Monthly Archives: September 2022

Before he became Britain's monarch, King Charles III faced criticism over the years for promoting alternative medical therapies and treatments.

In 2019 for example, he received pushback for becoming a patron of the Faculty of Homeopathy.

According to the Cleveland Clinic, homeopathy "believes that using extremely minute diluted amounts of plants and minerals can help the body repair itself by promoting healing." Though popular, the Cleveland Clinic says that "there's no strong evidence for homeopathy's effectiveness greater than a placebo."

"We have been reminded only recently that plenty of homeopaths claim to be able to treat autism and discourage vaccination," Michael Marshall, of the Good Thinking Societya nonprofit organization that is self-described as "pro-evidence" and dedicated to combating "pseudoscience"said in 2019, according to The Guardian.

"If Prince Charles wants to have a genuine positive effect on the health of the nation he intends to one day rule, he should side against those who offer dangerously misleading advice, rather than fighting their corner," Marshall added.

Edzard Ernst, a former professor of complementary medicine at Exeter University, has frequently criticized King Charles III, writing a book about the royal's support of alternative medicine entitled Charles, the Alternative Prince: An Unauthorised Biography.

"Prince Charles contributes to the ill-health of the nation by pretending we can all over-indulge, then take his tincture and be fine again," Ernst said in 2009, according to Reuters. "Under the banner of holistic and integrative healthcare he thus promotes a 'quick fix' and outright quackery," Ernst added.

In a statement published by CNN in 2019 when King Charles III became the patron of the Faculty of Homeopathy, a spokesperson for the royal said the then-prince "believes that safe and effective, complementary medicine can play an important role in healthcare systems, as long as approaches are integrated with conventional treatments, a position he has reached after years of talking to experts in many different areas of medicine."

Newsweek has reached out to Buckingham Palace for comment.

The BBC reported in 2014 that an ex-cabinet minister claimed then-Prince Charles had asked him to press Welsh officials to add complementary medicine to the U.K.'s National Health Service.

"He had been constantly frustrated at his inability to persuade any health ministers anywhere that that was a good idea, and so he, as he once described it to me, found me unique from this point of view, in being somebody that actually agreed with him on this, and might want to deliver it," the former cabinet minister Peter Hain said, according to the BBC.

According to the Cleveland Clinic, complementary medicine "is a term used to describe types of treatments you may receive along with traditional Western medicine."

The BBC noted that a report commissioned by King Charles III that was published in 2005 found that the use of complementary therapies should be expanded within the National Health Service.

King Charles III became Britain's monarch after Queen Elizabeth II died Thursday at the age of 96. After his mother's death, the king said that he wants members of the royal family to observe official royal mourning for a week following her funeral.

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King Charles III Has a History of Promoting 'Quackery' Alternative Medicine - Newsweek

Save for the green leaves of a black olive tree, the interior of Remedy Place New York is completely gray. The spaces monochromatic scheme isnt a style statement. In fact, its the opposite. In color psychology, the ashen shade represents neutrality and balancewhich also happens to mirror the ethos of Remedy Place.

Founded by Dr. Jonathan Leary, Remedy Place is a social wellness club. ( Let Leary himself define that for you: Its a club that is temptation and toxin-free, that enhances health and social life at the same time.) Theres no gym equipment, massage tables, or beauty offerings. Instead, theres an extensive array of holistic treatments. Facilities include an infrared light sauna, acupuncture and cupping rooms, cryo chambers, hyperbaric chambers (theyre different!), and ice baths, just to name a few.

IV Suites, where two guests can lay facing each other.

Some experiences are solitary, but many can be done with friends. For example, those aforementioned ice baths are offered in group classes, where an instructor guides attendees through 10 minutes of holotropic breathwork followed by six minutes submerged in 38-degree water. Meanwhile, the vitamin IV suites are arranged so two people can sit facing each other while taking intramuscular B-12 shots.

Leary, who has his doctorate in chiropractic and alternative medicine, developed Remedy Place while he was a concierge doctor in Los Angeles. His practice catered to those seeking a non-surgical approach to chronic pain rehabilitation and attracted an impressive clientele of celebrities, CEOs, and pro-athletes.

Continue reading here:

Remedy Place: The Fashionable Social Wellness Club Where You Can Bring All Your Friends - Vogue

BANGKOK, Sept. 5, 2022 /PRNewswire/ --Living with the COVID-19 pandemic, people start to recognize the equal importance of modern medicine and preventive practices in maintaining their good health and wellbeing. With a strong healthcare and wellness infrastructure and reputation for highly-skilled professionals, Thailand is more than ever ready to realize its goal to become "The Worlds's Medical and Wellness Hub". The country has pushed towards providing a comprehensive and holistic healthcare services to serve the rising consumer demand for the overall treatment of body and mind.

In 2021, Thailand has been ranked 5th place in the world, and 1st place in Asia, in the Global Health Security Index by John Hopkins University for its pandemic response capacity. The Health Care Index 2021 by CEO World magazine has ranked Thailand in the 13th place based on overall health factors.

Affordable costs, high quality medical professionals, world-class healthcare facilities and superb wellness services have propelled demand for Thailand's medical and wellness services from abroad. Before the coronavirus pandemic, the value of medical tourism in Thailand amounted to around nine billion U.S. dollars in 2019, and was forecast to reach approximately 24.4 billion U.S. dollars in 2027, according to Statista. Among the most sought-after medical services are general medical care and surgeries, sophisticated orthopedics, in vitro fertilization, dental care and physical check-up.

"The growing in strength of healthcare sector in Thailand has been supported by highly qualified and attentive medical personnels and world-class standard facilities. Of more than 370 hospitals and medical facilities, 60 of them are accredited by the US-based Joint Commission International (JCI) as of December 2021, making the country top-five in the world in terms of the number of JCI-accredited healthcare facilities," said Joel A Roos, Vice President of International Accreditation, Quality Improvement and Safety in an interview with the International Travel & Health Insurance Journal.

Building on a strong foundation, the country aims to promote ten areas of the medical and wellness services including regenerative and anti-aging sciences, alternative medicine, cardio science, musculoskeletal, dental clinic, In Vitro fertilization, cancer treatment, surgeries, ophthalmology (cataract) and precision medicine.

The traditional therapeutic treatment such as Thai massage and herbal medicine has increasingly gained worldwide recognition. Many hospitals in Thailand have bridged the gap between medical treatment and preventive care, making healthcare more effective and comprehensive. The country has also earned itself a reputation "The Spa Capital of Asia" for its top-rated wellness experience that blends a variety of traditional healing practices with state-of-the-art health and wellness technologies.

Banking on the growing awareness of alternative healthcare's benefits, especially the preventive and holistic healing effects, the Thai government has initiated Green Medicine to innovate from its rich heritage of traditional medicine. More scientific researches are being conducted to validate and develop traditional herbs for recognition and integration into modern healthcare services.

It's high time to embrace modern and traditional solutions for healthier and happier life.

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Thailand heightens its healthcare hub ambition with integrative medicine - PR Newswire UK

This week, a Twitter thread advertising to followers that cancer can be fought naturally, mostly through changes in diet, got 200,000 likes in just 48 hours. The post tells patients to fast in order to starve the cancer, and to hack your DNA and boost your stem cells by eating certain foods. It attracted scores of supportive comments.

Scientists and doctors then chimed in to debunk the misinformation on the thread. Dr. David Robert Grimes, a cancer researcher, was one scientist who responded, challenging some of its claims. This kind of advice doesnt help patients, and often shames them needlessly, or drives them to dangerous restrictive diets, he wrote, describing how dietary quackery for cancer is a huge, widespread problem that can push patients into dangerous choices.

Grimes told me last year that anyone with cancer is especially vulnerable to snake oil.

In those circumstances, even the most sober-headed realist can be taken in by those who promise miraculous cures with no side-effects, he said.

On the thread, scientists predictably became the targets of attacks, being told to stop poisoning cancer patients with chemo. The alternative cancer treatment movement is a massive, multi-million dollar industry dealing out false hope. Its a topic weve been tracking at Coda for years from the global campaign to discredit the HPV vaccine against cervical cancer, to the myriad bogus cancer treatments, such as light therapy and ozone treatments, that are peddled to vulnerable cancer patients and their families.

