International Headache Society Guidelines for Trials of Preventive Treatment of Pediatric Migraine

Coexistent Disorders

All coexistent conditions, including psychiatric disorders, should be assessed prior to inclusion in a clinical trial. Patients with conditions that may have an impact on the conduct or results of a trial should be excluded from participation.

Treatment History

Patients with a history of treatment failure, defined as insufficient efficacy following adequate treatment doses and duration or tolerability/safety concerns, may be included in clinical trials.

Recommendations for Trial Design

Blinding

To establish the efficacy, safety, and tolerability of treatments for the prevention of migraine in children and adolescents, investigators must use double-blind trial designs; blinding further helps eliminate investigator and participant bias.

Controls

Clinical trials should compare the preventive intervention with placebo, sham, attention control, or an active comparator. Most migraine trials in pediatric populations have already been performed successfully in adults, and certain expectations may contribute to an increased placebo response in studies with children and adolescents.

Design Type

The IHS recommends parallel-group trial designs over crossover designs: crossover designs include the possibility of a carryover effect and require longer study periods, which increases the chance of participants dropping out. Additionally, certain novel trial designs may be considered, including Sequential Multiple Assignment Randomized Trial or Multiphase Optimization Strategy.

Randomization

An established method of randomization should be specified prior to trial initiation, and random assignment of participants should occur following the baseline phase. As trial participants are part of the intention-to-treat population, randomized positions should not be reassigned during the trial period.

Stratification

To overcome potential confounding, stratification of participants by age, gender, comorbidity, and medication use should be included in parallel-group trial designs.

Data Collection

Well-designed data collection systems should be used to gather essential data regarding headache characteristics, medication use, adverse events, and intervention adherence.

Baseline Period

A baseline period of 28 days up to 56 days is recommended to confirm the eligibility of enrolled participants. A headache diary used during this period can capture important diagnostic information, including migraine attack frequency, duration, intensity, and associated symptoms (such as nausea, photophobia, and phonophobia).

Duration of Treatment

The IHS recommends a minimum treatment period of 84 days (12 weeks). Although treatment periods extending beyond 12 weeks risk identifying a separation between intervention and control, longer treatment periods may be used to evaluate the cumulative or sustained benefit and to identify additional adverse events.

Follow-up

Ideally, participants should continue to record any perceived adverse events in a daily diary after the randomized treatment period. Follow-up is recommended to evaluate long-term safety risks and potential rebound phenomena after treatment termination.

Dosage or Procedure

Trial results in adult populations and known pharmacokinetics and pharmacodynamics should guide the widest possible range of doses used in preventive treatment phase II trials involving children and adolescents. Dosing in phase III trials should be administered according to weight and match the participants’ stage of development.

Concomitant Treatment

Participants and their guardians should record all treatments used for headache in their trial diaries, including type and frequency of acute medications. Concomitant therapies that are permitted should be pre-specified upon enrollment; therapies with potentially preventive capabilities for migraine, however, should not be allowed unless dosage has been stabilized for at least 2 months prior to randomization.

Monitoring

Regular monitoring of participants in clinical trials is recommended throughout the trial phases: face-to-face visits are recommended every 4 to 8 weeks and telephone or video contact between visits may be used to encourage treatment adherence. Smart packaging, pill counts, and device reminders may be considered to monitor adherence.

Recommendations for Outcome Measures and End Points

Primary End Points

Primary efficacy end points in preventive treatment trials should either measure headache frequency or 50% responder rate, which are defined by the number of migraine days a patient experiences during the treatment period or the absolute reduction in headache frequency, respectively.

Secondary End Points

Secondary outcomes to consider include the effect of treatment on specific headache characteristics (headache intensity, headache hours per 28 days, frequency of migraine aura), depression and anxiety, and disability and functioning.

Exploratory Outcome Measures

These outcomes are captured by measures deemed clinically meaningful and which correlate to primary and secondary end points, including number of headache-free days, number of symptom-free days, and presence of biomarkers.

Pharmacoeconomic End Points

The economic value of preventive treatments for migraine should be captured by assessing the direct and indirect costs of treatment, including the price of the treatment and time lost from school or work.

Adverse Events

The IHS recommends that participants and investigators document all adverse events and serious adverse events occur during a clinical trial openly as not all events are related to treatment. Documentation of adverse events should follow the nomenclature and hierarchy of the Medical Dictionary for Regulatory Activities.

Recommendations for Statistics

In reporting statistics, it is recommended that investigators preplan their statistical analysis and define a priori issues, including measurement time to determine study outcomes, primary efficacy end points, modalities of data collection to evaluate change in efficacy variables, sample size required to achieve appropriate study power, baseline and treatment phase comparisons as primary or secondary end points, protocol for imputation of missing data, and methods of comparing treatment groups.

Recommendations for trial registration, publication of results, ethics, conflicts of interest, independent data safety monitoring board, steering committee, post-approval registries, and health technology assessment follow those published by the IHS Guidelines for trials of preventive treatments of migraine in adults.

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Reference

Abu-Arafeh I, Hershey AD, Diener HC, Tassorelli C; on behalf of the Clinical Trials Standing Committee and the Child and Adolescent Standing Committee of the International Headache Society. Guidelines of the International Headache Society for controlled trials of preventive treatment of migraine in children and adolescents, 1st edition [published online April 4, 2019]. Cephalalgia. doi: 10.1177/0333102419842188

This article originally appeared on Neurology Advisor