Kids get headaches too! Evaluation and treatment of the pediatric headache

Transcription

1 3:45 4:25pm Approach to the Child with Headaches SPEAKER Jason T. Lerner, MD Presenter Disclosure Information The following relationships exist related to this presentation: Jason T. Lerner, MD: No financial relationships to disclose. Off-Label/Investigational Discussion In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. Kids get headaches too! Evaluation and treatment of the pediatric headache Jason T Lerner, MD Assistant Professor Director, Pediatric Neurophysiology Lab Director, Child Neurology Residency Program April 10, 2015 Learning Objectives Define basic headaches in children using the most recent International Headache Society recommendations Review the conventional headache therapies available for children Analyze the most recent literature on alternative therapies for headaches Integrate a variety of lifestyle changes into your patient s headache treatment plan 1.1 Migraine Without Aura 1.2 Migraine with aura A. At least 5 attacks B. Headaches last 4-72 hours (pediatrics = 1-72 hours) C. Headaches have at least 2 of: A. location = unilateral (commonly bilateral in children B. quality = pulsating and frequently frontotemporal) C. severity = moderate to severe D. worsened by or prevents routine physical activity D. During headaches at least 1 of: A. nausea and/or vomiting B. photophobia or phonophobia (can be inferred by behavior) (IHS 2013) A. At least 2 attacks B. 1 or more of the following fully reversible symptoms: A. visual, sensory, speech and/or language, motor, brainstem, retinal C. At least 2 of the following 4: A. at least one aura symptom develops gradually over >5 minutes or 2 or more symptoms occur in succession B. each symptom lasts 5-60 minutes C. at least 1 aura symptom is unilateral D. aura is accompanied or followed by a headache within 60 minutes (IHS 2013)

2 2.1 Infrequent episodic tension-type headache A. At least10 episodes occurring on >1 day per month average B. headache lasting 30 minutes to 7 days C. headache has at least 2 of the following characteristics: A. bilateral location B. pressing/tightening (non-pulsating) C. mild to moderate intensity D. not aggravated by routine physical activity D. both of the following A. no nausea/vomiting B. no more than one of photophobia or phonophobia (IHS 2013) Epidemiology Mean age boys = 7 years girls = 11 years age preschool school age adolescents prevalence 1 3% 4 11% 8 23% sex ratio M > F M = F F > M In adolescence 27% of girls and 20% of boys describe frequent headaches 8% of girls and 5% of boys have had a migraine in the last year The overall prevalence of migraine is equal to the combined prevalence of asthma and diabetes (Blume, 2012) Prognosis reviewed 60 patients 20 years after initial diagnosis 73% continued to have headaches 33% had tension type 17% had migraine 23% had mixed migraine and tension type 66% reported improvement 70% were using nonprescription medications 14% were using prescription medications 45% believed nonpharmacologic methods were most effective (Brna, 2005) Prognosis Similar study recently followed 28 patients over 30 years and also found 70% continued to have headaches (Dooley, 2014) Prognosis study 195 students form an elementary school prevalence of headaches = 97% 51% migraine 33% tension type Migraine and more severe headaches associated with lower quality of life More severe headaches associated with lower grades in school (Rocha-Filho, 2014) Pathophysiology Cortical spreading depression (CDS) cortical hyperexcitability followed by suppression originated & migrated slowly over the surface of the brain (3-4mm/minute) change in blood flow seen is a result of the CDS (Reddy 2013) Pathophysiology Inflammation calcitonin gene related peptide substance P neurokinin A Susceptibility thought to be modulated by genetic factors environmental factors sleep dysfunction certain foods stress transient hypoxic events (PFO) (Reddy 2013)

