This Neuroscience Grand Rounds session, led by Ruying Fu, MD, highlights evidence-based strategies for acute, preventive and interventional migraine management in pediatric patients. Migraine care requires a comprehensive approach, combining rapid symptom relief with therapies that reduce frequency and severity over time.
The presentation reviews pharmacologic options alongside interventional and non-pharmacologic therapies including nerve blocks, botulinum toxin, neuromodulation, and lifestyle modifications to support individualized, multidisciplinary care and improve patient outcomes.
Learning Objectives:
Identify evidence-based acute treatment strategies for migraine, including triptans, gepants, and non-specific analgesics.
Describe preventive pharmacological treatment options for migraine, including oral medications and CGRP monoclonal antibodies.
Recognize interventional procedures for migraine management, including botox injection and nerve blocks and non-pharmacological treatment approaches for migraine, including neuromodulation devices, lifestyle modifications.
OK, thank you. OK. Wonderful. Good morning, everyone. I have the pleasure of introducing this morning our current headache medicine fellow, Doctor Wu Ying Foo. Doctor Fu earned her medical degree, excuse me, from Sun Yat Sun University and completed her residency training at an affiliated hospital of Sun Yat Sun University. Um, and she's been with us since last July, and, uh, it's crazy to think that the year, uh, end of the year is now approaching. Um, Doctor Fu's research interests focus on migraine pathophysiology and precision treatment of headache disorders, and she will be presenting on that this summer at the American Headache Society scientific meeting in Orlando in June. We're, we're very excited about that. And this morning she's going to be talking about acute preventive and intervention, interventional strategies for migraine. Thank you for the introduction, Doctor Rassady. Uh, hi, everyone. I'm Lu Yifu and um I'm headache fellow. It's my great pleasure to be here to have a presentation today. Um, my topic today is uh about uh pediatric migraine management. So, um, migraine, um, is the 2nd, 2nd leading, leading, disabling disorder in the world and it's affecting over 1 billion people worldwide and, uh, um, and, uh, um, it's, uh, and you can see that it's a female dominant disorder that is affecting. Uh, 1 in 5 women and 1 in 16 men in the, in the US and 1 in 4 homes in the US. And, uh, uh, um, in the pediatric population, it affects 1 in 11 children. That's important for us. So, um, So, uh, let's see the diagnosis of migraine. Uh, we followed the SCH 3, SCHD 3 criteria, and, uh, um, uh, at least 5 attacks, uh, meeting the following criteria. So, um, for pediatrics, uh, migrants, so, uh, the duration is, uh, lasts at least 2 hours, and, uh, which is different than Adults requires at least 4 hours and more than 2 of the following location should be, can be unilateral or bilateral and there should be uh uh uh pulpitating pain, moderate to severe pain intensity, and the pain can be aggravated by uh um causing avoidance of routine physical. Physical activity and 111 of the following, uh, nausea or vomiting, and the photophobia and the phonophobia. The key here is that the kids cannot, uh, for the younger kids, they usually cannot verbally describe photophobia and phonophobia. So, it's important for us to infer this from their behaviors such as seeking a dark room or or covering their ears. So, and also it's important that um the headache not attributed to another disorder. And, uh, um, so understanding the pathophysiology, it's very important for us to understand the, the new drugs for migraine. So, uh, calcitonin generated um protein, which is CGRP is 37 um amino acid uh neuropeptide. Um, it is a member of calcitonin family of peptide. And uh, um, the clinical evidence suggests that CGIP may play a causal role in migraine. So, this is the uh CGRP molecular and the um the, it, um, mm. Uh, located in many places, such as the smooth muscle cell and the ferritin and the efferritin panignal and the glial cells mast cells. And you can see from here the Uh, um, sorry. The TG and the TCC and the thalamus and the cortex. It was, um, localized very, um, broadly in the, um, migraine pathophysiology. And, um, so it, um, The mechanism uh in the