Migraine in Adolescents

We focus on talking to the patients because this is their migraine. We want them to describe it, and to be involved in the treatment. But the final decision for treatment is on the parents and their involvement is really important too.

—Dr. Kabbouche

The FDA-cleared devices are not medications and so more easily accepted as treatment options. Some of them have been through clinical trials with adolescents, and have less side effects than medications, most of which have not been specifically tested on people under 18.

To take a medication, you have to leave the classroom, go to the nurse to get it. With the devices, you can do it in the classroom. For chronic patients, they cannot take acute medication every day, so using a device is helpful for that also.

Most patients are excited to try a device and want to see if it works. The barrier is usually more about the cost than willingness to use it.

—Dr. Kabbouche

Some of them do, but some don't yet have an adolescent indication. Also, some that are FDA cleared for migraine treatment are also cleared for preventive treatment too. So not just to break an acute attack, but also helping prevent another one from happening.

To be FDA cleared, devices have to show from clinical trials that they are effective and do not have too many side effects. If they're not cleared, it means they did not go through a scientific study to prove efficacy and lack of side effects. To have an adolescent indication means that the device has specifically been tested in clinical trials on that age group.

—Dr. Kabbouche

Yes, the Nerivio is indicated for ages 8 and up.
*Nerivio is indicated for acute and/or preventive treatment of migraine with or without aura in patients 8 years of age or older. It is a prescription use, self-administered device for use in the home environment at the onset of migraine headache or aura for acute treatment, or every other day for preventive treatment. 

• Nerivio is placed on the upper arm halfway between the shoulder and the elbow for a 45 min treatment.
• gammaCore is placed on the side of the neck against the vagus nerve for a 2 min treatment.
• SaviDual is placed on the back of the head for a treatment that takes less than 1 min

Treating adolescents with migraine disease requires a comprehensive approach that addresses physical, biobehavioral and social factors. The high-safety profile and dual-use acute and preventive indication [of the Nerivio REN wearable] make it a compelling first-line intervention for early and effective migraine treatment.

—Dr. Kabbouche

Patients who are younger than 18 don't have all the treatment options that adults have. It takes 10 to 20 years to get something approved for kids after they're approved for adults. For the acute treatment, since migraine includes some inflammation, we use NSAIDs such as ibuprofen and naproxen. If that does not work we have triptans, some of which are now FDA approved for adolescents. One is even approved for as young as 6 years old. The other ones we use are the CGRP inhibitor medications, but they are not approved for younger kids and so it is really hard to get it approved by insurance unless it is “medically necessary.”

—Dr. Kabbouche

Even over-the-counter medications can cause side effects. For example, we use ibuprofen, and that can cause stomach pain. We limit the treatment of that to no more than three times a week because the body can become immune to it, and not only that, one of the side effects is headache – we call that analgesic overuse headache.

As far as medications go, yes, they do all have potential side effects. They’re not that frequent, but you need to know what they are because you may be the one who gets them. We let the parents and the kid decide which medications they prefer based on the information we give them. For prevention, some of them are once a day, some it's twice a day. For adherence, you want the once-a-day ideally. Also, I always like to talk about the side effects of NOT taking medication or not using devices. Migraine will easily chronify.

—Dr. Kabbouche

It is very hard to take medicine every day for any person, and that's why we want the adolescent to be involved in the final decision. We will ask them if they want to be on a daily medicine. If they say no, we will watch it for six weeks then bring them back. Then if the
migraine attacks are still intractable, we may need to be a little bit more aggressive in treatment. This way they feel they are in control in their treatment, rather than just us throwing things at them.

—Dr. Kabbouche

If they've committed to do one of the preventive medications, we try to talk about what barriers there might be. Are there other medications that they take at this time of day? Is there something you always remember to do that we can pair this with? Are there some reminders that we can put on your phone? We try to have that behavioral piece in there to empower them.

—Shalonda Slater, PhD

Generally, they will not have enough medication to treat more than three migraine attacks a week. They also can use one of the medical devices. We tell them that if it is a small attack then still treat it right away, but maybe with ibuprofen or a device. Then as soon as they know it's a bad one, they can add the backup medicine such as a triptan. We usually try to prescribe the medications where they can get 12 per month. The important thing is for them to take it as soon as they know it's bad.

—Dr. Kabbouche

Sometimes there is some hesitance with the nasal sprays because patients may not like the way it tastes. They also don't really like injectables because often people are scared of needles. There’s so many different treatment options, and we offer all of those to them. Sometimes kids don’t know how to swallow pills, or are afraid of doing that. So we talk to them about their concerns.

—Dr. Slater

At our centers there are four vitamins we look into. Vitamin D, because it has shown to be low in any type of pain, not just migraine. Coenzyme Q10 has also been shown in some studies to be low. Then riboflavin (vitamin B2). And now there have been a lot of studies on folic acid that can be low too in migraine. We don't look at magnesium right away.

—Dr. Kabbouche

First, we teach our patients to treat their migraine as soon as it starts. If they don't do that it's going to be harder to stop. When parents call about a really bad migraine, we ask them if they treated it, and if they repeated treatment the way we told them. If they did the right thing and the migraine is continuing, that is called status migrainosus, which is a severe migraine that's not breaking with anything and is very disabling. If they get to that point, then they may need IV treatment. There are infusion centers, which are better than the ER which is loud, bright and has a long wait, so we prefer sending them there. If that is not available they have to go to the ER to have it broken. About 75 % will respond in the infusion center, but there will be some patients who do not respond. If they're not back to zero pain then we offer an admission to the hospital to get a medication called DHE every eight hours until we break it.

—Dr. Kabbouche