Title: Diagnosis and Treatment of Pediatric Migraine
1Diagnosis and Treatment of Pediatric Migraine
- Susan LeCates, MSN, CNP
- Family Nurse Practitioner
- Neurology Department / Headache Center
- Cincinnati Childrens Hospital Medical Center
2Disclosure
The content of my presentation will include
discussion of unapproved or investigational uses
of medication for acute and preventative
treatment of migraine headache in children
3Objectives
- Understand diagnosis of primary headache in
children using the International Classification
of Headache Disorders (ICHD-3) - Develop an appropriate treatment plan for
children diagnosed with migraine headaches - Recognize when to refer children with migraine
headaches
4Migraines are Common
- There are 28 million people in the world with
Migraine - Migraines occur at all ages
- Migraine headaches in children and adolescents
are often under recognized or NOT taken seriously -
-
Headache 19933329-35
5Migraine Prevalence in Childhood
gt
3 to 7 year olds
6Migraine Prevalence in Childhood
7 to 11 year olds
7Migraine Prevalence in Childhood
lt
11 to 15 year olds
8Pediatric Migraine Impact
- Migraine - Top 5 most prevalent childhood
disorders - Headache - 3rd ranked illness - related cause of
school absence - Pediatric migraine - 36 billion impact in USA
- WHO Survey - rates severe migraine with
quadriplegia as one of the Most Disabling chronic
disorders
9What is the Key to Diagnosing Migraine?
- Accurate Diagnosis
- Effective Communication
10International Headache Society (IHS)
- Classification system for headache diagnosis
developed in 1988 - International Classification of Headache
Disorders 3rd Edition (ICHD-3) -
-
11Headache Classification
- 1. Primary Headache is the Problem
- 2. Secondary Symptom of Underlying Disorder
- 3. Painful cranial neuropathies, other facial
pains and other headaches
12Diagnosing Migraine
13Migraine without AuraICHD-3, 2013
- At least 5 attacks
- Last 4 -72 hours untreated (2 - 72 for children
under 18 years of age) - Two of four characteristics
- Unilateral location (commonly bilateral in kids)
- Pulsating quality
- Moderate or severe intensity
- Aggravated by routine activity
14Migraine without AuraICHD-3, 2013
- During the HA at least one of the following
- Nausea and/or vomiting
- Photophobia and phonophobia (may be inferred by
childs behavior) - Not attributed to another disorder
15Migraine with AuraICHD-3, 2013
- Criteria same as Migraine without Aura but also
have - Focal neurological symptom usually developing
over 5-20 minutes and lasts less than 60 min - Visual, Sensory, Speech, Motor, Brainstem,
Retinal - At least 2 attacks
- Headache begins during the aura or follows aura
within 60 minutes
16The Visual Aura
17The Sensory Aura
http//www.youtube.com/watch?viZ-RzRUynAEfeature
player_embedded
18Chronic MigraineICHD-3, 2013
- Headache occurring on 15 or more days per month
for gt 3 months, which has the features of
migraine headache on at least 8 days per month - Often results from unresolved status migrainosus
- Not attributed to another disorder
19Status MigrainosusICHD-3, 2013
- Present attack meets criteria for migraine
without aura and is typical of other attacks - Both of the following
- HA gt 72 hours
- Severe intensity
- Not attributed to another disorder
-
- Interruption during sleep and short lasting
relief due to medication are disregarded
20Challenges of Treating Pediatric Migraine
- Diagnosis and assessment of symptoms is
complicated by the inability of children to
articulate their complaints - Other infectious, allergic, or gastrointestinal
disorders of childhood may mimic symptoms of
migraine - Lack of research conducted in children and
adolescents
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24If It Isnt Migraine What Is It?