migraine, uh, is that it can cause vasodilation and uh no receptor uh activation and uh uh neurogenic information and uh and it also play a role in central sensitization. So, um, so, uh, during migraine attack, the, uh, plasma CGRP levels significantly, um, increased compared to the, um, compared to the, uh, control subjects. And, uh, um, and interestingly, it uh returned to normal level after, um, Uh, after, um, triptan treatment and, uh, um, achieved the, um, migraine relief. So, um, so, So we, uh, so, um, it, so it, uh, it was indicated to be a, a generator molecular in migraine pathophysiology. So, um, the pans and the, um, Uh, GPENS and the CGRP monoclonal antibody are the newer drugs for migraine, and GPAs are small molecular molecule that target at uh CGRP receptor. So, and the, the um CGRP monoclonal antibodies target either the uh CGRP receptor or the CGRP ligend. These are the, uh, the medications Urojepan, adjapant, remijepan orient. Uh, so, and the, the, um, the, uh, this other, uh, mono uh monoclonal antibodies. And let's see how triptans and detons work. So, uh, triptans work on 5-HT1B and 5-HT1D receptors. So, it can cause, um, so, um, the activation of 1B receptor can cause uh vessel constriction. And the, the, um, the ID receptor activation can uh inhibit CGRP release. And uh so, this is uh triptone was the, uh, is the standard treatment for migraine. And the right side is how Dittens. This is also uh a newer medication which uh stimulate the 5-HT1F receptor. So, um, Dittons do not have the effect of um vasoconstriction. So, um, but it can also cause the inhibit, uh, inhibition of CGRRP release. This is, uh, um, uh, how it will work for migraine. And uh uh let's see, uh, the overview of migraine management. So, uh, for migraine, we have both preventive treatment and acute treatment. So, the preventive treatment, uh, is for, uh, to reduce the um frequency Frequency of headache, uh, to reduce the headache days and the, the acute treatment, treatment, um, to, uh to um control the pain, uh, as we use as needed at the onset of headaches. So, these are the, um, mm. So, these are, uh, these are the, uh, uh, medications and the, the management we have for migraine. So, uh, let's say acute treatment first. So, uh, this is, um, the guideline, guideline, uh, mm, made by the uh AAH and the AHA and the AHS um for acute treatment of migraine in children and adolescents. Uh, this guideline was published uh in Neurology in 2019. So, let's see, uh, for the, uh, acute treatment, the guideline recommend uh recommend NSAIDs, uh, ibuprofen and uh triptans such as uh sumatriptan and sumatriptan, naproxen and the zommatriptan nasal spray. Uh, these medications, uh, received the recommendations with high or moderate confidence in evidence, and the, uh, Amo chieftain and the rise chieftain, um, received the recommendation with low confidence. Um, so, and also they, um, they recommend, um, the dopamine, uh, antagonists to, uh, use as acute treatment. So, um, the right side is the, uh, dose for these medications. So, uh, let's see, uh, analgesics first. So, um, uh, acetaminophen, ibuprofen, naproxen, and the aspirin and the catararac were recommended in the guideline. So, um, acetaminophen is a, is a non-opioid analgesic. So, uh, for the pediatric, we use 150 mg per kg and maximum 1000 mg per dose and um we can use every 4 to 6 hours. The side effects include hetotoxicity and the, the, um, the data shows that it's inferior to ibuprofen at 2 hours uh headache recommendation. Uh, or headache free and the, the ibuprofen, uh, was regarded, uh, was recommended as the initial option to, um, uh, to, to, uh, Um, to reduce the pain which got the level B evidence and uh um. We use, uh, uh, the dose is 75, 7.5 to 10 mg per kilogram, and the maximum 400 mg per dose, and uh we can also use every 6 to 8 hours. And naproxen, um, mm. The, the dose is 5 to 10 mg per kg and the maximum 500 mg per dose and we can use every 12 hours and the aspirin is also a size, so, the pediatric dose is 1010 to 15 mg. Uh, per kilogram, um, but, uh, remember this one can only use in adolescents over 16 years due to the concerning of rising germ risk in kids under 16 years. So, uh, So, at this age group, uh, it's contraindicated. So, um, and the cataractlog which use um usually in the emergency setting, so the dose is 0.5 mg per kilogram. Uh, uh, IV