Tools & Tips for Headache Management in Special populations: The Young & Old, Pregnant & Lactating, and those with Heart or Kidney Disease

Transcription

1 Tools & Tips for Headache Management in Special populations: The Young & Old, Pregnant & Lactating, and those with Heart or Kidney Disease Lauren Doyle Strauss, DO Wake Forest Baptist Medical Center Assistant Professor, Child Neurology Assistant Residency Director, Child

2 No disclosures Disclosures

3 Objectives Recognize diagnostic considerations and treatments for patients with headaches of special populations. Define diagnosis of various pediatric periodic syndromes. Familiar with different treatment strategies in special populations. Aware of potential medication safety concerns in pregnancy and lactation. Familiar with types of headache in patients with renal disease receiving dialysis.

4 Case 1: 8 yo girl with high frequency episodic migraine without aura. Which medication is FDA approved in her age group? A. Aspirin B. Rizatriptan C. Almotriptan D. Topiramate E. Amitriptyline

5 Migraine Definition 2-72 hours duration-ichd-iii β (ICHD-II, 1-72 hrs) Bilateral, fronto-temporal CAUTION if occipital Younger Patients (<18yo) Photo/phono (can be inferred from behavior)

6 Migraine Definition 2-72 hours duration-ichd-iii β (ICHD-II, 1-72 hrs) Bilateral, fronto-temporal CAUTION if occipital Younger Patients (<18yo) Photo/phono (can be inferred from behavior) Preventive Treatment Topiramate, FDA approved 12-17yo CHAMP study ongoing: topiramate vs. amitriptyline vs. placebo (through 2016) Also often used: cyproheptadine, propranolol, gabapentin, verapamil, flunarazine (not in US) KEY: Healthy habits (hydration, sleep, caffeine, stressors, exercise, no skipped meals) CBT, physical therapy Don t neglect dental care/optho

7 Migraine Definition 2-72 hours duration-ichd-iii β (ICHD-II, 1-72 hrs) Bilateral, fronto-temporal CAUTION if occipital Younger Patients (<18yo) Photo/phono (can be inferred from behavior) Preventive Treatment Topiramate, FDA approved 12-17yo CHAMP study ongoing: topiramate vs. amitriptyline vs. placebo (through 2016) Also often used: cyproheptadine, propranolol, gabapentin, verapamil, flunarazine (not in US) KEY: Healthy habits (hydration, sleep, caffeine, stressors, exercise, no skipped meals) CBT, physical therapy Don t neglect dental care/optho Acute Treatment FDA approved triptans: Rizatriptan, 6-17yo (<40 kg, 5mg), MLT/PO Almotriptan, 12-17yo (6.25 or 12.5mg) Treximet (sumatriptan 10mg/ naproxen 60mg),12yo+ AAN practice parameters (2004): Sumatriptan NS & PO (12yo+) Ibuprofen and acetaminophen AVOID aspirin- risk of Reye syndrome Other medication options to consider: Non-pill Naproxen Diclofenac Potassium (FDA approved >18yo) NS/chewable Zolmitriptan Antiemetics (but higher rate dystonic rxns)

8 Case 2: 15 yo boy with no prior history presents with new episodes of vomiting, worsening frequency over the last year. Which of the following characteristics are typical of cyclical vomiting? A. Age of onset: 15 years B. Periodicity: 1x/month 1x/week over the year C. Timing: early morning D. Associated severe HA preceding, during or following E. Frequency: 1-2 episodes of emesis/episode

