Treatment of Pediatric Migraine

TO THE EDITOR

Powers and colleagues (Jan. 12 issue)¹ report the results of a randomized, double-blind, placebo-controlled trial investigating the efficacy of amitriptyline and topiramate versus placebo as potential preventive treatments in children and adolescents with migraine. Placebo that was administered for 24 weeks was associated with a clinically significant 61% reduction from baseline in the incidence of migraine, which was larger than the reductions from baseline that were observed with amitriptyline (52%) and topiramate (55%), a finding that brings attention to the placebo response.² However, caution is needed in interpreting the reduction in the placebo group.³ Placebo effects are neurobiologic changes that possibly occur as the result of patients’, caregivers’, and clinicians’ expectations. A measurement of expectations⁴ and the inclusion of a no-intervention group³ may be required in order to separate placebo effects from placebo responses that derive from regression to the mean, spontaneous remission, and symptom fluctuation. The detection of true placebo effects is valuable for health care providers as well as for children with migraine.⁵ Perhaps it is time to consider randomized clinical trials that include a no-intervention group and measures of expectations in children, parents, and clinicians.