Amid a changing and evolving landscape for adult migraine care, Christina Szperka, MD, MSCE, director of the CHOP Pediatric Headache Program, offered insight into the standard experience in pediatric migraine care.
Karl Doghramji, MD, FAASM, DFAPA
This is part 2 of this conversation. For part 1, click here.
The clinical care of adult patients with migraine has undergone a revolutionary period in the past 2 years, as a number of novel—and effective—therapies have become available for clinicians to prescribe.
For pediatric patients, though, little has changed. Many of the new preventive calcitonin gene-related peptide (CGRP) antibodies and acute gepants have still not been assessed in children, making it challenging to use them in clinical practice. Christina Szperka, MD, MSCE, director, Pediatric Headache Program, Children's Hospital of Philadelphia, is one of these specialists, and she noted that the therapeutic challenge is merely the tip of the metaphorical iceberg of hurdles.
In a conversation with NeurologyLive®, she offered up her perspective on the current ongoing challenges in the day-to-day care of children with migraine, and offered up her experience in maintaining treatment adherence, determining prognosis for patients, as well as handling the transition to adult care.
Christina Szperka, MD, MSCE: It seems simple, but one the outcomes of the of the CHAMPS study was that, in some ways, we really don't actually right now know what to use for first line treatment. You can't prescribe placebo in clinical care. They actually used to make it—they used to use Obecalp, which was placebo backwards—but you can't prescribe that now. What that means is different people have interpreted the study results differently. Should you use a prescription because that's what the study did, and the prescriptions worked? Writing the prescription is part of the benefit, and using those medications makes sense. So, some people still use those meds. Or is it that you have to take something and do all the other counseling and appropriate acute therapies and all the other things we're doing? At which point, it doesn't matter what's in that pill as much. That's where a lot of people now use various nutraceuticals as the first line. They use vitamin B2 (which is riboflavin) or magnesium, melatonin—any of these things, essentially, can be used. There is some degree of some evidence of benefit for most of these relatively common nutraceuticals. We use some in adults, some in kids. The philosophy is that it's certainly still likely to help and has, potentially, a lower risk of adverse effects.
It's really a question of: What's your balance? Are you saying, “I want a bigger a bigger gun,” sort of a higher likelihood of improvement if I use a prescription versus a lower risk of side effects? Or do you believe that they're actually equivalent? Because we haven't really looked at that. I think that figuring out what first line might be really, is a really important next step.
The cognitive behavioral therapy (or CBT) studies have, I think, pretty clearly shown that if you don't benefit from a medication as your first line, and you add on cognitive behavioral therapy, as an add on second-line therapy, there's clear evidence of benefit. I feel like that question to me is simpler—that that's been more clearly spelled out. So, if two-thirds of kids are going to respond in the first place, and then you add on CBT, and a lot are going to respond, then you have a relatively smaller portion who are then refractory. But those kids can be really hard to treat and have tremendous disability. That, I would say, in my actual clinical practice, is the group I really, really want to help on a population level. I want to figure out the first line so that pediatricians know what the best thing to use is, and what can they do to help that child walking in their door.
It certainly can be, and I think there's a couple of pieces to it. There's the adherence of the pill: taking the pill on schedule as its prescribed, which is usually less of a problem in younger kids, and it can become more of an issue as people as teenagers get older. Any time a teenager is coping with chronic illnesses, and they're trying to sort of come into their own and figure out who they are as a person—certainly not universally, but—sometimes there's some degree of rejection of, “I don't really want to take this pill, I don't want to be part of this.” For some teens, they're very regimented, they take their own meds, they're very sort of independent about it. Others, their parents still give them all the pills. Then some are sort of in between, trying to figure it out. We always have to just address that openly and say, “How are things in your family,” and encourage that it be the teen who drives the conversation, so that if they want to bring up a conversation about their migraine, it'd be an open space to do so. So to have the parents not the asking constantly about the about their headaches. “Did you have a headache today? Did you take your meds?” Because it's often helpful to let the teen develop that independence and manage things.
The other piece is how long do people take things, right? It's important to build expectations, realistically. If I am going to prescribe you this pill, whatever this pill may be, I need you to understand that if it's for a preventive purpose, it is very likely that it's going to take weeks. We used to say 12 weeks, but now we're actually thinking that, potentially, within 6-8 weeks, you’ll have a hint of whether it's going to make you better. If you're not seeing any movement by then, then you may not get benefit. Then we need to see you back and make a change. But, I always try to make sure that it's a conversation and that we are all in agreement right before the physic closes, that everybody agrees that we're going to try this for 6 weeks and if you have a serious problem that you need to tell me about and if you don't think you can continue it. Tell me, send a message. With these lovely patient portals, they can write in much more easily now. Tell me, “I'm having a side effect, and this isn't working,” and then either I can help you tweak it, or we say, “Let's do something else.” But I think if we aren't clear, then sometimes people will take something for 2 weeks, say, “I'm no better. I don't like this,” and stop it. Then they don't come back to see you for a while, and then there's a missed opportunity. That's why I think it's really important to engage in that shared decision-making and say, “What are we going to do together? How are we going to help it together?”
I would say that—just when I think about prognosis—I do still leave room for hope. So, if I have a child in front of me or a teenager in front of me who's having 5 days of headache a week and they are really disabled, while I don't pretend that it's necessarily going to go away—because particularly for girls, it's less likely that they'll outgrow it, but the boys can, and certainly some girls, but less frequently—but it doesn't mean that this level of frequency and disability is going to maintain. Interestingly, one of the things that's come out recently, actually, in the past year, has been a follow-up study from the CHAMP study. They showed that of the patients who had gone through the study, about 75% of them are able to maintain their improvement without reusing preventive therapies 3 years out. That, essentially, we take to say, “If we can help you early on, maybe we can change the trajectory of the disease. Maybe we can decrease the disability you're going to have as an adult if we fix the problem early. We don't have the secondary effects.” We’re really in the infancy of figuring that out. But I think it's a really promising, hopeful idea.
When we think about transition—honestly, it's a rocky piece in child neurology, in general. A group of us from the American Headache Society got together and prepared some recommendations and a shortlist of things to put together for transition. I think the actuality of how well patients are transitioned depends on how closely your individual neurologists are working together. If you are seeing a child neurologist and need to transition to an adult neurologist, are they working together? Do they already have a system set up so that they can talk about a patient if they need to have a standard system?
This is a situation where, quite frankly, the sharing across the different electronic health records has helped. Because if I'm going to transition a child, I no longer need to say, “Please fax all of these letters,” they actually can go and then they're visible, right? Which is makes life a lot easier. We do certainly try to do things like keep a running list of the meds that they have previously tried and found helpful or not helpful, things like that, so that they don't need to reinvent the wheel on the adult side. Then, certainly, there are obviously times where adult neurologists will see teenagers and then just sort of keep them, or we may see a child, they have enough improvement, and I'll send them back and say, “You can follow with your general practitioner,” and really, it's just a triptan that's needed, we refill it once a year, and I don't think you necessarily need to continue to see a specialist. It just depends on the level of what's needed.
Transcript edited for clarity.