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Expert commentary

by Marcy Yonker, MD, FAHS

The CHAMP 3 year followup study looked at headache frequency and disability at 3 then 6 month intervals for a total of 3 years after completing CHAMP in 205 children in the study. It provides information on a previously unstudied aspect of migraine treatment- long term outcomes of children treated with migraine preventives. It showed that patients in the study generally maintained the improvement seen during the study over the next 3 years whether taking preventive therapy or not.

The results of this study should help to reduce use of pharmacologic agents for extended periods of time in children who may not require them. Generally, when approaching migraine prevention in children, based on this data, providers should emphasize that this is not a "forever" therapy and that medication can be stopped when the patient is doing better and it is a convenient time. Many families worry about long term effects of medication use in their children and may be more willing to undertake treatment if there is an endpoint in sight. For many children who suffer from frequent disabling migraine attacks, in the moment, they worry that this is how they will feel for the rest of their lives. This study helps to give hope that migraine will resolve in many patients. Additionally, individuals with chronic migraine are often stigmatized as having a difficult or impossible to treat problem and are labeled as having bad health habits or mental health problems that are causing their suffering when, in fact, they get better and stay better at the same rate as children with less severe migraine burdens.

When discussing a trial of preventive medication in a pediatric patient, based on this study, it is important for the provider to emphasize the following: 1) most patients get better within a few months of starting medication so it is important to followup then to determine whether to continue medication 2) there is an endpoint to treatment which can be as soon as several months after starting medication 3) even children with daily or nearly daily headaches get better, so there is reason for hope for improvement.

Although the CHAMP study suggests that improvement in migraine frequency may not rely solely on the use of a pharmacologic agent, it is important to remember that patients were excluded if they had previously been treated with amitriptyline or topiramate. This would exclude a significant number of treated patients as these are the most commonly used medications. This may have enhanced the placebo response rates in children who qualified for the study as they likely had not seen a neurologist or headache specialist previously and thus may have had higher expectations of successful treatment. Thus the conclusion of both CHAMP and the study upon which the approval for topiramate was based, may be true as they may represent a different baseline population. Additional limitations of this study and CHAMP are that they do not address the approximately 40% of patients who did not improve during the double blind phase.

 

Reference:

  1. Powers SW, Coffey CS, Chamberlin LA, et al. Trial of Amitriptyline, Topiramate, and Placebo for Pediatric Migraine. N Engl J Med. 2017;376(2):115-124. doi:10.1056/NEJMoa1610384
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