CHRONIC HEADACHES IN CHILDHOOD

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Rolf Edwards
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1 CHRONIC HEADACHES IN CHILDHOOD EDWIN LIU, MD PEDIATRIC NEUROLOGISTS OF PALM BEACH PEDIATRIC SLEEP CENTERS OF FLORIDA ASSISTANT CLINICAL PROFESSOR FSU ASSISTANT CLINICAL PROFESSOR NOVA SOUTHEASTERN

2 PEDIATRIC NEUROLOGISTS OF PALM BEACH

4 POTENTIAL CONFLICTS OF INTEREST I am a contracted clinical researcher for Impax Laboratories/Astra Zenica

5 CHRONIC HEADACHES-INTRODUCTION

6 DEFINITIONS Chronic Headaches Headaches occurring >15 days/month over a period longer than 3 months Frequent Episodic Headaches At least 10 episodes of headache occurring on 1-14 days/month on average for >3 months

7 NUMBER OF VISITS BY DIAGNOSIS (PNPB) Headaches Epilepsy ADHD Sleep Disorders Autism Tics Visits/year

8 CHRONIC DAILY HEADACHES The frequency of chronic headaches 4 percent in adults 2.4 percent in adolescent females 0.8 percent in adolescent males.

9 CHRONIC HEADACHES Non Classifiable Secondary Other Primary Mixed 29% 9% 51% n=1029 age 7-17 yrs Migraine Tension Type Pacheva et al, Pediatr Dimensions, 2016

10 OTHER Primary Headaches Chronic Cluster Headache New Daily Persistent Headache Secondary Headaches Medication-overuse/Caffeine-withdrawal headache Headache Due to Mild Traumatic Head Injury Headache Due to Idiopathic Intracranial Hypertension

11 EVALUATION

12 HISTORY Time course Location Quality Associated symptoms Treatments Sleep Hx

13 HISTORY Time course Location Quality Associated symptoms Treatments Sleep Hx Transformed Migraine

14 HISTORY Time course Location Quality Associated symptoms Treatments Sleep Hx Chronic Non-progressive Transformed Migraine

15 HISTORY Time course Location Quality Associated symptoms Treatments Sleep Hx Mixed Chronic Non-progressive Transformed Migraine

16 HISTORY Time course Location Quality Associated symptoms Treatments Sleep Hx Progressive Mixed Chronic Non-progressive Transformed Migraine

17 HISTORY Time course Location Quality Associated symptoms Treatments Sleep Hx Progressive Mixed Chronic Non-progressive Transformed Migraine

18 HISTORY Time course Location Quality Associated symptoms Treatments Sleep Hx Progressive Mixed Chronic Non-progressive Transformed Migraine

19 PHYSICAL EXAM BP BMI Optic Nerve Tonsils Joint Mobility Trigger points

20 PHYSICAL EXAM BP BMI Optic Nerve Tonsils Joint Mobility Trigger points

21 PHYSICAL EXAM BP BMI Optic Nerve Tonsils Joint Mobility Trigger points

22 PHYSICAL EXAM BP BMI Optic Nerve Tonsils Joint Mobility Trigger points

23 PHYSICAL EXAM BP BMI Optic Nerve Tonsils Joint Mobility Trigger points

RED FLAGS Systemic symptoms (fevers, prominent nausea, vomiting) Neurologic sx (stroke like sx, syncope, seizures, deterioration in school performance,

24 RED FLAGS Systemic symptoms (fevers, prominent nausea, vomiting) Neurologic sx (stroke like sx, syncope, seizures, deterioration in school performance, personality changes) Onset (thunderclap) Occipital Positional (wakes at night, present upon awakening) Progressive Symptoms Parents without hx of headaches Years (<6)

25 NEUROIMAGING n=407 age 2-18 yrs 128 (31%) had MRI abnormalities Of these 5 (4%) had primary pathology 123 (96%) were incidental Gurkas E, et al. Arch Argent Pediatr 2017 Chiari Asymmetric Ventricles Arachnoid Cyst White matter abnormalitie s Enlarged PV Spaces

26 NEUROIMAGING 4% n=407 age 2-18 yrs 128 (31%) had MRI abnormalities Of these 5 (4%) had primary pathology 123 (96%) were incidental Gurkas E, et al. Arch Argent Pediatr 2017 Chiari Asymmetric Ventricles Arachnoid Cyst White matter abnormalitie s Enlarged PV Spaces

28 CADASIL

29 CADASIL

32 NEPHROGENIC SYSTEMIC FIBROSIS First reported 2006 Triad Gadolinium exposure Renal insufficiency Pro-inflammatory state e.g. post op, sepsis As of Sept 2012, 23 pediatric cases reported, none <6 yrs old No pediatric cases have been reported since 2007 after adoption of guidelines published contraindicating use in patients with GFR < 30 ml/min

