Migraine Madness: Treatment of Childhood Migraine. Candida M. Brown, MD. Division of Neurology

Transcription

1 Migraine Madness: Treatment of Childhood Migraine Candida M. Brown, MD Division of Neurology

2 Following print-publication of The International Classification of Headache Disorders, 2 nd edition (ICHD-II), a web-based version was developed. This has many facilities that are not present in the printed version or the simple electronic file on this site. Since a headache classification and the diagnostic criteria for all disorders cannot be learned by heart, it is of immense value that doctors all over the world may find, on the internet, the answer to whatever question they may have regarding ICHD- II. Visit the ICHD-II Website at: 2

3 Nonspecific Acute Class of Medication Low range analgesics Name of Medication Acetaminophen Excedrin for migraine Comments LIMIT USE FOR ALL TO 3 DAYS/WEEK to PREVENT MOH Weak analgesic; better antipyretic Combination of acetaminophen, aspirin, and caffeine. Note: ASA! Motrin/Advil Aleve (Naprosyn) Indomethicin Dose at 10 mg/kg/ Longer acting than Motrin; decreases risk of MOH Available in rectal suppository Ketorolac May be given parentally in ER. Available in a self-administered cartridge needle unit for IM Mid-range analgesics Fiorinal Esgic, Fioricet ASA 325 mg, butalbital 50 mg, caffeine 40 mg Acetaminophen 325 mg, butalbital 50 mg, caffeine 40 mg Esgic plus Phrenilin Phrenilin Forte Acetaminophen 500 mg, Butalbital 50 mg, Caffeine 40 mg Acetaminophen 325 mg, Butalbital 50 mg Acetaminophen 500 mg, butalbital 50 mg 3

4 Midrin Isometheptene (a sympathomimetic), acetaminophen, and dichloralphenazone ( a choral hydrate derivative ` High-range analgesics Opioids: Codeine Meperidine Oxycodone Morphine Intranasal butorphanol Rarely used due to risk of physical dependence, tolerance, addiction. Limit use to reliable patients with severe migraine unresponsive to other analgesics, ergots and serotonin agonists. Specific Acute Ergot Derivatives Ergotamine Titrate (Ergomar) (Cafergot) Route Preparation Dose per attack Sublingual (Ergomar) 2 mg 1-3 tablets (maximum 3) Maximum limits 2 d/wk and 10 mg/wk Oral (Cafergot) 1 mg ( with caffeine 100 mg) 1-6 tablets (maximum 6 tablets) 2 d/wk and 10 mg/wk Suppository (Cafergot) 2 mg (with caffeine 100 mg) ½ to 2 suppositories 2 d/wk and 10 mg/wk Dihydroergotamine (DHE) Route Preparation Dose per attack Intranasal 4 mg/ml 0.5 mg in each nares, repeat after 15 minutes (total 2 mg) Maximum limits 20 mg/wk Intramuscular Intravenous 1 mg/ml Age 6-9 yrs: 0.1 mg/ Age 9-12 yrs: 0.15 mg/ Age yrs: 0.2 mg/ 20 mg/wk Pre-treat with : Metoclopramide 0.2 mg/kg Or Ondansetron 0.15 mg/kg 30 minutes prior 4

5 0.2 mg/ Ondansetron 0.15 mg/kg 30 minutes prior Selective Serotonin Receptor Agonists Binds to 5 HT- 1B and 1D receptors Sumatriptan (Imitrex) Zolmitriptan (Zomig) Naratriptan HCl (Amerge) Rizatriptan benzoate (Maxalt) *If patient is taking propanolol, only the 5 mg tablet should be used. Formulation Available Adult Start Repeat time Maximum Dose in 4 hours SQ 6 mg 6 mg 1 h 12 mg NS 5 mg, 20 mg 20 mg 2 h 40 mg Tablets 25 mg, 50 mg, 100 mg Formulation Available 50 mg 2 h 200 mg Adult Start Repeat time Maximum Dose in 4 hours Tablet 2.5 mg, 5 mg 2.5 mg 2 h 10 mg Wafer 2.5 mg, 5 mg 2.5 mg 2 h 10 mg Formulation Available Adult Start Repeat time Maximum Dose in 4 hours Tablet 1 mg, 2.5 mg 2.5 mg 4 h 5 mg Formulation Available Adult Start Repeat time Maximum Dose in 4 hours Tablet 5 mg, 10 mg 10 mg 2 h 30 mg Wafer 5 mg, 10 mg 10 mg 2 h 30 mg 5

