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VBCN - July 2015 Volume 2, No 2 - Headache Management
Chase Doyle

National Harbor, MD—A retrospective review of pediatric emergency department data showed significant pain reduction when sodium valproate (VPA) was used in the second-line setting for the treatment of adolescent patients with migraine. Patients achieved an additional 44% average pain reduction after VPA infusion, according to David C. Sheridan, MD, Department of Emergency Medicine, Oregon Health & Science University, Portland, who presented the results at the 2015 American Academy of Pain Medicine annual meeting.

“There are really no true, FDA-approved migraine medications for kids other than triptans,” Dr Sheridan told Value-Based Care in Neurology. “Some of the therapies we use have been around for 20 to 30 years. These drugs make kids really tired, and they’ll stay in the emergency department for 3 to 4 hours sleeping off their headache.”

Pediatric headache accounts for nearly 500,000 emergency department visits annually, and migraine is the most common, according to Dr Sheridan. Despite the prevalence of this condition, however, many abortive medications have several potential side effects, and fewer options are available to providers after a child fails first-line treatments.

“VPA appears to be an effective agent for acute pediatric migraine,” noted Dr Sheridan and colleagues. “Patients responded well to VPA in a relatively short amount of time, but further studies are needed to evaluate its effectiveness in combination with other first-line medications or as a single agent.”

Although Dr Sheridan emphasized the need for faster-acting medications, he also underscored the dangers of prescribing opioids for headaches.

“One of the biggest mistakes that some providers make is giving kids opioids and narcotics for a headache, which multiple studies have shown can make their headaches worse in the long run,” he said. “And obviously, because migraines are a chronic pain disorder, you don’t want to start patients in adolescence taking opioids. That can lead to other issues.” He added, “That’s why we’re looking for other migraine medications we can use in the emergency department.”

VPA has been shown to be effective for the treatment of acute migraine in adults, but no data exist in the pediatric population.

Reduced Pain Scores

This retrospective review of data from 2 pediatric emergency departments revealed that 12 patients under age 19 years received VPA as a second-line agent for migraine headache between July 2010 and February 2014. The average age of these patients was 15 years, with an equal number of male and female patients.

Of these 12 patients, 83% were discharged home, and 1 patient had a second visit within 72 hours. The average length of emergency department stay before VPA use was 395 minutes, which fell to 120 minutes after VPA ad­min­istration.

Patients achieved a 17% average pain score reduction before VPA use but showed an additional 44% average pain reduction after VPA infusion.

Despite these positive results, Dr Sheridan remained cautious in assessing the drug’s potential.

“It was effective,” Dr Sheridan said. “Unfortunately, there isn’t a magic pill for migraine. However, if you look at the pain scores of the kids before receiving VPA, they were pretty dismal—between 15% and 20%. After receiving VPA, they had another 30% to 40% reduction. So, by the time they got home, we had their pain basically cut in half.”

All but 2 of the patients were able to be discharged rather than stay in the hospital, Dr Sheridan noted, in large part as a result of the effectiveness of VPA.

Combination Therapy

Given the small number of patients who suffer from migraine, Dr Sheridan is embarking on a study of the drug in combination with other therapies and in a long-term setting.

“The standard cocktail we give is 3 different medications,” he said. “In a future trial, we would like to try combining VPA with that cocktail as another medication. We would also like to send kids home with a prescription for the drug and see how it handles their pain over time.”

Dr Sheridan reiterated the need for finding better medications for pediatric patients with migraine as an alternative to opioids.

“One of the biggest takeaways of why we’re doing the research is to limit opioid and narcotic use in adolescent headaches, because that’s a really big problem across the country,” Dr Sheridan concluded.

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Last modified: August 5, 2015
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