Ishaq Abu Arafeh Consultant Paediatrician Royal Hospital for Children, Glasgow Forth Valley Royal Hospital, Larbert

Ishaq Abu Arafeh Consultant Paediatrician Royal Hospital for Children, Glasgow Forth Valley Royal Hospital, Larbert

Childhood headache: Is it really difficult to manage? It shouldn t be... But it can be... 2

Objectives Discuss the principles of management of chronic headache Describe common headache disorders and their management Discuss headache disorders that are difficult to manage What makes a difficult headache, even more difficult How to make difficult headache disorders manageable 3

General principles for an optimum management of headache Recognition of the size of the problem in the community Making accurate positive diagnosis Application of recognised diagnostic criteria Understand what worries children and parents Assessment of impact of headache on child and family Evidence based recommendations whenever possible

Headache in children.. Systematic review Abu Arafeh et al, DMCN, 2010

Migraine in children. Systematic review Abu Arafeh et al, DMCN, 2010

Prevalence of primary headache in children Episodic TTH Unclassified Mixed headaches Migraine Chronic daily headache TAC's (cluster headache) 7

Causes of primary headache in clinical practice Chronic Daily Headache Migraine mithout aura Unclassified Mixed headaches Migraine with aura Chronic posttraumatic headache TAC's (Cluster headache) Episodic TTH 8

Making an accurate and positive diagnosis of headache 9

Making the correct diagnosis of headache disorders Essentials for diagnosis: History, history, history Duration of headache Frequency of attacks Duration of each attack Location of pain Severity of pain Quality of pain Trigger factors Associated symptoms Relieving factors

Making the correct diagnosis of headache disorders Examination: Weight, Height, blood pressure General examination Neurologic examination including optic discs Classification of Headache Disorders: ICHD 3 beta, 2013 Criteria for the diagnosis of headache disorders

Headache diaries Headache diary Attack number 1 2 3 4 Date Time started Time resolved Severity of headache* Type of headache** Site of maximal pain What started it off? What preceded headache Loss of appetite Nausea or feeling sick Vomiting Does light make it worse? Does noise make it worse? Is it worse on walking? www.bpna.org.uk Other symptoms Does rest make it better?

Assessment of migraine impact PedMIDAS based on the last 3 months Adults MIDAS Children Ped MIDAS 1. Days missed of work due to headache 2. Days of productivity at work by <50% due to headache 3. Days unable to do household work due to headache 4. Days productivity in household work by <50% due to headache 5. Days missed family, social or leisure activities due to headache 1. Days off school due to headache 2. Partial days off school due to headache 3. Days function at <50% of ability at school due to headache 4. Days unable to do normal work at home due to headache 5. Days not participating in activities due to headaches (i.e., play, go out, sports, etc.) 6. Days function at <50% of ability due to headache

Explore what worries the child and the parents 14

Clear the issues, exclude serious diseases from early on Luckily IT IS RARE <1/1000 of people with chronic headache as the only symptom, may have a brain tumour Abu Arafeh and MacLeod, Arch Dis Child, 2005

But occasionally, you may order a brain MRI scan... Raised intracranial pressure: Papilloedma Night or early morning vomiting Large head (especially in young children) Cerebellar dysfuction: Ataxia, Nystagmus, Intention tremor New neurological deficits: Recent squint Focal seizures Personality change Deterioration in work performance, behaviour, school work etc.

Common management plan All types of primary headache Reassurance Biopsychosocial model Education on natural course of the headache disorder Agree treatment targets and realistic expectations Explain treatment or no treatment options and choice of drugs profile Roles of patients and relatives An individual management plan May also involve family doctor, Practice nurse, and a psychologist Discuss specific issues such as trigger factors

Tension Type headache: diagnostic criteria ICHD III beta, Cephalalgia, 2013 Infrequent ETTH Frequent ETTH CTTH < 12 / year 12-180 / year >180 / year B. Headache lasting from 30 minutes to 7 days C. At least 3 of the following 1. Pressing / tightening quality 2. Mild to moderate severity 3. Bilateral location 4. Not aggravated by walking D. All of the following 1. No nausea (anorexia may occur) 2. No photophobia or phonophobia 18