9 Childhood Periodic Syndromes All: 5 attacks, with recurrence in semi-predictable pattern Normal between attacks, normal neuro exam, often family hx migraine Benign Paroxysmal Vertigo of Childhood (onset 2-5yo) VERTIGO, min-hrs, no warning, resolve spontaneously III-β: no LOC, at least 1: nystagmus, ataxia, vomiting, pallor, fearfulness Unilateral HA may occur Normal audiometric, vestibular testing, EEG Cyclical Vomiting (onset 5yo) 1 st described by Dr. Samuel Gee in 1882 Nausea/VOMITING, 1hr-5 days, 4 times/hr for at least an hr, symptom-free between attacks III-β: up to 10 days; 1 week apart between attacks Normal GI exam, no GI disease Abdominal Migraine (onset school age) Abdominal PAIN lasting 1-72 hrs midline location/peri-umbilical or poorly localized/dull or just sore quality/ moderate or severe intensity At least 2 during: anorexia, nausea, vomiting, pallor III-β: 2-72 hrs, complete freedom from symptoms between attacks Normal GI exam, no GI disease Abu-Arafeh I, et. al, JPGN, 1995 Ertekin V et al. J Clin Gastroenterol, 2006 Li et al. Gastroenterol Clin North Am, 2003

10 Case 2: 15 yo boy with no prior history presents with new episodes of vomiting, worsening frequency over the last year. Which of the following characteristics are typical of cyclical vomiting? A. Age of onset: 15 years B. Periodicity: 1x/month 1x/week over the year C. Timing: early morning D. Associated severe HA preceding, during or following E. Frequency: 1-2 episodes of emesis/episode

11 Case 2: 15 yo boy with no prev. PMHx w/ new onset episodes of vomiting worsening frequency over the last year. Which of the following characteristics are typical of cyclic vomiting? A. Age of onset: 15 years Usually preschool aged, although possible to present later B. Periodicity: 1x/month 1x/week over the year Usually stereotyped w/ predictable periodicity, this appears to be a worsening pattern C. Timing: early morning More common at night or early morning D. Associated severe HA preceding, during or following Usually headache is NOT the prominent feature E. Frequency: 1-2 episodes of emesis/episode More frequent over a shorter amount of time, 4 times/hr for min of 1 hr

12 Cyclical Vomiting Early Morning Onset Most Common Timing: 2-4 AM 6-8 AM 76% had either or both times Length and Variability of Episodes Length: Most commonly hrs Variability: 85% are uniform length Recovery Period: from the end of vomiting to being able to eat, turning off a switch Fleisher et al. JPGN, 1993 Li BUK, et al. Adv Pediatr, 2000

13 Additional Episodic Syndromes III-β: Recurrent GI disturbance 5 attacks of abdominal pain &/or discomfort &/or nausea &/or vomiting Normal GI Exam, no GI disease III-β: Benign paroxysmal torticollis (ICHD-II, appendix) Recurrent attacks (typically monthly) in a young child (begins in infancy) with tilt of the head (either side/can switch sides) w/w/o slight rotation, min-days, remit spontaneously At least 1: pallor, irritability, malaise, vomiting, ataxia (ataxia more in older) During attack, head can be returned to neutral position (with possibly some resistance)

14 Case 3: 85 yo man presenting with new onset recurrent HA that wakes him up from sleep. All of the following are very important tests to consider as first steps to diagnostic work up EXCEPT: A. MRI brain with contrast B. ESR, CRP C. Eye exam D. Head CT E. MRI full spine

15 Giant cell arteritis Hypnic headache Symptoms: jaw claudication, polymyalgia rheumatica Start prednisone 60-80mg/day prior to work up. Diagnostic Workup: Biopsy of temporal artery, Elevated ESR, CRP Dull HA occurs only during sleep, awakens patient 2 features: >15/mo; lasts 15 min; 1 st occurs >50yo No autonomic features, no more than 1: N/photo/phonophobia Treatment: Caffeine, lithium, melatonin, indomethacin Special considerations Trigeminal neuralgia, post-herpetic neuralgia Tumor, metastasis Medication side effects Subdural hematoma (fall) Obstructive sleep apnea Cervicogenic headache Teeth, eyes Treatment considerations: Discuss possible side effects lower dosing/uptitration Reducing polypharmacy Avoid Triptans (coronary artery disease)

