I have no financial relationships to disclose. I will not discuss investigational use of medication in my presentation.
In 1962, Bille published landmark epidemiologic survey of headache among 9,000 school children. More then 1/3 of 7 year olds and 50% of of 15 year olds reported having at least one headache. Studies from 1977-1991 of 27,606 children found the prevalence of any type of headache to range from 37-51% in 7 year olds and 57-82% by age 15. Prepubertal boys were more likely to have headaches than girls. After puberty, headaches more common in females. Practice Parameter: Evaluation of children and adolescents with recurrent headaches.
- About 70% of migraine patients have first degree relative with history of migraine. -Risk of migraine increased 4 fold in relatives of people who have migraine with aura -Nonsyndromic migraine headache with or without aura has multifactorial inheritance pattern -Other syndromes with migraine as a feature have autosomal dominant inheritance http://www.americanheadachesociety.org/assets/1/7/nap_for_web_-_pathophysiology_of_migraine.pdf http://emedicine.medscape.com/article/1142556-overview#a4
Pathophysiology (in brief): - Incompletely understood - Neurovascular theory - Cortical spreading depression National Headache Foundation http://www.headaches.org/2007/10/25/migraine/
- Inadequate documentation in literature to support any recommendation as to appropriateness of routine lab studies or performance of lumbar puncture - EEG is not recommended - Neuroimaging study on routine basis is not indicated in children with recurrent headaches and normal exam.
Neuroimaging should be considered in children with abnormal exam or other physical findings suggestive of CNS disease. Variables that predict presence of space occupying lesion: - Headache < 1 month duration - Absence of FH migraine - Abnormal exam - Gait abnormalities - Occurrence of seizures.
14 year old otherwise healthy female presents with recurrent headaches. Describes pain as typically R side throbbing, but can also start on the L side. Reports that light bothers her with these headaches and will typically need to stop what she is doing and be in a dark room. She'll usually take a nap or go to sleep for the night and be pain free at time of waking. No visual changes noted. Mother with strong FH of similar headaches since adolescence. Exam is normal.
Diagnosis? 1. Tension type headache 2. Migraine without aura 3. Migraine with aura 4. Cluster headaches
Migraine without aura- IHS classification Diagnostic criteria: A. At least 5 attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) C. Headache has at least 2 of the following characteristics: - Unilateral location - Pulsating quality - Moderate or severe pain intensity - Aggravation by or causing avoidance of routine physical activity
D. During headache at least one of the following: - Nausea and/or vomiting - Photophobia or phonophobia E. Not attributed to another disorder * Children can typically have attacks lasting 1-72 hours and migraine is often bilateral in younger children. ihs-classification.org
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Headache hygiene: - Sleep - Exercise - Stress management - Fluid intake - Protein intake - Food triggers
Acute migraine treatment NSAIDs and Acetaminophen: - Two double blind placebo controlled class I studies have shown that Ibuprofen 7.5-10mg/kg is safe and effective. - One study compared Ibuprofen 10mg/kg v. Acetaminophen 15mg/kg v. placebo. At 1 and 2 hour points, Ibuprofen and Acetaminophen were significantly more effective than placebo. Difference in effectiveness, in terms of alleviation of headache, between Acetaminophen and Ibuprofen at the 2 hour point was not statistically significant.
- Complete resolution of headache was seen in 60% of those treated with Ibuprofen, 39% of those treated with Acetaminophen, and 28% of those treated with placebo. - Second class I study of Ibuprofen 7.5mg/kg showed significant reduction in headache frequency in 76% of children on drug and 53% on placebo at 2 hour endpoint.
Sumatriptan nasal spray: - Three controlled class I trials have demonstrated efficacy and safety of sumatriptan nasal spray is adolescents with migraine. - Bad taste is most common side effects Oral Sumatriptan: - One class I clinical trial failed to clearly demonstrate efficacy greater than matched placebo at the primary endpoint of pain relief at 2 hours
Other triptans: Rizatriptan: - Limited data - Single class I report found no difference compared with placebo in pain relief at 2 hour primary endpoint - Did demonstrate good tolerability and safety with adverse events (asthenia, dizziness, dry mouth) being comparable to placebo Zolmitriptan: - Class IV open-label multi-center trial of oral Zolmitriptan showed it was well tolerated. Overall improvement at 2 hours was seen in 88% of adolescents (12-17 year olds) on the 2.5mg dose and 70% on the 5mg dose. Freedom from pain seen in 66% of those children.