or IM, the maximum, uh, 30 mg. So, all the NSAIDs have um shared similar side effects such as GI upset or GI bleeding, or, uh, or renal impairment with chronic use. So, uh, for aspirin also have a side effect of platelet dysfunction. So, These are the analgesics um recommended in uh pediatric uh migraine. And the, the, uh, triptans are the um migraine-specific medications. Uh, so, the, um, in the guideline, it recommended the uh amotrip uh recommended the uh amotriptan, and the ristriptan, sumatriptan, and the sumatriptan. Uh, for the, uh, pediatric, um, Uh, migrant management. So, uh, these four me chieftains, they received the FDA approved for, um, for kids. So, red chieftain can use down to age 6 and the other 3 chieftains can use down to age 12. And uh so, um, So, um. So, you can also see that uh uh some some uh sumatriptan have different uh formulations such as oral tablets and nasal spray and the nasal powder and the subcu and the auto-injection and the zommatriptan also have nasal spray and the uh and the dissolvable tablets. And the rice chip can can also have the uh dissolvable um tablet. So, um, so, subcutaneous and the nasal sprays uh usually have the shorter T max, um, so they usually work faster than the oral tablets. So, um, and, uh, so, um. Amotriptan, so we use 12.5 mg and uh um that triptan, we use uh uh 5 or 10, uh, have 5 or 10 mg and the sumatriptan also have different dosage. And uh mm, so, um, OK. So, and uh this is uh and uh also the uh fluotriptan and the neurotriptans are the triptans that has longer uh half-life. So, this, uh, so we can use for uh recurrent headaches. So, um, these are the selection of triptans that we come, uh, we often, mm, based on the clinical scenario to choose which triptone we, mm, is better for, uh, the patient. So, uh, if we, uh, if you, um, uh, if you, uh, I think, um, uh, you are concerned about the side effects, so, uh, amatriptan, you can use amatriptan, noratriptan, and the fluotriptan. These medications have um better, uh, side effect profile. And uh, uh, if patients, they often experience early nausea or vomiting, and that could, they cannot hold down the medication. So, the sumatriptan nasal spray, sumatriptan nasal spray, and the sumatriptan um auto-injection and the uh retriptan, mm, this uh this uh integrating tablet, um, this can be your, um, Uh, can be your options. So, um, if the, if patients experience rapidly, uh, intensifying headache, uh, so we can use sumatriptan and suma nasal spray and the sumatriptan, um, uh, subcutaneous injection. This, um, uh, this, uh, work faster than other triptans. And uh if the, um, headache recurrence, then we can use the Uh, naratriptan and naratriptan, which has longer, uh, half time. So, these are the tips of, uh, for prescribing triptans. So the, uh, so we, the rule of two, so, uh, we, uh, uh, we can Um, so, uh, we can recommend the patients take a second dose after 2 hours and uh remember, no more than 2 doses, 2 dose, in 24 hours and uh uh maximum 2 days per week. And uh so, we also need to warn patients about the uh potential side effect. The common side effect are tightness of face. Neck and the chest and uh also feeling flushed or flu-like symptoms. And the, the contraindications include history of cardiovascular or cerebral vascular disease and uh uncontrolled hypertension and uh hemiplegic migraine, uh, migraine with brain stem aura or prolonged aura. So, Um, so, uh, so here is a question. Is combination treatment such as uh, triptans and NSAs used together can more, can be more effective? Yeah, the answer is yes. Uh, the data, the, um, Uh, data shows that, uh, which is the, um, Cochrane, um, systemic review. So, the data shows that, uh, sumatriptan combination with naproxen, so has the highest uh rate of reduction of um pain relief at 2 hours. So, uh, it works better than uh than placebo, or it, um, um, either one, monotherapy. So, So, um, sumatriptan and the naproxen, naproxen together also, um, mm, so, uh, which achieved the recommendation in the guideline. So, uh, let's move to the newer medication, Japan and the Dian. So, um, uh, these are the these 3 Gpan, ramitriptan, Urojepan, and the davatriptan. So these are recommended for acute, uh, for, uh, acute management migraine migraine. 