Ive written before about Ty and Charlene Bollinger, the former bodybuilder and ex-model who built an empire by promoting unproven cancer treatments, and who held an anti-science Make America Great Again freedom rally on January 6, 2021. They believe chemotherapy is poison and push vitamin C injections and vibrational therapy onto their 22 million viewers. They told me in a statement last year that theyre pro-science and pro-choice when it comes to cancer treatments and vaccines.

Theres a growing movement of scientists and doctors dedicated, like Grimes, to fighting back against this kind of cancer misinformation. A London School of Hygiene and Tropical Medicine researcher, Marco Zenone, posted a devastating series of screenshots showing comments from people who paid thousands of dollars to check into Mexicos myriad cancer treatment centers, which sell unproven and unapproved treatments to desperate patients whove run out of options.

When doctors tell you that your loved one has no chance of living due to cancer, wrote the daughter of a man who paid over $35,000 for alternative treatments in a Tijuana clinic, we all just want hope. Unfortunately this place sometimes gives false hope and takes advantage of people who are vulnerable. Her father went into septic shock and died within a fortnight of starting the alternative treatments.

Last year, Hungary promised to open a National Covid Vaccine Factory by the end of 2022. Its now September, and construction on the factory has barely progressed and its also shrouded in mystery. Recently the Hungarian government has been opaque about what vaccines will be produced there simply saying it will be a vaccine and the final cost of the factory is unknown. Before the invasion of Ukraine, Hungarys foreign minister promised to take vaccine cooperation with Russia to a new level with domestic production of Russias Sputnik shot. But since the war, theres been silence. Hungary was the first to break ranks with the EU in 2021 to buy Russias Sputnik V vaccine, a decision that came hand-in-hand with discussions of new, long-term gas shipments from Russias Gazprom. It now looks like the war in Ukraine is upending Russian vaccine diplomacy even as Hungary continues to step up its imports of Russian gas.

Staying in Hungary for a moment last month we brought you news of two meteorologists who were fired by Prime Minister Viktor Orbans government for getting the forecast wrong ahead of a patriotic event. Now weather announcers in Germany and Sweden too are facing a backlash. As Sweden prepares for elections on Sunday, a right-wing MP is accusing weather broadcasters of climate hysteria, falsely claiming that announcers are manipulating the graphic design of weather to exaggerate global warming. In Germany, a meteorologist who feels compelled to bring climate change into his forecasts has been facing accusations from climate deniers that he is secretly campaigning for the countrys green party. The weather reporter, Ozden Terli, told Politico he believes tracking climate change will increasingly become part of the meteorologists daily job. Perhaps weather reports wont exist anymore. Maybe well have climate reports instead, with the weather on the side, he said.Nearly 70% of South Africans oppose trophy hunting, the sport where animals are killed for fun, not food. Participants pay up to $150,000 to take part and bring a trophy back home with them. But the South African government has made repeated claims that regulated and sustainable hunting is an important conservation tool for South Africa. Its also a big tourist industry, worth more than $340 million to the countrys economy with South Africa exporting more than 4,000 trophies a year. But the governments claim that the practice is a helpful conservation tool has been widely disputed by experts. Only a quarter of the species hunted are managed under the national conservation plan, and earlier this year, South Africa announced it would allow the hunting of leopards, endangered elephants, and critically endangered black rhinos. Trophy huntings conservation claims made by the government are based on extremely little evidence, according to a recent report.

If you read one piece this week, make it Merope Millss devastating account of losing her daughter in a leading NHS Hospital in Britain, after a litany of shocking mistakes were made by the doctors caring for her. This newsletter champions the voices of doctors and scientists. It celebrates experts and evidence. But, as Mills writes for the Guardian, our blind faith in doctors should have limits. Educate yourself, ask questions, and, if you are unsure, insist on a second opinion, or a third, Mills writes. However indebted you feel to the NHS, dont be afraid to challenge decisions if you have a good reason to.

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How bogus cancer treatments prey on the most vulnerable - Coda Story

Introduction

Migraine is a primary headache disorder affecting up to 7 million children and adolescents in the United States.13 Females are disproportionately affected by migraine, and the prevalence of the disease increases over the course of development.4,5 The impact of migraine on quality of life among children and adolescents is comparable to that of other chronic illnesses such as rheumatic disease and cancer,6 and unfortunately, migraine tends to persist into adulthood.7

Chronic migraine is a subtype of migraine that affects approximately 12% of youth,5 and is typically characterized by a gradual progression (ie, chronification) of episodic symptoms over the course of weeks or months.8 Youth with chronic migraine may experience co-occurring medical concerns for which subspecialty care may be required, including abdominal or musculoskeletal pain complaints, clinically significant sleep disturbances, and other neurological conditions such as epilepsy.9 Children and adolescents with chronic migraine often report substantial impairment in school-related functioning,10,11 challenges related to engaging in leisure activities and spending time with friends,12 and difficulties in family relationships.13,14 Thus, the management of chronic migraine in children and adolescents requires a holistic, integrative, and multimodal intervention approach that incorporates both medical and non-pharmacological treatments to address the symptoms and functional impairment associated with this debilitating headache disorder.

The purpose of this narrative review is to provide an overview of current best practices for acute and preventive treatment of chronic migraine in children and adolescents, direct attention to the most recent developments in the field, and emphasize important avenues for clinical research. In this review, we use guidelines set forth by the American Academy of Neurology (AAN) and the American Headache Society as frameworks to highlight treatments that represent the current standard of care for pediatric patients with chronic migraine and identify relevant gaps in intervention research. We then highlight treatment options that are currently receiving rigorous clinical research attention, provide a discussion of novel directions for research focused on improving existing interventions for chronic migraine in pediatric populations, and describe targeted research strategies that may expand access to evidence-based care for these patients and their families.

Accurate diagnosis of chronic migraine requires thorough physical and neurologic examinations and assessment of headache history including pain location(s), headache frequency, severity, and associated symptoms. The diagnosis of migraine and chronic migraine is made in accordance with the International Classification of Headache Disorders, 3rd edition (ICHD-315) criteria. Accurate diagnosis typically requires a recorded history of headaches and symptoms that occur during an attack using a headache diary.

The majority of treatment-seeking patients present with migraine or probable migraine; a diagnosis of probable migraine may be assigned when a patient meets all but one of the ICHD-3 diagnostic criteria for migraine. As Table 1 highlights, migraine is characterized by headaches of moderate-to-severe intensity that are accompanied by nausea, vomiting, photophobia, and/or phonophobia. The primary differentiating feature between youth with migraine and chronic migraine relates to headache frequency, as youth diagnosed with chronic migraine must experience 15 or more days with headache per month for at least 3 months, and the majority of these headaches must have migraine features.15 Some patients experience an aura (ie, a warning signal) with their migraine, which include visual, sensory, motor, and other central nervous system disturbances that precede headache onset.

Table 1 International Classification of Headache Disorders (ICHD-3) Diagnostic Criteria for Migraine without Aura and Chronic Migraine

Some children and adolescents also present with chronic tension-type headache (CTTH), a headache disorder in which the frequency of headache episodes is similar to that of chronic migraine. However, patients with CTTH typically do not experience migraine features such as photophobia, phonophobia, and severe nausea or vomiting, and their headaches are typically not as severe in intensity. In rare cases, youth may present for treatment with new daily persistent headache (NDPH), a primary headache disorder characterized by a rapid onset of unremitting headache. Patients with NDPH may or may not have migraine features with their continuous headache. Patients often recall the date their unremitting headache began due to its abrupt onset, and therefore do not endorse a history of increasing headache frequency. Chronic migraine can also be characterized by daily or continuous headache presentations; however, this presentationas highlighted abovetypically occurs via gradual chronification of headaches over time.

One other type of continuous headache presentation is hemicrania continua. Patients with this headache disorder may experience migraine-like symptoms with their continuous headache, but their pain is isolated to one half of the face and head with ipsilateral autonomic features such as conjunctival injection or with agitation, and the headache is responsive to one particular drug (indomethacin). This is incredibly rare in youth16 but is important to consider in those with unremitting unilateral pain that is refractory to treatment. Similarly, clinicians should consider idiopathic intracranial hypertension as a possible diagnosis for pediatric patients, as these youth most commonly present with intermittent diffuse headache that often occurs with migraine-like symptoms such as nausea and vomiting. However, IIH is most clearly identified by the presence of papilledema, significant visual disturbances (eg, blurred or double vision), tinnitus, and neck stiffness.17

Once a chronic migraine diagnosis has been established, a biopsychosocial approach to care that incorporates both medical treatment and non-medicine intervention strategies is recommended. The gold-standard biopsychosocial intervention plan incorporates acute treatment, preventive treatment, healthy lifestyle habit recommendations, and relaxation and/or cognitive-behavioral interventions. Goals of treatment include reducing headache frequency, reducing disability associated with headaches, and improving the child or adolescents quality of life.18 The following subsections will review each of these treatment components in more detail, and a summary of the reviewed acute and preventive treatment options is presented in Table 2.

Table 2 Summary of Reviewed Acute and Preventive Treatment Options for Chronic Migraine in Children and Adolescents.

One challenge that can complicate a child or adolescents diagnostic picture and treatment planning relates to use of acute medications. Some youth with migraine can experience headache chronification related to overuse of analgesic or headache rescue medications (see Acute Treatments section for more information). Medication-overuse headache (MOH) can be diagnosed if a patient with a pre-existing primary headache disorder (eg, migraine, chronic migraine) uses acute medication on 10 or 15 (depending on the medication) or more headache days per month for more than 3 months. Research suggests that approximately half of youth with chronic migraine overuse acute medications to manage their symptoms.19

According to ICHD-3 criteria, a diagnosis of chronic migraine should still be assigned even if a patient also meets criteria for MOH. This is notable because epidemiologic studies have shown that the estimated prevalence of chronic migraine decreases from approximately 2% to roughly 0.8% when children and adolescents with MOH are excluded.19 Thus, it is imperative to diagnose MOH where appropriate to guide appropriate treatment planning and counseling. For patients with comorbid chronic migraine and MOH, a comprehensive acute medication weaning plan should be established. An emphasis on prevention therapy is also especially important for patients with MOH.20

The purpose of acute migraine treatment is to ameliorate pain and associated symptoms that occur during an attack, minimize side effects, and facilitate a return to typical functioning as quickly as possible.21 Headache specialists work with school systems and caregivers to ensure that children and adolescents are able to access acute treatments in school and at home to treat headaches at onset and minimize the disruptive impact of migraine on daily life. The most recent (2019) guidelines from the AAN emphasize early intervention that is tailored to the specific features of an individuals headache attack.22

The most commonly studied and prescribed acute migraine medications generally fall into three categories: nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, naproxen), analgesics (eg, acetaminophen), and the migraine-specific triptans (eg, sumatriptan). In addition, novel therapies known as gepants and ditans are used in adults and will be discussed later. Current evidence supports use of ibuprofen as an initial treatment for both children and adolescents experiencing an acute migraine attack. Naproxen and diclofenac are commonly used as well, though with less objective evidence for their efficacy. Oral sumatriptan plus naproxen or almotriptan may be also be prescribed for adolescents aged 12 and older. For patients who cannot tolerate oral formulations, sumatriptan and zolmitriptan are United States Food and Drug Administration (FDA) approved in nasal spray formulations for ages 12 and older. Of the seven triptans available, rizatriptan is the only FDA-approved triptan for use in children down to age 6.

Antiemetic treatments should also be offered for youth who commonly experience nausea and vomiting with migraine, as none of the available treatments demonstrate significant efficacy for treatment of these symptoms.22 Dopamine antagonists such as prochlorperazine, chlorpromazine, promethazine and metoclopramide have pain relieving attributes in addition to their antiemetic characteristics23 but patients should be warned about the potential for extrapyramidal side effects such as muscle stiffness, akathisia or agitation which is more common with recurrent use, in younger patients, and among those already taking antidopaminergic agents.24 Finally, ondansetron has not demonstrated pain relief but may be considered for those with prior adverse reaction to antidopaminergic agents or other contraindications to them.25 It is generally safe but may cause QT prolongation and dysrhythmia, especially with recurrent use.26

Because overuse of triptans and analgesics can be associated with MOH27 and migraine chronification,28 clinicians should recommend that all abortive medications be used on no more than three headache days per week21 and triptans be used no more than 2 days per week.29 There are currently no evidence-based recommendations to guide treatment of MOH in children and adolescents. In clinical practice, management of MOH may include abrupt cessation or weaning of acute medications with immediate or later initiation of preventive therapy.30 A 6-week washout period of all acute medications has been shown to result in recovery of specific gene expression changes related to medication overuse.29,31

Given that pill-based therapies can be associated with the development of medication overuse headache and migraine chronification, considerable clinical research effort has been dedicated to the development of nonpharmacologic treatment options for acute migraine management. Neurostimulation (also termed neuromodulation) has gained attention in the adult migraine literature as an alternative approach to migraine management for patients who do not respond to available pill-based treatments. Neuromodulation aims to inhibit pain signaling by delivering electrical impulses to nerves involved in sensory processing and pain perception. A number of non-invasive (eg, single-pulse transcranial magnetic stimulation or vagal nerve stimulation) and invasive (eg, occipital nerve stimulation) techniques have been developed and tested in adults with migraine, and these are generally associated with fewer side effects relative to traditional pharmacologic treatment options (see32 for review). The following two devices are FDA-cleared for use in adolescents with migraine.

A non-invasive vagus nerve stimulation (nVNS) device is FDA approved for acute and preventive therapy of migraine and other headache disorders in adults and adolescents over age 12. The device is held at the neck for two cycles of 12 minutes, which can then be repeated after 20 minutes and again after 2 hours if needed. A small open-label study by Grazzi et al33 showed that nearly half (46.8%) of attacks were effectively treated without need for rescue medication and did not report any device-related adverse events. This pilot study provides the foundation for larger studies of nVNS for acute and preventive migraine therapy in adolescents.

Recently, an open-label study conducted by Hershey et al34 examined the safety, tolerability, and initial efficacy of a remote electrical neuromodulation (REN) device for treatment of acute migraine attacks among adolescents with migraine. This sample included a subset of participants who met criteria for chronic migraine based on their number of monthly headaches with migraine features. In the study, participants used the REN devicewhich was worn on the lateral upper armto deliver electrical stimulation during four migraine attacks over an 8-week period. Results showed that use of the device was not associated with any significant adverse events or participant study withdrawal; 71% of the participants experienced pain relief and 35% achieved pain freedom within 2 hours of symptom onset. Sustained pain relief was demonstrated among 90% of the participants at 24 hours. These preliminary data resulted in FDA clearance for use among adolescents for acute treatment of migraine.

Further studies are underway to assess the utility of the REN device in the Emergency Department setting, and others are being planned as a preventive option. Though preliminary, the promising findings discussed above suggest that the safety and efficacy of REN should be tested in a larger, randomized placebo-controlled trial to determine whether this acute treatment option could be integrated into routine clinical practice, or even in the Emergency Department setting for youth with chronic migraine, particularly those who present with comorbid MOH.

Counseling patients about the roles of lifestyle and behavioral factors that reduce the likelihood of headaches occurring is a primary emphasis of preventive care. Inadequate hydration, skipping meals, poor sleep, and insufficient exercise are factors associated with increased headache risk.35,36 Conversely, engaging in routine aerobic activity, eating regular meals, getting sufficient sleep, and obtaining sufficient daily fluid intake can reduce headache frequency and intensity.3739

Recently, Robblee and Starling40 published practical guidelines for clinicians with detailed information about lifestyle factors that promote migraine prevention. These guidelines recommend that clinicians provide patients with guidelines about obtaining a sufficient number of hours of sleep for their developmental stage (eg, 912 hours for school-age children; 810 hours for teenagers); practicing good sleep hygiene (eg, maintaining a consistent sleep-wake schedule, discontinuing use of electronics 3060 minutes before bedtime; and practicing a consistent bedtime routine that can incorporate relaxation practices); maintaining a healthy and well-balanced diet that includes protein, leafy green vegetables, and fruit; avoiding skipping meals; engaging in regular aerobic exercise; and obtaining adequate daily fluid intake. For teenagers with chronic migraine, between 80 and 100 ounces of fluid per day is recommended.