25 Headache Attributed to Infection of Nose or
Paranasal SinusesICHD-3, 2013
- Frontal HA with pain in one or more regions of
face, ears or teeth - Clinical, nasal exam, CT and/or MRI imaging
and/or lab evidence of acute or acute-on-chronic
rhinosinusitis - Simultaneous onset of headache and facial pain
- Headache and/or facial pain resolve within 7 days
after successful treatment
26Episodic Tension-Type ICHD-3, 2013
- At least 10 attacks (more than once but less than
15 days/mos) - HA lasting from 30 minutes to 7 days
- At least 2 of the following
- Pressing/tightening quality
- Mild or moderate intensity
- Bilateral location
- Not aggravated by routine physical activity
27Episodic Tension-TypeICHD-3, 2013
- Both of the following
- No nausea or vomiting (anorexia may occur)
- Photophobia or phonophobia
- Not attributed to another disorder
28Medication-Overuse HeadacheICHD-3, 2013
- Analgesics at least 15 days/mos for gt 3 mos
- Triptans at least 10 days/mos for gt 3 mos
- HA has developed or markedly worsened during
analgesic overuse - Headache resolves or reverts to previous pattern
within 2 months after stopping analgesics
- Daily low dose medication use worse than high
dose use once a week - Caffeine can also be culprit
29Medication-Overuse HeadacheVasconcellos, et al,
1997
- Retrospective review of pts gt 4 HA/wk
- N 98, mean age 12.1
- Frequency of HA per month
- Initial 27.5
- After 1 mo. without analgesics 7.3
- After 2 mo. without analgesics 5.4
- (Plt0.0001)
- Daily use of analgesics may reduce the
effectiveness of preventative HA meds
30Acute headache attributed to traumatic injury
to the headICHD-3, 2013
- Traumatic injury to the head has occurred
- Headache is reported to have developed within 7
days after one of the following - 1. the injury to the head
- 2. regaining of consciousness following the
injury to the head - 3. discontinuation of medication(s) that impair
ability to sense or report headache following the
injury to the head - Either of the Following
- Headache has resolved within 3 months after the
injury to the head - Headache has not yet resolved but 3 months have
not yet passed since the injury to the head - Not attributed to another disorder
31 Episodic Syndromes that may be Associated with
MigraineICHD-3, 2013
- 4. Recurrent gastrointestinal
- disturbance
- Benign Paroxysmal Torticollis
- Others motion/car sickness sleep disturbances
recurrent unexplained fever
- Benign Paroxysmal Vertigo
- 2. Abdominal Migraine
- 3. Cyclical Vomiting Syndrome
32Headache Warning Signs Ferrari, 1998
- Sudden change in headache symptoms
- Sudden, substantial increase in frequency
- Abnormal neurological examination
- Aura lt 5 minutes or gt 60 minutes
- Aura always on same side
- Aura without headache
33When to Get an MRI in Kids
- Presence of any of the Warning Signs/Red Flags
- No family history of headaches
- Age less than 5 years old
- Persistent occipital headache
34Additional Headache Diagnostic Testing
- Abnormal HA Evaluation
- Blood work
- CT/MRI
- EEG
- LP
35So How Do You Treat Pediatric Headaches?
- Acute
- Preventative
- Biobehavioral
36Goals of Acute Treatment
- Treat attacks rapidly and consistently without
recurrence - Restore patients ability to function
- Minimize the use of rescue medications
- Optimize self-care and reduce use of resources
- Cost-effectiveness
- Minimal or no adverse events
37Acute Migraine Treatment
- Over-the-Counter Medication
- Ibuprofen most effective in children
- Dosage 10 mg/kg (Hamalainen, et al, 1997)
- Naproxen sodium (Aleve) may be substituted for
ibuprofen - Aspirin and Excedrin are other options (gt 16
years) - 24-32 ounces of sports drink for vascular
rehydration at HA onset - Early Treatment Successful Treatment
38Acute Migraine Treatment
- Faster Onset of Action
- Almotriptan (Axert)
- Eletriptan (Relpax)
- Rizatriptan (Maxalt, Maxalt-MLT)
- Sumatriptan (Imitrex-tablet, NS, SQ,)
- Sumatriptan Naproxen sodium (Treximet)
- Zolmitriptan (Zomig, Zomig-ZMT, nasal spray)
- Slower Onset of Action
- Frovatriptan (Frova)
- Naratriptan (Amerge)
39Acute Migraine Treatment
- No Narcotics!
- Use of opioids prevents reversal of established
migraine and central sensitization (Jakubowski et
al. Headache 2005 45850-61) - Patients with migraine were given parenteral
sumatriptan and ketorolac - 71 were pain free and without allodynia within
60 minute of ketorolac infusion - In contrast to the responders (9/9),
non-responders (1/19) had treated their migraine
with opioids
40Medication Overuse Prevention
- Limit analgesic use to 2-3 days a week
- Triptan use limited to 6 headaches a month
- Limit No more than 2 doses of medication per
headache- need IV acute tx if HA persists
41Management of Intractable Acute Migraines
42When do you Refer for Intravenous Acute Headache
Treatment?
