Frequently recurring migraines require targeted abortive and/or preventive therapy to lessen disability and prevent evolution to chronic or secondary progressive migraine, according to researchers.
Early optimal treatment of migraine in children and adolescents may prevent disease progression in these patients, according to James A. Charles, MD, and colleagues. Many adults with chronic or refractory migraine who developed their migraine as children or adolescents may not have received adequate treatment, the researchers suggested.
“Comprehensive acute care and preventive therapy for children, adolescents, and the recent-onset young adult migraineurs may be appropriate to curtail progression and improve long-term outcome,” reported Dr. Charles, Clinical Associate Professor, Department of Neurology and Neurosciences, New Jersey Medical School, University of Medicine and Dentistry of New Jersey in Newark, and coauthors in a review article published in the August Journal of Headache and Pain. “Rational combination therapy for the chronic migraineur and the patient in status migrainosus may be essential. Aborting and controlling central sensitization, accumulation of white matter lesions, and iron deposition in the periaqueductal gray may lead to disease modification based on our current understanding of migraine pathophysiology, epidemiologic data, and imaging studies.”
The Case for Early Treatment
A number of studies support the early treatment of migraine in younger patients. Kabbouche et al, in an observational study of childhood headaches at one, two, and five years after initial treatment, found that multidisciplinary treatment was effective for children and adolescents, with improvement of multiple outcome measures of pediatric migraine care, including frequency, severity, and school days missed. Wöber et al followed 64 patients with migraine after successful prophylaxis with flunarizine and propranolol or metoprolol and found that long-term responders with a sustained migraine frequency response by at least 50% during the entire 18- to 78-month follow-up period after treatment were younger (mean age, 42.4) with a younger age of onset measured as mean migraine duration years (18.9), compared with the worst responders (mean age, 50.1; mean migraine duration, 19.9 years).
Evidence-Based Strategies
Dr. Charles and colleagues recommend that a number of steps be undertaken to improve long-term outcomes in children and adolescents with migraine, including the implementation of public awareness programs and appropriate interventions regarding modifiable risk factors for migraine progression. “Some risk factors that seem to be operative are caffeine, analgesic, and other acute care medication overuse, hypothyroidism, sleep disorders, depression, anxiety, oral contraceptives, obesity, and two or more headaches per month,” the investigators noted.
“Patients should be considered as possible candidates for preventive treatment, and if so, should be kept on effective medication for a minimum of six months and reevaluated,” the authors continued. “The traditional stratified care approach as well as more current multimechanistic strategy of treating the migraine attack should be first-line treatment in the young headache population and in adults with new-onset migraine…. In light of the known efficacy delay of preventive therapy, which can be as long as two months while commencing long-term preventive therapy, it is reasonable to consider short- or long-term rational combination therapy in escalating episodic migraine, chronic migraine, refractory migraine, and especially status migrainosus.”
Dr. Charles and colleagues pointed out that further study is needed to prove that early and comprehensive treatment of new-onset migraine in younger patients will result in disease modification in adulthood. However, they concluded, “There should be little debate that early, comprehensive, targeted therapy under existing guidelines will at the very least prevent disability; and in a subset of patients, disease modification may occur.”
—Colby Stong