6 Almotriptan malate (Axert) Formulation Available Adult Start Repeat time Maximum Dose in 4 hours Tablet 6.25 mg, 12.5 mg 12.5 mg 2 h 25 mg Frovatriptan (Frova) Longest t½ life: 25 hrs Eletriptan (Replax) Formulation Available Adult Start Repeat time Maximum Dose in 4 hours Tablet 2.5 mg 2.5 mg 2 h 7.5 mg Formulation Tablet Available 20 mg 40 mg Adult Start Repeat time Maximum Dose in 4 hours 40 mg 2 h 80 mg Comparison of Triptan Characteristics Speed: sumitriptan SQ>sumatriptan nasal spray=rizatripotan tablet/wafer>zolmitriptan>sumatriptan oral=almotriptan>naratriptan Early effectiveness (1 and 2 hours): sumitriptan SQ> rimzatriptan tablet/wafer> sumiptriptan NS = zolmitriptan. sumatriptan oral = almotriptan > naratriptan Tolerability: naratriptan=almotriptan > sumatriptan oral = zolmitriptan = rizatriptan > sumatriptan nasal spray > sumatriptan SQ Formulations: sumatriptan > rizatriptan = zolmitriptan > naratriptan = almotriptan Antiemetics Metoclopramide Perphenazine Prochlorperazine Chorpromazine May cause dystonia Can give some forms as rectal suppository 6

7 Prophylactic Anticonvulsants Depacon Can give IV form up to 1000 mg in adult Beta-adrenergic blocking agents Tricyclic Antidepressants SSRIs Propanolol (Inderal) Timolol (Blocardren) Naldolol (Corgard) *Metoprolol (Lopressor) *Atenolol (Tenormin) Amitriptyline (Elavil) Nortriptyline (Pamelor) Desipramine (Norpramin) Doxepin (Sinequan) Protriptyline (Vivactil) Fluoxetine (Prozac) Venlafaxine (Effexor) * These two meds are cardioselective and therefore safe in patients with RAD Elavil most commonly used: slowly taper at 0.25 mg/kg, and increase by 0.25 mg/kg each week until a of 1 mg/kg is reached. Has not been well-studied, although the common wisdom is that they are effective. Effexor blocks both serotonin reuptake and NE reuptake. Also helpful in reducing anxiety. A recent retrospective study found the ER formulation to be useful for TTH and migraine. Anxiolytics Buspar Particularly helpful in comorbid anxiety present. Anticonvulsants Valproic Acid (Depakote) Gabapentin (Neurontin) Topiramate (Topamax) VPA: mg/kg/d Topomax: 25 mg bid Koch et. al found that 62 % of pts reported improved. Frequency decreased from 22.8 h/a per month to 7.2 h/a per month. Severity decrease from 8.1 to 3.7. First pilot study of 21 pts, ages 6-18, to look at children with chronic daily headaches. 7

