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 Childrens Hospital Medical Center

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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
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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

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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
• 
  
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  Headache 19933329-35

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

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

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What is the Key to Diagnosing Migraine?

• Accurate Diagnosis
• Effective Communication

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International Headache Society (IHS)

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

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Headache Classification

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

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Diagnosing Migraine
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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

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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

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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

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

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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

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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

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If It Isnt Migraine What Is It?
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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

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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

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Episodic Tension-TypeICHD-3, 2013

• Both of the following
• No nausea or vomiting (anorexia may occur)
• Photophobia or phonophobia
• Not attributed to another disorder

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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

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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

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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

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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

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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

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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

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Additional Headache Diagnostic Testing

• Abnormal HA Evaluation
• Blood work
• CT/MRI
• EEG
• LP

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So How Do You Treat Pediatric Headaches?

• Acute
• Preventative
• Biobehavioral

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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

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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

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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)

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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

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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

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Management of Intractable Acute Migraines
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When do you Refer for Intravenous Acute Headache
Treatment?

• Acute / Non-responsive to home abortive treatment
• Chronic Migraine - Impaired functioning
• Chronic Migraine - Acute exacerbation

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Acute Headache Treatment Algorithm
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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

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Migraine Preventative Treatment
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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

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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)

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Botox (onabotulinumtoxin A)

• Injected directly into overactive muscles
• Reduces contractions, relaxes muscles

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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

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Biobehavioral Treatment(Healthy Habits)
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Common Headache Triggers (Riback, P., 2000)

• Stress (23)
• Sleep Deprivation (16)
• Hunger (11)
• Heat (11)
• Bright Lights (9)

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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

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Healthy Eating Habits

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

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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

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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

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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

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When to Refer for Specialty Care?
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Child Psychologist

• Lifestyle changes
• Stress management
• Learn coping strategies for chronic pain
• Teach Biofeedback-Assisted Relaxation Techniques

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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

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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

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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

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Questions?