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Primary care management of headaches in pediatric patients
Steven Leber, MD, PhD Division of Pediatric Neurology
Department of Pediatrics
February 26, 2014
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Disclosures
• No financial disclosures
• Very limited evidence-based data
• Some off-label medication discussion
• I may use some brand names for medications; generics are fine for everything I mention
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Why am I doing this webinar?
• Headache is common
• Long, long wait times
• Seeking better patient care
– I’m NOT looking for more referrals (and longer wait times)
– You should be able to
• manage most of your own patients with headaches
• know when to worry
• know when to image
• know when to refer
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Schedule for today
30 min Informal talk – to be interrupted with questions!
• Headaches that are and aren’t concerning
• When to do tests, when to refer • How to treat • Sample cases
30 min Your questions
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Red flags! Primary headaches Migraine
Tension-type headache
Cluster – rare in children!
Secondary headaches Tumor or other mass lesion
Hydrocephalus, pseudotumor
Depression
Sleep disturbances
Subarachnoid hemorrhage
Meningitis
Sinus disease
Visual problems (very rare cause)
TMJ dysfunction / teeth clenching
Seizures
Hypertension
Caffeine withdrawal
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Red flags! Primary headaches Migraine
Tension-type headache
Cluster – rare in children!
Secondary headaches Tumor or other mass lesion
Hydrocephalus, pseudotumor
Depression
Sleep disturbances
Subarachnoid hemorrhage
Meningitis
Sinus disease
Visual problems (very rare cause)
TMJ dysfunction / teeth clenching
Seizures
Hypertension
Caffeine withdrawal
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Red flags! Primary headaches Migraine
Tension-type headache
Cluster – rare in children!
Secondary headaches Tumor or other mass lesion
Hydrocephalus, pseudotumor
Depression
Sleep disturbances
Subarachnoid hemorrhage
Meningitis
Sinus disease
Visual problems (very rare cause)
TMJ dysfunction / teeth clenching
Seizures
Hypertension
Caffeine withdrawal
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Red flags! Primary headaches Migraine
Tension-type headache
Cluster – rare in children!
Secondary headaches Tumor or other mass lesion
Hydrocephalus, pseudotumor
Depression
Sleep disturbances
Subarachnoid hemorrhage
Meningitis
Sinus disease
Visual problems (very rare cause)
TMJ dysfunction / teeth clenching
Seizures
Hypertension
Caffeine withdrawal
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Increased intracranial pressure
• Progressive headache
• Worsens with recumbency
• Wakes at night, present 1st thing in the a.m.
• Mental status changes
• Nausea and vomiting
• Papilledema
• VIth nerve palsies (false localizing)
• Infants: macrocephaly, bulging fontanelle
• "Sunsetting"
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Other specific concerns
• Focal neurological deficit
• Analgesic overuse
• Excessive school absence
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Diagnosis of migraine • Headache
– Usually throbbing, classically unilateral, and frontal or temporal, but….
– Gradual onset (minutes to an hour)
– Duration usually 1-6 hours (can last days)
– Increased by activity
• Sleep (even brief nap) relieves
• Anorexia, nausea, vomiting
• Photophobia, phonophobia
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Migraine with aura
• 10-15% of migraineurs have aura
• Not consistently present
• Usually 10-25 minutes
• Headache usually contralateral to side of symptoms
• Visual symptoms most common, but can be sensory, motor, language, cognitive, or cerebellar/cranial nerve
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Migraine variants • Complicated migraine (migraine w/ nonvisual aura)
• Ocular migraine
• Ophthalmoplegic migraine
• Basilar migraine
• Acute confusional migraine
• Migraine aura without headache
• Hemiplegic migraine
• Trauma-induced migraine
• Benign paroxysmal vertigo
• Paroxysmal torticollis
• Cyclic vomiting
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Chronic headaches
• 20% of migraineurs develop chronic headaches
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Chronic headaches
• Often tension-like or mixed tension-type and migrainous
• Postconcussive syndrome
• Dizziness. myalgia, and fatigue common
• May be accompanied by nausea and vomiting
• Increased by stress
• School absence a big problem
• Look for abuse, depression, psychosocial stress
• Rx: psychologic counseling (individual and family), prophylactics, biofeedback
• Avoid analgesics
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Evaluation of headache
• Blood-pressure
• Head circumference
• Sinus, temporalis tenderness
• Neurological examination, including funduscopy
• Evaluation for depression
• Rarely need to do EEG, imaging
• LP – Image 1st (and check!)
– When not to do: focal findings, mass lesion
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When to image?
• Abnormal neurological examination
• Headaches improve with sitting up
• Headaches frequently wake at night or are present first thing in a.m.
• Rapidly progressive course
• Change in severity or quality of headache (migraineurs can have tumors!)
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When to refer to neurologist?
• Abnormal neurological examination
• Associated seizure
• Associated change in mental status
• Progressive headache not responding to routine Rx
• Headaches commonly at night or present upon awakening
• Headaches worsening with recumbency
• Onset after traumas
• Analgesic abuse
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Treatment
• Natural history • Reassurance • Avoidance of precipitants • Sleep • Abortive • Prophylactic • Behavioral
• Evidence-based assessment limited by high rate of response to placebo
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Abortive medications
• Better if used at onset of headache
• Acetaminophen, ibuprofen, naprosyn, ASA, caffeine, combinations (good for tension-type headaches)
• Midrin (isometheptene, acetaminophen, caffeine)
• Fioricet (butalbital, acetaminophen, caffeine)
• Dihydroergotamine (DHE) (Migranal)
• Narcotics: risk of addiction in patients with chronic or frequent headaches, but occasionally useful in selected patients with infrequent migraines
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Triptans
• Block release of inflammatory peptides into walls of dural vessels
• Avoid in
• basilar and other complicated migraines – risk of stroke??
• Hypertension
• Pregnancy
• Hx of stroke or MI
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Tritptans • 7 triptans
• Oral, melts, nasal sprays, injections
• 2 FDA-approved for kids • Rizatriptan (Maxalt) 6-17 y.o.’s
• Almotriptan (Axert) 12-17 y.o.’s
• Generically available • Sumatriptan
• Side effects
• Chest, throat tightness
• Drowsiness, dizziness, nausea
• Bad taste (nasal spray)
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Prophylactic medications
• Indications: frequency >1-2 times/week; severity; complicated migraines
• Often use for 6-12 months, then attempt taper
• Amitriptyline, nortriptyline
• Cyproheptadine (Periactin)
• Calcium channel blockers
• Anticonvulsants (valproate, topiramate)
• ß-adrenergic antagonists
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Prophylactic medications
• Indications: frequency >1-2 times/week; severity; complicated migraines
• Often use for 6-12 months, then attempt taper
• Amitriptyline, nortriptyline
• Cyproheptadine (Periactin)
• Calcium channel blockers
• Anticonvulsants (valproate, topiramate)
• ß-adrenergic antagonists
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Nortriptyline
• Brand name: Pamelor
• Tricylic antidepressant
• Dosage forms:
– 10 mg capsule
– 25 mg capsule
– 50 mg capsule
– 75 mg capsule
– 10 mg/5 cc (liquid)
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Nortriptyline
• Effective at much lower doses than used for depression
– Typically 1020 30 mg Qhs
– Occasionally 25 50 75
• 1-2 month latency
• Baseline EKG?
• Interactions with SSRI’s
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Nortriptyline
• Potential side effects
– Sleepiness
– Dry mouth
– Orthostatic lightheadedness
– Weight gain (5% of patients)
– Arrhythmias
• Trachycardia
• Increased PR interval, QRS duration, QT interval
– Mood changes
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Cyproheptadine (Periactin)
• Drug of choice for young children
• Also for thin teens who cannot sleep
• Dosage forms
– 2 mg/5 mL liquid
– 4 mg tablet
• Typical dosage
– 2-4 mg/day ÷ BID (occasionally all HS)
– Advance slowly as tolerated up to 8-16 mg/day if needed
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Cyproheptadine (Periactin)
• Common side effects
– Sleepiness
– Weight gain
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Topiramate
• Brand name: Topamax
• Anti-epileptic
• Dosage forms
– 25, 50, 100, 200 mg tablets
– 15, 25 mg sprinkle capsules
– 6 mg/ml suspension (by pharmacy)
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Topiramate
• Effective at much, much lower doses than typically used for seizures
– Typical adult dose 50 mg BID (reasonable AED for 18 mo boy)
– Fewer side effects
• Build up gradually over one month
• Usually ÷ BID ; occasionally, just HS
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Topiramate • Side effects
– “Body”
• appetite, weight
• sweating
• Paresthesias
• Metabolic acidosis
• Kidney stones
• Acute glaucoma
– “Brain”
• Sleepiness
• Confusion, word-finding difficulty
• Mood changes
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Which preventative? First line
• Notriptyline – 1st choice, daily headaches
• Amitriptyline – thin, insomnia
• Cyproheptadine – young, thin, insomnia
• Topiramate – overweight
• Verapamil – complicated migraine (e.g., basilar)
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Which preventative? Backup
• Propranolol (Inderal)
• Gabapentin (Neurontin)
• Valproate (Depakote)
• Alternative meds
– Butterbur (Petadolex)
– Magnesium, riboflavin, feverfew (MigreLief)
– Melatonin
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Nonpharmacological treatment
• Go to school! Live your life as if you don’t have headaches!
• Exercise
• Fluids
• Biofeedback / relaxation / hypnosis
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How would you evaluate and treat?
• 12 y.o. girl with bad migraines every 3 weeks
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How would you evaluate and treat?
• 5 y.o. boy with migraines 2-3 times per week
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How would you evaluate and treat?
• 15 y.o. girl with basilar migraines, syncope every 2 weeks
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How would you evaluate and treat?
• 15 y.o. girl with menstrual migraines, regular menses
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How would you evaluate and treat?
• 9 y.o. boy with infrequent migraines, suddenly worse and now almost daily x 2 weeks
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How would you evaluate and treat?
• 13 y.o. girl with 6 months of daily headaches with migrainous features; depression; school absence