Lynne Kerr, MD

May 2014

Headache is one of top 5 health problems

in children

2nd most common diagnosis in the peds

neurology outpatient clinic

14 year old girl –severe headache

Headaches 1-2 times/month

Motion sickness as child

Bilateral – across the forehead

Throbbing

Wants to lie down in dark room and go to

sleep

Family history migraines mom, aunt

Very young child New onset headache Abrupt onset Progressive symptoms Abnormal neurologic signs Headache with exertion Change with head position Change with Valsalva manuever Headache/vomiting in AM Personality change

Headaches for several years

Are present in the AM at times, but don’t

get better as she becomes upright

Nausea/vomiting with headaches most of

the time

Review of systems normal except for

frequent abdominal pain – saw her PCP

without a cause being found

VS – BP normal

Appearance – alert, interactive

Weight – normal

General and physical exams normal

Overweight, BMI 29

Has many floaters in her vision

Is on minocycline for acne

May have peripheral vision loss

Primary – IIH

Secondary – venous sinus thrombosis,

medications, medical conditions

Need papilledema, MRI changes for

diagnosis

It is not helpful to do an LP for increased

pressure if ophthalmologic exam and

MRIs are normal

Friedman et al. 2013

No matter how you look at it, headaches

in children and teens are incredibly

common, one of the most likely reported

health complaints to providers

Germany – 2012 – mixed headaches in

19.8% of children and adolescents

Calculated life-time prevalence for

headache in children/adolescents 58.4%.

Prevalence 9.1% of children have

migraine (Wober-Bingol, 2013)

Children under 7– about ½ migraine,

15% tension, approx 1/3 mixed/unclass

(Ramdas, 2013)

Why – for choice of evaluation and

management

Classification by International Headache

Society Criteria

More specific diagnosis will also most

likely help billing, especially as we go

into ICD-10

Primary Headaches

Secondary Headaches

Caveat - individuals who are prone to

migraine are more likely to have

migraine type headaches even due to

secondary causes, so can’t go by

characteristics

Migraine

Tension

TACS-trigeminal autonomic cephalgia

Other – stabbing, hemicrania continua

and new daily-persistent headache

(others)

Chronic daily headaches

Two major subtypes • Migraine with aura

• Migraine without aura

“Common migraine”

At least 5 attacks lasting 4-72 hours

Unilateral location

Pulsating quality

Moderate or severe pain intensity

Aggravation by routine physical activity

At least one of following: • Nausea and/or vomiting

• Photophobia AND phonophobia

Exceptions to adult criteria • Attacks may last 1-72 hours

• Commonly bilateral in young children

• Nausea/photophobia/phonophobia may be

inferred from behavior

“Classic migraine”

20% of people with migraines

Often aura runs in family

May have many migraines without aura –

commonly a mix of those with and

without

Typical aura consisting of visual and/or

sensory and/or speech symptoms

Gradual development

Duration no longer than 1 hour

Mix of positive and negative features

Complete reversibility

Associated with a HA fulfilling criteria for

migraine without aura

NO motor weakness

Note that sensory symptoms such as

numbness might make a limb harder to

move, so must differentiate from

weakness

Positive examples – flickering

lights/spots/lines

Negative examples – numbness, loss of

vision

Visual aura is the most common type of

aura

Sensory disturbances next in frequency

Speech disturbances next

Motor symptoms – must differentiate

from stroke – familial hemiplegic

migraine or sporadic hemiplegic

migraine are diagnoses of exclusion

Migraine equivalents – precursors

Cyclical vomiting – episodes of

nausea/vomiting lasting a few days,

normal in between

Abdominal migraine – episodes of

abdominal pain without physical

explanation

Benign paroxysmal vertigo of childhood

– episodes of vertigo that come and go

Very rare that a child with a headache

has an underlying etiology; more than

3/4s have CTs or MRIs before their visit

with us.

CTs aren’t very good, they often lead to

an MRI, and expose the child to radiation.

Neuroimaging findings in only 1.2% of

neurologically normal patients.

Cumulative doses of 50 mGY can triple the risk of leukemia and 60 mGY can triple the risk of brain cancer.

Major concerns are tumor, vascular malformation, spread of infection, sinus thrombosis.

Instead, suggest complete history, family history, general (including VS) and neurologic exam (with fundoscopic exam). Alexious and Argyropoulou, 2013

MOST IMPORTANT There is NO magic pill Journal Headaches – identify and avoid

triggers Exercise Appropriate sleep Appropriate weight Stress/anxiety Diet No narcotics

Journaling is therapeutic on its own

Need to know the pattern of migraine

Every weekend, every Monday

Association with periods, sports, etc.

Headache journal

Teens like smart phone apps – • http://appfinder.lisisoft.com/app/headache-

relief-diary.html

• others

Acute, abortive, and preventive

Acute – what someone takes for a

standard type migraine

Abortive – what someone takes at home if

migraine horrible, last step before ED

Preventive – medication someone takes

every day to decrease headache

frequency and intensity

Need to take it as soon as possible after

start of headache

Not more than 3 times a week – may

cause medication overuse headache

May need form to allow administration at

school

Ibuprofen/acetaminophen

Dose appropriate for weight – 10 mg/kg

for ibuprofen, 15 mg/kg acetaminophen

Addition of caffeine may be helpful

Odansetron (serotonergic properties and

for n/v)

Orally disintegrating tablets 4 mg and 8

mg

Generic available

Others – phenergan, compazine,

thorazine (pretreat w/ benadryl?)

AAN suggests be used earlier for

migraine in adults

I use them rarely for kids/adolescents

Very expensive, and often not covered by

insurance

Like ibuprofen, not more than 3 X/week

Combined with ibuprofen/acetamin may

work better

Sumatriptan – only nasal spray had any

benefit in studies, and kids don’t like • 10 and 20 mg nasal, 25 and 50 mg oral

Rizatriptan – • 6 years and older

• ODT/tabs 5 and 10 mg

Almotriptan – • Comes in 6.25 and 12.5 mg capsules

• Kids 12 years of age and older

This is “so you can rest” medication

I add benadryl/phenergan on a routine

basis (not prn, but scheduled) so they

can sleep for a few days

My last step before the ED

Have included ED protocol at end

Occasional IV DHE (an admission) – data

shows not very helpful and $7500 av cost

Studies show preventive medications way

underprescribed

When headaches get to be 3 days a

month (1 HA 3 days or 3 1 day Has)

TAKE 4-8 weeks to work – need to warn

families

No evidence in children/teens except

flunarizine, a Ca channel blocker not

available in the US

Magnesium ending in “ate” • Adults 200-400 mg BID

• Loose stools side effects

• Class I evidence better than placebo

Butterbur (Petasites) • Class I evidence

• Petadolex (amazon.com) 50 mg 1/day

Riboflavin 100 mg/day Melatonin – new evidence lately (not

class 1)

Cyproheptadine

Topiramate

Amitriptyline

Valproic acid

Lamotrigine

Gabapentin

Propranol

Cyproheptadine – younger children,

weight gain a real problem, sleepiness

not a problem as given only at night, 2

mg/5 ml liquid, 4 mg tabs

Amitriptyline – EKG (50 or greater), low

therapeutic index; sleepiness, dry mouth,

and constipation, start at 12.5 mg and

increase to 25 – 75 mg.

Topiramate – 15 mg qHS only to increase to 30 mg after 1 week • Weight loss (may be good thing)

• Increase hydration

• Topastupid or Dopamax, but given only at night

• More news of effects on QT interval

Propranolol – can’t be used if asthma or depression – I rarely use • < 35 kg 10-20 mg tid

• > 35 kg 20-40 mg tid

• If dose high enough, can give as ER 60/80/120

> 15 days a month

Thought to be a complication of migraine

“transformed migraine”

Often looses migrainous features over

time

Only approved medication for this type

of headache: botox injections, insurance

usually requires trials of other preventive

therapies first, over 15 yoa

Pain that persists beyond the normal

tissue healing time, which is assumed to

be 3 months

Chronic pain in 1/3 adults

Early treatment to prevent chronification

“Pain that ceases to be symptomatic of

the initial cause and becomes an entirely

separate condition.” (Fine, 2011)

Pts with altered mental states/physical

dysfunction

Changes in excitability of brain and in

default mode network

Correlated with increased negative

affectivity (Kroner-Herwig, 2013).

“Pain has potential to become more

complex in its pathophysiology over

time” (Fine, 2011)

Medications

Plus Behavioral Health

The usual suspects

Amitriptyline

Topiramate

Other

New for chronic daily headache –

botulinum protocol

Usually a series of 3 given 3 months apart

Generally at least 2 series before much

relief

31 injection sites

Most common side effect neck pain

Recently approved in US

Unclear if insurance will pay

Stimulates the trigeminal nerve

Somewhere around $300

Medication + CBT better than medication

alone (Powers et al. 2013).

Treat anxiety/depression/sleep

problems

Get them back to school

Address family/social issues

Others – integrative medicine,

biofeedback, acupuncture, etc.