Management of Tension type headache Episodic tension type Headache Mainly non pharmacological: Rest Avoid aggravating factors Hydration Occasionally Paracetamol or Ibuprofen Chronic tension type headache Life style modification Regular meals Regular sleep Regular exercise Avoid caffeinated drinks Avoid Painkillers if at all possible Max 2 days per week 19

Classification of Migraine ICHD III beta, Cephalalgia, 2013 Migraine without aura Migraine with aura Migraine with typical aura Migraine with brainstem aura Hemiplegic migraine Retinal migraine Chronic migraine Complications of migraine Status migrainosus Persistent aura without infarction Migrainous infarction Migraine aura triggered seizure Probable migraine Probable migraine without aura Probable migraine with aura Episodic syndromes that may be associated with migraine Cyclical vomiting syndrome Abdominal migraine Benign paroxysmal vertigo Benign paroxysmal torticollis 20

Criteria for the diagnosis: migraine without aura ICHD III beta, Cephalalgia, 2013 A. At least 5 attacks fulfilling B D B. Headache lasting 4 72 hours (2 72 in children) C. Headache has at least two of the following characteristic 1. Unilateral location 2. Pulsating quality 3. moderate or severe intensity 4. Aggravation by walking or similar routine activity. D. During headache at least one of the following: 1. Nausea and/or vomiting. 2. Photophobia and phonophobia. 21

Management of Migraine

Management of acute migraine attacks Non pharmacological approach: Avoiding aggravating factors: light or noise Rest Sleep if possible Supporting role of the parent or the carer Supporting work or school environment Offer drinking water and avoid dehydration

Management of acute migraine attacks The pharmacological approach: The earlier to treat the more successful the treatment will be The most appropriate drug Appropriate dose Appropriate formulation Most appropriate route of administration

Evidence for acute treatment of migraine in children and the placebo effect..

Treatment: acute migraine attacks in children 1 First line Treatment Paracetamol (acetaminophen) Initial dose 20 mg/kg Further doses if required (6 hourly) 10 15 mg/kg Ibuprofen 7.5 10 mg/kg (6 hourly) as required

Treatment: acute migraine attacks in children 2 S umatriptan: 5HT 1B,D Agonist Nasal spray: 10 mg licensed for over 12 years S umatriptan: maximum 2 doses in 24 hours Oral tablets: 25 mg (age 6 10 years) 50 mg (age 10 12 years) 50 100 mg (age over 18 years) Subcutaneous injections: 6 mg (age over 10 years) Zolmitriptan: for age 12 18 years Oral tablets: 2.5 mg Nasal spray: 5 mg melt tablets

Other options: acute migraine attacks in children Others: Antiemetic medications: Domperidone 100μg/kg Cyclizine Ondansetrone Codeine (exceptional circumstances and as one off)

Prevention of migraine Non pharmacological strategies Avoidance of known trigger factors if possible Dietary advice Advice on healthy life style: Regular meals Regular sleep Regular exercise and rest Water and lots of it

When to consider preventative treatment? Frequent attacks 2 / month Long disabling attacks Unsuccessful acute treatment Adverse effects on: education, work, Social and family life

Drugs for prophylaxis of migraine in children DB, XO and placebo controlled trials Drug Dose No. Result Pizotifen 1 1.5 mg/d 39 No difference Propranolol 60 120mg/d 28 Less often, nausea Flunarizine 5 mg/d 70 Reduced headache frequency Topiramate 50 100 mg/d 103 Reduced headache days Amitriptyline + CBT 1mg/kg/d 64 Better reduction in headache Amitrityline + education 1mg/kg/d 71 Less reduction in headache

Other drugs in migraine prophylaxis Based on open studies and clinical experience Magnesium oxide Sodium Valproate Gabapentin Cyproheptadine Other beta blockers (Atenalol) Other calcium channels blockers (verapamil) Vitamin B2 Fever few Botulinum toxin

Drugs in migraine prophylaxis NICE update 2015 Offer: Consider: Propranolol Or Topiramate Amitriptyline Preventative treatment should be used: regularly for at least 4-6 weeks If sucessful, continue for 6-12 months

Preventative treatment should be used: regularly for at least 4-6 weeks if successful, continue for 6-12 months 34