33 Kanda et al, Radiology 2014

34 Kanda, et al, 2014

35 Kanda, et al, 2014

36 Kanda, et al, 2014 Macdonald et al 2015

39 Consider contrast: When sedation is necessary When contrast is required Known lesion possibly malignant, infections, inflammatory, demyelinating Cranial nerves Pituitary Orbits MRA neck When there is a possible lesion which may not be seen without contrast Caution in renal insufficiency, pregnancy, children

40 CASE STUDY

41 16 yo female with several year history of headaches Previously several/month, now daily Onset shortly after awakening, lasts all day Daily: 6/10, pressure, hatband, constant, no N/V, visual, focal neurologic symptoms Weekly: 9/10, pounding, behind her eyes, nausea, vomiting photo/phonophobia Takes ibuprofen 4-5x/week, no caffeine Menstrual periods regular but heavy

42 SOCIAL HISTORY 11 th grade, grades starting to deteriorate 2-3 hours homework/day but takes 5-6 hours to complete No longer has time for sports Stays connected through Instagram, Facebook, etc

43 SLEEP HISTORY Always tired, often takes 1-2 hour nap after school Difficult to wake in AM, best friend is the snooze button No known snoring but breathes through mouth Very restless sleeper, hx of growing pains

45 DIAGNOSES Chronic Daily Headaches (combined migraine, tension) Sleep Disorder inadequate sleep hygiene delayed sleep phase d/o possible sleep disordered breathing possible restless legs Medication overuse Possible ADHD, learning disabilities

46 ADOLESCENT HEADACHES THE PERFECT STORM Sleep Problems School Stress Family Conflicts Social Pressures Electronics Overuse Hormonal Changes Poor Diet Lack of Exercise Psychiatric Issues

47 MANAGEMENT Set Expectations Trigger Management Abortive Treatment Prophylactic Treatment Other

48 MODIFIABLE TRIGGERS Acute Fasting, dehydration, odors, foods, etc Chronic Sleep Stress Electronics Anxiety/Depression Exercise

49 SLEEP Insufficient sleep Inadequate sleep hygiene Delayed sleep phase syndrome Intrinsic sleep disorder Sleep disordered breathing Restless legs syndrome

51 SLEEP HYGIENE Consistent bed and wake times including weekends No televisions, electronics, phones in bedroom Electronics off 1-2 hours before bed No caffeine after lunch Limit naps to 15 minutes Low light in evening, bright in morning No exercise or other stimulating activity before bed

52 DELAYED SLEEP PHASE DISORDER

54 DELAYED SLEEP PHASE DISORDER-TREATMENT Sleep restriction therapy Light management Strategically timed melatonin: 1-3 mg 1-2 hours before bedtime

55 INTRINSIC SLEEP DISORDERS Sleep Disordered Breathing Restless Legs Syndrome

57 SCHOOL STRESS ADHD/Learning Disabilities Psychoeducational/Neuropsychological Testing School Accomodations/504 plan/iep Medication Missed Days Virtual/Home Schooling Social Pressures/Bullying Counseling Social Skills Training

58 PHARMACOTHERAPY

59 ABORTIVE: Use for acute exacerbations only Not to be used > 2 x/week NSAIDs Midrin Triptans DHE/Migranal Fioricet* (Opioids)* *Highest risk for medication overuse

60 PREVENTATIVE Melatonin Nutriceuticals: riboflavin, Mg++, CoQ10, feverfew Traditional Cyproheptadine Anti-hypertensives: beta blockers, verapamil Anti-depressants: amitriptyline, SSRIs Anti-convulsants: topiramate, levetiracetam, zonisamide New Erenumab (Aimovig), calcitonin gene-related peptide (CGRP) receptor monoclonal antibody

61 CHAMP TRIAL

62 RESULTS n=328 age 8-17 yrs (mean 14.2 yrs) 132 in the amitriptyline group 130 in the topiramate group 66 in the placebo group The trial was concluded early for futility after a planned interim analysis There were no significant between-group differences in primary end point 52% of the patients in the amitriptyline group had > 50% reduction in HAs 55% of those in the topiramate group 61% of those in the placebo group

63 ALTERNATIVE TREATMENTS Physical Therapy/Muscle Relaxants Relaxation, Cognitive Behavioral and EMG Biofeedback Therapies Occipital Nerve Block Botox Acupuncture TENS

64 % Pts with CDH PROGNOSIS n=122 ages yrs with >15/month Wang et al, Neurology Baseline 1 year 2 years 8 years

65 CONCLUSIONS: CASE REPORT Set Expectations Headache/trigger diary Sleep issues: sleep restriction, melatonin, sleep hygiene Electronics off 1-2 hrs before bedtime School issues: school accomodations, consider ADHD treatment Psychiatric issues: therapist Limit caffeine/medication <2d/week Exercise program Consider preventative medications, alternative treatments

66 THANK YOU

Outpatient Headache Care Guideline

Outpatient Headache Care Guideline 1 Outpatient Care Guideline Inclusion criteria: children > 3 yrs with headaches Is urgent emergency department, neuroimaging, or Neurology consultation indicated? Referral to ED if: New severe headache