16 Case 4: One of your complicated female migraine patients, who has finally reached good headache control, is contemplating pregnancy. Which of the following should you advise: A. Immediately stop amitriptyline B. Start using fioricet as her only abortive C. Start topiramate as a prophylaxis D. Stop using sumatriptan E. Take a class on relaxation techniques

17 Pregnant Women Diagnosis: is this migraine? Migraine improves in 50% in 1 st trimester, >75% by 3 rd trimester Consider preeclampsia, idiopathic intracranial hypertension, subarachnoid hemorrhage, tumor, pituitary apoplexy, cerebral venous thrombosis, eclampsia, RCVS Think about MRI over CT, avoid contrast

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19 Pregnant Women: Treatment Options Non-Pharmalogical: Healthy lifestyle habits Behavioral treatment options (relaxation training, CBT, biofeedback, stress management training) Procedural-based treatments: acupuncture, PT, occipital nerve blocks Dietary Supplements: Riboflavin (B2) - no studies in pregnancy Coenzyme Q10 - no studies in pregnancy, may help prevent preeclampsia Feverfew avoid given concerns for uterine contractions Pyridoxine (B6)- present in Diclegis (pyridoxine plus doxylamine succinate) which is Category A Pharmacological: IV hydration Acute Treatments: acetaminophen PO, anti-emetics (metoclopramide-b, prochlorperazine-c) Prophylaxis: cyproheptadine (B), propranolol (C), amitriptyline (C), verapamil (C) Steroids: methylprednisolone dosepak (C) over prednisone (D)

20 Treatment Options with New Potential Risks Magnesium Concern of low calcium and bone abnormalities in the fetus (18 case reports in AERS) New FDA warning against continuous admin of Mag sulfate > 5-7 d Reclassification of magnesium sulfate infections as category D (previously A) Ondansetron Does not have FDA indication for N/V in pregnancy FDA released warning on potential to cause serotonin syndrome and dysrhythmias Concern for risk of cleft palate (large case-control study)

21 Treatment Options with New Potential Risks Acetaminophen >65% of US women report use during pregnancy Concerns for increased risk in ADHD and wheezing based on large prospective studies Butalbital Concern for risk of congenital heart defects (TOF, pulm. valve stenosis, ASD) Risk reported around time of conception

22 Safety of Medications During Pregnancy Medication Class Potential Teratogenic Risk Cyproheptadine B Limited studies, hypospadias in mat. overdose Ondansetron B Congenital heart defects, cleft lip/palate Pindolol B Congenital heart defects Butalbital C Congenital heart defects Ibuprofen C, C, D 1 st : miscarriage; 3 rd : premature PDA closure Triptans C Registries with differing data Propranolol C Congenital heart defects, cleft lip/palate Atenolol D Congenital heart defects, cleft lip/palate Lisinopril D Fetal Death/oligohydramnios, fetal renal function, fetal lung hypoplasia, skeletal malformation Topiramate D Cleft lip/palate, structural, wt Magnesium D Long term use: low Ca and bone change Ergots X Fetal abnormalities Depakote X Neural tube defects, cognition

23 Safety of Medications During Pregnancy Medication Class Cyproheptadine B Limited studies, hypospadias in mat. overdose Ondansetron B Congenital heart defects, cleft lip/palate Pindolol B Congenital heart defects Butalbital C Congenital heart defects Ibuprofen C, C, D 1 st : miscarriage; 3 rd : premature PDA closure Triptans C Registries with differing data Propranolol C Congenital heart defects, cleft lip/palate Atenolol D Congenital heart defects, cleft lip/palate Lisinopril D Fetal Death/oligohydramnios, fetal renal function, fetal lung hypoplasia, skeletal malformation Topiramate D Cleft lip/palate, structural, wt Magnesium D Long term use: low Ca and bone change Ergots X Fetal abnormalities Potential Teratogenic Risk Depakote X Neural tube defects, cognition

