Miriam E. Tucker

June 22, 2015

Washington, DC — Nearly half of children and adolescents who present for the first time with migraine or probable migraine receive no treatment, and fewer than one in six receive evidence-based treatment, a new study finds.

The results, from an analysis of electronic health record data across practice settings in four US states, were presented here at the American Headache Society (AHS) 57th Annual Scientific Meeting by Robert A. Nicholson, PhD, director of behavioral medicine at Mercy Clinic Headache Center & Mercy Health Research, St. Louis, Missouri.

In another analysis from the same dataset, Dr Nicholson and colleagues found that nearly one in six kids were prescribed an opioid — not recommended as first-line treatment — at their first assessment for probable migraine.

The data also reveal that kids who were actually diagnosed with migraine or headache were more likely to receive evidence-based treatment.

"It's crucial that doctors and providers ask the right kinds of questions to be able to establish the kind of headache the child is having. And if it's migraine, there are things that they can recommend as first-line intervention that are consistent with evidence-based guidelines," Dr Nicholson told Medscape Medical News.

The findings also suggest that more appropriate prescribing takes place in a medical home. "I always try to encourage patients to establish a relationship with a provider with whom they have an ongoing relationship and can develop a migraine treatment plan as part of an overall continuum of care that is probably their best chance for success," Dr Nicholson told Medscape Medical News.

Asked to comment on the findings, session moderator Elizabeth W. Loder, MD, chief of the Division of Headache and Pain at Brigham and Women's Hospital and associate professor of neurology at Harvard Medical School, Boston, Massachusetts, told Medscape Medical News that the finding of nearly half of the kids getting no treatment is "disturbing, because migraine is a severe headache in most cases and can be disabling or disruptive. Since they're seeking treatment, presumably they've tried [nonsteroidal anti-inflammatory drugs] at home with no luck. It is worrisome that they have no specific treatment recommended."

However, she cautioned about interpreting data from electronic health records (EHRs).

"This is an early example of the value of EHR information and being able to mine things," she said. "But what you can't do with this sort of bird's eye view is delve into the reasons why something is happening. So I think it's important to be very careful about drawing conclusions…We don't know in any individual case whether the treatment was appropriate or what else was going on."

However, she added, "The general results are disturbing in that many children and adolescents are using opioids. It is a matter for concern, because of the potential for side effects and problems with that category of drugs. It certainly merits further investigation to see what's going on."

What Happens When Kids Present With Headache?

Nicholson and colleagues initially analyzed data for over 90,000 kids aged 6 to 17 years who presented for the first time for headache treatment during 2008–2014 in both metropolitan and nonmetropolitan areas to primary care, specialty care, or emergency department/urgent care settings. They analyzed laboratory values and other discrete variables, as well as the free-text EHR sections, in order to exclude all secondary causes of headache, such as infections, post-trauma, cancers, or pregnancy.

Of the resulting study sample of 38,296 individual pediatric patients, 57% were female and 78% were white. More than half (57%) had private insurance and 21% were on Medicaid. Of the 1617 providers in the sample, 78% were in metropolitan areas, 65% practiced primary care, 26.5% worked in emergency/urgent care, and 9% were specialists.

Of the total 38,296 pediatric patients with headache, 45.7% had no formal diagnosis recorded in the EHR, 36.6% were diagnosed with "headache not otherwise specified," and only 17.7% were diagnosed with migraine.

In all, 46% of the patients received no treatment and just 16% received evidence-based treatment, which Nicholson and colleagues defined on the basis of published guidelines and included both nonsteroidal anti-inflammatory drugs — over the counter or prescription — as well as triptans.

In the other analysis of 21,015 patients from the same database who had received a medication, 15.8% had been prescribed an opioid.

Predictors of Appropriate Treatment

Significant demographic predictors of receiving evidence-based medicine included older age, female sex, white race, and having government insurance compared with private or no insurance.

Those with a diagnosis of migraine were 4.71 times more likely to receive evidence-based medicine than were those without a diagnosis (P < .001), while those with just a "headache" diagnosis were 1.71 times more likely than those with no diagnosis to receive appropriate medication (P < .001).

But those diagnoses also predicted greater likelihood of receiving opioids, with odds ratios of 1.6 for both migraine and headache compared with no diagnosis (P < .001).

Primary care providers were more likely than specialists to provide evidence-based medicine (odds ratio for specialists vs. primary care, 0.71; P = .021) and less likely to prescribe opioids (odds ratio for specialists vs. primary care, 1.91; P = .001).

Children presenting to the emergency department were also twice as likely to receive opioids as were those presenting to primary care (odds ratio, 2.02; P < .001).

"The best care occurs for children diagnosed with migraine treated in a primary care setting," Dr Nicholson told delegates here.

Surprisingly, providers in nonmetropolitan areas were more likely than those in other areas to prescribe evidence-based medicine (odds ratio for metropolitan vs. nonmetropolitan, 0.65; P < .001).

"This is truly the opposite of what we thought, and we're going to do more work to find out exactly why that is," Dr Nicholson noted.

On a bright note, whereas there were only two triptans approved for use in kids at the time this study began, now there are four, including one for use in children as young as age 6 years and the first-ever nasal spray for kids aged 12 years and up.

Dr Nicholson and Dr Loder have disclosed no relevant financial relationships.

American Headache Society (AHS) 57th Annual Scientific Meeting. Abstracts OR13 & PS2. Presented June 20, 2015.

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