COMMENTARY

Migraine Therapy: Transitioning from Pediatric to Adult Care

Hope L. O'Brien, MD, MBA, FAHS; Shalonda K. Slater, PhD

Disclosures

January 11, 2023

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Hope L. O'Brien, MD, MBA, FAHS: Welcome to today's discussion, during which we'll be talking about issues related to the transition from pediatric to adult care in patients with migraine. My name is Hope O'Brien, founder, CEO, and medical director of Headache Center of Hope, located in Cincinnati, Ohio. I'm a headache specialty neurologist trained to manage both pediatric and adult populations, with a particular interest in late adolescents and young adults. I'm thrilled to be joined by my friend and colleague, Dr Shalonda Slater.

Shalonda K. Slater, PhD: I'm Shalonda Slater, a pediatric psychologist and professor in the Division of Behavioral Medicine and Clinical Psychology at Cincinnati Children's Hospital Medical Center. My specialty is in the treatment of children, adolescents, and young adults with chronic pain, particularly headaches.

O'Brien: I thought I'd start the conversation by sharing an encounter I had with a mom and her 17-year-old daughter, who was diagnosed with migraine at the age of 5. They were waiting for an appointment to see her pediatric neurologist in order to discuss plans for her continued care when she became an adult. They were concerned about when she was going to be discharged from pediatric care because she was about to turn 18 in a few days, and they had questions about what would happen at that point. Would she be immediately discharged? Where would she go? Who would she see as her neurologist? And how would she find an adult healthcare provider?

As most of you are aware, migraine is a chronic condition. It affects children and can persist into adulthood. Also, keep in mind that if not successfully managed through adulthood, there's a potential for worsening of migraine into a pattern that can become chronic. Aggressive and successful management is important and can lead to remission if managed properly.

There have been studies that have looked at patients with other chronic conditions that show that an organized program focused on transitioning patients into adult care can significantly improve outcomes. Yet, successful transition of care from pediatric to adult neurology continues to be a challenge, as there is no systematic approach that exists.

Dr Slater, can you describe some of the challenges that exist in terms of transition of care for patients with chronic migraine who require continued behavioral medicine or psychological intervention, and maybe discuss some of the comorbidities that exist in this population as well?

Developmental Challenges and Comorbidities: What to Look For

Slater: Transition from adolescence to adulthood is a critical time for those affected by migraine. There are a variety of things to consider in this population. Late adolescents may struggle with a variety of psychiatric comorbidities, including anxiety and depression, that can influence treatment options and create opportunities to manage multiple conditions with less medication. Cognitive-behavioral therapy (CBT) for pain is an empirically supported treatment for children, adolescents, and adults with chronic headache, including migraine.

As such, the continued involvement of behavioral medicine is important for adolescents with migraines that affect their functioning and that have psychiatric comorbidities. Psychologists who specialize in the treatment of chronic pain or chronic medical conditions can be located in a hospital, a university, or a private practice setting.

O'Brien: Adolescents and young adults face unique issues as it relates to development. For adolescent individuals, the beginning of sexual activity, the onset of gynecologic conditions, and the presence of irregular or painful menses may raise questions about the use of oral contraceptives to treat migraine. There are also the issues of alcohol use, cigarette smoking, and illicit drug use.

These should be topics brought up in conversations and counseling. As a provider, it's important to have these discussions with patients, and I find it helpful for adolescent patients to do this when they're not in front of their parents. As a result, I do ask that parents leave the room during part of the interview. It's very important to document these discussions as they occur.

As I mentioned before, in neurology, there's no formal process that exists for transition of care from pediatrics to adults. Each facility is left to decide when or whether a patient is ready to transition, along with how much guidance the patient will receive during the process.

A consensus statement that might be helpful for clinicians was published in Neurology and describes three phases in planning for a transition of care. The three phases are transition planning, patient education, and transition readiness.

Slater: That's right. Each phase has a distinguished goal. During transition planning, the goal is to expand the patient's personal knowledge of their condition and introduce skills for self-advocacy. It's a time to figure out what's important for the accepting provider to know prior to transfer. This applies both to the patient and the provider.

Patients should be introduced to the concept of self-management. What does that mean? It's ensuring that the patient understands the type of headache disorder they have and whether they know how to abort and prevent their headaches. They should know that prevention consists of healthy habits in the form of lifestyle modifications, biobehavioral approaches like CBT, biofeedback, and pharmacologic management. The patient starts to take ownership of self-care and to feel confident in their ability to make informed decisions.