00, Uh, I'm sorry I can't hear my voice. So, oh, it's OK now. So, uh, Rajpan, um. Um, so, um, the different, uh, we use, uh, 75 mg, um. Um, PO, uh, at, at the onset of headache and, uh, uh, Urogpan, we have 22 dosage, uh, 50 and 100 mg is also oral tablet and Zajepan 10 mg, uh, it comes as a nasal spray. So, this is good for patients who cannot hold down the medication. So, uh, So, for the uh Ramjapan and the Urojapan um and the Daojpan, they all, all of these can only use once in 24 hours and the Ramjapan and Urojapan. Uh, need to be very cautious to not take, take, taken with, uh, the strong CYP3A4 inhibitors such as uh ketoconazole, uh, inconazole, and uh uh erythromycin and uh dogepan. So, Uh, these are the GPs and, uh, um, the, uh, Ditton, uh, such as Lem Ditton. So, uh, this comes 50 and 200 mg, but, uh, uh, unfortunately, not really, it's off market currently in USA, so it's not, it's not available, um, currently, uh, so, mm. Looks like it's because of business reason, not that, not of the, uh, not because of the concerning of that effect. So, with Ditton, it's recommended to not drive or operate large machinery for 8 hours after taking the medication. So, uh, when to initiate, uh, the GAs or deters. Um, so, per AHS uh state, um, consensus statement. This is for, uh, adults, but, uh, in some specialized pediatric case, uh, the, um, statement also recommend. Can, um, start, um, GPA when, uh, if patients have a contraindication or inability or unable to tolerate triptans, uh, they have failed to, um, to triptans, then we can consider to uh start GPpan for these patients. So here uh is uh the power for acute treatment of migraine. So if patients had um significant nausea or vomiting, then we can we can consider to add an anti-emetic medication or we can consider non-oral uh drug routes such as the nasal spray and the, uh the auto auto injection and the, the And the, the dissolve uh dissolvable tablet. And so, If patients experience cheaptan side effect, uh, we can consider, um, the triptans with good uh side effect profile, as we mentioned before and uh if a patient cannot tolerate triptan or they are educated. To triptans then we can select to a different uh class of medications such as Gent uh Dtenses. And uh uh if patient achieve incomplete relief, uh, headache recurs. Then, except the um the two triptans that uh has longer half-life, we can also consider the combination of uh combination of um triptan and the and the NSAIDs. So, and also we can consider, uh, to add dopamine, um, uh, antagonist. Uh, so, if patients or the parents, they, um, they don't like, uh, uh, um, medications, then we can consider, also consider, uh, neuromodulation device. And, uh, if you are worried about the medication overuse, then we can um start uh migraine prevention and also we can discuss and uh Uh, also, we need to discuss, uh, medication overuse headache, uh, in, uh, in these in these patients. OK. Let's, uh, um, let's move to the preventive treatment. So, want to prescribe uh preventive medications. So, uh, if patients uh experience headaches more than once a week, uh, uh, if the migraine impairs their function on a regular basis, or if the patient or parents they They uh they prefer to uh help preventive treatment, or if, uh, the, uh, or if the acute medications are effective or be overused, or worry about their side effects, then we can uh start to, uh, start the preventive treatment. So, uh, this is, uh, uh, a list of migraine preventive medications for adults. So, uh, we can, mm, we can take a look and, uh, um, uh, so we have the, uh, oral. Uh, we have the, um, established, uh, uh, efficacy, uh, efficacy, um, medications and, uh, also have medications, uh, have probably, um, uh, probable efficacy. So we have the oral tablets and the parent uh parenteral, um, medications also and the non-pharmacological, uh, logic options. So, this is the AHS and the uh guidelines for uh pediatric uh patients uh for uh migraine. Uh, um, preventive treatment. So, um, topiramate and, uh, amitriptyline and uh propranolol and uh and uh uh cyproheptadlines, these are the, uh, commonly used medications for, uh, kids. So, uh, Uh, we will. So here is other, uh, here are the those and also the, uh, commonly side effect and, uh, uh, we will, um, hm, and we will discuss in the following, uh, slides to, uh, um, to have more details. And, uh, so let's see the, uh, Uh, tricyclic, uh, tricyclic antidepressant medications. Uh, amitriptyline and the