Goals of preventative migraine treatment: - Reduce attack frequency, severity, and duration - Improve function, reduce disability, and improve quality of life - Improve responsiveness to treatment of acute attacks
Good evidence: - Flunarizine is probably effective (not available in the US) - Pizotifen, Nimodipine, and Clonidine are not effective Insufficient evidence: - Insufficient evidence to make any recommendations concerning the use of cyproheptadine, amitriptyline, divalproex sodium, topiramate, or levetiracetam. - Recommendations cannot be made concerning propranolol or trazodone for preventative therapy, as evidence is conflicting. Lewis D, et al. Practice Parameter: Pharmacological treatment of migraine headache in children and adolescents. Neurology 2004;63:2215-2224
Nutraceuticals: - Not much data in pediatric population Magnesium: - Low quality evidence in support of its use - Unclear if magnesium deficient patients would benefit more than patients with normal magnesium levels - Several formulations - Can cause diarrhea - Magnesium oxide 9mg/kg/day
Riboflavin: - Vital component of mitochondrial energy production - Relatively benign side effect profile - AAN guidelines list as probably effective for episodic migraine prevention in adults - Current literature doesn t support use in pediatrics, but further research necessary - 200-400mg/day
CoenzymeQ10: - Helps sustain mitochondrial energy stores - Electron carrier in the mitochondrial electron transport chain - Low quality evidence for use - Side effects are mostly GI related - 1-3 mg/kg/day (maximum 100 mg/day)
Butterbur - Herbal supplement from butterbur shrub with potential effects on smooth muscle, anti-inflammatory pathways, and L-type voltage gated calcium channels. - Contains pyrrulizidine alkaloids, which are hepatotoxic, carcinogenic, and veno-occulusive. - Some formulations are labeled pyrrulizidine alkaloid-free, but the US FDA does not regulate and require extensive testing on herbal products - AAN included butterbur in their updated guideline as effective for treatment of episodic migraine - Low quality evidence to support use in pediatrics Orr S, et al. Nutraceuticals in the prophylaxis of pediatric migraine: Evidence-based review and recommendations. Cephalgia 2014. Vol 34, p 568-583. Complementary and Integrative Approaches for Pediatric Headache. Seminars in Pediatric Neurology. Feb 2016; Vol 23, p 44-52. Holland S, et al. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults. Neurology 2012. 78: 1346-1353.
12 year old male presents to your office with a history of 6 months of recurrent headaches. Reports headache occurs about 4 days/month. Has one headache type, which he describes as a squeezing/tightening sensation around his head. He doesn't miss school or soccer practice due to headaches. Does not report any nausea or vomiting with headache. Will infrequently use medication and is able to stay in his classroom during the headache that has fluorescent lighting and attend choir practice. No strong FH of headaches. Exam is normal.
Diagnosis? 1. Migraine with aura 2. Chronic daily tension-type headache 3. Frequent episodic tension-type headache 4. Idiopathic intracranial hypertension
Frequent Episodic Tension-type Headache Diagnostic criteria: A. At least 10 episodes occurring on 1 but <15 days per month for at least 3 months ( 12 and <180 days per year) and fulfilling criteria B-D. B. Headache lasting from 30 minutes to 7 days C. Headache has at least two of the following characteristics: 1. bilateral location 2. pressing/tightening (non-pulsating) quality 3. mild or moderate intensity 4. not aggravated by routine physical activity such as walking or climbing stairs
D. Both of the following: 1. no nausea or vomiting (anorexia may occur) 2. no more than one of photophobia or phonophobia E. Not attributed to another disorder ihs-classification.org
- Unlike migraine headache, hereditary factors play minor role
Treatment of tension type headaches: - Stress management - Relaxation techniques (breathing exercises, mental imagery) - Biofeedback (sensors are connected to the body and monitor changes in muscle tension, blood pressure, and heart rate and display feedback on computer screen). Therapist can help learn signs of tension and then use relaxation technique to release and control tension.
- For acute headaches, can use Tylenol, Advil, or Aleve - Be cognizant of usage as rebound headaches can become an issue - Evidence supporting prophylactic medications is limited and children with high placebo responder rate. - Low dose Amitriptyline may be helpful. Use mainly supported by adult studies. - Gabapentin and Topiramate are also used, but no controlled studies to support efficacy. - Cruse R, et al. Tension type headaches in children. Up to Date.
15 yo female with report of two headache types. Reports she has had weekly intense headaches with light and sound sensitivity for about 1 year, as well as a daily headache that she describes as more of a pressure-type pain that she notes in the morning. Has been using Tylenol, Ibuprofen, and Sumatriptan multiple times/week for the past four months. Does not feel that medications alleviate second headache type.
Diagnosis: 1. Migraines and medication overuse headache 2. Migraines and tension type headache 3. Tension type headache and hemicrania continua 4. Cluster headaches
Medication overuse headaches Diagnostic criteria: A. Headache occurring on 15 or more days per month in a patient with a pre-existing headache disorder B. Regular overuse for more than three months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache:
- Regular intake, for 10 days per month for >3 months, of ergotamines, triptans, opioids, or combination analgesics, or any combination of ergotamines, triptans, simple analgesics, nonsteroidal anti-inflammatory drugs (NSAID) and/or opioids without overuse of any single drug or drug class alone or when the pattern of overuse cannot be reliably established -Regular intake, for 15 days per month for >3 months, of simple analgesics (ie, acetaminophen, aspirin, or NSAID) C. Not better accounted for by another ICHD-3 diagnosis Garza I, et al. Medication Overuse Headache: Etiology, clinical features, and diagnosis. UpToDate.
Different thresholds of use depending on medication: Highest risk with butalbital containing analgesics or combination analgesics Intermediate to high risk with triptans Lowest risk with NSAID use
Treatment is to wean overused medication Anticipatory guidance- headaches typically get worse before they start to improve Can try steroids (no great data to support) to help while they are weaning off medications or consider starting preventative medication Future recommendation of limiting use of abortive medication to 2 times/week Sims K, et al. Handbook of Pediatric Neurology.
Questions? Thank you!