8 NSAIDs Calcium Channel Blockers Antihistamine 5-H2 antagonist Alpha 2 adrenergic agonist Leukotriene antagonist Naproxen (Naprosyn) Rofecoxib (Vioxx) Verapamil Cyproheptadine (Periactin) Tizanidine (Zanaflex) Montelukast sodium (Singulaire) mg bid 25 mg/day 240 mg/day Inhibits release and effectiveness of NE in brainstem (ie locus ceruleus) and spinal cord. Recent study presented at the AAN meetings showed superior efficacy over placebo for chronic daily headache. Titrate upward from 2 mg at bedtime to maximum of 18 mg divided tid over 4 weeks. Follow LFTs. Recent report of 5-10 mg per day showed improvement in chronic daily headache. Non-pharmacologic Approaches Alteration of diet, sleep pattern, activity Biofeedback training Relaxation training Cognitive Behavioral Therapy Operant Behavior Therapy Comments Helpful when a trigger has been identified Meditation, hypnosis, guided imagery Focuses on the relationships between cognition, feelings, and behaviors, and how these parameters contribute to the experience of migraine. Differs from operant behavior in that it focuses on techniques to manage pain before it becomes severe, such as specific behaviors to assume at the time of symptoms. Decrease the operant reinforcers for pain behaviors, while increasing reinforcements for healthy behaviors. Generally reserved for more functionally disabled patients who have a significant psychosocial component to their migraine experience. 8

9 Acupuncture Homeopathy, herbs & vitamins Botulinum toxin injections Based on a concept of vital energy called qi. Well-being depends on the harmonious flow of qi, while pain is the result of an imbalance of qi. Acupuncture aims to restore the appropriate balance by stimulating specific points arranged along energy meridians in the body. Feverfew B2 (Riboflavin) 400 mg/d B6 (Pyridoxine) mg/d Mg supplements mg of elemental mg Efficacy still not established 9

10 10

11 ACUTE TREATMENT OF MIGRAINE (From: The treatment of migraine involves three important strategies: behavioral and educational intervention (see table below), symptomatic (acute) therapies, and preventive considerations. All three approaches need to be employed for successful management of migraine. Behavioral Approach to Migraine Management Go to bed and wake up at the same time seven days a week. Get 8 to 9 hours of uninterrupted sleep each night. Instead of sleeping in on weekends, awaken at the usual time, get out of bed, walk around the house for 10 minutes, drink some juice, and then go back to bed. People who sleep in on weekends will likely develop "hangover headaches" from excessive sleep. Avoid working long hours or irregular shifts. Limit caffeine consumption to less than 240 mg a day. This is equivalent to two cups of coffee or two caffeinated sodas daily. Consumption should be progressively reduced at a rate of one cup a day per week. Thus, if one is drinking 10 cups of caffeine a day, it will take eight weeks to reduce caffeine consumption to two cups daily. Caffeine is also found in certain drugs, such as Excedrin. Taking two Excedrin migraine tablets is the equivalent of drinking two cups of coffee. Many weekend headaches are due to caffeine withdrawal. If one drinks coffee on weekdays, drinking a cup of coffee on weekends may stop caffeine withdrawal headaches. Do not skip or delay meals. Eat three meals daily, all at a scheduled time. Most migraineurs do not wake up hungry. During the migraine prodrome, patients may lose their appetite, but hunger may trigger a migraine. Do not smoke. Exercise five days a week by walking 30 minutes each day. This stabilizes pain receptors in the brain and may limit the weight gain experienced by patients taking some preventive medications. Use symptomatic headache medications only twice weekly. Patients with menstrual migraine may use daily symptomatic medications as described below. Avoid known headache triggers, especially during a prodrome. For example, if drinking red wine triggers migraine, avoid drinking wine during a prodrome or during a vulnerable time such as menstruation. Practice relaxation exercises, such as biofeedback or yoga, on a regular basis, especially during a prodrome. For thermal biofeedback, a thermometer is taped on the index finger and the

