Adult & Pediatric Patients. Stanford Health Care, Division Pain Medicine

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2 Acute Treatment Strategies in Adult & Pediatric Patients Theresa Mallick Searle, MS, RN BC, ANP BC

3 Disclosures Speakers Bureau: Allergan, Depomed Acute Treatment Strategies in Adult & Pediatric Patients Theresa Mallick Searle, MS, RN BC, ANP BC

4 Learning Objectives Identify the principles of acute treatment. Acute Treatment Strategies in Design treatment plans stratified to individual treatment needs. Adult & Pediatric Patients Theresa Mallick Searle, MS, RN BC, ANP BC Employ the Migraine Treatment Optimization Questionnaire (M TOQ) todetermine e if acute treatment e tplans need to be modified.

5 Strategies For Preventive Treatment Acute Treatment Strategies in Adult & Pediatric Patients Theresa Mallick Searle, MS, RN BC, ANP BC Treatment Preemptive Treatment Acute Treatment

6 Acute Treatment Principles Treat early in the attack. Acute Treatment Strategies in d d f l i Adult & Pediatric Patients Use correct dose and formulation. Use for maximum of 2 3 days per week. Theresa Mallick Searle, MS, RN BC, ANP BC Stratify treatment. Consider co morbidities/compliance. bd

7 Acute Treatment Principles If treatment is ineffective: Acute Treatment Strategies in Reconsider Adult diagnosis & Pediatric Patients Verify Theresa compliance Mallick Searle, MS, RN BC, ANP BC Change formulation/route Stanford Health Care, Division of Pain administration Medicine Change drug Add adjunct

8 The Migraine Treatment Optimization Questionnaire (M TOQ) Domain Functional response Consistency and onset Recurrence Questions Acute Treatment Strategies in Adult & Pediatric Patients Are you able to quickly return to your normal activities after taking your migraine medication? Can you count on your migraine medication to relieve your pain within 2 hours for most attacks? Theresa Mallick Searle, MS, RN BC, ANP BC Dose one dose of your migraine medication usually relieve your headache and keep it away for at least 24 hours? Yes/No Responses No No No Side effects Is your migraine i medication well-tolerated? l t Yes Global Are you comfortable enough to be able to plan your daily activities? No Helps determine met and unmet treatment needs

9 Formulating an Acute Treatment Plan Same drug and route use treatment differently Treat early with primary medication Acute Treatment Strategies in Adult & Pediatric Patients Improves onset and consistency of response Prevents disabilityand Theresa and Mallick Searle, recurrence MS, RN BC, ANP BC Reduces need for rescue May reduce risk of allodynia Caution: Guard against overuse

10 Formulating an Acute Treatment Plan Same drug, switch routes Optimize the route of administration for... Acute Treatment Strategies in Adult & Pediatric Patients Prominent nausea Consider non-oral therapy Injections Nasal spray Theresa Crash migraine Mallick Searle, MS, RN BC, ANP BC Vomiting Suppository Morning migraine Gastroparesis Inhaler Patch

11 Non specific effects NSAIDS Level A evidence Anti emetics Level B evidence Specific effects Triptans Level A evidence Dihydroergotamine/ergotamines Level A Opioid (butorphanol nasal spray) Level A reference

12 Non specific Treatments Reduce pain through general pain pathways. Acetaminophen NSAIDs Anti emetics (DA blockers) Opioids/barbiturates Muscle relaxants Specific Treatments Rd Reduce pain through hdirect action on serotonin 5 HT1B and 5 HT1D receptors incranialbloodvessels vessels. Triptans Dihydroergotamine (DHE) Ergotamines

13 Formulating an Acute Treatment Plan Primary Acute Treatment Secondary Acute Treatment Rescue Simple OTCs Yes Yes _ RX NSAIDs Yes Yes Ketorolac (parenteral) Acute Treatment Strategies in Adult & Pediatric Patients Combination Analgesics Rarely Rarely Rarely Triptans Yes Yes Yes Theresa Mallick Searle, MS, RN BC, ANP BC DHE Yes Yes Yes Lidocaine nasal Yes Yes Yes Muscle Relaxant Yes DA Blockers Yes Yes Yes Corticosteroids Yes Opioids/barbituates Rarely

14 Formulating an Acute Treatment Plan Dopamine Antagonists Prochlorperazine Metoclopramide Chlorpromazine Droperidol Acute Treatment 25 mg, Strategies 5 10 mg IV in Adult & Pediatric Patients 5 10 mg oral, syrup 5 mg/ml, injection 5 mg/ml, suppositories 5 20 mg oral, syrup 5 mg/ml, injection 5 mg/ml, 5 20 mg IV Theresa Mallick Searle, MS, RN BC, ANP BC mg every 6 h IV or mg oral mg IV every 6 to 8 h, or mg by injection Haloperidol 2 5 mg IV; 1, 2, or 5 mg oral