nortriptyline are the most commonly used in this, uh, class of medication. So, um, usually the low dose, low doses, uh, do not cause the, uh, do not have effect on mood and, uh, can, um, also be benefit for insomnia. So, Mm, can help them to sleep better. So, and, uh, um, Uh, currently, it has, uh, insufficient evidence to judge independent effective, uh, if you, uh, um, uh, amitriptyline alone, and, uh, uh, however, a few early studies in pediatrics showed benefits. And, uh, uh, CHAM study and uh uh P's 2013 trials, uh, at, uh, um. And the, uh, um, the, uh, the trials that, uh, um, mm, that, uh, also, uh, so for the, uh, amitriptyline. So, uh, in the POS 2013 trials, they uh demonstrated the efficacy of CBT plus amitriptyline which, um, uh, received a level B recommendation. And so, for uh these two medications, we usually start from 10 mg and uh uh gradually titrate up to 1 mg per kilogram per day. So, um, the maximum dose for amitriptyline is 75 mg. So, we need to be cautious about uh the prolonged QT, uh, if we use dose higher than 1 mg per kilogram per day. So, for this, for this case, we need to do an EKG before we uh use this um um the higher dose. So, the common side effect for amitriptyline includes sedation and uh uh dry mouth and uh um uh constipation and the weight gain. And it also carries the black box warning from FDA. Um, so, uh, for the suicidal ideation, uh, behavior, so, uh, for younger children, amitriptyline have the, uh, crush tab tablet, and for nortriptyline, we also have the liquid formulas. So other antidepressant medications include uh uh flu fluoxetine and the duloxetine and venlafaxine. So, uh, topiramate, uh, is the, is a medication, uh, achieved, uh, received the FDA approved, uh, approval, uh, to, for, for kids, um. Um, over modern age 12. So, uh, it's probably more likely, um, than, um, possible to decrease headache days and the migraine attacks. So, uh, it will received moderate confidence and, uh, um, from, uh, and also had for class one studies and the chances, um. Trump study also um mm have this medication. So, we usually start uh uh from 25 mg and uh uh titrate slowly over 8 to 10 weeks period up to 2 to 3 mg per kilogram per day. So, another common side effects for topiramate such as decreased appetite, so sometimes we saw kids lose weight from this medication and uh And, uh, um, they feel the, and the, the tingling and numbness in their hands and uh and their um feet and uh also it can cause, uh, brain foggy and the, the rare side effects such as kidney stone and uh glaucoma and uh uh metabolic acidosis, so. Oh. So, for uh topiramate, we have the, uh, also have the extended release tablet. And uh for younger kids, we have the crush tabs and the uh sprinkle capsules. So, uh, valproic acid. So, uh, pediatric studies have shown the efficacy of, uh, this medication. We, uh, use this, uh, the dosage usually range from 250 to 1000 mg daily, and the common side effects include, uh, GI upset, weight gain, and non uh somnolence, and, uh, dizziness and the tremor and, uh, um. We should, and also the uh uh teratogenic uh um side effect of this medication, we should uh also need to be very cautious, um. And uh so for younger kids, it has sprinkles and uh also have extended release formulation. And the other anti uh epileptic medications such as uh doisamide, uh, lootam, and the gabapentin, and uh um uh uh lucosamide. Uh, propranolol, uh, it, um, it's possibly more likely than placebo to achieve more than 15, 50% reduction in headache frequency, um. Uh, with low, uh, confidence evidence. So, uh, So, the dose, uh, so we usually start at 10 mg and uh titrate up to 60 mg per day or 3 mg per kg per day. So, um, So And the common side effect include the dizziness, fatigue, and the uh nightmares and the mood. So, it's contraindicated in asthma patients. And the other, uh, anti-hypertensive medications that can also use for migraine, um, preventive, prevention, uh, uh, metoprolol and, uh, uh, atenolol and, uh, uh, verapamil and uh uh flunazine. But uh uh fluorine is not available in USA. So, uh, cyproheptadline is also, um, commonly used medication for kids to prevent, to prevent, um, migraines, but, um, um, but with poor evidence. However, it's, uh, uh, we found, um, we found it's, uh, effective, um, for, for some kids, for many kids, and, uh, so it's uh um. It works by uh antihistamine