Headache disorders that are difficult to manage 35

Chronic migraine Defined as Headache on at least 15 days /month of which at least 8 days with typical migraine over at least 3 months Aim to revert to episodic migraine Explore medication overuse as a contributory factor Preventative treatment better than rescue treatment Multidisciplinary approach (life style modification) 36

Hemiplegic migraine A subtype of migraine with aura (motor aura) Associated with loss of power on one side of body with or without slurred speech Familial or Sporadic Diagnosis after excluding intracranial lesions MRI and MRA Acute Treatment: Triptans are not recommended Preventative treatment: Topiramate 1 2 mg/kg/day Fulnarizine 5 10 mg/day Propranolol: avoid to risk of infarction Avoid oral contraceptive pill 37

Prophylaxis in hemiplegic migraine Peer Mohamed et al, DMCN, 2012 38

Mixed types of headache: Mixed headaches Usually CTTH and migraine Migraine with and without aura Migraine and Trigeminal Autonomic Celphalalgias Migraine complicated with medication overuse Posttraumatic headache Postcraniotomy headache 39

Medications overuse headache Medication Overuse Headache is a chronic daily headache: in a patient taking rescue medications on 10 15 days per month for at least 3 months withdrawal of medication reduces headache frequency by at least 50% Occurs on the background of an episodic primary headache Treatment should include stopping all painkillers Headache will be worse before getting better May treat with pain modifying agents to reduce suffering 40

What makes a difficult headache, even more difficult? Co morbidity physical and psychological disorders Roles and expectations of child and parents 41

Psychiatric and behavioural co morbidities Prevalence of psychiatric disorders in adolescents with CDH (169) Disorder Current % Lifetime % Any Psychiatric 29.8% 35.5% disorder Any Anxiety 16.6% 12.4% disorder Any mood 9.5% 12.4% disorder Any Behavioural 11.2% 17.2% disorder > 1 diagnosis 13.6% 10.1% Slater et al, Cephalalgia 2012 42

Psychiatric and behavioural co morbidities Risk of migraine in adolescents of parents with psychiatric disorders Disorder Odds ratio (95% CI) Parental Major depressive disorder 1.59 (0.86 2.93) Parental Antisocial Behaviour 2.38 (1.39 4.08) Parental alcohol dependence 1.83 (0.91 3.67) Parental drug dependence 2.68 (1.31 5.50) Marmorstein et al, Cephalalgia 2009 43

Roles and expectations of parents 44

Roles and expectations of parents It is medical problem and should have a medical solution Convinced headaches are 100% due to a medical cause Bring with them detailed diaries of diet and events They score highly on the disability scales At least initially: resistant to biopsychosocial model of care My child is perfect Children tend to be high achievers high expectations to succeed athletics, social or academic 45

Parents experience and interpretations Parents views are influenced by their own experience with migraine: children do not get migraine there is no treatment for migraine I do not take any treatment is not effective nothing works for me Parents may over interpret causes of child s headache School avoidance Behavioural Eyesight Sinuses Anything but migraine.. 46

How to make difficult headache disorders manageable? 47

Amitriptyline + CBT vs amitriptyline + usual education Chronic migraine in adolescents Powers et al, JAMA 2013 48

Botox in chronic migraine PREEMPT study, adults Diener et al, Cephalalgia, 2010 49

Efficacy Effective for May be useful for Greater Occipital Nerve No evidence for efficacy for Block in adults Cervicogenic headache Cluster headache Occipital neuralgia Migraine Tension headache Hemicrania continua Chronic paroxysmal hemicrania, Indications not only for: Reproduction of headache pain with occipital nerve pressure (RHPONP) Occipital Nerve Tenderness to Palpation (ONTTP) 50

Transcranial neuromodulation Transcranial magnetic stimulation Peripheral nerve stimulation vagus 51

SUMMARY Children with primary headache 25% seek medical advice 75% OTC medication 10% referred to specialist care 15% treated in primary care 5% given preventative treatment 52

Summary Majority of children with primary headaches do not seek medical advice Those requiring treatment are successfully managed with advice and simple analgesics A small number of children will require MDT approach (biopsychosocial model) A very small number will require unlicensed unconventional treatment 53

240 x 170 mm / Hardback / 2013 ISBN: 978-1-908316-75-2