3 Diagnosis - Imaging Diagnosis Lumbar Puncture CT or MRI should be considered if: recent onset of severe headache chronic progressive headache change in type of headache abnormal neurologic exam focal findings increased intracranial pressure altered consciousness concurrent seizures LP is indicated if there is any concern for increased intracranial pressure inflammatory disease infiltrative disease infective process Always get an opening pressure! 4 primary ways of treating headaches 1. Lifestyle changes 2. Pharmacologic interventions 1. abortive 2. preventive Treatment Options 3. Complementary and alternative interventions 4. Bio-behavioral modalities Exercise (Physical Activity Guidelines for Americans) Stress 60 minutes of physical activity per day vigorous aerobic activity 3 days per week Muscle strengthening 3 days per week Bone strengthening 3 days per week Avoid stress 2 common stressors reported by teens Sport performance Acceptance to college Homework After school activities (

4 Diet Overall healthy diet Eat at regular intervals 3 meals daily snacks NEVER SKIP MEALS Identify food triggers chocolate, citrus fruit, aged cheese, red wine processed meats, yogurt, fried food, aspartame, monosodium glutamate Fluid Intake Drink 2-3 liters of fluid per day (approximately 4 small bottles) Increased intake over the summer and during sports Caffeine May be beneficial in aborting a migraine Linked to sleep & mood disturbance May cause rebound headaches Can be a trigger Sleep Hygiene 8-10 hours per night scheduled bed time and wake up time weekends wake up at regular time, have a snack and go back to sleep quiet routine before bedtime white noise machine use the bedroom for sleeping screen for sleep disorders Keys to using abortive medications Must be taken early (1 st 20 minutes) Use appropriate doses Abortive Medications Should be available where headaches occur

5 NSAIDS ibuprofen naproxen sodium intravenous migraine cocktail in the ER ketorolac prochlorperazine diphenhydramine Triptans Agonist on serotonin receptors Cranial Blood Vessels vasoconstriction inhibition of pro-inflammatory neuropeptide release Nerve Endings decreases release of calcitonin gene-related peptide and substance P Triptans Triptans Adverse effects chest pressure/tightness flushing dizziness, lightheadedness, drowsiness coronary vasospasm serotonin syndrome mental status changes, autonomic instability, neuromuscular abnormalities, gastrointestinal symptoms Contraindications vascular disease, uncontrolled hypertension, basilar migraine, pregnancy Generic ½ life Recurrence Approved Misc rizatriptan 2-3 hrs 40% > 6 years almotriptan 3-4 hrs 25% > 12 years -oral dissolvable tablet sumatriptan 2 hrs 33% some efficacy -multiple formulations zolmitriptan 2-3 hrs 31% some efficacy eletriptan 3-5 hrs 24% -helps with nausea and photophobia naratriptan 5-6 hrs 23% frovatriptan 26 hrs 17% -may be effective later in the headache Antiepileptics topiramate useful in obese patients FDA approved for migraine prophylaxis in adolescents years-old March 2014 Preventive Medications gabapentin # patients with other chronic pain valproic acid # patients with conduct disorder may not be not good for obese patients and teens # = off label use

6 Antihypertensives Antidepressants beta blockers propranolol metoprolol Ca + channel blockers # verapamil nimodipine ACE inhibitors # lisinopril little data in children Tricyclic antidepressants # amitriptyline patients with depression or sleep difficulties nortriptyline may be less sedating Selective serotonin reuptake inhibitor # venlafaxine some data in adults # = off label use # = off label use Others Antihistamines # cyproheptadine sedating NMDA receptor antagonist # memantine good for Alzheimer s disease Botox # small study in adolescents Complementary & Alternative Medicine # = off label use Complementary and Alternative Medicine in Children Physical Treatments years old with recurrent headaches 30% used CAM 40% + other chronic conditions or difficulties in daily function Day Care setting in Germany 75% received some form 58% received a combination informed the physician 50% of the time! Used to relieve neck pain Muscle tenderness Poor posture Studies are difficult to perform Types physical therapy massage therapy chiropractic care (Bethell 2013, Weissenstein 2013)

