Combining Guided Intervention of Education and Relaxation (GIER) with Remote Electrical Neuromodulation (REN) in the Acute Treatment of Migraine.

BACKGROUND: Evidence indicates that combining behavioral treatments with pharmacological treatments for migraine prevention improves efficacy, but little is known about the outcomes of combining neuromodulation and behavioral interventions for acute treatment of migraine. Remote electrical neuromodulation (REN) is a U.S. Food and Drug Administration (FDA)-cleared nonpharmacological migraine treatment. The present study evaluated the clinical benefits of augmenting REN treatment with a specially tailored behavioral therapy consisting of Guided Intervention of Education and Relaxation (GIER) for the acute treatment of migraine. METHODS: In this two-arm observational study, real-world data were collected from patients across the United States who were using the REN device. Eighty-five migraine patients ≥18 years of age who treated their attacks with REN in parallel with the GIER intervention were individually matched on age and sex with 85 patients who used REN alone. The groups were compared on the proportion of migraine attacks in which they achieved pain relief, pain freedom, improvement of function, and return to normal function, all at 2 hours after treatment. RESULTS: Data from 170 users were analyzed (85 per group). Compared with the REN-only group, the REN+GIER group displayed a statistically significant higher proportion of patients achieving consistent pain relief (P = 0.008), consistent improvement in function (P = 0.014), and consistent return to normal function (P = 0.005), all at 2 hours after treatment. CONCLUSIONS: The results suggest that combining the GIER behavioral intervention with REN treatment can improve the therapeutic efficacy beyond that of REN alone, in terms of both pain level and improvement of disability.

Development and Assessment of an Abbreviated Acupuncture Curriculum for Pediatricians.

OBJECTIVE: Acupuncture has been shown to improve pain and other health outcomes in children and is well tolerated. However, use of acupuncture by pediatric medical providers is rare, in part due to the cost and time associated with formal training. We aimed to develop an abbreviated acupuncture curriculum and assess its impact and acceptability with academic pediatricians. METHODS: In this pilot study, pediatricians received instruction in 2 acupuncture protocols for treating acute and chronic pain (Battlefield Acupuncture and Four Gates) during a 10-hour course developed by board-certified medical acupuncturists. Learning methods included an online module with videos and articles, 2 live workshops, and additional home practice. Participants completed a skills-based exam and pre- and post-tests measuring knowledge and attitudes about acupuncture treatment. RESULTS: Forty-five physicians (divided among 3 cohorts) began the acupuncture training course, and 38 (84.4%) completed all components. The course significantly increased participants' perceived efficacy of acupuncture for acute and chronic pain. Participants showed significant improvement in acupuncture knowledge. All participants agreed that the course would influence their current medical practice, and all participants felt confident utilizing basic acupuncture. Additionally, all participants indicated that they would recommend the abbreviated acupuncture curriculum to a colleague. CONCLUSIONS: Pediatricians became proficient in 2 acupuncture protocols with a 10-hour curriculum and found the format and content highly acceptable. Future plans include studying acupuncture implementation and expanding the course to other departments and institutions.

Contemporary Neuroscience Core Curriculum for Medical Schools.

Medical students need to understand core neuroscience principles as a foundation for their required clinical experiences in neurology. In fact, they need a solid neuroscience foundation for their clinical experiences in all other medical disciplines also, because the nervous system plays such a critical role in the function of every organ system. Due to the rapid pace of neuroscience discoveries, it is unrealistic to expect students to master the entire field. It is also unnecessary, as students can expect to have ready access to electronic reference sources no matter where they practice. In the pre-clerkship phase of medical school, the focus should be on providing students with the foundational knowledge to use those resources effectively and interpret them correctly. This article describes an organizational framework for teaching the essential neuroscience background needed by all physicians. This is particularly germane at a time when many medical schools are re-assessing traditional practices and instituting curricular changes such as competency-based approaches, earlier clinical immersion, and increased emphasis on active learning. This article reviews factors that should be considered when developing the pre-clerkship neuroscience curriculum, including goals and objectives for the curriculum, the general topics to include, teaching and assessment methodology, who should direct the course, and the areas of expertise of faculty who might be enlisted as teachers or content experts. These guidelines were developed by a work group of experienced educators appointed by the Undergraduate Education Subcommittee (UES) of the American Academy of Neurology (AAN). They were then successively reviewed, edited, and approved by the entire UES, the AAN Education Committee, and the AAN Board of Directors.