A variety of medications are currently used for pediatric migraine prevention, and include antidepressants (eg, amitriptyline), antiepileptics (eg, topiramate, gabapentin), and calcium channel blockers (eg, flunarizine).41 One preventive medication that is frequently used as a first-line drug therapy is amitriptyline, which is a tricyclic antidepressant that has shown to be effective in reducing headache frequency and disability in children while minimizing side effects when titrated slowly.42 Topiramate, a drug of the anticonvulsant class, is the only FDA-approved pediatric preventive migraine medication. Although topiramate has been shown to reduce headache frequency in youth,22,43 it is associated with more side effects than amitriptyline.44 Valproic acid, another anticonvulsant, has shown efficacy in youth with migraine, but its teratogenic (class X) and ovarian effects limit its use in females.45

Practice guidelines emphasize a 50% reduction in headache frequency as a benchmark for which the effectiveness of a preventive treatment can be evaluated. That all said, it should be noted that the largest comparative effectiveness trial of preventative medication for youth with migraine to datethe Childhood and Adolescent Migraine Prevention (CHAMP) trialwas discontinued early due to futility after interim results revealed that amitriptyline and topiramate were not superior to placebo in reducing headache days.44 Results from this study showed that up to 70% of youth in both the active drug and placebo groups exhibited a 50% reduction in headache days over the course of the trial. Further, meta-analytic evidence has demonstrated that there are limited data to support use of medication alone as an effective preventive treatment for youth with chronic migraine.46 These findings have led to an increasing call for pediatric headache providers to promote behavioral treatments as frontline preventive interventions.

The best available evidence, as described in current guidelines from the AAN and American Headache Society, supports use of a combined pharmacotherapy (ie, amitriptyline) and behavioral approach (ie, cognitive-behavioral therapy) for migraine prevention in children and adolescents. These recommendations were created after a large randomized controlled trial demonstrated that the combined treatment with cognitive-behavioral therapy (CBT) and amitriptyline was superior to amitriptyline and headache education in reducing youth headache frequency by at least 50% (from a baseline average of 21 headache days per month to approximately 10 after 20 weeks).47 An ancillary analysis from this trial revealed a linear trend and quadratic trend in headache day change, indicating that although decreases in headache days continued throughout the trial, the majority of clinical improvement occurred by the 8-week time point in the CBT+AMI group.48 These data suggest that these youth make relatively rapid treatment gains that can be sustained over time. The evidence base for CBT for pediatric migraine prevention continues to grow; a 2018 Cochrane review of all published clinical trials concluded that CBT is effective in reducing headache days and headache-related disability among youth with migraine.49

CBT is a skills-oriented treatment that provides training in coping techniques and behavioral strategies that can be applied to manage and prevent headaches.50,51 Typically, treatment begins with headache education and an introduction to the gate control theory of pain.52 In the initial stages of treatment, the therapist reviews family guidelines with youth and their caregivers; these guidelines offer practical steps to support the childs pain management and address family factors that may interfere with the patients daily functioning or increase their focus on current symptoms. Patients then receive instruction and practice several relaxation exercises including diaphragmatic breathing, progressive muscle relaxation, and guided imagery. These techniques decrease autonomic arousal and muscle tension that can be associated with pain, and serve as a means of distraction from symptoms. Relaxation training may be used in conjunction with biofeedback technology to allow youth to see for themselves how practicing relaxation skills results in physiological changes such as increased peripheral body temperature and decreased muscle tension.

Psychologists providing CBT also facilitate activity pacing and adherence to healthy lifestyle recommendations through instruction and collaborative problem-solving. This additional layer of intervention may be especially important given that youth with migraine frequently report difficulty with adherence to medical recommendations related to eating and hydration.53 Finally, cognitive reappraisal skills are provided to teach youth how thoughts and feelings are connected to the pain experience, and challenge negative or unrealistic thinking that can contribute to worsening pain and associated symptoms.

Despite the growing evidence base for CBT as an effective intervention for pediatric migraine prevention, it is important to consider that it is not a one-size-fits-all treatment, and may not meet the needs of each patient with chronic migraine. For example, although a majority of youth with migraine do not meet criteria for a co-occurring psychiatric disorder,54 children and adolescents with migraine are more likely than youth without migraine to report elevated internalizing symptoms (eg, anxiety, depression), attentional difficulties, and somatic complaints.55 Furthermore, the presence of co-occurring clinically elevated depressive or anxiety symptoms is associated with greater disability and diminished quality of life in youth with migraine.56,57 Thus, routine screening for co-occurring psychiatric comorbidities and appropriate follow-up should be routinely provided in specialty headache centers. If a clinically significant psychological disorder is detected in this assessment process, it should be considered a treatment priority.

The severity and disabling nature of chronic migraine in youth also presents numerous challenges for which traditional CBT may not promote effective management of symptoms. For example, some children and adolescents with chronic migraine have undergone several trials of preventive medication with varying success, and may therefore have different beliefs about how to best manage pain, what to expect from treatment, and goals for treatment relative to youth with less frequent or disabling headache presentations. The primary aim of CBT for migraine is to improve a patients functioning while reducing the frequency of symptoms. Other interventions may be needed to more specifically target disability and psychological factors that can impact day-to-day functioning in this patient population.

Third-wave psychological interventions, such as Acceptance and Commitment Therapy (ACT) and mindfulness-based approaches, focus primarily on increasing patients psychological flexibility and engagement in activity that they value as opposed to focusing on decreasing their pain or symptoms. Mindfulness, which is a core component of ACT, is derived from Buddhist spiritual traditions and involves bringing attention to the present moment, adopting a nonjudgmental, accepting stance about pain and symptoms, and flexibly adapting to daily fluctuations in pain and symptoms.58 The evidence for ACT in the treatment of pediatric chronic pain is growing.59 Two investigations of mindfulness-based interventions for chronic migraine in children and adolescents, including one recent open-label trial, have shown promising results in reducing migraine-related disability,60,61 mirroring findings from trials of mindfulness-based interventions among adults with migraine.62,63

Clinical research efforts have been devoted to studying alternative treatments that reduce risks associated with traditional pill-based migraine therapies given current practice guidelines. What follows is a discussion of alternative treatment options that have been studied extensively in adults with migraine, and may be recommended for pediatric patients who have not responded to available preventive treatments.

Youth with chronic migraine and their families often request trials of dietary supplements or nutraceuticals as alternative pill-based treatment options. Nutraceuticals, which are compounds derived from foods such as fruits and vegetables, are a form of complementary and integrative medicine (CAM) and are among the most commonly used treatments among pediatric patients with chronic pain conditions, including migraine.64 Despite the popularity and widespread use of nutraceuticals in pediatric pain populations, there are no practice guidelines regarding their use for acute migraine treatment or prevention.

Orr65 published, to our knowledge, the only existing review of nutraceuticals for the treatment of migraine in youth. The review summarized results from 11 observational studies, seven randomized controlled trials, and three systematic reviews. The reviewed nutraceuticals included vitamin D, riboflavin, coenzyme Q10, magnesium, butterbur, and polyunsaturated fatty acids. The review concluded that, given the relative absence of rigorous clinical trials, there is limited evidence for the efficacy of nutraceuticals for migraine prevention and acute treatment in children and adolescents. Coenzyme Q10 has demonstrated initial efficacy for migraine prevention compared to placebo, and oral magnesium may reduce pain intensity when acute headaches are treated with ibuprofen or acetaminophen. However, in the absence of clear, rigorous safety and efficacy data for nutraceutical use, clinicians should discuss with their patients that there is currently no evidence that these treatments are superior to placebo.