7 Acupuncture Used for 3,000 years one of the most commonly used therapies goal is to restore a state of equilibrium by removing blockages in the flow of blood and qi. Mechanisms activation of the nervous system structures in the control of pain perception anti-inflammatory effects Nutritional Supplements & Botanical Therapies There is some literature indicating effectiveness in children Magnesium Magnesium deficiency in Mg has been associated with cortical spreading depression platelet aggregation vasoconstriction neurotransmitter release inflammatory mediators (substance P) seen in women with menstrual related migraine Dosing 400 mg per day oral magnesium citrate can be used for abortive (1gm in adults) Adverse effects diarrhea caution in patients with kidney disease magnesium toxicity (loss of deep tendon reflexes, muscle weakness, respiratory paralysis) (Gallelli, 2013) (Gallelli, 2013) Vitamin B2 (riboflavin) Vitamin B2 (Riboflavin) found in milk, dairy products, beef, liver, eggs typical multivitamins has 12.5mg based on the idea that impairment of oxygen metabolism may contribute to the development of migraine attacks Handful of successful studies (mainly in adults) as successful as beta blockers in a head to head study Dosing 200mg daily x 1 month then 400mg daily x 2 months Adverse effects nausea (improves with time) (Sandor, 2000) (Sandor, 2000)

8 Butterbur (Petasites hybridus) measured CoQ10 levels in 1550 patients (3-22 years old) 33% were below the reference range given 1-3 mg/kg/day supplements (liquid gel capsule) results overall levels improved headache frequency dropped from 19 12/month headache disability improved significantly Perennial shrub found throughout Europe and parts of Asia Traditional remedy for pain, fever, spasms and wound healing Mechanism Calcium channel regulation inhibition of peptide leukotriene biosynthesis influencing the inflammatory cascade side effects GI disturbance and cutaneous allergy have been reported in adults but not children (Hershey, 2007) Butterbur (Petasites hybridus) Melatonin Adverse effects mild GI symptoms hepatotoxic components of the plant Only CAM therapy with multiple Class I trials (children & adults) showing effectiveness used 0.3mg/kg melatonin showed improvement in headaches frequency severity duration adverse effects sleepiness (daytime) vomiting mild hypotension constipation (Fallah 2014) Biobehavioral Therapies Summary Counseling & Guidance Relaxation techniques Biofeedback Cognitive behavioral therapy Grade A evidence by US Headache consortium can decrease tension type headache by 40-50% Pediatric headaches (migraine and TTH) are fairly common Counseling is essential (headache diary) Traditional abortive and prophylactic medications CAM therapies Nutritional supplements & herbals Biobehavioral therapies

9 References Bethell et.al. Complemetary and conventional medicine use among youth with recurrent headaches. 2013, Pediatrics 132;5: Blume HK. Pediatric headace: A review Pediatrics in Review 33;12: Brina et.al. The prognosis of childhood headache Arch Pediatr Adolesc Med 159: Fallah et.al. Safety and efficacy of melatonin in pediatric migraine prophylaxis Curr Drug Saf. Gallelli et.al. Effects of acetaminophen and ibuprofen in children with migraine receiving preventive treatment with magnesium. 2013, Headache 54;2: Hershey et.al. Coenzyme Q10 deficiency and response to supplementation in pediatric and adolescent migraine 2007 Headache 47: HIS Headache Classification Committee. The International Classification of Headache Disorders, 3 rd edition (beta version) Cephalagia 33(9) Matarese et.al. Management considerations in the treatment of migraine in adolescents Adolesc Health Med Ther 1: Reddy DS. The pathophysiological and pharmacological basis of current drug treatments of migraine headache 2013 Expert Rev Clin Pharmacol 6(3): Sandor et.al. Prophylactic treatment of migraine with beta-blockers and riboflavin: Differential effects on the intensity dependence of auditory evoked cortical potentials. 2000, Headache 40: Schetzek et.al. Headache in children: update on complementary treatments. 2013, Neuropediatrics 44: Sun-Edelstein C et.al. Alternative headache treatments: nutraceuticals, behavioral and physical treatments Headache Weissenstein et.al. The role of complementary medicine in a pediatric day center in Germany Forsch Komplementmed 20;4: