Management of Childhood Migraine by Headache Specialist vs Non‐Headache Specialists

Abstract

Objective This study aims to compare the management practices of a headache specialist with non‐headache specialists in the treatment of children with migraine. The use of appropriate rescue medications and prophylactic agents, application of neuroimaging, and short‐term outcomes are compared in children treated by the two groups of physicians. Methods A retrospective cohort study was conducted by utilizing the electronic medical records of children 3‐18 years of age with migraine, who were evaluated at a tertiary care children's hospital from 2016 to 2018. Results Of the 849 patients who met the study criteria, 469 children were classified as having chronic migraine or high‐frequency episodic migraine and were followed‐up on at least 1 occasion by the neurologists. Imaging was obtained in 66.5% of all children with migraine. The headache specialist used 5‐HT agonists (“triptans”) for migraine management in 56.7% (76/135) of cases compared to non‐headache specialists who prescribed them in 28.7% (96/334) of cases (P < .001). Of the children with chronic migraine, the headache specialist evaluated 135 patients while the non‐headache specialists treated 334 children. Non‐headache specialists prescribed prophylaxis in the form of natural supplements more frequently (63.8% of cases) compared to the headache specialist (38.5% of children) (P < .001). Moreover, prophylaxis with prescription drugs was utilized more often by headache specialist (66.7%) than non‐headache specialists (37.4%) (P < .001). Conclusions Imaging appears to be commonly recommended by both headache specialists and non‐headache specialists in children with migraine. The headache specialist was more likely to use triptans as rescue medications for pediatric migraine. Outcomes in the short‐term were not statistically different whether children were being managed by the headache specialist or the non‐headache specialists.

Headache in Children and Adolescents

“…Even when a diagnosis of migraine has been made, prescription of appropriate therapies by primary care providers is low 36 . A 2019 neurology clinic–based study demonstrated that only 5% of children with migraine who met criteria for use of preventive medication were started on one while awaiting referral to neurology, and no children were prescribed a triptan by their primary care provider 134 . Population-based studies have similarly reported low rates (varying from 1% to 20%) of preventive medication use among adolescents with chronic migraine 63,64 .…”

“…One center demonstrated that headache specialists were more than twice as likely to prescribe triptans as child neurologists who were not headache specialists, indicating that education and awareness will help. 134 Use of a headache questionnaire integrated into the electronic health record at a large academic pediatric neurology practice increased the likelihood of making a specific diagnosis, which, in turn, substantially increased the odds of appropriate treatment. 135 The HAPPY school-based intervention paired with online clinician decision support led to a modest improvement in the rate of prescription of evidence-based acute and preventive headache therapies by primary care providers.…”

“…Evidence-based solutions are available to improve the rate of appropriate prescriptions. One center demonstrated that headache specialists were more than twice as likely to prescribe triptans as child neurologists who were not headache specialists, indicating that education and awareness will help 134 . Use of a headache questionnaire integrated into the electronic health record at a large academic pediatric neurology practice increased the likelihood of making a specific diagnosis, which, in turn, substantially increased the odds of appropriate treatment 135 .…”

Ahead of the pain: Where we stand after a decade of growth in United Council for Neurologic Subspecialties‐certified headache subspecialists

“…Compared to physicians who have not received specialized training, headache subspecialists are less likely to prescribe opioids 5,6 and more likely to prescribe prophylactic medications 7 . Tertiary headache treatment by headache subspecialists leads to 25% fewer headache days, 79% fewer outpatient and 68% fewer Emergency Department visits for headache concerns, and 68% improvement in Migraine Disability Assessment Score 8 …”

“…Compared to physicians who have not received specialized training, headache subspecialists are less likely to prescribe opioids 5,6 and more likely to prescribe prophylactic medications. 7 Tertiary headache treatment by headache subspecialists leads to 25% fewer headache days, 79% fewer outpatient and 68% fewer Emergency Department visits for headache concerns, and 68% improvement in Migraine Disability Assessment Score. 8 The United Council for Neurologic Subspecialties (UCNS) is an independent, non-profit, professional medical organization that provides accreditation to fellowship training programs and certification to physicians who demonstrate competence in various neurologic subspecialties.…”