12 wine during a prodrome or during a vulnerable time such as menstruation. Practice relaxation exercises, such as biofeedback or yoga, on a regular basis, especially during a prodrome. For thermal biofeedback, a thermometer is taped on the index finger and the temperature of the finger is recorded. Migraineurs usually have a finger temperature below 80 F, whereas non-migraineurs typically have a finger temperature around 85 F. (Many migraineurs complain about chronically cold hands and feet.) By relaxing, practicing deep breathing, and listening to soft music for 10 minutes twice daily, a migraineur can increase his or her finger temperature. A goal of 96 F should be set. Once this has been attained, the body will have learned to replace the fight-or-flight response with the relaxation response. In this way, the number and severity of headaches decrease significantly. Research has indicated that thermal biofeedback is as effective in preventing migraine attacks as propranolol. Have a written plan for treating your migraine attacks. Do not vary from the plan unless authorized to do so by your physician. Keep a detailed headache diary, which is useful in assessing the efficacy of treatment and identifying specific migraine triggers. Acute intervention strategies vary, depending on the severity of the headaches. Mild, intermittent headaches may respond well to over-the-counter medications or anti-inflammatory drugs such as naproxen and ibuprofen. For best efficacy, these drugs should be used as early as possible after the onset of mild headache. Patients may prevent their acute migraine by recognizing their prodrome and treating themselves with naproxyn 500 to 750 mg. In addition, relaxation therapy and thermal biofeedback may be practiced during the prodrome. Patients who recognize a prodrome may also use naratriptan or frovatriptan to preempt a migraine attack. If they use naratriptan in advance of the onset of headache, during the prodrome, patients can usually abort the headache before the pain begins or they may experience a headache of much less intensity. The first migraine-specific drug, sumatriptan, was released in Until that time, migraine was treated with a variety of drugs, including ergotamines, which had many side effects and were difficult to use. The triptans are all excellent drugs. They rapidly eliminate pain while restoring patients to normal function. Studies have consistently demonstrated that triptans are the preferred symptomatic drug class of migraine patients. The table below lists the currently available triptans, their maximum daily s, and the period of time that must elapse before the can be repeated for headache recurrence. 2

13 Guide to Triptan Therapy Drug Dose Repeat Maximum /24 hrs sumatriptan oral tabs mg 2 hrs 200 mg sumatriptan nasal spray 5 and 20 mg 2 hrs 40 mg sumatriptan injection 6 mg 1 hr 12 mg zolmitriptan tabs mg 2 hrs 10 mg zolmitriptan ZMT 2.5 mg 2 hrs 10 mg zolmitriptan nasal spray 2.5 mg 2 hrs 10 mg rizatriptan tabs* 5 and 10 mg 2 hrs 30 mg naratriptan 1 and 2.5 mg 4 hrs 5 mg almotriptan 6.25 and 12.5 mg 2 hrs 25 mg frovatriptan 2.5 mg 4 hrs 5 mg eletriptan 20 and 40 mg 2 hrs 80 mg *If patient is taking propranolol, only a 5-mg should be used. Triptans are believed to alleviate migraine by several mechanisms. By binding to 5HT-1D receptors, triptans stop the release of neuropeptides at the trigeminal vascular junction. The cerebral meningeal vessels contain 5HT-1B receptors, which when triggered will produce sterile inflammation. The triptans bind to these receptors and stop the sterile inflammation of meningeal arteries. In addition, triptans may act on central 5HT-1D receptors to limit pain transmission and associated migraine symptoms, such as nausea, vomiting, light and sound sensitivity, and cognitive impairment. The most common side effects with the triptans are tingling, flushing, fatigue, and feeling warm. Chest tightness occurs occasionally and is thought to be noncardiac in origin. The table below lists "triptan pearls" that will improve the clinical efficacy of these drugs. 3