The Influence of Lifestyle Factors on the Burden of Pediatric Migraine.

There is a gap in patient education and coaching of lifestyle factors related to pediatric migraine, which nurses are in a unique position to fill in order to provide comprehensive care to these patients. In order to help fill this gap, we conducted a targeted review of studies examining migraine and lifestyle factors in children and adolescents. Studies older than 2010, studies examining adults above the age of 18, studies not available in the English language, and secondary sources were excluded from the review. A final sample of 42 studies was included in this review. Lifestyle factors including stress, sleep, obesity, and diet were identified as playing a significant role in increasing the frequency, severity, and duration of migraine attacks in pediatric patients. Based on these findings, a framework is discussed for practical applications of this knowledge by nursing staff working in primary and specialty care clinics.

Rates and Predictors of Using Opioids in the Emergency Department to Treat Migraine in Adolescents and Young Adults.

OBJECTIVES: This study aimed to determine the rate and context in which opioids are used to treat migraine in adolescents and young adults seen in emergency care settings. METHODS: Data from 2010 to 2016 in the Cerner Health Facts electronic health record data warehouse were analyzed using multilevel logistic regression to estimate the population likelihood of an opioid being used in the emergency department (ED) to treat a primary diagnosis of migraine in adolescents and young adults and to evaluate the extent to which this likelihood varies as a function of characteristics of the patient (age, sex, race, and insurance), encounter (referral source, provider specialty, and encounter duration and year), and ED (region, setting, size, payer mix, and academic status). RESULTS: The study identified 14,494 eligible ED encounters with unique patients, of which 23% involved an opioid. Likelihood of being treated with opioids was significantly higher for patients who were older, female, white, and seen by a surgeon and who had longer encounters and encounters earlier in the time period sampled. Sites varied widely in percentage of encounters involving opioids (mean, 26.4% ± 20.1%; range, 0-100%), with higher rates associated with smaller sites with relatively higher proportions of commercially insured patients. CONCLUSIONS: Use of opioids in the ED to treat migraine in youth is fairly common, with rate variation reflecting broader trends in for whom opioids tend to be more likely to be prescribed. These findings may be helpful for benchmarking and informing quality improvement efforts aimed at reducing unwarranted opioid exposure in youth.

Improving Acute Treatment of Pediatric Primary Headache Disorders With a Novel Headache Treatment Center: Retrospective Review of Preliminary Outcomes.

OBJECTIVE: To determine preliminary outcomes of targeted headache treatments provided at a novel outpatient acute care pediatric headache treatment center. BACKGROUND: Limitations exist in acute management of pediatric headaches, including inadequate access to specialty headache therapies and headache specialists in acute settings, variable success of emergency room treatments, and omission of comfort measures. An outpatient acute headache care clinic (the "Headache Treatment Center") was strategically initiated at a Midwestern pediatric academic hospital to provide acute and targeted headache therapies for children with active headaches. METHODS: We conducted a retrospective chart review of 154 visits from September through November 2018 of patients ages 7-18 years visiting the Headache Treatment Center. RESULTS: On average, headache intensity (measured on an 11-point pain numeric rating scale) decreased after interventions used in the Headache Treatment Center (mean change = 2.85 ± 2.81, P < .05, Cohen d = 1.01). Large effect sizes for reducing headache intensity were observed for pericranial, occipital/auriculotemporal, and occipital nerve blocks, Cohen d = 1.56, 1.64 and 1.02, respectively. Large effect sizes for reducing headache intensity also were observed for a transcutaneous supraorbital nerve stimulator device (Cefaly) (Cohen d = 1.02), acupuncture (Cohen d = 1.09), and intravenous migraine cocktails (Cohen d = 0.91-1.34). CONCLUSION: Targeted headache therapies to abort pediatric primary headaches as part of a novel headache clinic model may be beneficial for short-term management.

