Lynne Kerr, MD May 2014

Transcription

1 Lynne Kerr, MD May 2014

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3 Headache is one of top 5 health problems in children 2 nd most common diagnosis in the peds neurology outpatient clinic

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5 14 year old girl severe headache Headaches 1-2 times/month Motion sickness as child Bilateral across the forehead Throbbing Wants to lie down in dark room and go to sleep Family history migraines mom, aunt

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7 Very young child New onset headache Abrupt onset Progressive symptoms Abnormal neurologic signs Headache with exertion Change with head position Change with Valsalva manuever Headache/vomiting in AM Personality change

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9 Headaches for several years Are present in the AM at times, but don t get better as she becomes upright Nausea/vomiting with headaches most of the time Review of systems normal except for frequent abdominal pain saw her PCP without a cause being found

10 VS BP normal Appearance alert, interactive Weight normal General and physical exams normal

11 Overweight, BMI 29 Has many floaters in her vision Is on minocycline for acne May have peripheral vision loss

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14 Primary IIH Secondary venous sinus thrombosis, medications, medical conditions Need papilledema, MRI changes for diagnosis It is not helpful to do an LP for increased pressure if ophthalmologic exam and MRIs are normal Friedman et al. 2013

15 No matter how you look at it, headaches in children and teens are incredibly common, one of the most likely reported health complaints to providers

16 Germany 2012 mixed headaches in 19.8% of children and adolescents Calculated life-time prevalence for headache in children/adolescents 58.4%. Prevalence 9.1% of children have migraine (Wober-Bingol, 2013) Children under 7 about ½ migraine, 15% tension, approx 1/3 mixed/unclass (Ramdas, 2013)

17 Why for choice of evaluation and management Classification by International Headache Society Criteria More specific diagnosis will also most likely help billing, especially as we go into ICD-10

18 Primary Headaches Secondary Headaches Caveat - individuals who are prone to migraine are more likely to have migraine type headaches even due to secondary causes, so can t go by characteristics

19 Migraine Tension TACS-trigeminal autonomic cephalgia Other stabbing, hemicrania continua and new daily-persistent headache (others) Chronic daily headaches

20 Two major subtypes Migraine with aura Migraine without aura

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22 Common migraine At least 5 attacks lasting 4-72 hours Unilateral location Pulsating quality Moderate or severe pain intensity Aggravation by routine physical activity At least one of following: Nausea and/or vomiting Photophobia AND phonophobia

23 Exceptions to adult criteria Attacks may last 1-72 hours Commonly bilateral in young children Nausea/photophobia/phonophobia may be inferred from behavior

24 Classic migraine 20% of people with migraines Often aura runs in family May have many migraines without aura commonly a mix of those with and without

25 Typical aura consisting of visual and/or sensory and/or speech symptoms Gradual development Duration no longer than 1 hour Mix of positive and negative features Complete reversibility Associated with a HA fulfilling criteria for migraine without aura

26 NO motor weakness Note that sensory symptoms such as numbness might make a limb harder to move, so must differentiate from weakness Positive examples flickering lights/spots/lines Negative examples numbness, loss of vision

27 Visual aura is the most common type of aura Sensory disturbances next in frequency Speech disturbances next Motor symptoms must differentiate from stroke familial hemiplegic migraine or sporadic hemiplegic migraine are diagnoses of exclusion

28 Migraine equivalents precursors Cyclical vomiting episodes of nausea/vomiting lasting a few days, normal in between Abdominal migraine episodes of abdominal pain without physical explanation Benign paroxysmal vertigo of childhood episodes of vertigo that come and go

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30 Very rare that a child with a headache has an underlying etiology; more than 3/4s have CTs or MRIs before their visit with us. CTs aren t very good, they often lead to an MRI, and expose the child to radiation. Neuroimaging findings in only 1.2% of neurologically normal patients.