14 Triptan Pearls Early intervention with a triptan will often result in a more rapid reduction of headache pain and return to normal function. Treating headache during the mild pain phase will allow the patient to become pain-free within two hours 80% of the time versus only 36% of the time if a triptan is used during the moderate to severe headache phase. Mild-phase treatment also will lessen the likelihood of headache recurrence and limit the drug's side effects (such as paresthesias, throat discomfort, flushing, fatigue, and chest pain). Once allodynia develops, triptans may be less effective in stopping a migraine attack. Patients should experience significant pain relief within two hours of taking a triptan. The exceptions to this rule are naratriptan and frovatriptan, which may not reduce headache for four hours after dosing. Redosing of a triptan is advised if the headache is not improved after two hours (after four hours with naratriptan and frovatriptan) or if the headache resolves and then recurs within 24 hours. If a second is used, 90% of patients will have complete relief within four hours. Triptans should be used to treat at least three migraines before trying a different drug. Failure with one triptan does not imply that the patient will not find relief with one of the other triptans. Patients taking propranolol for migraine prophylaxis should reduce a single of rizatriptan to 5 mg and a total in 24 hours to 15 mg. Individuals taking a different beta blocker need not reduce the. If a patient's headache worsens after taking a triptan, try reducing the initial by 50%. Patients who are most disabled by their headaches should be prescribed a triptan before trying drugs that are not as migraine-specific (such as combination drugs, OTC analgesics, NSAIDs, and ergotamines). A headache diary is very helpful in assessing the efficacy of triptan therapy during the course of multiple migraine attacks. Migraineurs who experience nausea may add metoclopramide 10 mg to their oral treatment regimen. Adding an NSAID to a triptan may improve the efficacy of the triptan and prevent a postdrome phase during which the patient feels fatigued and has memory problems for 24 hours after the migraine resolves. If a patient receives a limited number of triptans per month from a third-party payer for frequent migraines, using an NSAID, such as naproxen 500 to 750 mg, at the onset of mild

15 feels fatigued and has memory problems for 24 hours after the migraine resolves. If a patient receives a limited number of triptans per month from a third-party payer for frequent migraines, using an NSAID, such as naproxen 500 to 750 mg, at the onset of mild headache may stop the pain within two hours. If the headache persists or worsens, a triptan can then be used. This "stagedcare approach" may reduce the number of triptans a patient needs each month. All of the triptans are highly effective in the acute treatment of migraine and are similar in their mechanism of action. However, some triptans have qualities that distinguish them from other drugs in their class. When prescribing a triptan, one should keep in mind certain objectives for treatment outcome: Patients should be pain-free within two hours of using the triptan. Patient should not experience a headache recurrence within 24 hours once they have become painfree. Patients should be able to return to full function within two to four hours after taking the triptan. Patients should be able to use the triptan without experiencing any significant adverse effects. 5

16 Rescue Medications Rescue medications can be given to patients who for whatever reason fail to find relief from acute migraine with triptans or ergotamines. Commonly used rescue medications and dosages are listed in the table below. These medications can also be used an alternative to migraine treatment in the emergency department. Migraine Rescue Medications Drug sumatriptan chlorpromazine prochlorperazine droperidol depakon Dose/Route 6 mg subcutaneously 12.5 mg slow IV push q 20 min (maximum 50 mg) 10 mg slow IV push 2.5 mg slow IV push q 30 min (maximum 7.5 mg) 1 gram IV push over 1 min magnesium sulfate 1 gram IV push over 1 min DHE45 + prochlorperazine dexamethasone Mix DHE45 1 mg plus prochlorperazine 10 mg. Give 1.5 ml slow IV push over 1-3 min. 6-8 mg IV push methylprednisolone mg IV push olanzapine 5-10 mg PO Patients may also respond to an occipital nerve block, in which bupivacaine 0.5% 4 ml and triamcinolone 40 mg (1 ml) are injected into the occipital notch. The injection is performed using a 21-gauge needle at the ipsilateral occipital notch. Palpation of the occipital notch may be very uncomfortable for the patient. After the injection, the patient's scalp may become numb for four to six hours, after which the pain begins to subside. An occipital nerve block can be useful in post-traumatic migraine (from whiplash, for example), pregnancy, occipital neuritis, chronic daily headache due to analgesic abuse, new daily persistent headache, and status migrainosus. Intravenous (IV) magnesium sulfate can also be given to patients with intractable migraine. We recommend using 1 gram, given IV push, over 30 to 60 seconds. Patients will develop a significant hot flash lasting up to a minute. However, as the hot flash ends, patients often note that their headache intensity is much improved and their symptoms are reduced. Up to 80% of patients note immediate improvement in their headaches, which often lasts for 24 hours or longer. 6

