Migraine in Children and Young People (C&YP)

Joanne Mortimer & Stacey Pruett

Specialist Headache NursesGreat Ormond Street Hospital NHS Foundation Trust

Why do we need to discuss Migraine in C&YP?

1 in 5 will experience

symptoms before their

5th birthday

Migraine has a

prevalence of

around 1 in 7

• Migraine is a complex brain condition with a strong genetic factor.

• Causes painful headache, but also includes other symptoms, such as:

▫ Disturbed vision▫ Sensitivity to light, sound and smells

▫ Feeling sick and vomiting▫ Pins and needles in limbs/face

▫ Numbness in limbs/face

Migraine – a neurological condition

Migraine without Aura

At least 5 attacks fulfilling criteria B-D ▫ B

Headache attacks lasting 4-72 hours Headache has at least two of the following characteristics:

unilateral location pulsating quality moderate or severe pain intensity aggravation by or causing avoidance of routine physical activity

(eg, walking or climbing stairs)

▫ D During headache at least one of the following:

nausea and/or vomiting photophobia and phonophobia

Not attributed to another disorder

70-90% of people with

migraine experience

this type

Migraine with Aura

What is aura?

▫ Aura is a term used to describe a neurological symptom of migraine, most commonly visual disturbances.

These neurological symptoms usually happen before a headache, which could be mild, or no headache may follow.

Visual disturbances can include:

• blind spots in the field of eyesight

• coloured spots

• sparkles or stars

• flashing lights before the eyes

• tunnel vision

• zig zag lines

• temporary blindness

Other aura symptoms can include:

• numbness or tingling

• pins and needles in the arms and legs

• weakness on one side of the body

• dizziness

• a feeling of spinning (vertigo)

• speech and hearing can be affected and some

people have reported memory changes, feelings of

fear and confusion and, more rarely, partial

paralysis or fainting

10-30% of people with

migraine experience

this type

• A distressed thirteen year old female called Sophie, attends A&E

• Today Sophie reports a “banging headache” with pain 9/10

• She has had four similar episodes in the last two months

• Today the pain is much worse

• She cannot bear the light or noise of the A&E and has put sunglasses on

• Sophie is feeling very nauseous and a bit dizzy

• Sophie had Neurofen (Ibuprofen) at home, but it hasn’t helped

Case Study - Sophie

• Diagnosis is based on:

➢ History given (including headache diary)

➢ Normal neurological assessment

➢ Diagnostic criteria of the International Headache Society (ICHD-3-beta)

• Diagnosis is crucial to correct treatment

• Diagnosis is easy to get wrong!

Diagnosis

Helps to identify:➢ Characteristics➢ Patterns (aura, headache, timing)➢ Frequency➢ Severity➢ Triggers➢ Medication use➢ Behaviours➢ Accurate recall

Headache diary Apps!!

Headache Diaries

- Paediatric Migraine Disability Assessment

(PediMIDAS)

- RCADS (Revised Children’s Anxiety and

Depression Scale)

- PedsQL (Quality of Life)

• Completed by the adolescent patient

• Impact of headache on day-to-day life

➢ School attendance

➢ Activities/exercise

➢ Socialising

➢ Homework

Questionnaires

Case Study Continued - Sophie

• Safety: Sophie is not in immediate or long term harm• Full set of observations taken in A&E are normal• Neurological examination is normal• Reports moderate to severe head pain • Pain is at front of the head and behind the eyes• Throbbing quality to the head pain• 5th episode today• Light sensitive• Sound sensitive• Nausea• Dizzy• Wants to lay still and alone

Diagnosis? 1.1 Migraine without aura• Previously used terms: Common migraine; hemicrania

simplex.• Description:

▫ Recurrent headache disorder manifesting in attacks lasting 4-72 hours.

▫ Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.

• Diagnostic criteria:▫ At least five attacks1 fulfilling criteria B-D▫ Headache attacks lasting 4-72 hr (untreated or

unsuccessfully treated)2;3

▫ Headache has at least two of the following four characteristics: unilateral location pulsating quality moderate or severe pain intensity aggravation by or causing avoidance of routine physical

activity (eg, walking or climbing stairs)

• During headache at least one of the following:▫ nausea and/or vomiting▫ photophobia and phonophobia

• Not better accounted for by another ICHD-3 diagnosis.

Migraine

without

aura

Differences in Migraine in C&YP

• ICHD-3 stipulates:➢In children and adolescents (aged under 18 years), attacks may last

2-72 hours

➢Migraine headache in children and adolescents (aged under 18 years) is more often bilateral than is the case in adults; unilateral pain usually emerges in late adolescence or early adult life

➢Migraine headache is usually frontotemporal

➢Occipital headache in children is rare and calls for diagnostic caution

➢In young children, photophobia and phonophobia may be inferred from their behaviour.