Orr65 also informs clinicians about differences in regulatory practices between pharmaceuticals and nutraceuticals, and encourages providers to educate patients about risks associated with nutraceuticals given the frequent assumption that they are safe if available without a prescription.66 For example, butterburwhich has a long history of use in adults with migraine and has been recommended in guidelines from the American and Canadian Headache Societieshas hepatotoxic properties and is generally not recommended for treatment of migraine among children and adolescents.65

OnabotulinumtoxinA (OBTA; ie, BOTOX) was approved in 2010 by the FDA for treatment of chronic migraine in adults. Data examining the efficacy of OBTA for treatment of youth with chronic migraine are limited. OBTA did not gain FDA approval in adolescents after failing to demonstrate greater efficacy compared to placebo.67 A later crossover trial of OBTA for treatment of youth with chronic migraine showed that, compared to a placebo group, youth who received a trial of OBTA injections administered in 3-month intervals and 6-week follow-up visits demonstrated a statistically significant decrease in migraine frequency and intensity, but not duration.68 Multiple retrospective reviews of outcomes for pediatric patients with chronic migraine who received treatment with OBTA after failing oral therapies showed a statistically significant reduction in headache days and disability, and that OBTA was well-tolerated.69,70 Current guidelines from the AAN state that there is currently insufficient evidence to support the use of OBTA for migraine prevention in youth. In practice, OBTA injections may be recommended when a patient with chronic migraine has not responded to two or more preventive therapies.

The calcitonin gene-related peptide (CGRP) is an amino acid peptide found in sensory fibers throughout the body, and particularly in the central nervous system. The CGRP pathway is involved in sensory processing and pain modulation, and has been implicated in the pathophysiology of migraine.71 In adults, antagonism of the CGRP pathway is associated with diminished headache days and medication usage.72 Monoclonal antibodies (mAbs) to CGRP or its receptorwhich require subcutaneous (erenumab, galcanezumab, fremanezumab) or intravenous administration (eptinezumab)have shown safety and efficacy in trials of adults with migraine,7377 some with open-label data for 1 to 5 years.78,79

To date, there are no published placebo-controlled trials of mAbs in children and adolescents with migraine. In 2018, Szperka et al published a set of recommendations for the use of anti-CGRP mAbs in children and adolescents with migraine.80 These guidelines emphasized that consideration of anti-GGRP mAbs should be limited to youth with a frequent migraine presentation and for whom established migraine preventive therapies have not been effective. These therapies should include oral treatments and may also include CBT, neuromodulation devices and nutraceuticals. The authors note that rigorous clinical research effort is needed to establish long-term safety and efficacy data for use of anti-CGRP mAbs in children and adolescents with migraine, and emphasize those youth with more severe migraine presentations (eg, continuous headache) should be included in future trials as these youth have the greatest need for targeted therapeutics.

Greene et al reported a multicenter retrospective study of children and adolescents treated with mAbs for chronic headaches including chronic migraine, persistent post-traumatic headache and NDPH.81 This report of 112 patients with nearly daily or continuous headaches was the first to provide safety and efficacy data in this group. Their data showed that side effects in adolescents are similar to those reported in adult trials and that mAb treatment may benefit youth who are otherwise refractory to other prevention therapies. Notably, severity of pain and functional status improved in more than half of cases. Several randomized controlled trials of mAbs in children and adolescents with episodic and chronic migraine are underway.

Newer targeted therapies known as gepants and ditans have made their way to market after decades of translational research. Gepants act as antagonists to calcitonin gene-related peptide (CGRP) receptors,82 while ditans likely act as agonists of the serotonin 5HT-1F receptors. In contrast to triptans, gepants and ditans do not cause vasoconstriction and are therefore safe for use in patients with history of cardiac or other vascular conditions including stroke.83 Rimegepant, ubrogepant and lasmiditan are currently FDA-approved for acute therapy in adults with migraine and studies are underway in children and adolescents. These drugs may therefore represent third- or fourth-line options for off-label use in youth with attacks refractory to other medications, or with contraindications or adverse reactions to triptans. Although no head-to-head studies have compared gepants and ditans to other pharmacologically active drugs, a meta-analysis showed that gepants and ditans were associated with a lower odds ratio than most triptans for pain relief or freedom at 2 hours.84

Rimegepant also recently gained FDA approval for migraine prevention in adults after showing superiority to placebo at reducing headache days in those with episodic and chronic migraine when dosed every other day.85 Adolescents who experience excellent and sustained (2448 hours) relief from headache with acute rimegepant use may be particularly good candidates for preventive therapy with rimegepant. In addition, atogepant is the only gepant with FDA approval solely for preventive therapy in adults with migraine. Finally, though not exclusively a pill-based therapy, zavegepant is currently being studied for prevention in its oral form and has evidence of efficacy for the acute treatment of migraine in its nasal form.86

Although there have been numerous advances in acute and preventive treatment over several decades, treatment of youth with chronic migraine continues to evolve. As highlighted in this review, available evidence suggests that pediatric patients with chronic migraine do experience a reduction in headache days when they receive multidisciplinary, biopsychosocially oriented intervention,87 and treatment gains made through preventive care are often maintained over time.88 Current practice guidelines for the prevention of migraine in youth emphasize a combined pill-based and nonpharmacological approach. We anticipate that a holistic approach to migraine management will continue to represent the best standard of care moving forward, even as considerable attention is being devoted to establishing an evidence base for the use of novel interventions such as neuromodulation, GGRP monoclonal antibodies, and targeted pill-based therapies for both acute and preventive treatment. In the following sections, we highlight important and novel avenues for advancing evidence-based care through future clinical research.

Despite the range of interventions that have been developed for the treatment of chronic migraine, additional research is needed to tailor available treatments for the clinical presentation and treatment needs of youth with chronic migraine and their families. Much of current clinical guidance has been gleaned from studies in adult patients; however, it has become increasingly apparent that children and adolescents with headache disorders can differ substantially from adults in terms of their responses to pharmacological treatments.

Given this, studies highlighted in this review underscore the importance of taking a developmental approach to research involving novel medical and nonpharmacological intervention approaches for youth with chronic migraine. As the field continues to evolve, prospective longitudinal research will be needed to advance our understanding of the developmental contributors to the progression and course of chronic migraine in children and adolescents. For example, epidemiologic studies have shown that pre-pubertal males have a higher prevalence of migraine relative to females, but there is a dramatic increase in migraine prevalence among females post-puberty.89 Prospective longitudinal studies that examine the roles of age and development (eg, puberty, hormonal changes) in relation to the presentation of migraine, or investigate neural changes associated with migraine progression may enhance our identification of targets for early intervention tailored to the needs of each individual. Further, given the strong link between genetics and migraine, studies identifying the monogenic and polygenic contributors to the pathophysiology of migraine disease are crucial as the field works toward precision medicine as a standard of care.31,90

The effectiveness of CBT for prevention of pediatric migraine also raises important questions about how and why this treatment approach works. Recently, our research group published an overview of psychological interventions for pediatric headache disorders,51 in which we discuss the role of mechanistic studies and their importance for elucidating neural alterations associated with CBT treatment. Research has demonstrated that pre-post CBT alterations in resting state brain activation and functional connectivity occur among youth with migraine who have received this intervention for headache.91 Our group is also conducting an ongoing mechanistic study (funded by the National Center for Complementary and Integrative Health and the National Institute of Neurological Disorders and Stroke) may be able to answer why patients with migraineincluding chronic migrainemake such rapid treatment gains in response to gold-standard preventive care by determining the extent to which components of CBT intervention are associated with particular neural changes among youth with migraine.

Empirical support for the treatment of migraine in youth is largely based on studies that have included patients recruited from specialty headache centers, patients who meet very specific diagnostic criteria, and patients without medical or psychiatric comorbidities. While this level of rigor in clinical trials increases our confidence in the benefit of available interventions, it is possible that the stringent nature of referrals from tertiary care clinics and inclusion criteria has resulted in many youth with chronic migraine being excluded from clinical trials, leaving a gap in our fields ability to conceptualize and understand which treatments work best for which patients. Furthermore, participants in migraine research studies tend to be predominantly White, female, and from upper middleclass backgrounds.92 Improving the representativeness and generalizability of our treatments will require prioritizing the inclusion of patients from underrepresented backgrounds in all aspects of the research process, from recruitment and retention to intervention development and dissemination of findings.