and uh um anti uh serotonergic um mechanism. For this medication. So, uh, it has a very old, uh, evidence that, uh, from the reports that in pediatrics, they, um, Uh, date back to 1970s. So, uh, we usually start from 42 to 4 mg per day and uh up to uh 0.2 to 0.4 mg per kg per day. So, usually we, uh, use no more than 3 tablets in most cases. Um, uh, so if they use more than 3 tablets, we commonly see, uh, side effects such as, um, mm, extremely tired or drowsiness from this medication. So, the common side effect includes sedation, so we use at bed night and, uh, uh, appetite stimulation. So, we saw some kids they can, um, They can uh gain weight from um cyproheptadine. So, uh, this one is a good medication in younger children, so it has liquid formulation. So, That's a good choice for kids that cannot uh swallow tablets. OK, let's see the uh famous CHM trial. So, uh, in this trial, it compares the efficacy of amitriptyline, topiramate and the, and the placebo in migraine prevention. So, uh, uh, So, uh, the, this trial enrolled 361 children aged 8 to 17. Uh, with the episodic or chronic migraines. So, uh, surprisingly, the child was stopped early for fertility. So, uh, in this child, it, um, in this study, they found that no significant difference for any primary or secondary outcome. So, it means that the placeable do not inferior to the active medication and the medication, the drugs also um Um, has more, uh, reported, uh, with more, uh, associated with more adverse, uh, effects. So, um, So, uh, so, OK, let's see. The, another, um, trial for, uh, PS 2013 trial, uh, which compares CPT plus amitriptyline and, uh, uh, hm to uh headache education and amitriptyline in this trial. So, the, um, they found that among young persons with chronic migraine, the CPT plus, uh, amitriptyline. Uh, works better, uh, at reducing, uh, headache frequency and migraine related uh disability compared to the use of headache education plus amitriptyline. So, the CBT plus amitriptyline received the level B recommendation in the by AHA guidelines. So, let's move to, uh, let's see the newer medication, CGRP target therapy. So, um, So, uh, in, in this table, it lists the two GPAs, A GPA and the Ramjapan were recommended in the AHA guideline to uh use as preventive treatment. So, another, uh, uh, so, uh, Rajapan was listed in both, uh, acute, can use as both acute and preventive treatment for migraines. So, uh, um, So, these are, um, so, uh, for, uh, atoypan, which is, uh, the brand name is Qlipta, it can uh use uh for both episotic and chronic migraine. And uh it has different dosage also. And the ramijapan for um migraine prevention, we usually use one tablet every other day. So, uh, these are the, uh, antibody, um, Anti, uh, monoclonal antibodies, um, for it it's for CGRP. So AOic, uh, the brand name Aovicjovi, M Gati, and YFT. So, uh, Amovic we use monthly and, uh, uh, so it has 70 mg and 140 mg. Two dosage and uh a joy, so we can use both quarterly or monthly. For monthly we use 225 and for quarterly we use uh 675 mg. So I'm guarantee it can uh the Uh, loading, we, um, the loading dose is 240. So, uh, so we use the loading dose first and then 120 mg monthly. And for YFT, uh, it's uh IV infusion, uh, medication. So, uh, we can use either 100 mg monthly or 300 mg quarterly. So, when to uh start uh initiate CGRP um antibodies. So, uh, this is the um AHS 2021 criteria for adults. Um, unfortunately, we do not have the, uh, guideline for, um, for kids to, um, for the CGRP uh, medications. Uh, so, uh, So, in this guideline, the general rules requires a failure of uh requires failure of two classes of the traditional um preventive medications such as the one we discussed before, topiramate and uh beta blockers and uh uh amitriptyline, uh, um, uh, venlafaxine. And so, So, uh, so here is the update of the 2024 NHS statements, uh, which list the CGRP, um, uh, mono, um, uh, antibodies and the GPS, um. As the first line options for both uh for both uh episodic and uh chronic migraines. And so, uh, so for, uh, you do not require to the failure of mm, migraine, traditional migraine preventive medication. So, this is, uh, uh, so, Um, so, how, but, however, in the real world, the, uh, insurance, uh, still, um, requires, uh, to requires the uh staff therapy of, uh, fail to, uh, class of, um, traditional migraine, um, preventive