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Outpatient Approach to Resistant and Refractory Migraine in Children and Adolescents: a Narrative Review

  • Headache (R.B. Halker Singh and J. VanderPluym, Section Editors)
  • Published:
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Abstract

Purpose of Review

Migraine is one of the top reasons for consulting a pediatric neurologist. Although the majority of children and adolescents who receive evidence-based first-line interventions for migraine will improve substantially, a subset of patients develop resistant or refractory migraine.

Recent Findings

In this review, we summarize the level of evidence for a variety of acute and preventive treatment options to consider in children and adolescents with resistant or refractory migraine. We describe the level of evidence for interventional procedures (onabotulinumtoxinA injections, greater occipital and other nerve blocks), neuromodulation (single-pulse transcranial magnetic stimulation, external trigeminal nerve stimulation, remote electrical neuromodulation, and non-invasive vagal nerve stimulation), calcitonin gene-related peptide (CGRP) pathway antagonists (anti-CGRP monoclonal antibodies and gepants), psychological therapies, and manual therapies (acupuncture, craniosacral therapy, massage and physical therapy, and spinal manipulation).

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Funding

This research was supported by the Alberta Children’s Hospital Research Institute and the Department of Pediatrics, Cumming School of Medicine, University of Calgary. The Alberta Children’s Hospital Research Institute and the Department of Pediatrics provided funding for this project but had no role in design or execution of the project.

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Authors and Affiliations

  1. Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

    Alison Marshall, Rebecca Lindsay & Serena L. Orr

  2. Departments of Psychiatry and Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA

    Michelle A. Clementi

  3. Child & Adolescent Headache Program, University of California San Francisco, San Francisco, CA, USA

    Amy A. Gelfand

  4. Departments of Community Health Sciences and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

    Serena L. Orr

  5. Alberta Children’s Hospital, 28 Oki Drive NW, Calgary, AB, T3B 6A8, Canada

    Serena L. Orr

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  1. Alison Marshall
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  3. Michelle A. Clementi
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  4. Amy A. Gelfand
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Corresponding author

Correspondence to Serena L. Orr.

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Conflict of Interest

Alison Marshall: none.

Rebecca Lindsay: none.

Michelle A. Clementi: has research funding from the Ludeman Family Center for Women’s Health Research at the University of Colorado Anschutz Medical Campus and from NIH/NCATS Colorado CTSA Grant Number UL1 TR002535. Contents are the authors’ sole responsibility and do not necessarily represent official NIH views.

Amy A. Gelfand: in the last 24 months, Dr. Gelfand has received honoraria from UpToDate (for authorship), and stipends from JAMA Neurology for editorial work (last in July 2020) and from the American Headache Society for her role as Editor of Headache. She received grant support from the Duke Clinical Research Institute and the UCSF Resource Allocation Program. Her spouse reports research support (to UCSF) from Genentech for a clinical trial, honoraria for editorial work from Dynamed Plus, and personal compensation for medical-legal consulting.

Serena L. Orr receives royalties from Cambridge University Press. She serves on the editorial boards of Headache and Neurology. She also has research funding from the Canadian Institutes of Health Research and the Alberta Children’s Hospital Research Institute.

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Marshall, A., Lindsay, R., Clementi, M.A. et al. Outpatient Approach to Resistant and Refractory Migraine in Children and Adolescents: a Narrative Review. Curr Neurol Neurosci Rep 22, 611–624 (2022). https://doi.org/10.1007/s11910-022-01224-4

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