Any further investigation needed?

• “Do not refer people diagnosed with tension-type

headache, migraine, cluster headache or

medication overuse headache for neuroimaging

solely for reassurance.” [NICE, 2012]

Episodic or Chronic Migraine

Episodic migraine

• <15 days of headache per month

• < 8 days of migraine symptoms

per month

• > 15 days of headache per month

• Of these day > 8 days of clear

migraine symptoms

• Present for > 3 months

Chronic migraine

Back to the case study…

Chronic or episodic??

Sophie has:

Episodic Migraine

Abdominal Migraine

• Recurrent attacks of moderate to severe midline abdominal pain

• May also experience nausea, vomiting, pallor and appetite loss

• Lasting 2-72 hours • Returning to full health and symptom freedom in

between episodes• Headache does not occur during these episodes• Diagnosed after at least 5 attacks have occurred• Investigations (e.g. blood tests, scans,

examination) find nothing abnormal• Likely to develop migraine in time

Case Study - Management

• Over the counter medication (Ibuprofen) hasn’t helped Sophie.

• Aspirin contraindicated in Paediatrics

• Codeine and morphine (OroMorph) are contraindicated:

Do not offer ergots or opioids for the acute treatment of migraine (NICE 2012)➢Associated with overuse and dependence

➢Inappropriate use

➢Withdrawal effects

➢Leads to medication overuse headache

➢Encourages headache chronicity

➢Long term use alters the brain structure

➢Codeine is easy to buy

Seven Triptans• None are licensed for <12 years

• Licensed for children >12 years:

➢ Sumatriptan

➢ Zolmitriptan

• Others are unlicensedBut, good evidence for Rizatriptan in adolescents

• Gut dysmotility in migraine is common

• Therefore intra-nasal or oro-dispersible preferred

• Injection available, but rarely chosen

Reliever Medication - Triptan

Dual Reliever Treatment

• Research:

➢Triptan and NSAID (Ibuprofen or Naproxen)

➢Or Triptan with Paracetamol

• Work synergistically

• Taken together as early in the attack as possible

Medication Overuse Headache

(MoH)

• Also known as drug-induced headache or rebound headache

• A consequence of very regular use of acute or symptomatic headache

medication

• Occurs when medication is used on 10-15 days, or more, per month

(ICHD-3, IHS, 2013)

• More than 50% of those people experiencing headache on >15days per

month have medication overuse headache (ICHD-3, IHS, 2013)

Treating MoH

• Take away the cause and headache will resolve

• Stop all analgesia and Triptans

(For at least 6 weeks and preferably longer)

• Consider timing – school summer holiday

• During medication withdrawal symptoms:

➢nausea, vomiting, low blood pressure, sleep disturbances,

restlessness, anxiety, tummy upset, diarrhoea, and nervousness.

➢Usually settle in 7-21 days

➢May need hospital admission during the withdrawal phase

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Triptan X X

Ibuprofen X X

Paracetamol X X

• To prevent medication overuse headache:

Each form of analgesia or Triptan can be taken

for only 2 days of any week.

• Full daily doses can be taken for those 2

days (i.e. Paracetamol 4-6hourly, Ibuprofen

6-8hourly)

• Frequent headaches = preventative

treatment, not excessive reliever treatment

Paediatric Preventives

• First line: Topiramate, Propranolol, Amitriptyline/Nortriptyline

• May also help paediatric abdominal migraine

• Some preventives are not licensed for migraine prevention in paediatrics

• An increasing regime is usually given

• Side Effects, vary in frequency and severity

• Greater Occipital Nerve Injection (GONI)

• Acupuncture

• Neuromodulation Devices

• Vitamins: Riboflavin, Magnesium

Psychology

• Managing & optimising functioning

• Dealing with feelings

• Help to understand triggers and to recognise any steps to reduce the triggers

• Psychological approaches can help to recognise cycles and to develop strategies to try to break or reduce them

• CAMHS referral if needed

• Mindfulness

• Headache group

1/3 of children with chronic headaches will

have associated problems like anxiety

disorders or depression

School

Environment

Timing

Pacing & Stamina

Self management

• Routine

• Regular eating, drinking, activity and sleep

• Pacing: avoid boom or bust situations

• Identify and avoid triggers (headache diary)

• Keep to a healthy weight

• Keep being social

• Involving young children in their management

• Encouraging adolescents to manage independently

Gadgets

Reassure

• No lasting harm will occur• Acute symptoms will reverse and

resolve• Symptoms are not life threatening