Recurrent Headaches in Children and Teenagers. Objectives. ARS Polling Question 1

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1 Recurrent Headaches in Children and Teenagers Jean Lake, M.D. Miller Children s Hospital/Long Beach Memorial Medical Center Assistant Clinical Professor Pediatrics and Neurology UCLA School of Medicine Objectives Review major categories of recurrent headaches in children and teens Guidance with respect to work-up Diagnosis of childhood migraine and migraine variants Treatment strategies for childhood migraine: abortive and preventative ARS ARS Polling Question 1 Question#1: The following statements are true or false with respect to childhood headaches? 1. It is unusual for children to have recurrent headaches 2. The history provided by the child is often helpful in diagnosing the etiology of the headache 3. Parents often demand neuroimaging studies 4. Pharmacologic treatment for childhood migraine is well studied Answers to Question #1: 1. False - Recurrent headaches are common in childhood 2. True - Even young children can give a very helpful history and description of their headache 3. True - Parents often request imaging but there are other methods of reassurance 4. False - Pharmacologic treatments of childhood migraine have not been well studied Prevalence of headaches in Children and Teens (Lewis, et al, 2002) 37-57% of all 7 year olds 57-87% by age 15 years Conclusion: It is a myth that children should not/do not have headaches 1

2 Categories of Recurrent Headaches Secondary headaches Tension-type headaches (TTH) Migraine and migraine-variants Secondary Causes of Recurrent and/or chronic headaches in Children Sinusitis Dental Cervical muscle spasm Psychogenic Pseudotumor cerebri (rare) Brain tumors (rare) Chiari malformations (rare) Vasculitis (rare) Approach to the Pediatric Patient with Recurrent Headaches History Physical Examination Laboratory testing (Bloodwork, LP) Neuroimaging HISTORY In a prospective study of 150 children with recurrent headaches, the history provided the correct diagnosis 100% of the time (Brna, et al 2006) Always start with patient first and let parents comment and amend later. Children are surprisingly good and creative when giving a description of their headaches. Historical features which raise concern: <1 month duration (maybe even <3 months) worrisome neurologic symptoms decline in school performance behavior or personality change History, continued Pattern and frequency of headache -progressive daily raises concern of secondary HA -chronic nonprogressive and daily suggests TTH -episodic suggest migraine When do the headaches start? -AM headaches suggest mass lesions or sinusitis -migraine can also awaken from sleep -school-related headaches can be tension or migraine What does the child do during the headache? - continuing with school and play suggests TTH - aborting such activities suggests migraine Headaches which start during the school day can be TTH, but migraine is often precipitated by stress, lighting, physical exertion, dehydration and diet. 2

3 Physical Examination Blood pressure Fundoscopic Cervical paraspinous muscles Focal neurologic signs Diagnostic Studies-AAN Practice Parameters (Lewis, et al 2002) Laboratory studies (including LP) - no evidence for usefulness EEG - not useful Neuroimaging - Data on 605 of 1,275 children with recurrent headache who underwent neuroimaging revealed ony 14 (2.3%) had abnormalities requiring surgical intervention. All of these children had abnormalities on neurologic examination. Recommendations for Neuroimaging in Children with Recurrent Headaches--Practice Parameters of the AAN (Lewis, et al 2002) Not indicated if neurologic exam is normal Should be considered, however, in children when historical features are disturbing, such as recent onset headache, change in type of headache or symptoms suggestive of neurologic dysfunction Prevalence of Migraine (Lewis, et al 2002) 1-3% in 3-7 year olds (M>F) 4-11% in 7-11 year olds (M=F) 8-23% in 11->15 year olds (F>M) ars ARS Polling Question 2 Question #2: Which of the following statements are true or false with respect to the differences in diagnostic criteria between adult and childhood migraine? 1. Children tend to have shorter and longer headaches than adults 2. Localization is less specific in children 3. Associated symptoms such as photophobia and phonophobia are not seen in children 4. Childhood migraine is not disabling 3

