Want to take quizzes and track your credits?
What are the most effective, safe, and accepted pharmacologic treatments for migraine prophylaxis in children and adolescents?
In this network meta-analysis, comparing head-to-head and placebo-controlled trials found no significant long-term effects for migraine prophylaxis relative to placebo. Medium-sized short-term effects were found for propranolol and topiramate, but the prediction interval indicates that significant beneficial effects are to be expected in only 70% of similar studies conducted in the future.
Considering the limited effect size, a cautious, individual, and tailored treatment approach to migraine prophylaxis is of great importance.
Migraine is one of the most common neurologic disorders in children and adolescents. However, a quantitative comparison of multiple preventive pharmacologic treatments in the pediatric population is lacking.
To examine whether prophylactic pharmacologic treatments are more effective than placebo and whether there are differences between drugs regarding efficacy, safety, and acceptability.
Systematic review and network meta-analysis of studies in MEDLINE, Cochrane, Embase, and PsycINFO published through July 2, 2018.
Randomized clinical trials of prophylactic pharmacologic treatments in children and adolescents diagnosed as having episodic migraine were included. Abstract, title, and full-text screening were conducted independently by 4 reviewers.
Data Extraction and Synthesis
Data extraction was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis network meta-analysis guidelines. Quality was assessed with the Cochrane Risk of Bias tool. Effect sizes, calculated as standardized mean differences for primary outcomes and risk ratios for discontinuation rates, were assessed in a random-effects model.
Main Outcomes and Measures
Primary outcomes were efficacy (ie, migraine frequency, number of migraine days, number of headache days, headache frequency, or headache index), safety (ie, treatment discontinuation owing to adverse events), and acceptability (ie, treatment discontinuation for any reason).
Twenty-three studies (2217 patients) were eligible for inclusion. Prophylactic pharmacologic treatments included antiepileptics, antidepressants, calcium channel blockers, antihypertensive agents, and food supplements. In the short term (<5 months), propranolol (standard mean difference, 0.60; 95% CI, 0.03-1.17) and topiramate (standard mean difference, 0.59; 95% CI, 0.03-1.15) were significantly more effective than placebo. However, the 95% prediction intervals for these medications contained the null effect. No significant long-term effects for migraine prophylaxis relative to placebo were found for any intervention.
Conclusions and Relevance
Prophylactic pharmacologic treatments have little evidence supporting efficacy in pediatric migraine. Future research could (1) identify factors associated with individual responses to pharmacologic prophylaxis, (2) analyze fluctuations of migraine attack frequency over time and determine the most clinically relevant length of probable prophylactic treatment, and (3) identify nonpharmacologic targets for migraine prophylaxis.
Sign in to take quiz and track your certificates
JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC
CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Joe Kossowsky, PhD, MMSc, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, 333 Longwood Ave, Boston, MA 02115 (firstname.lastname@example.org).
Accepted for Publication: September 25, 2019.
Published Online: February 10, 2020. doi:10.1001/jamapediatrics.2019.5856
Author Contributions: Drs Kossowsky and Meissner had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Locher and Kossowsky contributed equally to this study.
Concept and design: Locher, Kossowsky, Linde, Meissner.
Acquisition, analysis, or interpretation of data: Locher, Kossowsky, Koechlin, Lam, Barthel, Berde, Gaab, Schwarzer, Meissner.
Drafting of the manuscript: Locher, Kossowsky, Koechlin, Meissner.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Locher, Kossowsky, Koechlin, Berde, Schwarzer.
Obtained funding: Locher, Meissner.
Administrative, technical, or material support: Locher, Kossowsky, Barthel, Gaab.
Supervision: Locher, Kossowsky, Berde, Gaab, Linde, Meissner.
Conflict of Interest Disclosures: Dr Berde reports grants from Amgen and other support from Grunenthal and Akelos outside the submitted work. Dr Locher reported grants from Swiss National Science Foundation during the conduct of the study. Dr Meissner reported grants from Schweizer-Arau Foundation, Germany, during the conduct of the study. No other disclosures were reported.
Funding/Support: This work was supported in part by the Sara Page Mayo Endowment for Pediatric Pain Research, Education, and Treatment. Dr Locher received funding for this project from the Swiss National Science Foundation (P400PS_180730). Dr Meissner received funding from the Schweizer-Arau-Foundation and the Theophrastus Foundation, Germany.
Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
You currently have no searches saved.
You currently have no courses saved.