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JAMA Pediatrics Journal Club Slides: Pharmacologic Treatment of Pediatric Headaches

JAMA Pediatrics Journal Club Slides: Pharmacologic Treatment of Pediatric Headaches.

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JAMA Pediatrics Journal Club Slides: Pharmacologic Treatment of Pediatric Headaches

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  1. JAMA Pediatrics Journal Club Slides: Pharmacologic Treatment of Pediatric Headaches El-Chammas K, Keyes J, Thompson N, Vijayakumar J, Becher D, Jackson JL. Pharmacologic treatment of pediatric headaches: a meta-analysis. JAMA Pediatr. Published online January 28, 2013. doi:10.1001/jamapediatrics.2013.508.

  2. Introduction • Background • Up to 15% of children and adolescents experience tension headaches; 4% experience migraines. • Diagnostic criteria for migraines have evolved over time. • Prior emphasis: tension vs migraine. • Recent emphasis: acute vs chronic nature. • Diagnosis of headache in children and adolescents is especially challenging because of the variety of symptoms, including abdominal pain. • Pharmacologic prophylaxis includes many options; decision regarding agent typically depends on comorbid conditions and adverse effect profile. • Study Objective • To assist in clinical decision-making by conducting a meta-analysis to assess comparative effectiveness and adverse effects of available agents for prophylactic treatments.

  3. Methods • Study Design • Systematic review of randomized controlled trials identified through PubMed, EMBASE, bibliographies of all retrieved articles, and Cochrane Database of Clinical Trials for each class of medications. • Evidence must have compared drug vs placebo OR 2 or more active medications. • Could be regarding tension, migraine, or chronic daily headache. • Compared numbers of headaches across trials. • Setting • Multiple different trial settings across 21 studies. • Patients • Trials included adolescents (as young as 11 years) and adults. • All but one trial focused on episodic migraine headaches.

  4. Methods • Outcome • Reduction in headaches with prophylaxis. • Limitations • Relatively small number of studies, focusing almost exclusively on migraines. • Use of different measures across studies. • Heavy emphasis on a few medications (eg, propranolol) with relatively few studies of other agents (eg, clonidine).

  5. Results • Original search: 2918 articles. • Included in analysis: 21 randomized controlled trials. • Common reasons for exclusion: • Trial did not actually measure headaches (n = 221 trials). • Review article (n = 102). • Case series (n = 36). • Distribution of medications most commonly tested (could include >1 medication in a given trial): • Propranolol (n = 8). • Flunarizine (n = 5). • Topiramate (n = 3). • Valproate (n = 3). • Clonidine (n = 2).

  6. Results Reduction in headaches per month among placebo-controlled trials. WMD indicates weighted mean difference.

  7. Results Pooled Relative Risk of Adverse Effects Compared With Placebo

  8. Comment • Limited evidence of efficacy of trazodone or topiramate for prophylaxis of episodic migraines. • No evidence of efficacy beyond placebo for clonidine, flunarizine, pizotifen, propranolol, or valproate. • Improvement with placebo was observed in several trials, with a mean decrease of nearly 3 headaches per month. • Overall favorable adverse effects profile. • Clinical trials in this arena are of markedly inconsistent quality and are often too small to be certain of statistical differences when the clinical differences appeared meaningful (eg, reduction of >2 headaches per month). • There are very few trials on prophylaxis of headaches among children and adolescents.

  9. Comment • Adolescents could not be distinguished from adults through subgroup analyses in these trials because there were too few children to permit robust estimates. • Comparative effectiveness assessment could not be performed because of an insufficient number of subjects. • Future research needs: • Trials of children and adolescents with chronic daily headaches. • Placebo controls in all trials, given strong placebo responses across several trials.

  10. Contact Information • If you have questions, please contact the corresponding author: • Jeffrey L. Jackson, MD, MPH, Department of Medicine, Medical College of Wisconsin, 5000 W National Ave, Milwaukee, WI 53295 (jeffrey.jackson6@va.gov). Conflict of Interest Disclosures • None reported.

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