15 Formulating an Acute Treatment Plan Triptans Formulations Doses Max daily Notes sumatriptan (Imitrex) zolmitriptan (Zomig) rizatriptan (Maxalt) Tablets Nasal spray Intra-nasal powder SC injections Suppositories i Transdermal 25, 50, 100 mg 5, 20 mg 11 mg 200 mg 40 mg 44 mg 4, 6 mg 12 mg Acute 25 mg Treatment 50 mg Strategies in 6.5 mg 13 mg (2 patches) Adult & Pediatric Patients Tablets 2.5, 5 mg 10 mg Oral dissolving Nasal spray , 5 mg 10 mg Tablets Oral dissolving Off-label: ages 6+: SC 3-6 mg; max 12 mg/24h & ages 5+: Nasal spray max 40 mg/24h FDA labeled ages 12+ Nasal spray max 10 mg/24h 2.5, 5 mg 10 mg Theresa Mallick Searle, MS, RN BC, ANP BC 5, 10 mg 5, 10 mg 30 mg 30 mg FDA labeled ages 6-17 (5-10 mg) naritriptan Tablets 1, 2.5 mg 5 mg Only triptan NOT contraindicated with MAOI, slower onset. (Amerge) almotriptan (Axert) Tablets 12.5 mg 25 mg FDA labeled ages (6.25, 12.5 mg) frovatriptan Tablets 12.5 mg 25 mg Longest half-life: life: 25 hr, slow onset (Frova) eletriptan (Relpax) Tablets 20, 40 mg 80 mg

16 What is medication overuse? The most commonly used drugs that can lead to medication overuse headache (MOH) include analgesics in combination with barbiturates or other non narcotic substances, simple analgesics, opioids, triptans and ergotamine. Simple l analgesics: aspirin, i acetaminophen, NSAIDS (Ibuprofen, others) may contribute t to MOH >15 days/month. Combination pain relievers: Over the counter pain relievers that contain a combination of caffeine, aspirin and acetaminophen or butalbitol >10 days/month. Triptans & Ergotamine: Triptans and Ergotamines usd >10 days/month. The relapse rate is comparatively lesswhen compared to other medications like combination or simple analgesics. Opioid medications: MOH occur frequently if opioid use is >10 days in a month. Caffeine use: Patients who drink beverages with caffeine in large amounts are also at a risk for development of rebound headaches. It is important to limit the amount of caffeine to 200mg per day.

17 Medication Overuse Headache acetaminophen/aspirin/caffeine (Excedrin)

18

19 Non pharmacological Strategies Educate headache sufferers about their condition & treatment options. Educate about medication overuse headache. Acute Treatment Strategies in Adult & Pediatric Patients Most treatments are classified into three broad categories: Relaxation training Theresa Mallick Searle, MS, RN BC, ANP BC Biofeedback therapy Cognitive behavioral training Transcranial magnectic stimulation (TMS).

20 Assessing Treatment Efficacy Sustained freedom from pain with no adverse events (SNAE): Freedom from Acute pain Treatment within 2 hours. Strategies in Adult & Pediatric Patients No use of rescue medicine/headache recurrence within 24 hours. No adverse Theresa events. Mallick Searle, MS, RN BC, ANP BC Recurrence (use of rescue, second dose of medication) Rt Return to normal function/activities iti Patient satisfaction

21 Non pharmacologic measures: Quiet, dark environment Encourage PO fluid intake Pediatric Considerations Acute Treatment Strategies in Adult & Pediatric Patients Pharmacologic measures: 1) Non specific analgesics: Studied down to Age 4 Acetaminophen NSAIDs: Naproxen, Ibuprofen, Ketorolac 2) Dopamine receptor antagonists: e.g. prochlorperazine 3) Dihydroergotamine (DHE): IM, IV, NS 4) Triptans Theresa Mallick Searle, MS, RN BC, ANP BC

22 Pediatric Considerations Drugs Formulations Dosing Max daily Notes ibuprofen Tablets Suppositories 10mg/kg, repeat in 4-6hr. 40mg/kg Acute Treatment Strategies in 25 mg 50 mg Adult 5mg wafer & Pediatric 30 mg Patients OTC analgesics. acetaminophen Tablets 10-20mg/kg (max 1000mg), 3000mg/(3 Suppositories repeat 2-4hr. doses) Triptans Triptans sumatriptan rizatriptan zolmitriptan almotriptan Recommendations for non-vomiting, headaches, refractory to 2.5-5mg 10 mg Theresa Mallick Searle, MS, RN BC, ANP BC mg 25 mg FDA approvals = almotriptan/rizatriptan/zolmitriptan nasal sumatriptan/naproxen 10/60 mg 85/100 mg & (sumatriptan/naproxen) sumatriptan nasal zolmitriptan nasal 5 mg, repeat in 4-6hr. 5 mg, repeat in 4-6 hr. 20 mg 10 mg Triptans Sumatriptan SC 3-6 mg 12 mg 6 y/o+ Recommendations if headache w/nausea & vomiting. At least 5 yrs. of age for sumatriptan; 12 y/o for zolmitriptan. promethazine Suppositories mg/kg every 4-6hr. 25 mg As an adjuvant for nausea/vomiting