Patients should be spoken to directly and clearly instead of focusing on addressing caregivers. By doing that, the clinician can gain an understanding of the patient's knowledge base and be able to directly communicate the expectation that they take greater responsibility for their health.

Tips for Easing the Shift to Migraine Care

O'Brien: You bring up excellent points, Dr Slater. I do want to go back to your point on pharmacologic management, because a number of options will open up to patients once they're over the age of 18. As you know, most migraine medications are approved for adults in that age group.

Now, prior to transition, it's important to identify an adult provider. Patients and caregivers may search on their own or seek recommendations from others, including their pediatric provider. It's important to identify somebody 1-2 years prior to transition, especially if they prefer a provider who specializes in headache medicine.

Given the shortage of providers in the field, this may not be practical. Through the expansion of telemedicine and partnering with our colleagues who are willing to help care for patients with recurrent headaches, my hope is that every patient is able to gain access to the best care in migraine management.

Dr Slater, are there any other tips that transferring providers should be mindful of?

Slater: Moving away to attend college can present a challenge. The patient may require assistance in locating a provider where they're going to school. College students may choose to have their physicians and healthcare team based in their hometown instead of where they're going to be attending college.

O'Brien: Patients should also be educated on the basics of the healthcare system, including how medical insurance coverage works, especially should there be a change in coverage, which could hinder the process of health maintenance. They should also know that health insurance, these days, can limit requirements as to which provider they can choose. Patients should receive a summary of their health history at an age-appropriate reading level in an electronic format.

Now, is there a way to assess whether a patient is ready to transition their care? The American Academy of Neurology and the Child Neurology Society endorse a consensus statement, documented in the previously mentioned article in Neurology, which introduced the Transition Readiness Assessment Questionnaire (TRAQ). This is considered the best validated transition readiness tool.

It's been widely used to help providers identify the areas to address where a patient may not feel ready to transition. The questionnaire focuses on five categories, including managing medications, appointment keeping, tracking health issues, talking with providers, and managing daily activities. Patients should fill out the form independently in order to gain an idea of where they are in their transition readiness.

Dr Slater, what are some of the things that you recommend in order to help patients become better prepared and ready to transfer to their adult provider?

Slater: The patient must feel comfortable making phone calls to providers on their own behalf for scheduling and discussing their medical condition. A preliminary visit with an adult provider can ease stress and anxiety associated with transitioning. Patients who are not prepared have poor outcomes, including increased morbidity.

Factors that contribute to poor transition include lack of resources targeting late adolescents and the fact that many young adults feel unprepared to enter the adult healthcare environment. This is a major challenge to the transition process.

Therefore, yearly assessment should include knowledge of their medical condition and medications, understanding of the side effects of various treatments, identifying significant signs and symptoms of potential mood disorders, and assessing overall psychological health.

O'Brien: Are there additional factors that contribute to successful transition?

Slater: Yes. Successful transition is associated with patients who are older at their last visit at their pediatric center, without comorbid conditions, no history of substance use, adherence to using preventive treatments and procedures, attending appointments without parents or siblings, living close to the medical facility, and having documented recommendations in the patient's chart.

I have a question for you, Dr O'Brien. As an adult migraine specialist, what would be helpful to you as the receiving provider?

O'Brien: A brief summary of the patient's information, otherwise known as the transfer packet, would be helpful. It should include the headache history; diagnosis; treatment plan, including failed medication; length of medication trial; comorbid conditions, including anxiety and depression; and nonpharmacologic headache treatments. It should also include an emergency plan in the form of an emergency department protocol letter in case a patient needs to seek urgent care at an outside facility while away at college, for instance.

A backup plan should also be included. A list of preferred medications should be summarized, with specifics on dosing and frequency. It would also be helpful to have a list of medications that should be avoided. The packet can be used for coordination of care and also communication between providers. It should be updated regularly based on the patient's input on goals and preferences.

One may ask, what would be a good age to start this transition process? Studies have shown that the process should start as early as age 13. This allows for everyone to understand all that is required for transition of care. At the age of 14, a transition packet should be developed in collaboration with the patient, caregivers, and healthcare team.

Dr Slater, it's always a pleasure seeing you. I'm glad we had this opportunity to share information on ways to facilitate successful transfer of care for patients as they continue to manage migraine as adults.

Slater: Thanks, Dr O'Brien. It's been a really great discussion.

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