As discussed previously, a subset of treatment-seeking children and adolescents who meet the criteria for chronic migraine present with continuous (ie, unremitting) headache. Unfortunately, these patients are often excluded from research studies as they are considered to be much more complex in terms of their psychosocial profile and refractory to treatment relative to other youth with less frequent headache presentations. As the field moves forward, it will be important to recruit subpopulations of pediatric patients with chronic migraine experience continuous headache to determine their patterns of treatment utilization, preferences for treatment, and whether available treatments are also effective for patients with this headache presentation. Understanding the treatment priorities and goals of patients with more severe and disabling chronic migraine presentations may also lead to the development and testing of tailored interventions. It will be exciting to learn whether ACT and mindfulness-based approaches demonstrate efficacy for treatment of headache days and disability among youth with migraine, and whether principles of these treatments could augment traditional CBT intervention.

Population-based studies have shown that migraine is more prevalent among youth from lower socioeconomic (SES) backgrounds.93 Moreover, there are considerable racial and ethnic disparities in the prevalence of migraine. For example, in the United States, the prevalence of migraine is highest among Native Americans. These disparities reflect inequities in access to care and treatment practices that lead to poorer long-term health outcomes.94

An unfortunate reality stemming from differences in health equity is that many of the newer and investigational treatment options discussed in this paper, such as neurostimulation and anti-CGRP antibodies, are not consistently covered by third-party payors and have extremely high out-of-pocket costs. Access to adequate healthcare in the United States remains poor for many pediatric patients and their families, and this is a substantial barrier to evidence-based migraine treatment that has not improved in recent years. Indeed, a recent review published by Yu et al showed that percentage of children and adolescents experiencing underinsurance rose from 30.6% in 2016 to 34.0% in 2019.95 Even gold-standard preventive treatments, such as cognitive-behavioral therapy, are not consistently covered by insurance providers. The result of inequality in healthcare access is that under-resourced children and adolescentsthe young people who need the best available care the mostare not being seen for care in specialty headache centers. These children and their families understandably rely on the types of care that are available to them, and community clinics or hospitals may not employ neurologists with a specialization in headache medicine or pediatric psychologists who practice behavioral headache medicine.

One tangible approach that begins the process of addressing barriers to patients access to equitable care involves leveraging the potential of innovative study designs to expand the reach of evidence-based interventions. For example, a current study funded by the National Center for Complementary and Integrative Health (NCCIH U01 AT010132) is employing a multiphase optimization strategy (MOST;96) to develop a cognitive-behavioral intervention delivered by nursing staff in outpatient neurology clinics. The goal of this study is to identify which components and doses of CBT are most effective to promote change in key headache outcomes, with treatment being provided by healthcare professionals besides trained psychologists. The data gleaned from this study will inform the development of a large pragmatic or sequential multiple randomization (SMART) trial that will be conducted in neurology clinics and, in the long term, could also be conducted in primary care or pediatric practices. Expanding the availability of evidence-based pediatric behavioral medicine beyond secondary and tertiary care should be considered a priority as our field works to increase the accessibility of care for all patients and their families.

It is also crucial that clinicians and researchers continue to advocate for their patients as the field of pediatric headache medicine works toward a more equitable and inclusive scientific practice. The COVID-19 pandemic has exposed vulnerabilities in the healthcare system and further underscored racial and ethnic disparities in healthcare.97 Yet, the proliferation of telemedicine over the past 2 years perhaps represents an opportunity to rigorously study the efficacy of interventions that can be feasibility delivered remotely in the context of a pragmatic clinical trial. As the field works to expand care beyond specialty clinics, pragmatic trials may represent one clear opportunity to advance clinical practice and facilitate the successful dissemination and implementation of migraine treatment. For example, a trial examining the efficacy of CBT delivered entirely remotelyand casting a wide net to include patients with chronic migraine, including those who may have been historically excluded from trials (eg, youth with continuous headache)could facilitate the eventual integration of CBT into traditional clinical practice, thus increasing its accessibility to patients and families. If researchers can leverage the potential of innovative study designs to improve the availability of evidence-based care in a manner that allows patients to access it earlier, the field of pediatric headache medicine may be better positioned to prevent chronic migraine from progressing further and persisting into young adulthood.

Chronic migraine is a disabling migraine subtype that affects a substantial proportion of children and adolescents and tends to persist into adulthood. Over the past several decades, substantial gains have been made in advancing both acute and preventive treatments for this debilitating headache disorder. We have learned that a biopsychosocial approach to the conceptualization and treatment of migraine is most beneficial to patients, and current research is advancing our understanding about why nonpharmacological treatment strategies for migraine prevention work. As the field moves forward, considerable clinical research effort should focus on expanding access to evidence-based care, testing novel therapeutics, leveraging the potential of innovative study designs such as SMART and pragmatic trials to inform precision medicine and wider dissemination of interventions, recruiting patients for research studies who have traditionally been underrepresented, and tailoring existing nonpharmacological interventions to meet the unique needs of each child and their family. We believe the future of pediatric headache medicine is bright, and feel confident that the coming years will provide new insights into the optimal management of chronic migraine in children and adolescents.

This work was supported by R01 (R01AT010171) and U01 (U01AT010132) grants from the National Center for Complementary and Integrative Health, an R01 grant (R01NS101321) from the National Institute of Neurological Disorders and Stroke, and a training grant from the National Institute of Diabetes and Digestive and Kidney Diseases (T32DK063929).

Dr Robert C Gibler reports grants from National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases T32 Training Grant (T32DK063929), outside the submitted work. Dr Brooke L Reidy reports grants from NIH, during the conduct of the study; Frontiers in Headache Research Scholarship (travel award to attend Conference) in 2018 from American Headache Society, Travel Award to attend conference 2018 from International Society for Developmental Psychobiology, outside the submitted work. Dr. Powers reports funding to the Cincinnati Childrens Hospital Medical Center Research Foundation from the National Institutes of Health. The authors report no other conflicts of interest in this work.

1. Abu-Arefeh I, Russell G. Prevalence of headache and migraine in schoolchildren. BMJ. 1994;309(6957):765769. doi:10.1136/bmj.309.6957.765

2. Ozge A, Samaz T, Budayc R, et al. The prevalence of chronic and episodic migraine in children and adolescents. Eur J Neurol. 2013;20(1):95101. doi:10.1111/j.1468-1331.2012.03795.x

3. Wber-Bingl . Epidemiology of migraine and headache in children and adolescents. Curr Pain Headache Rep. 2013;17(6):341. doi:10.1007/s11916-013-0341-z

4. Wang SJ, Fuh JL, Lu SR, Juang KD. Chronic daily headache in adolescents: prevalence, impact, and medication overuse. Neurology. 2006;66(2):193197. doi:10.1212/01.wnl.0000183555.54305.fd

5. Lipton RB, Manack A, Ricci JA, Chee E, Turkel CC, Winner P. Prevalence and burden of chronic migraine in adolescents: results of the chronic daily headache in adolescents study (C-dAS). Headache. 2011;51(5):693706. doi:10.1111/j.1526-4610.2011.01885.x

6. Powers SW, Patton SR, Hommel KA, Hershey AD. Quality of life in childhood migraines: clinical impact and comparison to other chronic illnesses. Pediatrics. 2003;112(1 Pt 1):e15. doi:10.1542/peds.112.1.e1

7. Bille B. A 40-year follow-up of school children with migraine. Cephalalgia. 1997;17(4):488491; discussion 487. doi:10.1046/j.1468-2982.1997.1704488.x

8. Youssef PE, Mack KJ. Episodic and chronic migraine in children. Dev Med Child Neurol. 2020;62(1):3441. doi:10.1111/dmcn.14338

9. Bellini B, Arruda M, Cescut A, et al. Headache and comorbidity in children and adolescents. J Headache Pain. 2013;14(1):79. doi:10.1186/1129-2377-14-79

10. Powers SW, Gilman DK, Hershey AD. Headache and psychological functioning in children and adolescents. Headache. 2006;46(9):14041415. doi:10.1111/j.1526-4610.2006.00583.x

