Adolescent Migraine Treatment O F A

Transcription

1 Adolescent Migraine Treatment M A R C Y Y O N K E R, M D F A H S D I R E C T O R, P E D I A T R I C H E A D A C H E P R O G R A M A S S O C I A T E P R O F E S S O R, C H I L D H E A L T H, U O F A

2 Goals Review epidemiology of adolescent migraine Review evidence based treatment Discuss approach to adolescents vs adults

3 Migraine Epidemiology AMPP-2007 Total 1 year prevalence ages % Female 7.7% Male 5.0%

4 Migraine Epidemiology Wober-Bingol 2013-reviewed all epidemiologic studies on migraine published in prior 25 years in children and adolescents Migraine prevalence 9.1% Lipton et al CM without MO-0.79% CM with or without MO-1.75%

5 Migraine Epidemiology Closer to home- 30% of teens I see have CM

6 Case 1 The patient is a nearly 14 yo recently seen for headache. She has a many year history of migraine and has been treated in Mexico with flunarizine and amitriptyline prophylaxis but is currently having only 3 migraines/month. Headache Sx: holocranial throbbing, photo/phono/nausea, 7/10, lasting 6 hrs.

7 Case 1 Imaging? Acute RX? Preventative RX? Healthy Habits! Headache Diary!

8 Acute Treatment Principles: Trigger avoidance-sleep, stress, H20, healthy habits but don t be judgy Give them permission to treat early Warn about medication overuse but don t blame the patient if they are reacting to their pain, or fear of pain. Warn them about potential side effects of triptans. Address nausea and vomiting- ondansetron, nasal formulations, injectables

9 Acute Treatment What s the evidence? Riza- 6 and up Suma, Zolmi, Almo-12 and up What do I do? Insurance formulary? Can you swallow pills? Is it full blown when you wake up? What works for your mother?

10 Case 1 Imaging-nope Acute RX= ondansetron + rizatriptan 10 Prophylaxis=nope Followup 2 months with headache calendar Psychology consult for anxiety

11 Cases 2 and 3-2 consecutive patients Monday am Oct 31st 13 y 10 mo girl 1 year history 27 days/month Duration 1 day Bitemp squeezing 8/10 Photo/phono FHx-migraine mother, MGM PMHx:obesity,insulin resistance ROS:snoring, daytime fatigue with at least 9 hrs sleep/night MOH: ibuprofen 3 days/wk PedMidas:21 13 y 11 month old girl 3 year history Daily Duration 1-2 days Holocranial throbbing N/V/photo/phono FHx-migraine-mother PMHx: none ROS: neg MOH-excedrin/ibuprofen 4 days/wk PedMidas:124

12 Prophylactic Treatment Who? What? How long?

13 Prophylactic Treatment Who? greater than 4/month Mod-High disability-pedmidas Unresponsive to acute medication

14 What? Before Oct. 28, 2016 Assess comorbidities Amitriptyline vs topiramate After Oct. 28, 2016????

15 CHAMP! Multicenter NINDS sponsored trial Amitriptyline vs topiramate vs placebo :2:1 randomization real world study - episodic and chronic, could titrate medication Primary outcome >50% reduction in headache days comparing first 28 days in baseline to last 28 days Stopped early for futility-52% ami, 55% topiramate 61% placebo achieved primary outcome Higher AEs in medication groups

16 Monday, 10/31 Healthy habits Addressed MOH and Rxed triptan, naproxen Recommended PSG Riboflavin Followup in 2 months Healthy habits-doing everything right Explained results of CHAMP Discussed CBT optionlive in Prescott Addressed MOH-rxed triptan, naproxen Problems with sleep- Rxed amitriptyline

17 Some Deep Thoughts Despite prevailing opinion, adolescents are people too. Their personalities/habits/issues are not the cause of their headache problem but may contribute to the overall picture. Even most obese teenage girls with insulin resistance, anxiety/depression and 24/7 headache get better pretty easily. But if you don t believe it, they won t either.

18 Some Deep Thoughts from Teens it s so nice to know that you don t think I m crazy and that you are doing the best you can to help me

19 Tips for dealing with teens Talk to the patient first Acknowledge parental concerns but try to encourage the patient tell you the story Commend the patient for toughing it out and empathize with what they are going through. Explain the options and involve the teen in the decision making. Give them permission to complain Set the goal for treatment- less than 4 migraines/month with as needed medicine that works within an hour See them back in 2 months if you are prescribing prophylaxis

20 My Schtick The idea of coming to see me is to make your life better, not worse, so if something I am doing is making your life worse, complain about it. This is the complaining zone. I know you are used to toughing it out, but I can t fix it if I don t know it s a problem. I won t be offended if you say, Dr. Yonker, I hate your stupid medicine!

21 Summary Migraines are a frequent disabling problem for teens. There is evidence based acute treatment. More work needs to be done in establishing effective accessible evidence based care for prophylaxis. Engage teens to work with you to help to solve their headache problems.