OR-11 - Effectiveness of Treatments used in New Daily Persistent Headache in Children & Adolescents

Children and adolescents with NDPH often experience treatment delays, which are associated with lower odds of headache improvement; for each month delay in treatment initiation, odds of any headache improvement at 1-year were reduced by over 20% (OR=0.787, 95% CI 0.651-0.951, p-value=0.013).

Background: NDPH is a primary headache disorder that often presents in adolescence and can be difficult to treat. In this study, we explored the relative benefit of treatments used for NDPH in real-world clinical practice.

Methods:

This was a retrospective chart review study. Patients aged 5-17 years old with possible NDPH were identified based on patient responses to a Headache Questionnaire in child neurology clinic, confirmed with chart review, allowing abrupt onset continuous headache of at least 1 month duration. We included treatments started during continuous headache until both break in continuous headache and sustained improvement in headache. “Bridge therapies” refers to treatments used for severe headaches that are unusually prolonged (e.g., a course of corticosteroids). For treatments tried by ≥10 patients and for the first treatment tried in each category, we calculated proportions with any documented benefit (“significant” (≥30% lasting ≥4 weeks) + “some” improvement) or negative outcome (worsened+side effects), as well as median time to treatment. Treatments may have overlapped.

Results:

172 charts were reviewed. First bridge therapy provided benefit to the largest proportion overall (62/108, 57%). First supplement, usually riboflavin ± magnesium, offered benefit in (36/118, 31%), with few negative outcomes (3/118, 3%).  First prescription preventive, usually amitriptyline or topiramate, offered similar benefit (37/106, 35%) as first supplement, but with more negative outcomes (25/106, 24%). Despite being tried after oral preventives, onabotulinumtoxinA injections offered benefit to the largest proportion (14/20, 70%) without negative outcomes (0%). Overall, time to first therapy was far into continuous headache – shortest for bridge therapies (median 49 days, IQR 17-92), longest for non-medication treatments such as cognitive behavioral therapy (median 144 days, IQR 61-381).  For each month delay in treatment initiation, odds of any headache improvement at 1-year were reduced by over 20% (OR=0.787, 95% CI 0.651-0.951, p-value=0.013).   This relationship persisted in sensitivity analyses.  Additionally, there was a significant relationship between longer time to initiation of non-medication therapies (e.g., cognitive behavioral therapy (CBT)) and lower odds that a patient’s headache transitioned to non-continuous at last follow-up (OR=0.941 per month delay, 95%CI 0.889-0.996, p-value=0.034).

Conclusion:

Youth with NDPH experience treatment delays which may hamper benefit. Clinicians should consider use of bridge therapies in combination with preventive treatments as early as possible. Non-medication therapy, such as CBT, should also be initiated as early as possible. Prospective natural history studies and formal trials are needed.