11. Kashikar-Zuck S, Zafar M, Barnett KA, et al. Quality of life and emotional functioning in youth with chronic migraine and Juvenile Fibromyalgia. Clin J Pain. 2013;29(12):10661072. doi:10.1097/AJP.0b013e3182850544

12. Larsson B, Sigurdson JF, Sund AM. Long-term follow-up of a community sample of adolescents with frequent headaches. J Headache Pain. 2018;19(1):79. doi:10.1186/s10194-018-0908-5

13. Palermo TM, Putnam J, Armstrong G, Daily S. Adolescent autonomy and family functioning are associated with headache-related disability. Clin J Pain. 2007;23(5):458465. doi:10.1097/AJP.0b013e31805f70e2

14. Lewandowski AS, Palermo TM. Parentteen interactions as predictors of depressive symptoms in adolescents with headache. J Clin Psychol Med Settings. 2009;16(4):331338. doi:10.1007/s10880-009-9173-8

15. Arnold M. Headache Classification Committee of the International Headache Society (IHS) The international classification of headache disorders, 3rd edition. Cephalalgia. 2018;38(1):1211. doi:10.1177/0333102417738202

16. Ghosh A, Silva E, Burish MJ. Pediatric-onset trigeminal autonomic cephalalgias: a systematic review and meta-analysis. Cephalalgia. 2021;41(13):13821395. doi:10.1177/03331024211027560

17. Albakr A, Hamad MH, Alwadei AH, et al. Idiopathic intracranial hypertension in children: diagnostic and management approach. Sudan J Paediatr. 2016;16(2):6776.

18. Powers SW, Gilman DK, Hershey AD. Suggestions for a biopsychosocial approach to treating children and adolescents who present with headache. Headache. 2006;46(Suppl 3):S149150. doi:10.1111/j.1526-4610.2006.00568.x

19. Gelfand AA, Goadsby PJ. Medication overuse in children and adolescents. Curr Pain Headache Rep. 2014;18(7):428. doi:10.1007/s11916-014-0428-1

20. Moavero R, Stornelli M, Papetti L, et al. Medication overuse withdrawal in children and adolescents does not always improve headache: a cross-sectional study. Front Neurol. 2020;11:823. doi:10.3389/fneur.2020.00823

21. Kacperski J, Kabbouche MA, OBrien HL, Weberding JL. The optimal management of headaches in children and adolescents. Ther Adv Neurol Disord. 2016;9(1):5368. doi:10.1177/1756285615616586

22. Oskoui M, Pringsheim T, Holler-Managan Y, et al. Practice guideline update summary: acute treatment of migraine in children and adolescents: report of the guideline development, dissemination, and implementation subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2019;93(11):487499. doi:10.1212/WNL.0000000000008095

23. Patniyot IR, Gelfand AA. Acute treatment therapies for pediatric migraine: a qualitative systematic review. Headache. 2016;56(1):4970. doi:10.1111/head.12746

24. Wijemanne S, Jankovic J, Evans RW. Movement disorders from the use of metoclopramide and other antiemetics in the treatment of migraine. Headache. 2016;56(1):153161. doi:10.1111/head.12712

25. Talai A, Heilbrunn B. Ondansetron for acute migraine in the pediatric emergency department. Pediatr Neurol. 2020;103:5256. doi:10.1016/j.pediatrneurol.2019.06.011

26. Freedman SB, Uleryk E, Rumantir M, Finkelstein Y. Ondansetron and the risk of cardiac arrhythmias: a systematic review and postmarketing analysis. Ann Emerg Med. 2014;64(1):1925.e6. doi:10.1016/j.annemergmed.2013.10.026

27. Diener HC, Limmroth V. Medication-overuse headache: a worldwide problem. Lancet Neurol. 2004;3(8):475483. doi:10.1016/S1474-4422(04)00824-5

28. Bigal ME, Lipton RB. Overuse of acute migraine medications and migraine chronification. Curr Pain Headache Rep. 2009;13(4):301307. doi:10.1007/s11916-009-0048-3

29. Orr SL, Kabbouche MA, OBrien HL, Kacperski J, Powers SW, Hershey AD. Paediatric migraine: evidence-based management and future directions. Nat Rev Neurol. 2018;14(9):515527. doi:10.1038/s41582-018-0042-7

30. VanderPluym J, Gautreaux J, Burch R, et al. Evidence regarding medication overuse headache in children and adolescents: protocol for a systematic review. Headache. 2020;60(1):171177. doi:10.1111/head.13726

31. Hershey AD, Burdine D, Kabbouche MA, Powers SW. Genomic expression patterns in medication overuse headaches. Cephalalgia. 2011;31(2):161171. doi:10.1177/0333102410373155

32. Puledda F, Goadsby PJ. An update on non-pharmacological neuromodulation for the acute and preventive treatment of migraine. Headache. 2017;57(4):685691. doi:10.1111/head.13069

33. Grazzi L, Egeo G, Liebler E, Padovan AM, Barbanti P. Non-invasive vagus nerve stimulation (nVNS) as symptomatic treatment of migraine in young patients: a preliminary safety study. Neurol Sci. 2017;38(Suppl 1):197199. doi:10.1007/s10072-017-2942-5

34. Hershey AD, Lin T, Gruper Y, et al. Remote electrical neuromodulation for acute treatment of migraine in adolescents. Headache. 2021;61(2):310317. doi:10.1111/head.14042

35. Raucci U, Boni A, Evangelisti M, et al. Lifestyle modifications to help prevent headache at a developmental age. Front Neurol. 2021;11:618375. doi:10.3389/fneur.2020.618375

36. Lin YK, Lin GY, Lee JT, et al. Associations between sleep quality and migraine frequency. Medicine. 2016;95(17):e3554. doi:10.1097/MD.0000000000003554

37. Lemmens J, De Pauw J, Van Soom T, et al. The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: a systematic literature review and meta-analysis. J Headache Pain. 2019;20(1):16. doi:10.1186/s10194-019-0961-8

38. Sullivan DP, Martin PR, Boschen MJ. Psychological sleep interventions for migraine and tension-type headache: a systematic review and meta-analysis. Sci Rep. 2019;9(1):6411. doi:10.1038/s41598-019-42785-8

39. Khorsha F, Mirzababaei A, Togha M, Mirzaei K. Association of drinking water and migraine headache severity. J Clin Neurosci. 2020;77:8184. doi:10.1016/j.jocn.2020.05.034

40. Robblee J, Starling AJ. SEEDS for success: lifestyle management in migraine. Cleve Clin J Med. 2019;86(11):741749. doi:10.3949/ccjm.86a.19009

41. Papetti L, Ursitti F, Moavero R, et al. Prophylactic treatment of pediatric migraine: is there anything new in the last decade? Front Neurol. 2019;10:771. doi:10.3389/fneur.2019.00771

42. Hershey AD, Powers SW, Bentti AL, Degrauw TJ. Effectiveness of amitriptyline in the prophylactic management of childhood headaches. Headache. 2000;40(7):539549. doi:10.1046/j.1526-4610.2000.00085.x

43. Sakulchit T, Meckler GD, Goldman RD. Topiramate for pediatric migraine prevention. Can Fam Physician. 2017;63(7):529531.

44. Powers SW, Coffey CS, Chamberlin LA, et al. Trial of amitriptyline, topiramate, and placebo for pediatric migraine. N Engl J Med. 2017;376(2):115124. doi:10.1056/NEJMoa1610384

45. Vatzaki E, Straus S, Dogne JM, Garcia Burgos J, Girard T, Martelletti P. Latest clinical recommendations on valproate use for migraine prophylaxis in women of childbearing age: overview from European Medicines Agency and European Headache Federation. J Headache Pain. 2018;19(1):68. doi:10.1186/s10194-018-0898-3

46. El-Chammas K, Keyes J, Thompson N, Vijayakumar J, Becher D, Jackson JL. Pharmacologic treatment of pediatric headaches: a meta-analysis. JAMA Pediatr. 2013;167(3):250258. doi:10.1001/jamapediatrics.2013.508

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Management of Chronic Migraine in Children and Adolescents | PHMT - Dove Medical Press

Keeping your mouth shut isnt easy, but a viral TikTok trend is out to change your mind about that. Known as mouth taping, the idea is to literally tape your mouth closed while you sleep to improve snoring, allergies and bad breath brought on by sleeping with your mouth open. But does it work and is it safe?