23 Summary Stratify treatment. Aware of refractory symptoms, looking forpatient co morbidities, non compliance, alternate diagnosis. Treat early in an attack. Treatment Strategies in Adult & Pediatric plan: Patients Be sure the patient leaves your office with a treatment Theresa Mallick Searle, MS, RN BC, Primary ANP BC acute tx. Stanford Health Care, Division Pain Secondary Medicine acute tx. Rescue tx. Use highest dose medication tolerated first, for best efficacy. Use non oral routes for nausea/vomiting.

24 References Ahonon K, et al. A randomized trial ofrizatriptan in migraine attacks in children. Neurology, 2006;67: Bajwa ZH & Smith JH. Acute treatment of migraine in adults. UpToDate. Available at treatment of migraine in adults. Accessed May 1, Dodick DW, Sandrini G, Williams P. Use of the sustained pain free plus no adverse events end point in clinical trials of triptans in acute migraine. CNS Drugs, 2007;21(1): Gelfand AA & Goadsby PJ. Treatment of pediatric migraine in the emergency room. Pediatric Neurology, 2012;47: Ho TW, et al. Efficacy and tolerability of rizatriptan in pediatric migraineurs: Results from a randomized, doubleblinded, placebo controlled trial using a novel enrichment design. Cephalgia, 2012;32: Linder SL, et al. Efficacy and tolerability of almotriptan in adolescents. A randomized, double blinded, placebo controlled trial. Headache, 2008;48: Lipton RB, Dodick DW, Silberstein SD, et al. Single pulse transcranial magnetic stimulation for acute treatment of migraine with aura: a randomized, double blinded, parallel group, sham controlled trial. Lancet Neurol, 2010;9(4): Lipton RB, Kolodner K, Bigal ME, et al. Validity and reliability of the migrainetreatment optimization questionnaire. Cephalalgia, 2009;29:

25 References Marmura MJ. Use of Dopamine Antagonists in Treatment of Migraine. Current Treatment Options in Neurology. 2012;14(1): Silberstein SD. Practice parameter: evidenced based guidelines for migraine headache (an evidenced based overview): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 2000;55(6):

26 Question #1 You re seeing a 15 year old girl who has migraine attacks twice a month. The pain during her attacks is severe and associated with photophobia and phonophobia, but not nausea or vomiting. Acute Treatment Strategies in Adult & Pediatric Patients Naproxen (Aleve) helps a bit but she is still not able to get out of bed during an attack. Would you: A) Refer her to Neurology for treatment recommendations Theresa Mallick Searle, MS, RN BC, ANP BC B) Curbside Neurology regarding which triptan would be appropriate in her age group and what dose C) Prescribe a triptan D) Prescribe another class of medication

27 Acute When to consider a triptan Child has moderate or severe pain with attacks. NSAIDs or acetaminophen inadequately treat the pain. When not to consider a triptan History of stroke or myocardial infarction Uncontrolled hypertension Hemiplegic or basilar type migraine Pregnancy (relative contra indication) In someone with triptan overuse Mdi Medication i overuse headache; h a risk ikwhen using triptans 10 triptan days/month for 3 months

28 Question #2 You would like to try a triptan to treat the 15 year old patient from Question #1. Which one would you choose? A) Sumatriptan PO B) Sumatriptan NS C) Frovatriptan PO D) Zolmitriptan NS E) Rizatriptan MLTts

29 Sumatriptan: In clinical use in the U.S. since early 1990s Pediatric studies: PO: one negative trial, but SC: Open labelusesuggests suggests efficacy NS: 3 positive double blind, placebo controlled trials. Labeled for use in year olds in the UK, now generic so unlikely to ever get labeled U.S.

30 Ages studied Dose Used Pain Relief 6-9 years1y 20 mg 2 hrs years mg 2 hrs. Acute Treatment Strategies in Adult & Pediatric Patients 8-17 years mg 2 hrs Practice Parameter from American Academy of Neurology and Child Neurology Society: Theresa Mallick Searle, MS, RN BC, ANP BC Sumatriptan nasal spray Stanford is effective Health and Care, should Division be Pain considered Medicine for the acute treatment of migraine in adolescents 4 1Ueberall Neurology Ueberall, Neurology, Winner, Pediatrics, Ahonen, Neurology, Lewis, Neurology, 2004

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