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Sara Pavitt, MD, Assistant Professor of Neurology at Dell Medical School and Chief of the Pediatric Headache Center at Dell Children’s, recently described the use of intravenous valproate in significantly reducing pain for children with chronic headache.

Pavitt and her colleagues summarized 45 children with refractory headache disorders who completed a standardized four-day inpatient repetitive valproate infusion protocol. Patients with chronic migraine had undergone a median of seven previous migraine prevention trials, and 85% had completed one or more previous intravenous therapies with other agents. One week after completing the valproate infusions, each patient began a new headache preventive agent. The baseline headache frequency did not change significantly for the cohort as a whole, but two-thirds of the patients experienced long-term improvement based on a combined analysis of headache frequency, headache intensity, and diminished use of acute pain medications.

Refractory migraine causes substantial discomfort and long-term disability. These children are seldom included in clinical trials, so there is a paucity of objective evidence to guide therapy. Based on this report, valproate infusions may be an encouraging option.

Pavitt S, Gelfand AA, Zorrilla N, Allen I, Riggins N. Efficacy and safety of repetitive intravenous sodium valproate in pediatric patients with refractory chronic headache disorders: a retrospective review. Pediatr Neurol 2022;128:52-57. doi: 10.1016/j.pediatrneurol.2021.12.008

The diagnosis and treatment of multiple sclerosis has improved dramatically in the last several years, in both adults and children. Most discussions of multiple sclerosis center on secondary prevention with agents intended to prevent disease progression and limit the ultimate severity of neurological disability. Such disease-modifying treatments are particularly important for children, because children with multiple sclerosis have more years to accumulate lesions. What is not often discussed, however, is primary prevention strategies for multiple sclerosis.

In a Frontiers in Neurology article, Duriel Hardy, MD, and colleagues take a critical look at the difficult topic of multiple sclerosis risk factors that might be modified in the pediatric population. Concern about exposure to Epstein-Barr virus, inhalation of passive cigarette smoke, and exposure to other environmental toxins is bolstered by considerable statistical evidence. An increased body mass index also seems to increase the multiple sclerosis risk, albeit at a lower level.

Although the studies are inconsistent, preliminary evidence suggests that breastfeeding protects against development of multiple sclerosis (possibly by avoiding molecular mimicry between cow milk proteins and brain antigens). Other possible protective factors include sun exposure and higher serum vitamin D levels.

Although many of these factors are modifiable, altering them would require extensive public health changes.

Hardy D, Chitnis T, Waubant E, Banwell B. Preventing multiple sclerosis: the pediatric perspective. Front Neurol 2022;13:802380. doi: 10.3389/fneur.2022.802380

The COVID-19 pandemic altered virtually every facet of health care. Nonemergency procedures were postponed to preserve hospital bed capacity, routine health care was often deferred, cumbersome patient and provider screening procedures were implemented, and telemedicine was embraced to reduce the exposure risk for both patients and health care workers.

The presurgical neuropsychological evaluation of children with drug-resistant epilepsy is particularly challenging under these conditions. The standard test instruments have only been validated for in-person use, and we cannot assume that remotely administered tests are equally valid. Environmental distractions are more difficult to control when the patient is at home. Cooperation with testing is improved by establishing rapport with the patient and family, but this is more difficult with remote testing. The remote examiner could also miss subtle clues about the child’s effort level or understanding the task at hand.

Nancy Nussbaum, PhD, and her colleagues at Dell Medical School explored these pandemic-related challenges as they related to pediatric patients with drug-resistant epilepsy, analyzing evidence-based methods of virtual evaluation to develop a systematic decision-making process for remote neuropsychology. In this article they provide several scenarios to guide the use of virtual neuropsychological assessment and discuss the potential pitfalls of remote testing. The need for remote test validation remains, of course, but in the meantime, the models presented here may be useful for other multidisciplinary surgical teams who need to utilize remote neuropsychological testing.

Nussbaum NL, Young SR, DeLeon RC, Engelmann ML, Schraegle WA. The future is now: pediatric neuropsychological presurgical epilepsy evaluation in the age of COVID-19. Epileptic Disord 2021;23:274-280.