17 Understanding Migraine: Strategies for Prevention One of the most important contributions primary care can make in managing migraine is to prevent the evolution of the episodic syndrome of migraine into the biopsychosocial disease of chronic migraine. As with acute therapy, early interventions with education, lifestyle changes, and medications can prevent significant disability for this population of patients and decrease the impact of migraine on the health care system and society in general. Thus, migraine prevention is a critical component of care for the migraine patient. Indications for Using Migraine Prophylactic Medications Patients requiring symptomatic treatment more than two days a week or eight days a month Headaches that occur more than twice a week Headaches that continue to be disabling and interfere with the patient's quality of life despite appropriate abortive treatment Patient has contraindications for using abortive medications such as triptans and ergots Patient has history of complex auras, migraine with stroke, or prolonged auras Patient needs to use rescue medications more than once a month Patient has an evolving comorbidity such as depression, panic disorder, or sleep disturbance Migraine prevention can lessen the number, intensity, and duration of attacks. In addition, the efficacy of symptomatic medications is often enhanced when prophylactic drugs are employed. The indications for using migraine preventive therapy are listed in the table above and the specific prophylactic drugs that are helpful in limiting migraine attacks are listed in the table below. 7

18 Migraine Prophylaxis Medication Dosing range Beta blockers propranolol mg/day nadolol mg/day atenolol mg/day Common adverse effects Cold hands, fatigue, shortness of breath (asthma) Calcium channel blockers verapamil mg/day amlodipine mg/day Flushing, ankle edema, constipation Antiepileptic drugs valproate valproate ER gabapentin topiramate mg/d mg/d mg/d mg/day Hair loss, weight gain (except weight loss with topiramate), tremor, heartburn, paresthesias Tricyclic antidepressants amitriptyline mg/day nortriptyline mg/day doxepin mg Weight gain, fatigue, dry mouth, arrhythmias, blurred vision, urinary hesitancy Serotonin reuptake inhibitors sertraline mg/d fluoxetine mg/d venlafaxine mg/d paroxetine mg/d Tremor, weight gain, sexual erectile dysfunction (anorgasmia) Atypical antipsychotic olanzapine 5-10 mg/d Weight gain, drowsiness Nonprescription drugs magnesium mg at bedtime Diarrhea 8

