:Rationale Slide 27 Patients respond differently to the same medication. In adults, failure to respond to one triptan does not preclude response to an alternate triptan.22 In adults, a second dose of triptan at 2 hours does not increase initial efficacy or prevent or delay headache recurrence but is effective in treating migraine recurrence.23 Children might have the same experience, but product monograph daily maximum doses must be followed. Migraine features (severity, associated symptoms, disability, and most bothersome symptoms) differ among individuals and among different attacks in the same individual.24 Intranasal sumatriptan and zolmitriptan are absorbed more quickly than the oral form25,26 and have a faster onset of action.27,28 For migraines that rapidly peak in severity or are associated with nausea and vomiting, nonoral forms of treatment may be more effective. Thus, children with migraine may benefit from more than one acute treatment choice and different delivery routes, depending on their individual headache characteristics.
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Practice Recommendations Slide 28
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Practice RecommendationsAcute Migraine TreatmentRecommendation 4:Rationale Slide 29 Sumatriptan/naproxen OT (10/60 mg, 30/180 mg, and 85/500 mg) is more likely than placebo to result in headache pain-free status at 2 hours. Sumatriptan and naproxen have a different pharmacokinetic profiles targeted to aid in migraine relief.29 In adults, the sumatriptan/naproxen combination OT is more effective than monotherapy with either component.30 Because of cost and insurance issues, not all patients have access to all available formulations of medications. Given the distinct mechanisms of action among medications in the triptan class and the nonsteroidal anti-inflammatory drug (NSAID) class, the addition of an NSAID to a triptan may improve rates of pain response and pain-free status .
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Practice Recommendations Slide 30
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Practice RecommendationsTreatment of Associated SymptomsRecommendation 5:Rationale Slide 31 Migraine is typically accompanied by other symptoms (nausea, vomiting, photophobia, phonophobia) in addition to head pain. Antiemetics are often prescribed along with specific (triptan) and nonspecific (NSAID) migraine treatments to address nausea and vomiting and to speed the rate of medication absorption. In pediatric migraine trials, the treatment effects on migraine-associated symptoms were less pronounced than the treatment effects on pain. While photophobia and phonophobia were responsive to zolmitriptan nasal spray and sumatriptan/naproxen, none of the treatments studied had demonstrated effectiveness against nausea or vomiting. Antiemetics are available to treat nausea and vomiting related to other pediatric conditions (acute gastroenteritis, postoperative state, chemotherapy)31,32 and may be of benefit for migraine-associated nausea, although no clinical trials specifically evaluating antiemetics for pediatric migraine-associated nausea have been performed. Nasal spray formulations of zolmitriptan and sumatriptan may be easier to administer in adolescents with migraine with prominent nausea and/or vomiting .
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Practice Recommendations Slide 32
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Practice RecommendationsCounselingRecommendation 6:Rationale Slide 33 Patient education can improve patient safety and adherence to interventions. It is important to learn about the behavioral aspects of self-care that might improve migraine, including healthy habits with lifestyle modification, potential migraine triggers/aggravating factors, and the risk of overusing medication. Maintaining a headache diary is helpful to track response to any new therapy. Patients and families will benefit from understanding the limitations of current available treatments. Overuse of medication to treat acute attacks has been associated with medication overuse headache in adults33 but has not been well studied in children. Methods to prevent medication overuse headache are included in adult treatment plans.
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Practice Recommendations Slide 34
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Practice RecommendationsContraindications and Precautions to Triptan UseRecommendation 7:Rationale Slide 35 According to the FDA, triptans are contraindicated in patients with a history of cardiovascular disease, including stroke, transient ischemic attacks, myocardial infarction, severe peripheral vascular disease, ischemic bowel disease, and coronary vasospasm, including Prinzmetal angina. Triptans are also contraindicated in patients with cardiac accessory conduction pathway disorders, including Wolff-Parkinson-White syndrome. Although the 2004 American Headache Society consensus statement does not consider these as absolute contraindications,34 these contraindications are based on the known pharmacology of the triptans35 and triptan effects on vascular muscle.36 While these medical contraindications are less prevalent in the pediatric population, they are important to consider. .
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Practice Recommendations Slide 36
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Practice RecommendationsContraindications and Precautions to Triptan UseRecommendation 8:Rationale Slide 37 In adults who have migraine with typical aura, there is evidence that it is safe to take triptans during the aura, although the triptan may be more effective if taken at the onset of pain.37,38 The use of triptans during the aura phase is of concern because of potential difficulties differentiating early stroke symptoms from migraine aura. While this is unlikely a problem in those with established migraine with visual aura, caution is warranted in those with more complex aura presentations. According to the FDA, triptans are contraindicated in those with a history of hemiplegic aura or migraine with brainstem aura. This contraindication was based on a view of migraine pathophysiology that is no longer considered current.
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Practice Recommendations Slide 38
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Suggestions for Future Research Slide 39 Most adults with migraine have onset in childhood or adolescence. Accurate diagnosis and treatment in childhood and adolescence can prevent migraine-related disability and significantly improve quality of life.19 Lifestyle modifications and acute pharmacologic treatments are the mainstay of management. Although the pathophysiology of migraine is presumed to be the same as in adults, a higher placebo response is observed in children and adolescents, with a lower therapeutic gain measured in clinical trials.39 Patterns of migraine presentation and associated symptoms in children and adolescents evolve into the adult patterns and their shortest headaches may be shorter in duration.1 These factors should be considered when designing clinical trials. The fact that all acute treatment trials in children and adolescents are performed after proven efficacy in adults may be a contributor to the expectation response adding to the placebo effect. This expectation response is widely seen in pain studies and may explain why so few trials of acute migraine therapy in children and adolescents have shown positive results.
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Suggestions for Future Research (continued) Slide 40 Although there is a growing body of evidence to support recommendations for the acute treatment of pediatric migraine, challenges remain. Many children and adolescents do not respond to treatment at home with NSAIDs and triptans and seek pain relief at an emergency department or infusion center.40 Trials of refractory headache treatment in children and adolescents have been conducted41 but therapeutic approaches in these circumstances vary.42 Studies are also needed of alternate delivery routes for acute treatments such as transdermal patches because oral medications are poorly absorbed in children and adolescents with nausea and vomiting. Regardless of the strategy chosen for acute migraine therapy, treatment plans should be individually tailored to the patient and family and include education about migraine prevention strategies.
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References References cited here can be found in the guideline summary article. To locate this material, please visit AAN.com/guidelines. Slide 41
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Access Guideline andSummary Tools To access the complete guideline and related summary tools, visit AAN.com/guidelines. Summary guideline article Full-length guideline article Summary for clinicians Summary for patients/families Slide 42
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Questions?