Psychology/psychiatry/social work

Can be primary or secondary Not as common in the office, but more

common in life Criteria: at least 10 episodes

• Lasting 30 minutes to 7 days

• Bilateral location

• Pressing/tightening (non-pulsating)

• Mild to moderate intensity

• Not aggravated by routine physical activity

• No N/V, either photo or phonophobia, not both

Ibuprofen/acetaminophen

Caffeine may help

Some people think triptans help – not

good evidence

Avoid narcotics

Preventive treatments may help

Headache that within 3 days of onset is

daily and unremitting for > 3 months,

with 2 of following characteristics • Bilateral

• Pressing/tightening

• Mild/moderate

• Not aggravated by physical activity

• No more than one of

photophobia/phonophobia/nausea/vomiting

Often, patient can recall exact moment

headache began

Sometimes precipitating event such as

viral infection or concussion

Rule out underlying causes (especially

CSF increase/decrease pressure) and

medication overuse headache

Difficult

Reassuring that most go away, although

may be months to years

Possibilities discussed under migraine –

the usual suspects, no evidence for one

more than the other

IV DHE/botox injections

Called ice-pick pains, jabs and jolts

Usually first division of trigeminal nerve

Lasts a few seconds, recur one to many

times a day

No other symptoms

Change sides (if not, consider imaging)

Occur in individuals with migraine

May respond to indomethacin (I usually

use ER form, 75 mg and give it two weeks

– give at night because may upset

stomach)

May respond to melatonin or gabapentin

Trigeminal autonomic cephalgias

Cluster headaches

Paroxysmal hemicrania

SUNA/SUNCT – short acting unilateral

neuralgiform headaches with autonomic

features (conjuctival injection and

tearing)

Rare in children (and adults) (M>F)

Sharp/throbbing/severe pain

May have migrainous features

Abortive – sumatriptan nasal

spray/oxygen/steroids

Preventive – topiramate/verapamil

Nerve blocks (usually greater occipital

nerve block)

Severe/sharp pain

Many times a day, 2-30 minutes

Autonomic features

Preventive – indomethacin

Sometimes will try greater occipital

block nerve injection

Seconds long

Stabbing/burning

Severe

Rare migrainous features

Preventive • Topiramate

• Lamotrigine

• Gabapentin

• May try greater occipital nerve block

1) Stick with family – trial and error

2) Child should NOT miss school – get

them back as soon as possible

3) Integrative medicine referral

4) Behavioral health referral

5) Psychiatry as necessary

http://chautauqua.pastperfect-

online.com/34268cgi/mweb.exe?request

=record;id=55F7BA86-E0D6-

Alexiou, GA, Argyropoulou, MI. 2013

Neuroimaging in childhood headache: a

systematic review. Pediatr Radiol 43: 777.

Connelly, M. 2013 Cognitive behavior

therapy for treatment of pediatric chronic

migraine. JAMA 310: 2617.

Winner, P. 2013 Migraine-related

symptoms in childhood. Curr Pain

Headache Rep 17:339.

Sheridan et al 2012 Low-dose propofol

for the abortive treatment of pediatric

migraine in the emergency department.

Pediatr Emerg Care 28: 1293.

Wober-Bingol. 2013. Epidemiology of

migraine and headache in children and

adolescents. Curr Pain Headache Rep 17:

341.

Blank Headache diary sheets

PEDS MIDAS questionnaire for disability

Pediatric Symptom Checklist for

screening for psychological barriers to

improving from headaches

PCH ED protocol for treatment of acute

headaches

Rizzoli, B. 2012 Acute and preventive treatment of migraine. Contin 18: 764.

Babineau, SE and Green, MW. 2012 Headaches in children. Contin 18: 853.

Continuum volume 18, Headache. Journals.lww.com/continuum/Fulltext/2012/08000/Table_of_Contents.3.aspx

Friedman et al 2013 Revised diagnostic criteria for the PTC syndrome in adults and children. Neurol 81: 1159.

Alexious, GA and Argyropoulou, MI 2013 Neuroimaging in childhood headache: a systematic review. Pediatr Radiol 43: 777.

Connelly, M. 2013 Cognitive behavior therapy for treatment of pediatric chronic migraine. JAMA 310: 2617.

Gertsch et al 2013 Intravenous Mg as acute treatment for headaches: A pediatric case series. J Emerg Med S0736.

Kroner-Herwig 2013 Pediatric headache: associated psychosocial factors and psychological treatment. Curr Pain Headache Rep 17:338.

Ramdas et al 2013 Primary headache disorders in children under 7 yoa Scott Med J 58: 26.

Winner, P. 2013 Migraine-related symptoms in childhood. Curr Pain Headache Rep 17:339.

Wober-Bingol. 2013. Epidemiology of migraine and headache in children and adolescents. Curr Pain Headache Rep 17: 341.