- Acute / Non-responsive to home abortive treatment
- Chronic Migraine - Impaired functioning
- Chronic Migraine - Acute exacerbation
43Acute Headache Treatment Algorithm
44What Happens if the Acute Refractory Headache
Doesnt Break?
- Admit for Inpatient Treatment using
- Pharmacological agents
- IV DHE
- IV Valproate sodium
- IV Magnesium
- IV Steroids
- IV fluids
- Others
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46Migraine Preventative Treatment
47Goals of Migraine Prevention
- Reduce HA attack Frequency, Severity and Duration
- Improve Responsiveness to TX of Acute Attacks
- Improve Function and Reduce Disability
- Improve Quality of Life
- Educate Patient/Family to become Active
Participants in HA Management
48Common Preventative Medications
- Antidepressants
- Amitriptyline (Elavil)
- Anticonvulsants
- Topiramate (Topamax)
- Valproic Acid (Depakote)
- Levetiracetam (Keppra)
- Antiserotonergic
- Cyproheptadine (Periactin)
- Neutraceuticals
- -Vitamin B2 (Riboflavin)
- -Coenzyme Q10
- -Vitamin D3
- Botulinum toxin A (Botox)
-
49Botox (onabotulinumtoxin A)
- Injected directly into overactive muscles
- Reduces contractions, relaxes muscles
50Preventative Treatment Principles
- Criteria to Start
- Frequency gt1 week and/or
- Disability from HA
- Purpose is to prevent not cure migraines
- Never expect a lifetime of preventative treatment
- Start low and go slow when increasing dose to
limit side effects
- Full response to medication not seen until on
full dose for at least 6-8 weeks - Slowly wean medication after treatment goal (3-4
HA/month) for 4-6 months - No medications FDA approved for migraine
prevention in children
51Biobehavioral Treatment(Healthy Habits)
52Common Headache Triggers (Riback, P., 2000)
- Stress (23)
- Sleep Deprivation (16)
- Hunger (11)
- Heat (11)
- Bright Lights (9)
53Daily Fluid Intake
- Recommend 2-3 liters daily
- Provide letter for school giving kids permission
to carry water/sports drink bottle at school and
use restroom as needed - Eliminate Caffeine
- Diuretic
- Addictive
- Caffeine-Withdrawal Headache
54Healthy Eating Habits
- Regular meals and snacks
- Encourage regular intake of fruits, vegetables,
and dairy - Food triggers uncommon in children
55Healthy Sleep Habits
- Recommend 8-9 hours
- No Naps
- Keep regular sleep schedule
- Do not oversleep more than 2-3 hours on weekend,
especially on Sunday - Avoid naps
- Establish a bedtime routine to help child fall
asleep
56Exercise
- Three times a week for 20-30 minutes
- Hydrate before, during, and after exercise
- May need 32 ounces before and after exercise to
prevent dehydration triggered headache - Sports drink is best
- Do not exercise before bedtime
57School Issues Proactive Approach
- Provide School Letter with Acute Headache
Treatment Plan, Hydration/Restroom Needs - Recommend Parent/Child Review Headache Tx Plan
with Teachers - Discuss Expectations for School Attendance with
Headache - Evaluate Headache Disability at Each Visit
58When to Refer for Specialty Care?
59Child Psychologist
- Lifestyle changes
- Stress management
- Learn coping strategies for chronic pain
- Teach Biofeedback-Assisted Relaxation Techniques
60Child Neurologist/Headache Specialist
- Any concern about a secondary cause of headaches
(unless it is sinus disease) - Headaches that do not meet ICHD-II criteria
- Headaches unresponsive to treatment interventions
- Transient neurological signs during headache
episodes
61Conclusions
- Migraine headaches are common and may often be
under-recognized - Think Migraine! - Diagnosis should rely on standardized criteria
- Imaging should be guided by warning signs with
specific criteria used as suggestions - Multi-modal treatment may be necessary
- Acute Preventative Healthy Habits
Pain Management - Consider referral for Headache Specialty Care
62Website Resources for Headache
- American Council for Headache Education (ACHE)
www.achenet.org - American Headache Society
- www.ahsnet.org
- Cincinnati Childrens Hospital Med Center
www.cincinnatichildrens.org - National Headache Foundation
- www.headaches.org
- American Migraine Foundation
- http//www.americanmigrainefoundation.org
63Questions?