Treatment of Acute Migraine Headache in Children
Condition: Migrainous Headache
MeSH terms: Migraine Disorders; Headache
Study type: Interventional
Phase: Phase 2

Summary: 
      Migraine is common in children and is one of the most common etiologies of headache leading
      to emergency room presentation in children. Despite this, few studies have investigated the
      treatment of acute migraine headache in the emergency room. We will perform a prospective,
      double-blind, placebo-controlled study of metoclopramide versus placebo in the treatment of
      acute migraine headache. The primary outcome will be the number of subjects headache free at
      two hours.
    

Detailed description: 
      Migraine is common in children and is one of the most common etiologies of headache leading
      to emergency room presentation of children [1-3]. Despite the high prevalence, there have
      been few pediatric studies of the acute treatment of migraine headache. Anti-dopaminergic
      medications such as metoclopramide are often considered first line medications in the
      emergency room treatment of acute migraine [personal communication with Children's Hospital
      of Philadelphia Emergency Department physicians], but only two pediatric studies guide this
      clinical management. One was a retrospective, uncontrolled, descriptive study [4] and one was
      a prospective, double-blind study that compared an anti-dopaminergic medication to a
      different medication but did not include a control group [5]. More rigorous studies are
      needed to determine whether commonly utilized anti-dopaminergic medications are efficacious.

      We will perform a prospective, randomized, double-blind placebo controlled study of the acute
      treatment of pediatric migrainous headache with metoclopramide.

      Primary Objective The primary objective of the study is to determine whether metoclopramide
      added to standard care [intravenous (iv) hydration, darkened room] is superior to placebo and
      standard care in resolving acute migraine headache intensity within two hours in children
      aged 8 to 18 years presenting to the emergency department (ED).

      Secondary Objectives:

        1. Determine whether metoclopramide added to standard care (iv hydration, darkened room) is
           superior to placebo and standard care in resolving acute migraine headache intensity
           within one hour in children aged 8 to 18 years presenting to the emergency department.

        2. Determine whether metoclopramide added to standard care (iv hydration, darkened room) is
           superior to placebo and standard care in resolving acute migraine headache intensity at
           24 hours in children aged 8 to 18 years presenting to the emergency department.

      Study Design:

      The study is a prospective, randomized, double-blind, placebo-controlled study of
      metoclopramide versus placebo. Subjects may receive up to two doses of study medication one
      hour apart.

      Children who present to the emergency department with migraine headache based on
      International Classification of Headache Disorders (ICHD) criteria will be eligible for
      enrollment. A standard assessment form will be sued to ensure children meet ICHD criteria.
      Children will then be randomized to receive either metoclopramide or placebo (intravenous
      fluid injection). Both patients and the study investigator performing assessments will be
      blind as to group assignment, while the Emergency Department physician will be aware of group
      assignment (acting as the pharmacist) so that if problems arise they can be evaluated and
      treated as clinically indicated. Assessment of headache and associated features will occur at
      one hour. If the child is not headache free, they will receive a second dose of either
      metoclopramide or placebo. If they received metoclopramide initially the second dose will be
      metoclopramide, and if they received placebo initially the second dose will be placebo.
      Assessment of headache and associated features will occur again at two hours. This marks the
      primary endpoint, as our primary objective is to determine whether metoclopramide is superior
      to placebo in making patients headache free at two hours.

      Headache recurrence will be assessed at 24 hours.

      Subject Population:

      Children will be recruited from the Emergency Department. Consent and assent will be obtained
      as described in the protocol.

      Number of Subjects:

      All subjects will be recruited from the Emergency Department of a single institution. Sample
      size calculation suggests we will need 44 subjects for analysis.

      Study Duration The total duration of the study is one day for each subject. The maximum time
      spent in the Emergency Department will be six hours. We expect subject enrollment to take
      approximately six months.

      Study Phases:

        1. Screening Phase: Upon presentation to the Emergency Department, patients diagnosed with
           migrainous headache based on International Classification of Headache Disorders criteria
           will be considered for enrollment. If they meet inclusion and exclusion criteria they
           will be consented/assented and enrolled in the study.

        2. Basic Information Collection Basic demographic information, medical history,
           psychological/psychiatric history past headache history, and information regarding the
           current headache will be gathered.

        3. Double-Blind Study Subjects will be randomized to receive metoclopramide or placebo in a
           double blind study. Baseline headache and associated symptom data will be gathered.
           Assessments will be performed at one hour and two hours. The two hour assessment is the
           primary endpoint. If the headache has not resolved, the cross-over will occur. Children
           who received metoclopramide initially will receive a placebo injection and, if needed, a
           second injection one hour later. Children who received placebo initially will receive
           metoclopramide and, if needed, a second injection one hour later. Headache assessments
           will be performed one and two hours after the cross-over.

        4. Follow-up Phase Patients will rate their headache intensity and associated symptoms at
           one day in order to assess for recurrence.

      Efficacy Evaluations:

      Efficacy will be judged hourly after each medication (or placebo administration). Efficacy in
      reducing headache intensity will be judged on a 0-10 point numerical rating scale. The
      primary measure of efficacy will be headache freedom (rating of zero). Secondary measures
      will be improvement in headache intensity that is clinically relevant (6 point improvement)
      or improvement that is measurable (3 point improvement), improvement in associated symptoms
      (based on a 4 point categorical scale), or improvement in disability (based on a 4 point
      categorical scale).

      Safety Evaluations:

      All subjects entered in the study will be included in safety analysis. The frequency and
      descriptions of all adverse events will be summarized. Any serious adverse events will be
      described in detail.

      Statistical And Analytic Plan:

      Based on prior studies, we estimate a metoclopramide efficacy of 80% and placebo rate of 35%.
      Sample size and power calculations using an alpha value of 0.05 and power of 0.8 demonstrate
      that we will need to enroll 44 patients in the study. Subjects who drop out due to need for
      faster rescue medication will be maintained in the analysis which will be performed in an
      intent-to-treat manner.
    

Intervention name(s): Metoclopramide; Placebo
Intervention type(s): Drug; Other
Intervention description(s): Intravenous bolus administration.; Standard care including intravenous fluid, but no metoclopramide.
Other intervention name(s): Reglan
Intervention MeSH terms: Metoclopramide
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment