Novel Treatments for Pediatric Headache

Transcription

1 Novel Treatments for Pediatric Headache Deanna Duggan, MS, RN, CPNP-PC, PMHS Headache Clinic Blue Bird Circle Clinic for Pediatric Neurology- West Campus Amanda Jones, MSN, RN, CPNP-PC Blue Bird Circle Clinic for Pediatric Neurology

2 Conflicts of Interest None

3 Objectives 1. Recognize primary versus secondary headache types 2. Identify treatment modalities relevant to headache types 3. Familiarize anatomy of the head and neck with migraine and cervicogenic headaches 4. Analyze clinical outcomes of occipital nerve block injections used in children and adolescents with chronic headache types at Texas Children s Hospital

4 Overview Accurate diagnosis is key International Headache Society Classification Primary headaches Secondary headaches

5 Examples of headache types described in ICHD-2 Part I: The Primary Headaches Tension-type Headache Migraine (with or without aura) Chronic Migraine Cluster Headaches and other Trigeminal Autonomic Cephalalgias Part II: The Secondary Headaches Headache Attributed to Head or Neck Trauma Acute Post-Traumatic Headache Chronic Post-Traumatic Headache Acute Headache Attributed to Whiplash Injury Post-craniotomy Headache Medication Overuse Headache Cervicogenic Headache Part III: Cranial Neuralgias, Primary and Central Causes of Facial Pain Occipital neuralgia

6 History/symptomatology Characteristics of the headache pain Radiation of pain Consider other disorders or triggers Is there a history of trauma? Mechanism of injury Aggravating factors/triggers Physical and Neurological exam (incl. fundoscopy) Consider neuroimaging

7 Management Options Pharmacological treatment Abortives: NSAIDS, Antiemetics including antidopaminergics,triptans, muscle relaxers Daily preventatives: Supplementation amitriptyline, topiramate (Topamax), propranolol, gabapentin, SSRIs coenzyme Q10, riboflavin, chelated magnesium, vitamin D Herbals: Butterbur root extract (petasites hybridus), feverfew (tanacetum parthenium) Ancillary treatments Physical Therapy: Massage, TENS Psychology: Biofeedback, Cognitive Behavioral Therapy Alternative treatments Chiropractic Acupuncture Yoga

8 Innovative/Experimental treatments Peripheral nerve block and trigger point injections Onabotulinumtoxin A (Botox) per chronic migraine protocol Radiofrequency ablation Cervical C2 and C3 (unilateral or bilateral) Facet block Occipital nerve decompression Neuromodulation: Occipital nerve stimulator Transcranial magnetic stimulation (TMS) Sphenopalatine ganglion stimulation Vagus Nerve stimulation Hypothalamic deep brain stimulation

9 Physical Exam of Headache Patient General Neuro Exam General appearance Cranial Nerves Motor Sensory Reflexes Coordination Gait Additionally Palpate: Sinuses Temporal region (trigger points) Temporal mandibular joint Occipital nerve distribution Neck Shoulders Spine Range of Motion of head/neck Listen for carotid bruit

10 Anatomy and Physiology of Headaches

11 Musculoskeletal Cervicogenic headaches are commonly associated with tenderness in the large superficial muscle groups of the neck and shoulders

12 Musculoskeletal

13 Nerves

14 Trigeminal Nerve Branches V1 = Ophthalmic Lacrimal Frontal Supraorbital and Supratrochlear Nasociliary V2 = Maxillary V3 = Mandibular emedicine

15 Cervical Nerves Dorsal C1 = Suboccipital Nerve C2 = Greater Occipital Nerve * C3 = Third (Least) Occipital Nerve * Ventral C1-4 = Cervical Plexus Lesser Occipital Nerve * Greater Auricular Nerve * Transverse Cervical Nerve Supraclavicular Nerve C5-8 = Brachial Plexus

16 Literature Review

17 Peripheral Nerve Blocks and Trigger Point Injections in Headache Management A Systematic Review and Suggestions for Future Research Ashkenazi, A., Blumenfeld, A., Napchan, U., Narouze, S., Grosberg, B., Nett, R., DePalma, T., Rosenthal, B., Tepper, S., and Lipton, R.B Headache: The Journal of Head and Face Pain, 50: classified the abstracted studies based on the procedure performed and the treated condition few controlled studies on the efficacy of PNBs for headaches, and virtually none on the use of TPIs for this indication Majority of studies involved GON block, most small and non-controlled Techniques, as well as the type and doses of local anesthetics used for nerve blockade, varied greatly among studies Conditions treated also varied, and included both primary and secondary headache disorders. Trigeminal (eg, supraorbital) nerve blocks were used in few studies Results were generally positive, although there were methodological limitations of available studies The procedures were generally well tolerated need for more rigorous clinical trials to clarify the role of PNBs and TPIs in the management of various headache disorders, and standardize the techniques

18 Greater Occipital Nerve Injection (GONI) for chronic headache in children Renaudon-Smith, E, Toolis, C., Goadsby, P., Prabhakar, P., (Abstract) J Headache Pain, 2010; 11 (Suppl 1): 76. Children s headache clinic in London, UK 17 children with chronic, medication refractory migraine Age range 14 to 18 years Average duration of migraine in this cohort = 7 years Combination of methylprednisolone and lidocaine Injections administered around GON at most tender site (palpation); unilateral or bilateral(left in 15 and right in 7) Outcomes Complete resolution of headache at 2 weeks, sustained up to 12 weeks in 16/23 Partial response 2/23 No response 5/23 5 patients reported local tenderness and soreness for 3 days to 1 week 1 patient felt dizzy and unsteady (resolved), 3 patients reported increased headache up to 4 weeks. None had alopecia.

19 Outcomes of Greater Occipital Nerve Injections in Pediatric Patients With Chronic Primary Headache Disorders Gelfand, A., Reider, A., Goadsby, P Pediatric Neurology Retrospective chart review of patients < 18 years with chronic primary headache disorder undergoing first-time injection Unilateral injections, containing mixture of methylprednisolone acetate adjusted for weight and lidocaine 2%. 46 patients 35 (76%) Chronic Migraine 9 (20%) New Daily Persistent Headache 2 (4%) Chronic Trigeminal Autonomic Cephalalgia Ages 7 to 17 26% had Medication Overuse

20 Gelfand, Reider, Goadsby /cont. Results 21/40 (53%) benefitted 11/21 (52%) benefitted significantly Benefit onset ranged from 0 to 14 days, mean 4.7 with mean benefit duration of 5.4 (SD 4.9) weeks. 18/29 (62%) patients with CM benefitted 10/18 (56%) patients with CM significantly benefitted 1 patient with NDPH significantly benefitted Neither child with chronic TAC benefitted. In logistic regression modeling, medication overuse, age, sex, and sensory change in the distribution of the infiltrated nerve did not predict outcome No serious side effects

21 Peripheral Nerve Injections in a Pediatric Population

22 The Texas Children s Hospital Experience Retrospective study to evaluate the safety and efficacy of our patients who received peripheral nerve blockade for treatment of headaches **In progress, preliminary results**

23 Peripheral Nerve Block Injections LMX-4% (topical lidocaine) is applied to site prior to injection Bupivacaine 0.5% is used to block each nerve/muscle area Sites: Occipital nerves lesser/greater (1 ml) Supraorbital/supratrochlear nerves (0.5 ml) Muscle trigger points trapezius (1 ml) or temporalis (0.5 ml)

24 Preliminary Results Number of patient encounters 49 Number of patients /49 were repeat patients Average age 15.2 years (range 10-18) Female: 25 (86%) Male: 4 (14%) Number of sites injected mean 6.57 sites Range: 2-10 Most common sites injected bilateral greater occipital nerves, bilateral lesser occipital nerves, bilateral trapezii

25 Preliminary Results Continued Most patients had multiple headache types Primary Cervicogenic headaches - 94% (46) Chronic daily headaches - 31% (15) Chronic migraine - 61% (30) New daily persistent headache 2% (1) Secondary Occipital neuralgia 53% (26) Post traumatic 12% (6)

26 Efficacy of PNBI Change in pain score Number of patients Ø Average reported change in pain score 3.76 based on a scale of 0-10/10 Of note, one patient presented with a pain score of 0 thus there was no change in her pain after receiving the injections

27 Safety of PNBI One report of syncope for approximately 10 seconds following injection One report of prolonged soreness and four reports of soreness for one day after the procedure There were no allergic reactions

28 Limitations of our Study All patients are offered Diazepam 2 mg orally prior to procedure which has an anxiolytic affect and acts as a short term muscle relaxant Most of our patients are pre-medicated LMX-4 was used on all patients prior to injection which provides analgesia to site Placebo effect of procedure Study was not double-blinded Procedure is offered based on the clinical judgment of the provider Not all headache patients are offered PNB for treatment Two patients received Bupivacaine buffered with sodium bicarbonate

29 Findings Although all data is not conclusive, we have found that peripheral nerve blocks offer a rapid, safe and effective treatment option for multiple different headache types in pediatric patients

30 Areas for Future Research A double-blinded study would strengthen our findings Patients should be randomized to avoid selection bias Control group for patients who do not receive diazepam prior to procedure Duration of effect

31 References Baron, E. P., Cherian, N., & Tepper, S. J. (2011). Role of greater occipital nerve blocks and trigger point injections for patients with dizziness and headache. The Neurologist, 17, 6: doi: /nrl.0b013e318234e966 Gefland, A. A., Reider, A. C. & Goadsby, P. J. (2013). Outcomes of greater occipital nerve injections in pediatric patients with chronic primary headache disorders. Pediatric Neurology, XXX, 1-5. Guvencer, M., Akyer, P., Sayhan, S., & Tetik, S. (2011). The importance of the greater occipital nerve in the occipital and the suboccipital region for nerve blockage and surgical approaches An anatomic study on cadavers. Clinical Neurology and Neurosurgery, 113, doi: /j.clineuro Kemp, W.J., Tubbs, R.S., & Cohen-Gadol, A.A. (2011). The innervation of the scalp: A comprehensive review including anatomy, pathology, and neurosurgical correlates. Surg Neurol Int 2:178. doi: / Retrieved from Li, F., Ma, Y., Zou, J., Li, Y., Wang, B., Huang, H., Wang, Q., & Li, L. (2012). Microsurgical decompression for greater occipital neuralgia. Turkish Neurosurgery, 22, 4: doi: / JTN

32 References Continued Pisapia, J. M., Bhowmick, D. A., Farber, R. E., & Zager, E. L. (2012). Salvage C2 ganglionectomy after C2 nerve root decompression provides similar pain relief as single surgical procedure for intractable occipital neuralgia. World Neurosurgery, 77, 2: doi: /j.wneu Weibelt, S., Andress-Rothrock, D., King, W., & Rothrock, J. (2010). Suboccipital nerve blocks for suppression of chronic migraine: Safety, efficacy, and predictors of outcome. Headache, 50, doi: /j.clineuro

33 QUESTIONS?