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Diagnosis and Treatment of Pediatric Migraine

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Diagnosis and Treatment of Pediatric Migraine Susan LeCates, MSN, CNP Family Nurse Practitioner Neurology Department / Headache Center Cincinnati Children s ... – PowerPoint PPT presentation

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Title: Diagnosis and Treatment of Pediatric Migraine


1
Diagnosis and Treatment of Pediatric Migraine
  • Susan LeCates, MSN, CNP
  • Family Nurse Practitioner
  • Neurology Department / Headache Center
  • Cincinnati Childrens Hospital Medical Center

2
Disclosure
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
3
Objectives
  • 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

4
Migraines 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

5
Migraine Prevalence in Childhood
gt
3 to 7 year olds
6
Migraine Prevalence in Childhood

7 to 11 year olds
7
Migraine Prevalence in Childhood
lt
11 to 15 year olds
8
Pediatric 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

9
What is the Key to Diagnosing Migraine?
  • Accurate Diagnosis
  • Effective Communication

10
International Headache Society (IHS)
  • Classification system for headache diagnosis
    developed in 1988
  • International Classification of Headache
    Disorders 3rd Edition (ICHD-3)

11
Headache Classification
  • 1. Primary Headache is the Problem
  • 2. Secondary Symptom of Underlying Disorder
  • 3. Painful cranial neuropathies, other facial
    pains and other headaches

12
Diagnosing Migraine
13
Migraine 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

14
Migraine 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

15
Migraine 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

16
The Visual Aura
17
The Sensory Aura
http//www.youtube.com/watch?viZ-RzRUynAEfeature
player_embedded
18
Chronic 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

19
Status 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

20
Challenges 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

21
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22
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23
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24
If 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

26
Episodic 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

27
Episodic Tension-TypeICHD-3, 2013
  • Both of the following
  • No nausea or vomiting (anorexia may occur)
  • Photophobia or phonophobia
  • Not attributed to another disorder

28
Medication-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

29
Medication-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

30
Acute 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

32
Headache 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

33
When 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

34
Additional Headache Diagnostic Testing
  • Abnormal HA Evaluation
  • Blood work
  • CT/MRI
  • EEG
  • LP

35
So How Do You Treat Pediatric Headaches?
  • Acute
  • Preventative
  • Biobehavioral

36
Goals 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

37
Acute 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

38
Acute 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)

39
Acute 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

40
Medication 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

41
Management of Intractable Acute Migraines
42
When do you Refer for Intravenous Acute Headache
Treatment?
  • Acute / Non-responsive to home abortive treatment
  • Chronic Migraine - Impaired functioning
  • Chronic Migraine - Acute exacerbation

43
Acute Headache Treatment Algorithm
44
What 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

45
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46
Migraine Preventative Treatment
47
Goals 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

48
Common 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)

49
Botox (onabotulinumtoxin A)
  • Injected directly into overactive muscles
  • Reduces contractions, relaxes muscles

50
Preventative 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

51
Biobehavioral Treatment(Healthy Habits)
52
Common Headache Triggers (Riback, P., 2000)
  • Stress (23)
  • Sleep Deprivation (16)
  • Hunger (11)
  • Heat (11)
  • Bright Lights (9)

53
Daily 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

54
Healthy Eating Habits
  • Regular meals and snacks
  • Encourage regular intake of fruits, vegetables,
    and dairy
  • Food triggers uncommon in children

55
Healthy 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

56
Exercise
  • 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

57
School 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

58
When to Refer for Specialty Care?
59
Child Psychologist
  • Lifestyle changes
  • Stress management
  • Learn coping strategies for chronic pain
  • Teach Biofeedback-Assisted Relaxation Techniques

60
Child 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

61
Conclusions
  • 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

62
Website 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

63
Questions?
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