Migraine Preventive Medicine: Research Update

Huma U. Sheikh, MD, is a board-certified neurologist with specialization in both vascular neurology and headache at Mt Sinai Beth Israel in New York City. She is the co-chair of the Migraine and Vascular Disease special interest section at the American Headache Society (AHS) and on the AHS committee to develop guidelines for vascular issues and headache.

Below, she reviews recently published research on headache disorders and discusses clinical application.

Acute Treatment Therapies for Pediatric Migraine: A Qualitative Systematic Review – Patniyot IR et al

In a systematic review published in Headache, Patniyot IR, et al¹ summarizes the evidence for acute therapies for migraine in the pediatric population, especially in the emergency department (ED) setting. A total of 31 articles were included in the final review. The primary measure of efficacy was pain-free at 2 hours. Seventeen of these studies were randomized controlled trials, 9 were retrospective reviews, and 5 were prospective chart reviews. The medications reviewed in those studies included IV fluids, analgesics, dopamine receptor antagonists, valproic acid, propofol, magnesium, bupivacaine, triptans, and dihydroergotamine (DHE).

One study examined the use of intravenous fluids for headache without any other added medication. This treatment showed some efficacy, as many patients can have nausea and subsequently decreased oral intake, which can lead to dehydration. Acetaminophen and ibuprofen, both commonly used for headache, were compared in one randomized trial against placebo. Ibuprofen was found to be most helpful in relieving headache at 2 hours, although acetaminophen was also superior to placebo. A number of dopamine receptor antagonists were also studied. One of them, prochlorperazine, was studied in a retrospective review in which 80% of participants reported headache resolution at 1 hour. Similar results were observed in 3 other studies for other phenothiazines.

The authors recommend using diphenhydramine with phenothiazines to prevent extrapyramidal side effects. Triptans can also be used in the pediatric population, with most oral options found to be effective. Valproate sodium, IM sumatriptan, and IV DHE were thought to be probably effective. There were not enough studies to common on the efficacy of magnesium, bupivacaine, and propofol.

This study helps to summarize which medications are not only efficacious but well-tolerated in the pediatric population. The study can also be used to develop an algorithm for pediatric patients who present to the ED with protracted headache or status migrainosus. It is a useful reference for when deciding on abortive therapy in the acute setting. It is limited by the fact that there are not many studies for each drug and some are lower quality studies. However, given the limited studies, this is overall an important review that offers guidance on how to treat headaches in the pediatric population.

Patent Foramen Ovale and Migraine: Closing the Debate – A Review – Tariq N et al

Another interesting article published recently in Headache attempts to identify the role of patent foramen ovale (PFO) in migraine.² There has been debate for some time whether closing a PFO can improve migraine. There is also some evidence suggesting a genetic link between the persistence of a PFO after birth and genes possibly linked to migraine. The article by Tariq N, et al also attempts to determine if closing a PFO would result in change in migraine frequency or severity.