Dr. Nicholson completed his project in 2014, and his findings are alarming: he found 5 of 6 kids with migraine are receiving poor care. Among those who received medication, 15.8% were prescribed an opioid, contrary to best practices. These disturbing results demonstrate the need for increasing doctors’ awareness of appropriate migraine care for kids and teens.

FINAL REPORT: Assessing adherence to guidelines for the acute treatment of pediatric migraine

Presented at the 57^th Annual Scientific Meeting of the American Headache Society

Summary

There is little research about whether doctors in the US care for children and teens with migraine consistent with evidence-based guidelines and whether they prescribe opioids for acute migraine management. Our study used Electronic Health Record data to look at how nearly 40,000 children and teens with migraine who presented to primary care, specialty care, or Emergency Room/Urgent Care (ER/UC) across four states in metropolitan and non-metropolitan areas were treated from 2009-2014.

Our results showed that among children and teens presenting for care for migraine or likely migraine, nearly half (46.0%) were not prescribed or recommended any medication. Only one in six (16.1%) were prescribed or recommended an evidence-based medication. Among those who received medication, nearly one in six (15.8%) were prescribed an opioid, and these numbers are even higher among teens 15-17.

The findings also revealed that the odds of getting an evidence-based medication were significantly higher if migraine was diagnosed, and the odds of getting any medication (evidence-based or not) were higher in non-metropolitan areas. Children and teens treated in a specialty care setting or the ER/UC were twice as likely to be prescribed an opioid than if treated in primary care.

Hypothesis vs. Findings

We hypothesized that adherence to evidence-based guidelines would be lower in both non-metropolitan areas and in ER/UC settings. Instead, we found doctors in non-metropolitan areas were more likely to adhere to evidence-based guidelines than in metropolitan areas. There were no significant differences between treatment in the ER/UC and metropolitan areas.

We also hypothesized that opioid prescribing rates would be higher in non-metropolitan areas and ER/UC settings than in metropolitan areas.  Our findings showed no significant differences between non-metropolitan and metropolitan area opioid prescribing rates. But, doctors in ER/UC settings were twice as likely as primary care providers to prescribe an opioid.

Unanswered Questions

Our study raises a number of questions. We believe the answers to these questions would advance migraine science and help children and teens with migraine.

1. Are the prescribing patterns across the rest of the US similar to those found in the current sample?
2. How can we identify patients with likely migraine who aren’t accurately diagnosed? This likely would identify gaps in provider accuracy in diagnosing (and subsequently suboptimally treating) children and teens with migraine.
3. How can we identify the population-level impact of suboptimal pediatric migraine care, including impact on healthcare costs related to increased use, likelihood of presenting to the ER/UC, impact on patient disability and quality of life, risk for migraine chronification, treatment-related adverse events, and medical safety issues? All of these would drive home the need for improved care for pediatric migraine.
4. How can we design interventions to improve diagnosis and treatment of pediatric migraine?

What This Research Means to You

Too many children who present for migraine or likely migraine are not getting any medication for their pain. Too few are receiving care consistent with evidence-based guidelines. And far too many are being prescribed an opioid. Five out of six children and teens are receiving suboptimal migraine care. A significant need exists to increase doctor awareness of the benefits of optimal migraine care and the potential dangers of prescribing opioids for children and teens with migraine.