19 melatonin riboflavin 5-10 mg at bedtime mg/day Nightmares PROPHYLACTIC MEDICATIONS The choice of prophylactic medications depends largely on the presence of coexisting disorders. For example, consider a selective serotonin reuptake inhibitor (SSRI) or tricyclic antidepressant (TCA) in depressed patients. Atypical antipsychotics or an antiepileptic medication may be useful for patients with migraine and bipolar depression. Patients with sleep disturbances and those who frequently awaken with migraine should do well with a TCA. If a patient has hypertension, calcium channel blockers or beta blockers are helpful. Patients who prefer to take nonprescription medications can be placed on melatonin, magnesium, feverfew, or riboflavin. Antiepileptic drugs. These drugs have become popular choices recently for migraine prophylaxis. Antiepileptic drugs decrease migraine frequency, intensity, and duration at much lower s than those used to treat seizure disorders. Side effects are not uncommon, however, and should be discussed with patients before the drugs are prescribed. Common adverse effects associated with divalproate sodium include weight gain, hair loss, gastric reflux, tremor, and potential neural tube defects if the drug is used during the first 15 weeks of pregnancy. Adverse effects associated with topiramate include paresthesias, memory impairment, language disturbances, and, rarely, visual disturbances (including glaucoma), and kidney stone formation. Topiramate can cause weight loss rather than weight gain and may be the drug of choice for obese patients with migraine. Topiramate should be prescribed at a low starting (25 mg) and titrated slowly to a of 100 to 200 mg. The effective for divalproate sodium is 500 to 1000 mg daily. Tricyclic antidepressants. When taken in low s two hours before bedtime, TCAs may be helpful in treating migraineurs who have sleep disturbances, anxiety, and depression. Side effects, such as dizziness, weight gain, blurred vision, and sexual dysfunction, become more problematic as the increases. Selective serotonin reuptake inhibitors. While SSRIs have not been shown to be beneficial in migraine prophylaxis, patients with coexisting anxiety and depression are often placed successfully on these drugs and may note improvement in their migraine management. Side effects include difficulty with ejaculation, anorgasmia, tremor, and gastrointestinal distress. Patients taking triptans can safely use SSRIs concomitantly. Beta blockers and calcium channel blockers. Beta blockers are well tolerated and effective in migraine prevention. Side effects include fatigue, cold hands, and, in patients with asthma, shortness of breath. Nadolol is preferred by many clinicians because titration is not usually necessary. Although calcium channel blockers have been used for migraine prevention, evidence-based studies suggest they may have greater efficacy in cluster headache patients than in migraineurs. Magnesium. This over-the-counter drug is helpful in decreasing many types of pain syndromes. It should be used in s of 250 to 750 mg. Side effects may include diarrhea. Plain magnesium should be used. Combinations of magnesium with calcium and zinc are not helpful. Melatonin. This drug has recently been advocated for use in patients who awaken from sleep with various headache disorders, especially cluster headaches. We have been using melatonin at a of 10 to 15 mg taken at bedtime to prevent migraine headaches that awaken patients from sleep. Although no published data is available on melatonin use for migraine, the drug is safe and appears to eliminate up to 60% of nocturnal migraine. The most common side effect with melatonin appears to be bad dreams and difficulty sleeping for the first two or three nights of use. Aspirin. At a of 325 mg, aspirin has been shown to reduce the incidence of migraine in male patients. It should be prescribed prophylactically to patients having migraine with aura. For patients who are obese, smoke cigarettes, have migraine with aura, or take birth control pills, the risk of migrainous stroke is quadrupled. Aspirin is also helpful in preventing retinal migraine, a form of migraine that occurs in older women who experience an aura but no migraine pain. 9

20 Riboflavin. This drug may be used in patients who prefer taking an alternative medication. The recommended is 200 to 400 mg daily. No side effects have been reported, but the drug may take two to five months to take effect. Unlike abortive medications for migraine, prophylactic drugs may take several days or weeks to become effective. Low s are usually very successful in limiting migraine attacks and side effects. Prophylactic drugs should be taken consistently at the same time each day. Once a patient responds well to prophylactic intervention, the drug should be continued for at least six months. The patient and physician can then discuss whether or not to taper off the medication or continue it, possibly at a lower. Botulinum toxin A (Botox). This is a new therapeutic option for the preventive treatment of migraine and chronic daily headache, especially headaches that are refractory to other treatments. The drug is injected into the muscles of the face, head, and neck in s of up to 100 units every three to four months. Botox has been shown to reduce the need for multiple preventive medications, to reduce the frequency of triptan use, and to minimize the frequency of headacherelated emergency department and office visits. Side effects of Botox include mild pain and bleeding at the injection sites, possible worsening of the headache condition, drooping eyelid, and dry mouth. Some patients may experience aching in the injected muscles. Physicians who have used Botox since 2000 report a success rate of 75% in patients for whom conventional forms of treatment have failed. Success is defined as a 50% reduction in the frequency, duration, and intensity of headaches. The exact mechanism of action of Botox is unknown. The neurotoxin may reduce the release of neuropeptides within the trigeminal vascular system. These neuropeptides are known to potentiate the migraine process. Patients are injected with Botox in muscles of the eye area, nose area, forehead, sides of the head, and neck. Many migraineurs report tenderness in these muscles during an acute migraine attack. Physical examination may reveal tender, knotted muscle tissue in these areas. Each muscle is injected with between 2.5 and 5 units of the neurotoxin, resulting in a total of 18 to 24 separate injections. Two different injection strategies are used. In the so-called fixed-site pattern, the muscles in the face and sides of the head receive the neurotoxin. If the patient experiences frequent neck pain in association with the headaches, a "follow the pain" approach can be used and additional neck injections are performed. Often a combination of the two injection techniques is employed. After the injections, most patients notice improvement in their headaches within three to seven days. The effects of the neurotoxin will last for three to five months, after which the headaches commonly recur. As more injections are administered, however, the efficacy of the drug often improves. Patients should receive injections every three months unless their headaches stop completely. The table below lists the indications for use of Botox injections. Indications for Use of Botox Injections Patients experiencing neck or jaw spasm Patients with headache originating in the cervical spine Patients who have failed standard preventive medications Patients who have side effects with standard preventive medications Patients who, for whatever reason, prefer not to take standard preventive medications Patients who prefer to receive Botox injections 10

