Presentation on theme: "Copyright restrictions may apply JAMA Pediatrics Journal Club Slides: Pharmacologic Treatment of Pediatric Headaches El-Chammas K, Keyes J, Thompson N,"— Presentation transcript:
Copyright restrictions may apply 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.
Copyright restrictions may apply 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. Introduction
Copyright restrictions may apply 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. Methods
Copyright restrictions may apply 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).
Copyright restrictions may apply 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).
Copyright restrictions may apply Results Reduction in headaches per month among placebo- controlled trials. WMD indicates weighted mean difference.
Copyright restrictions may apply Results Pooled Relative Risk of Adverse Effects Compared With Placebo
Copyright restrictions may apply 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.
Copyright restrictions may apply 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.
Copyright restrictions may apply 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 (firstname.lastname@example.org). Conflict of Interest Disclosures None reported. Contact Information