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Sickle cell disease (SCD)* is one of the most common inherited blood disorders in the United States (US), found in nearly 1/3000 Americans 1 and disproportionately affecting Black (1/365 births) and Hispanic (1/16300) populations. 1 Clinical manifestations start in early childhood, including severe episodic and chronic pain, multisystem organ failure, stroke, and lifethreatening infections. In addition, patients experience lower academic achievement compared to healthy individuals with similar demographic characteristics, have lower chances of meaningful employment in adulthood, face trouble in attention and concentration, score lower on measures of intelligence, 2 have increased school absences, and are more likely to repeat grades. 3 For children with

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Objective: To characterize treatment decision-making processes and formalize consensus regarding key factors headache specialists consider in treatment decisions for patients with migraine, considering novel therapies.Background: Migraine therapies have long been subject to binary classification, acute versus preventive, due to limitations of available drugs. The emergence of novel therapies that can be used more flexibly creates an opportunity to rethink this binary classification. To determine the role of these novel therapies in treatment, it is critical to understand whether existing guidelines reflect clinical practice and to establish consensus around factors driving management. Methods:A three-round modified Delphi process was conducted with migraine clinical experts. Round 1 consisted of an online questionnaire; Round 2 involved an online discussion of aggregated Round 1 results; and Round 3 allowed participants to revise Round 1 responses, incorporating Round 2 insights. Questions elicited likelihood ratings (0 = highly unlikely to 100 = highly likely), rankings, and estimates on treatment decision-making.Results: Nineteen experts completed three Delphi rounds. Experts strongly agreed on definitions for "acute" (median = 100, inter-quartile range [IQR] = 5) and "preventive" treatment (median = 90, IQR = 15), but noted a need for treatment customization for patients (median = 100, IQR = 6). Experts noted certain aspects of guidelines may no longer apply based on established tolerability and efficacy of newer acute and preventive agents (median = 91, IQR = 17). Further, experts agreed on a treatment category referred to as "situational prevention" (or "short-term prevention") for patients with reliable and predictable migraine triggers (median = 100, IQR = 10) or time-limited periods when headache avoidance is important (median = 100, IQR = 12). Conclusions:Using the modified Delphi method, a panel of migraine experts identified the importance of customizing treatment for people with migraine and the utility of "situational prevention," given the ability of new treatment options to meet this need and the This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

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