21 Patients who prefer to receive Botox injections Treatment of Status Migrainosis Migraine status is defined as migraine that lasts greater than 72 hours. In these situations, it is necessary to use DHE intravenously. Normally, attempts are made to control the headaches on an outpatient basis for hours, but if the medications are continuing to fail, DHE is an appropriate course of treatment. Articles have been published outlining the use of DHE in adolescents and children in inpatient and outpatient settings. Before initiating the protocol, a detailed history, physical examination and neurological examination are necessary to define the situation clinically. Dihydroergotamine Protocol Age (y) Antiemetic Dose (mg/kg) DHE (mg/) 6-9 Metoclopramide Metoclopramide Metoclopramide For prolonged vascular headache, repeat oral metoclopramide and IV DHE every 6 hours for maximum of 12 s. When the headache ceases, give 1 additional. The DHE may be increased by 0.05 mg/ to the point where the patient has mild abdominal discomfort. The antiemetic is administered orally 30 minutes before the administration of the IV DHE; maximum of metocopramide is 15 mg. If EPS occur, give benadryl 1 mg/kg (maximum 50 mg) and discontinue metoclopramide. For subsequent treatments, administer ondansetron HCL 0.15 mg/kg IV or orally, 30 minutes before DHE. If significant myofacial component, use IV Ketorolac 5-15 mg every 6 hours alternating with DHE. 11

22 DHE Protocol for Adults Metaclopramide 10 mg IV DHE 0.5 mg IV (over 2-3 minutes) Nausea Head pain persists; Head pain stops; No nausea No nausea No DHE for 8 hours then give 0.3 or 0.4 mg q 8 hrs Repeat DHE 0.5 mg IV DHE 0.5 mg IV for 3 days plus metoclopramide 10 mg in one hour q 8 hrs plus (without Metoclopramide) metoclopramide 10 Nausea No Nausea DHE 0.75 mg q 8 hrs for 3 days plus Metaclopramide 10 mg DHE 1.0 mg q 8 hrs for 3 days plus Metoclopramide 10 mg 12

23 Internet Sites for Pediatric Headaches National Headache Foundation: Headaches and Children Good resource for information about the cause and treatment of tension and migraine headaches in children. Information addresses the needs of parents, but health care professionals may find it a good refresher. The Migraine Association of Canada Canadian-based site for migraines, geared at children. A starting point for parents and children to work together to learn about migraines. The American Association for the Study of Headaches: Kids Get Headaches too! Possibly the best pediatric headache site online. Detailed information for parents and their child. Good review information for the health care professional. KidsHealth.org: What to do when your child has a headache A three page summary for patients with pediatric headaches. Good pamphlet to give patients wanting more information. The International Classification of Headache Disorders, 2 nd Edition-R Classification and coding for all headache disorders. 13