Implications of 3-Year Follow-up Data From the Childhood and Adolescent Migraine Prevention Medication Trial.

The last several years have brought us new, effective, and evidence-based treatments for adult migraine. However, for children and adolescents, our evidence for effective therapies remains limited. The study by Powers et al1 represents the fourth installment of the Childhood and Adolescent Migraine Prevention Medication (CHAMP) trial,2 which worked to provide evidence-based approaches to pediatric migraine management. The drug phase of the CHAMP study—a multicenter, randomized, double-blinded, and placebo-controlled trial—examined the efficacy of amitriptyline and topiramate in the prevention of migraine in children.3 Unexpectedly, the study was halted early because of futility. Despite a clinically meaningful reduction in headache days, neither medication was more efficacious than placebo, perhaps owing to patients in all interventions, including placebo, receiving extensive education on migraine management as well as frequent clinical follow-up. The current study1 presents interval follow-up data over a 3-year period for participants who were initially enrolled in the drug phase of CHAMP and primarily interrogates whether participants maintained therapeutic gains after completion of the drug phase. The study found that regardless of drug group—amitriptyline, topiramate, or placebo—over the 3-year period, participants maintained therapeutic gains with a reduction in headache days (a mean decrease of 5 days in a 28-day period), a reduction in disability as measured by a lower PedMIDAS score, and a low percentage of participants using preventive medication.1 The study concludes that a pediatric and adolescent population with long-standing headaches (>5 years) can make long-lasting improvement in migraine control without persistent use of pharmacological prevention.1 Although the initial CHAMP trial2 provided compelling evidence of what we already suspected— that is, treating pediatric migraine is not simply treating adult migraine with lower doses—it simultaneously incited serious debate among practitioners treating and researching pediatric headache. Does equal efficacy of amitriptyline and topiramate to placebo equate to a failure of these medications in reducing migraine frequency and severity, particularly given the confounding behavioral interventions that were offered to the placebo group (making it not a true placebo group)? Should we still prescribe pharmacologic preventatives to children? This follow-up study1 will similarly continue to generate significant and much needed debate. For instance, what did all 3 groups have in common that led to a clinically significant and sustained reduction in headaches, regardless of drug group? To properly interpret an investigation such as this, we must consider the natural course of pediatric migraine. Previous longitudinal studies in children show that migraine prevalence increases over time, especially in girls. One longitudinal study4 followed 1185 students over a 25-year period and observed a low prevalence of migraine in early childhood (3.7% in female and 4.2% in male individuals). However, migraine prevalence steadily increased throughout adolescence (15% in female and 7% in male individuals) and adulthood (22% in female and 8% in male individuals).4 Therefore, it seems that left without intervention, whether pharmacological or behavioral, a subset of pediatric patients will experience an increase in headache burden throughout childhood and into adulthood. It is important to note that several longitudinal studies reveal that migraine frequency evolves over time, for better and for worse. For example, Sillanpää et al4 also noted that two-thirds of child participants demonstrated changes in headaches over the study period, with 10% remitting at the end of the 25-year study. Thus, as appropriately acknowledged by Powers et al,1 we must + Related article