Enhancing Outpatient Dihydroergotamine Infusion With Interdisciplinary Care to Treat Refractory Pediatric Migraine: Preliminary Outcomes From the Comprehensive Aggressive Migraine Protocol ("CAMP").

OBJECTIVE: To determine preliminary outcomes of a treatment for refractory pediatric migraine that integrates outpatient dihydroergotamine (DHE) infusion with interdisciplinary adjunctive care. BACKGROUND: Limited data are available to inform treatment of refractory migraine in children. Intravenous DHE therapy has shown promise but has been implemented in costly inpatient settings and in isolation of nonpharmacological strategies shown to enhance analgesia and functional improvement. METHODS: We conducted a retrospective chart review of 36 patients ages 11-18 with refractory migraine who underwent a pilot treatment program in an outpatient neurology clinic. The treatment integrated up to 5 days of outpatient DHE infusion with adjunctive nonpharmacological care (pain coping skills training, massage, aromatherapy, and school reintegration support). Changes in headache, healthcare utilization, and functional limitations were assessed as indicators of treatment response through 3-month follow-up. RESULTS: On average, headache intensity declined (M = 5.8 ± 2.5 to M = 2.4 ± 2.7; P < .0001) during the treatment period and remained statistically significantly improved through 3-month follow-up. Headache frequency decreased by a mean of 1.5 days per week (M = 6.7 ± 1.0 vs M = 5.2 ± 2.7, P = .012) through 3-month follow-up, with a 27% reduction (from 0.91 to 0.66) in the proportion of patients reporting a continuous headache (P = .009). Over this same follow-up period, there was a reduction in school days missed per month (median [25th, 75th percentile]: 4.5 [0, 21.0] vs 0 [0.0, 0.5]). There also were reductions in headache-related visits per month to the emergency department and medical providers. Adverse effects were common but typically minor and transient. CONCLUSIONS: Combining outpatient DHE infusion with interdisciplinary adjunctive care has promise as an effective treatment option for adolescents with refractory migraine.

Primary Care Access to an Online Decision Support Tool is Associated With Improvements in Some Aspects of Pediatric Migraine Care.

OBJECTIVE: To evaluate whether primary care provider (PCP) access to an online decision support tool is associated with a change in evidence-based primary care medical management of pediatric migraine. METHODS: In this prospective observational study, PCPs serving a target community were educated on the availability and use of an online clinical decision support tool that was developed to inform treatment of pediatric migraine. For 9 months before and after implementation of the decision tool, the proportions of children with migraine prescribed evidence-based and contraindicated medications by PCPs in the target region were monitored using electronic medical record query and statistically compared to these same proportions for patients in surrounding (control) regions. Rates of visits to the emergency department for migraine also were tracked pre- and postimplementation as an indirect measure of impact of the decision tool. Provider usage of the decision tool was monitored and summarized using web analytics. RESULTS: Approximately half (56%) of target region PCPs used the online tool at least once over the project period. Relative to control regions and baseline trends, the proportion of children residing in the target region who were prescribed recommended abortive and preventive medications for treating migraine was statistically significantly higher following implementation of the tool. No significant changes to frequency of emergency care visits for migraine by youth in the target region were observed. CONCLUSIONS: Availability to PCPs of an online decision support tool for pediatric migraine is associated with a modest change in some aspects of evidence-based medical care.

Pediatric Headache Clinic Model: Implementation of Integrative Therapies in Practice.