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Sleep medicine specialist Cinthya Pena Orbea, MD, talks about why you should be skeptical of mouth taping and when clinicians tend to put it to good use.

Mouth taping is just what it sounds like its the act of taping your mouth closed with skin-safe tape to force you to breathe through your nose instead of your mouth. But why would a mouth breather ever be interested in changing their habits?

Breathing through your nose may have various benefits that breathing through your mouth doesnt have, including:

On the flip side, mouth breathing has various side effects, including:

Sometimes, people who are mouth breathers snore, which is a common symptom, along with restlessness and fatigue, seen in people with obstructive sleep apnea.

We usually breathe through our mouths as a backup for when we cant breathe through our nose. Blockages can be caused by a few different conditions, including congestion from allergies or sinus infections, a deviated septum, enlarged tonsils or enlarged adenoids.

The goal of mouth taping is to reduce the negative side effects and reroute your breathing through your nose. But studies done so far appear inconclusive and the jurys still out on whether or not mouth taping is beneficial.

One small study showed 30 patients snored less after mouth taping. But another study of 36 patients with asthma showed no signs of change in their condition after using mouth taping. And a 2022 study revealed that 10 patients continued to try mouth breathing even after their mouths had been taped, a phenomenon known as mouth puffing.

Most of the evidence is anecdotal. There is not strong enough evidence to support that mouth tape is beneficial, says Dr. Pena Orbea. Mouth taping is not part of our current practice to treat any sleep disorder. Nonetheless, in patients with sleep apnea, we may recommend mouth taping or to wear a chin strap to decrease an air leak while youre using a continuous positive airway pressure (CPAP) machine at night.

Rather than rely on mouth taping, Dr. Pena Orbea suggests using alternative methods to address conditions like snoring and sleep apnea directly.

Causes of snoring vary, but the main reason it happens is that your airway becomes restricted and your tissues vibrate against one another as you try to force air through. If youre having trouble snoring (or if your partner keeps you awake with their snoring), you can try a few solutions like:

Snoring is something that you should consult with your doctor about because snoring can be a sign of other conditions like sleep apnea, notes Dr. Pena Orbea.

Sleep apnea is a condition in which you stop breathing repeatedly while you sleep. This can be caused by an obstructed airway or because your brain has trouble signaling your muscles to help you breathe. One major treatment for sleep apnea is using a CPAP machine to help open your airway while you sleep.

When patients wear a CPAP at night, some patients may swallow air during the night which causes them to feel bloated or have abdominal pain the next morning, explains Dr. Pena Orbea. By closing their mouth with mouth taping or a chinstrap, we can help alleviate these problems.

Taping your mouth shut impairs your ability to breathe in full, deep breaths. Plus, you could also experience skin irritation, an allergic reaction or rash from using the wrong kind of tape. It is never advised to use duct tape or any other kind of tape on your body for any reason.

Mouth taping could cause an allergic reaction from the tape or a skin irritation or rash, warns Dr. Pena Orbea. Before starting this practice, you should talk to your doctor about this.

Mouth taping isnt recommended because theres not enough scientific evidence to support the anecdotal benefits behind this viral trend. If youre concerned about improving your snoring, bad breath, sleep apnea or any other breathing or sleep-related conditions, you should talk to a healthcare provider to figure out safer alternative treatments.

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Mouth Taping: Is It Safe? - Health Essentials

After seven decades on the throne, Queen Elizabeth II, Britains longest reigning monarch, died Thursday at Balmoral Castle. She was 96.

Elizabeth is succeeded by her eldest son, Charles. Royal officials confirmed the new monarch will be known as King Charles III.

Here are seven things you need to know about the Queens passing.

How did it happen?

Early Thursday morning, news broke that the Queen was placed under medical supervision, just two days after she appointed British Prime Minister Liz Truss the 15th prime minister to serve under her reign.

Hours later, around 1 p.m. EST, a notice was posted at the gates of Buckingham Palace notifying the public of the Queens death.

The Queen died peacefully at her estate in the Scottish Highlands, Balmoral castle, officials announced. Members of the royal family including Prince William Charles eldest son and now heir-apparent and the Queens other sons Princes Andrew and Edward were in attendance.

When is the Queens funeral?

The funeral will take place at least 10 days after the Queens passing, following a traditional period of mourning across the nation.

According to Politico, Elizabeths official send-off is expected to take place in Westminster Abbey, with members of the royal family, dignitaries and heads of state from around the world in attendance.

Elizabeth will be laid to rest at St. Georges Chapel, on the grounds of Windsor Castle. She will be buried beside her late husband Prince Philip, her father King George VI and her sister Princess Margaret.

The royal family is expected to release concrete details soon.

Whats Operation London Bridge?

Operation London Bridge is the code name for the U.K. governments secretive plans covering the immediate aftermath of the Queens death.

According to Politico, it includes a detailed schedule of the 10 days of national mourning, including a large security operation overseeing the potentially unprecedented crowds of mourners surging into London.

The plans span from the important to the seemingly mundane, from how official government websites and social media should behave to how the U.K. prime minister should.

For a full overview of the plan, click here.

Whos next in line after the Queen?

King Charles III was named king immediately after Elizabeths death. The order of succession after the 73-year-old monarch is as follows:

Prince William, eldest son of Charles and the late Princess Diana, is now the heir apparent. He is married to Catherine, Duchess of Cambridge. Their three children Prince George, Princess Charlotte and Prince Louis will succeed him in that order.

Prince Harry, younger son of Charles and Diana, follows. He will be succeeded by his children with Meghan, Archie Mountbatten-Windsor and Lilibet Mountbatten-Windsor, respectfully.

Prince Andrew, Queen Elizabeth II and Prince Philips second-eldest son, is eighth in succession. Andrew is followed by Princess Beatrice, his eldest daughter with former wife Sarah Ferguson.

With the death of Queen Elizabeth II, her son Charles becomes Britain's new king. The oldest person to ever assume the British throne, he became King Charles III on Thursday. (Sept. 8)(AP video/Mike Householder)

What do we know about King Charles III?

After a lifetime of preparation, Charles has finally ascended to the throne. His coronation marks him the oldest person ever to assume the British crown.

His wife, Camilla, Duchess of Cornwall, was named queen consort. Charles and Camilla wed in 2005 following his controversial divorce with Princess Diana in 1996. Diana later died in a car crash the following year.

Charles became the first royal heir to earn a university degree and not be educated at home. Unlike his mother, who was steadfastly apolitical, Charles delivered speeches and penned articles on topics including climate change, green energy and alternative medicine.

How will the Queens death affect Canada?

Immediately after the Queens death, King Charles III automatically became Canadas head of state. Everything else in Canadian government essentially remains the same.

The monarchs role in Canadian governance is extremely limited. Their representative, the governor general, carries out responsibilities on their behalf, most of which are largely ceremonial. One of these tasks is to formally announce the new king.

Read more here: How will Queen Elizabeth IIs death affect Canada's government?

All coins engraved with the Queen will remain legal tender and stay in circulation indefinitely. The current $20 polymer bill will continue to circulate for years to come, although Elizabeths image will eventually be replaced with her successor.

Read more here: What happens to Canadas currency, stamps, place names after the Queens death?

How are world leaders reacting?

In a news conference Thursday, newly appointed Prime Minister Liz Truss reflected on the Queens legacy and spoke on ushering in a new era. She ended her speech with God save the King.

In a speech soon after the Queens death, Canadian Prime Minister Justin Trudeau called Elizabeth one of my favourite people in the world, adding that he will miss her so.

World leaders from Ukrainian president Volodymyr Zelenskyy to the King of Jordan Abdullah bin AlHussein took to Twitter to pay their tributes. Read what they said here.

World leaders and citizens across the globe expressed their condolences and memories of Queen Elizabeth II, who died Thursday at age 96. (Sept. 9 / THE ASSOCIATED PRESS)

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Original post:

Queen Elizabeth: Seven things you need to know about the Queens passing - Toronto Star