31 Cumulative doses of 50 mgy can triple the risk of leukemia and 60 mgy can triple the risk of brain cancer. Major concerns are tumor, vascular malformation, spread of infection, sinus thrombosis. Instead, suggest complete history, family history, general (including VS) and neurologic exam (with fundoscopic exam). Alexious and Argyropoulou, 2013

32 MOST IMPORTANT There is NO magic pill Journal Headaches identify and avoid triggers Exercise Appropriate sleep Appropriate weight Stress/anxiety Diet No narcotics

33 Journaling is therapeutic on its own Need to know the pattern of migraine Every weekend, every Monday Association with periods, sports, etc. Headache journal Teens like smart phone apps others

34 Acute, abortive, and preventive Acute what someone takes for a standard type migraine Abortive what someone takes at home if migraine horrible, last step before ED Preventive medication someone takes every day to decrease headache frequency and intensity

35 Need to take it as soon as possible after start of headache Not more than 3 times a week may cause medication overuse headache May need form to allow administration at school

36 Ibuprofen/acetaminophen Dose appropriate for weight 10 mg/kg for ibuprofen, 15 mg/kg acetaminophen Addition of caffeine may be helpful

37 Odansetron (serotonergic properties and for n/v) Orally disintegrating tablets 4 mg and 8 mg Generic available Others phenergan, compazine, thorazine (pretreat w/ benadryl?)

38 AAN suggests be used earlier for migraine in adults I use them rarely for kids/adolescents Very expensive, and often not covered by insurance Like ibuprofen, not more than 3 X/week Combined with ibuprofen/acetamin may work better

39 Sumatriptan only nasal spray had any benefit in studies, and kids don t like 10 and 20 mg nasal, 25 and 50 mg oral Rizatriptan 6 years and older ODT/tabs 5 and 10 mg Almotriptan Comes in 6.25 and 12.5 mg capsules Kids 12 years of age and older

40 This is so you can rest medication I add benadryl/phenergan on a routine basis (not prn, but scheduled) so they can sleep for a few days My last step before the ED Have included ED protocol at end Occasional IV DHE (an admission) data shows not very helpful and $7500 av cost

41 Studies show preventive medications way underprescribed When headaches get to be 3 days a month (1 HA 3 days or 3 1 day Has) TAKE 4-8 weeks to work need to warn families No evidence in children/teens except flunarizine, a Ca channel blocker not available in the US

42 Magnesium ending in ate Adults mg BID Loose stools side effects Class I evidence better than placebo Butterbur (Petasites) Class I evidence Petadolex (amazon.com) 50 mg 1/day Riboflavin 100 mg/day Melatonin new evidence lately (not class 1)

43 Cyproheptadine Topiramate Amitriptyline Valproic acid Lamotrigine Gabapentin Propranol

44 Cyproheptadine younger children, weight gain a real problem, sleepiness not a problem as given only at night, 2 mg/5 ml liquid, 4 mg tabs Amitriptyline EKG (50 or greater), low therapeutic index; sleepiness, dry mouth, and constipation, start at 12.5 mg and increase to mg.

45 Topiramate 15 mg qhs only to increase to 30 mg after 1 week Weight loss (may be good thing) Increase hydration Topastupid or Dopamax, but given only at night More news of effects on QT interval Propranolol can t be used if asthma or depression I rarely use < 35 kg mg tid > 35 kg mg tid If dose high enough, can give as ER 60/80/120

46 > 15 days a month Thought to be a complication of migraine transformed migraine Often looses migrainous features over time Only approved medication for this type of headache: botox injections, insurance usually requires trials of other preventive therapies first, over 15 yoa

47 Pain that persists beyond the normal tissue healing time, which is assumed to be 3 months Chronic pain in 1/3 adults Early treatment to prevent chronification Pain that ceases to be symptomatic of the initial cause and becomes an entirely separate condition. (Fine, 2011)

48 Pts with altered mental states/physical dysfunction Changes in excitability of brain and in default mode network Correlated with increased negative affectivity (Kroner-Herwig, 2013). Pain has potential to become more complex in its pathophysiology over time (Fine, 2011)

49 Medications Plus Behavioral Health

50 The usual suspects Amitriptyline Topiramate Other New for chronic daily headache botulinum protocol

51 Usually a series of 3 given 3 months apart Generally at least 2 series before much relief 31 injection sites Most common side effect neck pain

52 Recently approved in US Unclear if insurance will pay Stimulates the trigeminal nerve Somewhere around $300

53 Medication + CBT better than medication alone (Powers et al. 2013). Treat anxiety/depression/sleep problems Get them back to school Address family/social issues Others integrative medicine, biofeedback, acupuncture, etc. Psychology/psychiatry/social work