The demand for integrative medicine has risen in recent years as research has demonstrated the efficacy of such treatments. The public has also become more conscientious of the potential limitations of conventional treatment alone. Because primary headache syndromes are often the culmination of genetics, lifestyle, stress, trauma, and environmental factors, they are best treated with therapies that are equally multifaceted. The Children’s Mercy Hospital, Kansas City, Missouri Headache Clinic has successfully incorporated integrative therapies including nutraceuticals, acupuncture, aromatherapy, biofeedback, relaxation training, hypnosis, psychology services, and lifestyle recommendations for headache management. This paper provides a detailed review of the implementation of integrative therapies for headache treatment and discusses examples through case studies. It can serve as a model for other specialty settings intending to incorporate all evidenced-based practices, whether complementary or conventional.

The Headache Action Plan Project for Youth (HAPPY): School Nurses as Facilitators of System Change in Pediatric Migraine Care.

Migraine is a common health problem in youth that is ranked highest for disability among neurological conditions and is one of the leading reasons for school absences. Children with migraines frequently are seen by the school nurse for care, sometimes before ever being seen by another healthcare provider for evaluation and treatment. As such, school nurses have the unique opportunity to provide education and resources to children with migraines and their family. This article provides information on the Headache Action Plan Program for Youth (HAPPY), a project involving the provision of live and online migraine education and management resources to school nurses, children, families, and primary care providers in an effort to improve migraine recognition and care in the community.

Headstrong intervention for pediatric migraine headache: a randomized clinical trial.

BACKGROUND: The purpose of this study was to evaluate the efficacy of a self-guided CD-ROM program ("Headstrong") containing cognitive-behavioral self-management strategies versus an educational CD-ROM program for treating headaches, headache-related disability, and quality of life. METHODS: Participants were 35 children ages 7-12 years with migraine recruited from one university medical center and two children's hospital headache clinics. Participants were randomly assigned to complete the Headstrong or educational control CD-ROM program over a 4-week period. Data on headache frequency, duration, and severity, migraine-related disability, and quality of life (QOL) were obtained at baseline, post-intervention, and 3-months post-intervention. RESULTS: At post-intervention, Headstrong resulted in lower severity (on a 10-point scale) than the control group by child report (5.06 ± 1.50 SD vs. 6.25 ± 1.92 SD, p = 0.03, ES = 0.7). At 3-months post-intervention, parents reported less migraine-related disability (on the PedMIDAS) in the Headstrong group compared to the control group (1.36 ± 2.06 SD vs. 5.18 ± 6.40 SD; p = 0.04, ES = 0.8). There were no other group differences at post treatment or at 3-months post-intervention. CONCLUSIONS: When compared to an educational control, Headstrong resulted in lower pain severity at post-treatment and less migraine-related disability at 3-months post-intervention, by child and parent report respectively. Headache frequency and quality of life did not change more for Headstrong versus control. Additional research is needed on the Headstrong Program to increase its efficacy and to test it with a larger sample recruited from multiple centers simultaneously.

Relationship between daily mood and migraine in children.

BACKGROUND: Retrospective and cross-sectional studies have suggested a bidirectional relationship between migraine and mood disturbance. OBJECTIVE: The present prospective daily diary study examined the prevalence and temporal associations between migraine and daily mood, mood and next-day headache, and headache and next-day mood. METHODS: Sixty-nine children (50 females, 19 males) between the ages of 7 and 12 years and their parents attending neurology clinic appointments and having a diagnosis of migraine as defined by International Headache Classification 2nd edition criteria completed measures on the quality of life, headache disability, child emotions, and child behaviors. Children and parents then recorded children's headache occurrence, headache duration, headache severity, mood, daily hassles, and medication use on paper diaries once a day for 2 consecutive weeks. "Mood" was defined using the Facial Affective Scale, which is a visual representation of negative and positive affect. Data were analyzed using multilevel models. RESULTS: Controlling for age, sex, quality of life, headache disability, and medication use, worse mood was associated with same-day occurrence, longer duration, and more severe headache in both child and parent report. Today's mood was not consistently associated with next-day headache, and today's headache was not associated with next-day mood in either child or parent report. CONCLUSIONS: Results of this study lend support to a complex relationship between mood and headache in children with migraine. More research is needed to further elucidate the temporal nature of this relationship within a given day and over an extended period of time.