24 Safety of Medications During Pregnancy Medication Class Potential Teratogenic Risk Cyproheptadine B Limited studies, hypospadias in mat. overdose Ondansetron B Congenital heart defects, cleft lip/palate Pindolol B Congenital heart defects Butalbital C Congenital heart defects Ibuprofen C, C, D 1 st : miscarriage; 3 rd : premature PDA closure Triptans C Registries with differing data Propranolol C Congenital heart defects, cleft lip/palate Atenolol D Congenital heart defects, cleft lip/palate Lisinopril D Fetal Death/oligohydramnios, fetal renal function, fetal lung hypoplasia, skeletal malformation Topiramate D Cleft lip/palate, structural, wt Magnesium D Long term use: low Ca and bone change Ergots X Fetal abnormalities Depakote X Neural tube defects, cognition

25 Safety of Medications During Lactation Abortive Acetaminophen (L1) Ibuprofen (L1) Consider Pump and Dump Triptans (L3): Sumatriptan - best studied AAP rated Safe Low oral bioavailability/milk concentrations One study of SC 6mg - no SE Eletriptan - one study, 8 on 80mg - no SE Avoid Zolmitriptan - higher bioavailability and higher CNS penetration, no studies on milk transfer Preventive Amitriptyline, Nortriptyline Propranolol, Nadolol, Timolol Verapamil Gabapentin Magnesium Vitamin B2 Use with caution: Zonisamide Atenolol Tizanidine Resources: Hale Ratings (L1-L5) and LactMed

26 Cardiac disease & HA Angina treatment (nitro) can trigger HA Cardiac Cephalalgia (ICHD-II) HA aggravated by exertion, may be severe and accompanied by nausea Acute MI has occurred HA develops concurrently with acute MI Evidence of both HA & cardiac ischemia during treadmill/nuclear cardiac stress test HA resolves/no recurrence after effective MI treatment/coronary revascularization III-β: 2 of 4: severe, nausea, NO photo/phono, aggravated by exertion HA relieved by nitroglycerine

27 Renal Failure & Headaches Dialysis HA, ICHD-II 3 attacks in patient on dialysis Develops during at least ½ of sessions Resolves within 72 hrs of dialysis/after transplant HA common in dialysis patients, must r/o: Low Mg, hypotension, caffeine withdrawal, PRES Disequilibrium syndrome (rare) HA, cerebral swelling, stupor, sz, coma If have kidney disease & HA, consider Rx: Gabapentin, does note undergo hepatic or renal metabolism (renally excreted)

28 For Younger patients: Final Tips & Pearls Remember typical age and prominent symptom of periodic syndromes Think about FDA approved meds and preparations For Older patients: Don t miss secondary headaches unique to this age group Think carefully about medications For Pregnant/Lactating women: Ask yourself: Is this migraine? Should I be worried? Be aware of fetal effects with medications Start using available references (Lactmed, Hale Ratings, FDA) For Cardiac/Renal patients: Is this due to their disease &/or treatment? Repeat EKG/labs? Read all the answer options for each question

29 Thank you and good luck studying! Any Questions? Lauren Doyle Strauss, DO Wake Forest Baptist Medical Center Assistant Professor, Child Neurology Assistant Residency Director, Child

30 Extra Slides

31 Sheehan Syndrome Reversible Cerebral Vasoconstriction Syndrome (RCVS) Pituitary apoplexy and hypopituitarism Pituitary failure Headache Opthalmoplegia Visual field loss May be associated with preeclampsia, eclampsia Formerly Post-partum angiopathy or Call Fleming Syndrome Recurrent thunderclap headache

32 Pediatric Brain Tumors 2 nd most common malignancy, most common solid tumor H/A is the most common presenting symptom, however, usually with other features (N/V, unsteadiness, focal weakness) Most sensitive indicators: abnml neuro exam or seizures H/As > 6 mos AND nml neuro exam, prevalence is % H/As < 6 mos AND nml neuro exam, prevalence is 4% Hayashi, Brain Dev, 2010