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55 Can be primary or secondary Not as common in the office, but more common in life Criteria: at least 10 episodes Lasting 30 minutes to 7 days Bilateral location Pressing/tightening (non-pulsating) Mild to moderate intensity Not aggravated by routine physical activity No N/V, either photo or phonophobia, not both

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57 Ibuprofen/acetaminophen Caffeine may help Some people think triptans help not good evidence Avoid narcotics Preventive treatments may help

58 Headache that within 3 days of onset is daily and unremitting for > 3 months, with 2 of following characteristics Bilateral Pressing/tightening Mild/moderate Not aggravated by physical activity No more than one of photophobia/phonophobia/nausea/vomiting

59 Often, patient can recall exact moment headache began Sometimes precipitating event such as viral infection or concussion Rule out underlying causes (especially CSF increase/decrease pressure) and medication overuse headache

60 Difficult Reassuring that most go away, although may be months to years Possibilities discussed under migraine the usual suspects, no evidence for one more than the other IV DHE/botox injections

61 Called ice-pick pains, jabs and jolts Usually first division of trigeminal nerve Lasts a few seconds, recur one to many times a day No other symptoms Change sides (if not, consider imaging) Occur in individuals with migraine

62 May respond to indomethacin (I usually use ER form, 75 mg and give it two weeks give at night because may upset stomach) May respond to melatonin or gabapentin

63 Trigeminal autonomic cephalgias Cluster headaches Paroxysmal hemicrania SUNA/SUNCT short acting unilateral neuralgiform headaches with autonomic features (conjuctival injection and tearing)

64 Rare in children (and adults) (M>F) Sharp/throbbing/severe pain May have migrainous features Abortive sumatriptan nasal spray/oxygen/steroids Preventive topiramate/verapamil Nerve blocks (usually greater occipital nerve block)

65 Severe/sharp pain Many times a day, 2-30 minutes Autonomic features Preventive indomethacin Sometimes will try greater occipital block nerve injection

66 Seconds long Stabbing/burning Severe Rare migrainous features Preventive Topiramate Lamotrigine Gabapentin May try greater occipital nerve block

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68 1) Stick with family trial and error 2) Child should NOT miss school get them back as soon as possible 3) Integrative medicine referral 4) Behavioral health referral 5) Psychiatry as necessary

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71 Alexiou, GA, Argyropoulou, MI Neuroimaging in childhood headache: a systematic review. Pediatr Radiol 43: 777. Connelly, M Cognitive behavior therapy for treatment of pediatric chronic migraine. JAMA 310: Winner, P Migraine-related symptoms in childhood. Curr Pain Headache Rep 17:339.

72 Sheridan et al 2012 Low-dose propofol for the abortive treatment of pediatric migraine in the emergency department. Pediatr Emerg Care 28: Wober-Bingol Epidemiology of migraine and headache in children and adolescents. Curr Pain Headache Rep 17: 341.

73 Blank Headache diary sheets PEDS MIDAS questionnaire for disability Pediatric Symptom Checklist for screening for psychological barriers to improving from headaches PCH ED protocol for treatment of acute headaches

74 Rizzoli, B Acute and preventive treatment of migraine. Contin 18: 764. Babineau, SE and Green, MW Headaches in children. Contin 18: 853. Continuum volume 18, Headache. Journals.lww.com/continuum/Fulltext/2012/ 08000/Table_of_Contents.3.aspx Friedman et al 2013 Revised diagnostic criteria for the PTC syndrome in adults and children. Neurol 81: 1159.

75 Alexious, GA and Argyropoulou, MI 2013 Neuroimaging in childhood headache: a systematic review. Pediatr Radiol 43: 777. Connelly, M Cognitive behavior therapy for treatment of pediatric chronic migraine. JAMA 310: Gertsch et al 2013 Intravenous Mg as acute treatment for headaches: A pediatric case series. J Emerg Med S0736. Kroner-Herwig 2013 Pediatric headache: associated psychosocial factors and psychological treatment. Curr Pain Headache Rep 17:338.

76 Ramdas et al 2013 Primary headache disorders in children under 7 yoa Scott Med J 58: 26. Winner, P Migraine-related symptoms in childhood. Curr Pain Headache Rep 17:339. Wober-Bingol Epidemiology of migraine and headache in children and adolescents. Curr Pain Headache Rep 17: 341.