Chronic daily headache in children and adolescents: science and conjecture.

SUMMARY Chronic daily headache comprises a group of headache disorders in which headaches occur almost daily or continuously over several months. Although chronic daily headache is one of the most common chronic pain disorders in pediatrics, data on pathophysiological mechanisms and relative efficacy of treatments remain sparse. In this review, we aim to provide contemporary information on classification, epidemiology, etiology and treatment of pediatric chronic daily headache based on extant empirical data when available, or general consensus in the field when not.

An electronic daily diary process study of stress and health behavior triggers of primary headaches in children.

OBJECTIVE: To determine through a daily process study whether alleged psychological and health behavior headache triggers reliably predict headache occurrence in children. METHODS: Twenty-five children aged 8-17 years with primary headaches reported on their expectancies for headache triggers and then used electronic diaries three times daily for 2 weeks to record headache occurrence, stressors, type and timing of food and drink intake, sleep and wake times, and sleep quality. Hypotheses pertaining to the association of presumed headache triggers and headache occurrence were evaluated using multilevel models. RESULTS: Only changes in stress level reliably preceded the occurrence of a new headache episode. Nights in which a child had less than his/her typical sleep quantity also tended to predict headache occurrence. Consumption of certain food and drink items was found to be protective. CONCLUSIONS: Daily stressors seem to be a more reliable trigger of children's headaches than diet or sleep factors.

Electronic momentary assessment of weather changes as a trigger of headaches in children.

BACKGROUND: Variables that are thought to precipitate migraine or tension-type headache episodes in children hitherto have only been studied using retrospective reports. As such, there is little empirical evidence to support the actual predictive association between presumed headache triggers and actual headache occurrence in children. OBJECTIVE: The present study sought to determine if fluctuations in weather, a commonly reported headache trigger in children, predict increased likelihood of headache occurrence when evaluated using rigorous prospective methodology ("electronic momentary assessment"). METHODS: Twenty-five children (21 girls, 4 boys) between the ages of 8-17 years attending a new patient neurology clinic appointment and having a diagnosis of chronic migraine, chronic tension-type, or episodic migraine headache (with or without aura) participated in the study. Children completed baseline measures on headache characteristics, presumed headache triggers, and mood and subsequently were trained in the use of electronic diaries to record information on headaches. Children then completed thrice daily diaries on handheld computers for a 2-week time period (42 assessments per child) while data on weather variables (temperature, dew point temperature, barometric pressure, humidity, precipitation, and sunlight) in the child's geographic location were recorded each time a diary was completed. Data were analyzed using multilevel models. RESULTS: Of the weather variables, relative humidity and presence of precipitation were significantly predictive of new headache onset, with nearly a 3-fold increase in probability of headache occurrence during times of precipitation or elevated humidity in the child's area, b = 0.38, t(821) = 2.10, P = .04, and b = 0.02, t(821) = 2.81, P = .01, respectively. These associations remained after accounting for fluctuations in mood, and associations were not significantly stronger in children who at baseline thought that weather was a headache trigger for them. Changes in temperature, dew point temperature, barometric pressure, and sunlight were not significantly predictive of new headache episode occurrence in this sample. CONCLUSIONS: Results of the present study lend some support to the belief commonly held by children with recurrent headaches that weather changes may contribute to headache onset. Although electronic momentary assessment methodology was found to be feasible in this population and to have the potential to identify specific headache triggers for children, it remains to be determined how best (or even whether) to incorporate this information into treatment recommendations.