Headache in children and adolescents Çiçek Wöber-Bingöl HEADACHE UNIT FOR CHILDREN AND ADOLESCENCE Dept. of Psychiatry of Childhood and Adolescence Medical University of Vienna, Vienna, Austria
Impact of Migraine Impact of migraine Unpredictable attacks Headache, associated symptoms Impaired social activities Family Peer group, friends Leisure time Impaired performance at school Absenteeism Reduced learning capacity Diagnostic aspects I History and clinical examination No routine radiological or laboratory examinations, but clear-cut indications CCT for initial evaluation of acute, possibly sinister headaches otherwise MRI plain X-rays: rarely required EEG: not indicated in migraine; only useful, if epilepsy is suspected
Diagnostic aspects II Consider fears and worries Parents Patient Successful migraine therapy Reduces headache duration headache frequency headache intensity Relieves associated symptoms nausea, vomiting photo- and phonophobia aura other symptoms
Successful migraine therapy Improves the quality of life Treatment of migraine Acute therapy Non-pharmacological Pharmacological Prophylaxis Non-pharmacological Pharmacological
When do we need non- pharmacological treatment? Always When do we need pharmacological treatment? Sometimes
Therapeutic decision I The patient's symptoms direct the decision to admininister pharmacological treatment the choice of the drug. Administering a drug without considering the patient's symptoms may cause treatment failure and other problems. Therapeutic decision II Prescribing no drug may be better than prescribing the wrong drug. There is no drug without potential risks. Even homeopathy may harm: The child learns to grab for a drug instead of acquiring appropriate coping strategies. There is no evidence that homeopathic treatment is effective in migraine and tension-type headache.
Migraine Non-pharmacological acute therapy Rest in darkened, quiet room Sleep Additional pharmacotherapy in patients with attacks lasting > 2 hours Pharmacological acute therapy - General aspects I Relevant pre-requisitesrequisites Diagnosis Headache duration Headache intensity Headache frequency Associated symptoms
Pharmacological acute therapy - General aspects II Medication as soon as possible after the onset of a migraine attack Appropriate dosage Information of the parents careful use of medication maximum dosis per day and per month time until relief of headache possible side effects Pharmacological acute therapy - General aspects III No ergots and no triptans for tensiontype headache. No treatment against the will of the patient or of the parents.
Pharmacological acute therapy of migraine Paracetamol/acetaminophen Ibuprofen Acetylsalicylic acid Triptans Ergots Problem: Only few controlled studies Paracetamol/Acetaminophen Clinical experience: extensive Controlled studies: yes (1+/0-) Drug of first choice Single dose: 15 mg/kg Max. daily dose: 100 mg/kg Side effects: very rare, overdosage may cause hepatic failure Contraindication: liver disease
Ibuprofen Clinical experience: large Controlled studies: yes (1+/0-) Drug of first choice Single dose: 10 mg/kg Max. daily dose: 40 mg/kg Side effects: gastric pain, bronchospasm, hemorrhage Contrindications: asthma, GI-ulcer Acetylsalicylic acid Clinical experience: large Controlled studies: no Drug of second choice Single dose: 10-15 mg/kg Max. daily dose: 30-45 mg/kg Side effects: like Ibuprofen, Reye syndrome! Contraindications: fever and viral infection in children < 12 ys., GI-ulcer, asthma
Nasal spray Sumatriptan Clinical experience: increasingly large Controlled studies in adolescence: yes (2+/0-) limited data in children First choice for adolescence with refractory migraine attacks Tablets, suppositories, i injections Clinical experience: some (off lable use) Controlled studies: negative or no published data Might be tried (off lable!) Further triptans I Rizatriptan Clinical experience: some (off lable) Controlled studies: yes (1+) Limited recommendation for adolescents Might be tried (off lable!)
Further triptans II Naratriptan, Zolmitriptan, Eletriptan, Almotriptan, Frovatriptan Clinical experience: some (off lable use) Dihydroergotamine Ergots Clinical experience: large (?) Controlled studies: yes (1+/0-) Second choice for children and adolescents with refractory migraine attacks Ergotamine tartrate Clinical experience: limited (?) Controlled studies: no Not recommended
Nonpharmacological prophylaxis I Reassurance and education Modification of lifestyle sufficient sleep morning free of stress regular drinks and meals sufficient breaks while studying sufficient physical exercise Nonpharmacological prophylaxis II Identification of trigger factors stress in the family stress at school learning difficulties menarche, menstruation environmental factors noise, bright lights,... physical exhaustion
Nonpharmacological prophylaxis III Identification of trigger factors dietary triggers often overestimated! NO RESTRICTIVE DIETS! exception: proven food intolerance Evalutation of psychiatric comorbitity Evaluation of psychosocial factors Nonpharmacological prophylaxis IV Relaxation training Biofeedback Behavioural therapy Other types of psychotherapy Possibly acupuncture
Pharmacological prophylaxis: General aspects Indicated in patients responding inadequately to nonpharmacological prophylaxis >1 long-lasting attack per week Consider synergistic effects and contraindications e.g. low weight, lack of appetite: use flunarizine e.g. overweight: use topiramate: Education of parents and patients Pharmacological prophylaxis: Flunarizine Controlled studies: yes (3+) Treatment of first choice Starting dose: 0.1 mg/kg/day Maintenance dose: 0.1-0.3 mg/kg/day Side effects: fatigue, weight gain, depression, extrapyramidal symptoms Contraindications: Depression, obesity, extrapyramidal disorders
Pharmacological prophylaxis: Propranolol Controlled studies: yes (2+/2-) Treatment of first/second choice Starting dose: 0.5 mg/kg/day Maintenance dose: 1-2 mg/kg/day Side effects: fatigue, hypotension, sleep disturbance Contraindications: asthma, bradycardia, AV-block, diabetes mellitus, psoriasis Pharmacological prophylaxis: Topiramate Controlled studies: yes (1+/0-) Treatment of second choice Starting dose: 25 mg/day Maintenance dose: 50-100 mg/day Side effects: paresthesia, fatigue, weight loss, difficulties to concentrate, behavioural changes
Pharmacological prophylaxis: Further compounds Alternative drugs (efficacy in children and adolescents not proven) valproic acid magnesium riboflavin Not recommended dihydroergotamine (low dose) acetylsalicylic acid, NSAIDS other ß-blockers Outline Genetics Neurophysiology Psychological and behavioral aspects Epidemiology Diagnosis Classification Prognosis Treatment
Prognosis of migraine and TTH Persisting M or TTH 41 49 % Remission 25 38 % Evolution from M to TTH or vice versa 20 26 % Kienbacher et al., Cephalalgia 2006 Monastero et al., Neurology 2006 Prognosis of migraine and TTH Number of patients sl 70 60 50 40 30 20 10 0 1.1 1.2 1.6 2.2 2.3 2.4 5-14 HA-free 1.1 1.2 1.6 2.2 2.3 2.4 Kienbacher et al., Cephalalgia 2006