4 Answers to question #2: Revised HIS Diagnostic Criteria for Pediatric Migraine Without Aura 1. True 2. True 3. False 4. False 1. At least 5 attacks fulfilling criteria 2 through 4 below: 2. Headache attacks lasting 1 to 72 hours 3. Headache has at least 2 of the following characteristics: (1) unilateral location, may be bilateral, frontotemporal (2) pulsing quality (3) Moderate or severe pain intensity (4) Aggravation by or causing avoidance of routine physical activity 4. During the headache, at least one of the following: (1) nausea, vomiting or both (2) Photophobia and phonophobia, which may be inferred from behavior 5. Not attributed to another disorder Symptoms can be inferred from appearance and behavior: Migraine Variants in Childhood If the child cannot describe how he/she feels, how does the child look to the parent during the episode? Is there pallor? Is there a change in behavior and activity level? These are all consistent with migraine. 1. Basilar Migraine 2. Cyclic Vomiting Migraine Variant --Basilar Migraine Most common migraine variant in children (3-19%) Aura characterized by vertigo, dizziness, dysarthria, visual disturbance, ataxia, parasthesias Headache which follows may be occipital May have transient LOC Mean age 8-10 years Treatment strategies identical to other forms of migraine but with more emphasis on prevention Case History #1 14 year old female present with a 6 month history which started as near-daily headaches characterized by onset several hours after awakening, occipital in location, pulsatile in quality and associated with extreme vertigo and photophobia. With 2 of these headaches she had transient loss of consciousness. She was seen in an ER on both occasions where exam was normal and CT head scan was normal. Cranial MRI was also normal. She was referred to a cardiologist and a normal 24 hour holter monitor was normal. The patient had also experienced a change in personality and complained of feeling depressed. She was seen by a therapist and it was revealed during counselling that she had been sexually assaulted by a boyfriend. She was started on Zoloft. The headaches have subsequently reduced in frequency and severity. She has mild headaches associated with menses. Her neurologic examination has repeatedly been normal and she now uses Relpax on a prn basis. 4

5 Migraine Variant - Cyclic Vomiting Predominantly in young children Characterized by severe discrete episodes of nausea, vomiting, lethargy often less than 24 hours in duration Often a precursor to migraine - 82% in one study (Li Bu, et al 1999) Evidence for mitochondrial disorder because of strong maternal inheritance and association with other dysautonomic conditions (Boles, et al 2005) Case #2 The patient is a 7 year old girl who first presented at 18 months of age with a several month history of monthly episodes of vomiting followed by lethargy. The episodes were preceded by a head tilt which lasted for several hours. She was initially seen by a metabolic geneticist who did a work-up for mitochondrial disease which was negative. Cranial MRI was negative. She was started on a mitochondrial cocktail without change in her symptoms. When seen by the neurologist at 18 months her neurologic exam was normal. She was diagnosed with cyclic vomiting and started on Periactin without improvement. At 22 months she was started on Amitryptiline with a decrease in the vomiting frequency. At 4 years of age she began to complain that her head hurt during these episodes. The patient now has episodes of headache, nausea and vomiting approximately every 3 months. Oral Zomig is partially effective in aborting the episodes. Case #2 continued Treatment Strategies in Migraine When the child in this case was 4 years old, her 8 month old sister presented with episodes of vomiting every 1-2 months also preceded by head tilt. The family opted against preventative medications and she is treated with Tigan on a prn basis. She is now 3 1/2 years old and has episodes every 4-6 months during which she now complains of headache. Her episodes of vomiting and headache last less than 1 day. There is a positive maternal history of migraine. Non-Pharmacologic therapies Abortive (acute) therapies Preventative therapies Non-Pharmacologic Strategies/Therapies Modify life-style to reduce stress Emphasize need for sleep Adequate nutrition and hydration (especially during physical activity) Ask questions about the environment (is there cigarette smoke, perfumes, etc) Elimination diets typically are ineffective Massage therapy/physical therapy Acupuncture Vitamin B2 (Riboflavin) Magnesium/Calcium supplements Children and teens have stress but they don t always recognize it. Ask about common stressors at home and at school. 5

6 Treatment of Acute Migraine (Abortive Therapy) in Children < 10 years Treatment of Acute Migraine in Children > 10 years Ibuprofen ( mg/kg) Acetominophen (15 mg/kg) Anti-emetics Triptans - few studies Avoid Aspirin or Aspirin-containing drugs For optimal therapy, treat as soon as symptoms begin. This requires education of the child to recognize early symptoms and arranging for medication to be administered at school. NSAIDS Midrin/Fioricet Fiorinal/Excedrin migraine if > 15 years Triptans -Sumatryptin nasal spray, tablet, SQ injection -Rizatriptan 5 mg -Zomig (88% improvement in 2 hours with 2.5 mg dose. 69% eventually pain-free) (Linder, et al 2000) Treatment of Status Migraine DHE protocol Definition - Unremitting headache of more than 72 hours Many children/teens present with headaches of 1-4 weeks in duration Off-label use of inpatient IV Dihydroergotamine is effective (Kabbouche, et al 2009) -32 patients retrospective review -80% female -Mean age 14 1/2 years -Upon discharge 74 % were headache free -Average length of stay - 3 days All females must have negative pregnancy test No triptans within preceding 24 hours DHE dose is 1 mg IV q8h (0.5 mg q8h if <25 kg or <9 years of age) Premedicate 30 minutes earlier with antiemetics Start with test dose of 1/2 dose and if tolerated give remainder of dose 30 minutes later Continue protocol until headache-free plus 1 additional dose (maximum 9 doses) Preventative Therapies - When to use? Consider when headaches occur 3 to 4 times per month Are abortive therapies effective? Is the child missing school or less productive in school? Is the child missing social/sporting activities? Preventative Therapies (Lewis, et al 2004) Cyproheptadine (Periactin) 2-4 mg tid (3-12 years) Amitryptiline (Elavil) 10 mg/day (3-12 years) up to 1 mg/kg/day (9-15 years) Topiramate (Topamax) mg/day (8-15 years) 6

7 Preventative Therapies, continued Divalproex Sodium (Depakote) mg/kg/day (7-16 years) mg/day (9-17 years) Levitiracitam (Keppra) mg/day (3-17years) Zonisamide (Zonegran) 5-6 mg/kg/day ARS Polling Question 3 ARS Question #3: Which of the following are true about recurrent headaches in childhood? Answers Question #3: 1. Recurrent headaches are common in children and teens 2. Despite having associated morbidity, studies evaluating abortive and preventative treatments are few 3. Non-pharmacologic strategies to improve quality of life and reduce morbidity are important in the treatment of childhood headaches 4. The history and physical examination are the keys to accurate diagnosis with imaging studies playing a minor role 5. We can make a positive impact on children s lives by effectively treating their headaches 1. True 2. True 3. True 4. True 5. True References Apostol, G, et al. Safety and tolerability of Divalpoex Sodium Extended-Release in the prophylaxis of migraine headaches: results of an open-label extension trial in adolescents. Headahce. 2009; 49(1): Boles, RG, et al. Maternal interheitance in cyclic vomiting syndrome. Am J Med Genet A. 2005; 133A(1):71-7 Borzy, John et al. Effectiveness of Topiramate in the treatment of pediatric chronic daily headache. Pediatric Neurol 2005;33: Brna, Paula M., et al. Headaches in the Pediatric Population. Semin Pediatr Neurol 2006;13: Buck, Marcia. Recent actions by the Food and Drug Administration. Pediatr Pharm. 2005;11(3) degrauw, T, et al. Diagnosis of migraine in children attending a pediatric headache clinic. Headache 1999;39: Guidette, V, Falli, F. Evolution of headache in childhood and adolescence: an 8-year follow-up. Cephalgia. 1998;18: Gunner, Kathy, et al. Practice Guideline for diagnosis and management of migraine headaches in children and adolescents: Part Two. J Pediatr Health Care. 2008;22(1):52-59 Kabbouche, M., et al. Inpatient treatment of status migraine with Dihydroergotamine in children and adolescents. Headache. 2009;49(1): Kan, Li, et al. Headaches in a pediatric emergency department: etiology, imaging, and treatment. Headache 2000;40:25-29 Lewis, D. Paradiso, E. Double-blind, dose comparison study of Topiramate for prophylaxis of basilar-type migraine in children: a pilot study. Headache 2007;47(10): Lewis, D., et al. The placebo responder rate in children and adolescents. Headache. 2005;45(3): Lewis, D., et al. Practice Parameter: Pharmacological treatment of migraine headache in children and adolescents. Neurology 2004;63:

8 Lewis, D., et al. Practice Parameter: Evaluation of children and adolescents with recurrent headaches. Neurology 2002;59: Li, BU, et al. Is cyclic vomiting syndrome related to migraine? J Pediatr. 1999;134(5): Stickler, GB. Relationship between cyclic vomiting syndrome and migraine. Clini Pediatr (Phila). 2005;44(6):