medications. Uh, so, the, uh, uh, from Moi Zuma, which is a joy, um, just recently, uh, received, um, um, FDA approval for the preventive treatment, uh, for, uh, episodic migraine, which has less than 15, um, 150. days per month headaches. Uh, so, in pediatric patients, so it goes uh age down to age 6 and uh also requires uh uh the kilo weight more than 45 kg. So, uh, this is the space trial. Uh, uh, which demonstrated the, um, the reduction of 2.5 mgm days per month and, uh, also 47.2% of, uh, patients treated with HIV received, achieved, uh, uh, over 50% reduction in migraine days, um, compared to 27% with placebo. So, this is good news for us. We have, we have the uh CGRP targeted therapy for kids for uh which uh received the FDA approval. So, the safety and the uh safety uh standpoint for CGRP uh it is generally well tolerated and the, the, um, the injection site reactions are the most commonly reported side effects. And the other side effects such as, um, upper respiratory tract infection, constipation. and uh uh back pain and the sinusitis. So, uh uh Emmavi was reported to have a side effect of blood pressure elevation and uh um Ajovi and Agati reported to have the, uh, have sensitivity reactions and, uh, so, um, otherwise it's generally well tolerated. So, um, we also have the, uh, nutraceuticals as an alternative or objective options. So, riboflavon and magnesium and coenzyme Q10 are commonly used for kids. So, um, these are generally, um, have, uh, have favorable, uh, safety profile, um, but the, um, And, uh, uh, but the, uh, evidence, uh, even the evidence is poor, but many clinicians use these medications, uh, prior to, um, As first line treatment prior to medications after the CHAMP study, and usually we recommend uh give a trial of at least 3 months to uh um to uh assess to before assessing the efficacy. So, riboflavin, we use 50 to 200 mg BID. So, uh, it can cause the urine, um, it can turn the urine to yellow orange color. And magnesium. So, uh, we use 9 mg per kilogram per day BID. So, uh, the side effects include the common side effects include, uh, diarrhea. So we usually use the uh collated forms such as magnesium. Uh, uh, oxidation and magnesium gly uh glycinate, uh, which can be, um, better tolerated and than, uh, Q1, we can, uh, we use, uh, 50 to 100 mg BID. So, this is generally tolerated, so. These are the, um, these are the uh natural supplements for options for migrant kids. So, uh, for migraines, we usually, we also have the interventional procedures. So, uh, Botox injection, which is FDA approved for chronic migraine as preventive treatment. So, we use T30, 30 gauge um uh syringe and uh uh uh dilation we, uh, for 200 unit tablets, we dilate with uh 4 mL normal saline and, uh, we, uh So, we usually ask for uh patients to sit for the posterior injections and lying down for frontal and temporary injection. Um, you can also ask them to lie down for other, uh, uh, for other injections for the entire injection. So, uh, this is the, um, uh, pre um preempt uh preemptive, uh. Um, protocol for, uh, Botox injection. So, um, it recommended 31 injection sites and divided across 7 specific areas in, uh, uh, over the head and the neck muscle. So, um, So, this, uh, from the picture, you can see the, uh, injection sites on the, on the, on the front, the, uh, temporal, uh, temporalis, and the occipitalis and the, the, uh, cervical, pronasal, and the, uh, trapezius. So, for the nerve block, uh, we, uh, the nerve block usually used as an acute and the transitional treatment for acute and chronic migraine. So, uh, the, uh, figure one is the greater and the less occipital nerve block, and the, the figure 2 is the uh supraorbital and the supratrachlear nerve block, and the figure 3 is the uh auriculotemporal nerve block. So, uh, we usually use, uh, pivacaine and, uh, uh, 27 gauge needles and a 3 cc syringe, syringe. And, uh, uh, so, uh, for greater occipital nerve, we can, uh, for the, um, occipital nerve block, we can use either 3 cc in greater occipital nerve bilaterally, or we can use 2 cc in the, um. Greater occipital nerve, um, uh, and the YCC in the uh lesser uh occipital nerve bilaterally. And uh for the uh supraorbital and the supratrochlear and the auriculotemporal nerves, we usually use 0.5 cc bilaterally. So, we also have SPG block. We um we use uh sometimes for the status microcells in emergency uh emergent setting. So, uh, the left side shows the uh uh spinalantian ganglia. So this is the place we, uh, put the medication. So, So, uh, we use uh lidocaine and, uh, um, Q-tips. So, uh, So, before the, uh, before we start the, um, the procedure, we need to check, uh, check for any uh uh anatomical variance uh obstructions first and then we insert the lidocaine gel with Q-tips and the, the, uh, patient and the We ask patients to lie down with the neck extended and uh Um, And uh so then, uh, we can, um, catheter placed in nostria and advanced to the point of resistance. So we use 1 cc per nostril of uh 2% lidocaine. So, uh, here, here are the non-pharmacological, um, options for, uh, migraine prevention. So, the neuromodulation devices, uh, these are the three, devices that FDA cleared for pediatrics down to age 12 for which can use both, um, Uh, uh, as can can use as both, uh, acute and preventive treatment. So, uh, the remote electrical, uh, neuromodulation, uh, the brain name reveal, and the non-invasive vagus nerve stimulation, um, gamma core and the, the, uh, uh, single pulse transcranial magnet magnetic stimulation. So the Inurra. So the Narivia we use most commonly for kids. Uh, which, uh, and the kids, um, many kids, some kids, uh, like this, like this one, but we also see some kids cannot get benefit from it. So, um, so, uh, these are the two, another two options, transcutaneous, uh, supraopttal nerve stimulation is, uh, cephaly and the, the, uh, external combined occipital and the trigeminal neuro stimulation. Uh, the brand name, uh, Relivian. Can also, uh, as options. So, uh, behavioral therapies, uh, are also, uh, such as, uh, uh, biofeedback and the cognitive behavioral therapy and the relaxation training. These achieved a great evidence. Um, so, um, These are also, uh, these are effective at all life, uh, stages. So, uh, this can be used alone or combined with the other medications. So, uh, so, patient education is also very important for migraine management. So, uh, here are the smarts habits. Uh, see, uh, see, uh, we recommend to sleep well and, uh, also we, uh, also we screen for, uh, insomnia and the sleep apnea in the clinical setting. And, uh, um, So, and uh meals and the hydration. So, eat 3 meals regularly and keep hydrated. And, uh, um, and uh also uh exercise at least 3 to 5 days per week. And, uh, uh, relaxation, uh, are also very helpful. So, uh, for kids, we also need to screen for, uh, depression and anxiety. And we also, uh, the, uh, the avoidance of triggers are also, um, recommend, are also very important. So, these are, uh, here are the resources for families. Um, so the, uh, the left side is a headache relief guide on the right side is, uh, American, uh, the website of American Migrant Foundation. In this uh website, there are some, uh, some useful, uh, um, uh, useful management, uh, for, uh, migrants. Thank you very much uh for your attention. So, uh, here is my, uh, email. I'm ready for the questions. Thank you. That was excellent. Thank you so much for that very Uh, good, good, um, update, and I like the idea of the sort of the precision medicine. How do you figure out these, uh, different, uh, devices for different people based on their side effects, so I appreciated that. I have one question for you. Well, you mentioned when you use topiramate, the research shows that above a certain level, you have to be careful about Um, interaction with birth control pills, for example. Is there any thought on dosing of topiramate or valproate as to when you would have to give folic acid supplementation? I know that they say you should use it even for low doses, but is it, is there anything to say that it's dose-related or just if you're on topiramate or valproic acid, you should be on supplementation of folic acid. OK. Uh, that's a good question. So, uh, for topiramate, uh, if, uh, when we use, um, higher than 200 mg per day, then we should be, uh, so it may have the, uh, um, I mean, uh, interaction with the OCPs. Right, but with folic acid, not, not sure if it's dose related. Mm yeah that was a great job. Thank you. I think the sorry, I can answer. um I think the recommendation is to start folic acid supplementation with topiramate regardless of dose. Thank you. Good to hear. Thank you. So, thank you, everyone. Wish you have a great day ahead. Thank you. Bye. Thank you, Doctor Phil.
