it’s not all about migraine!az-ns.org/presentations/its-not-all-about-migraine.pdf13 year old with...

E R I C H A S T R I T E R , M D F A H S

B A N N E R P E D I A T R I C S P E C I A L I S T S

C A R D O N C H I L D R E N ’ S M E D I C A L C E N T E R

D E C E M B E R 6 T H , 2 0 1 6

It’s not all about Migraine!

MY PROCESS

THE SAGA CONTINUED

Program Disclaimer: The accuracy and utility of the

materials presented are based on the International

Classification of Headache Disorders, 2nd edition (ICHD-

II), statements made will be evidence-based, the

limitations being due to the nature of trials in children,

most of the evidence comes from adult studies but clinical

evidence across the pediatric headache community will be

discussed

Conflict of Interest: There is no conflict of interest at this

time

Objectives

Describe a typical diagnostic path used by neurologists obtaining proper primary headache diagnosis other than migraine

Understand the utility of preventative or abortive medications, diagnostic tests, and psychological/bio-behavioral approaches in management of diagnosis

Discuss the timing of when to refer to a specialist

Migraine Criteria- ICHD-II

At least 5 attacks, lasting 1 to 72 hours

Headache has at least 2 of the following:

• Unilateral location, may be bilateral, frontotemporal (not occipital)

• Pulsating quality (throbbing)

• Moderate or severe pain intensity

• Aggravated by routine physical activity

• at least 1 of the following:

Nausea and/or vomiting.

Photophobia and phonophobia

may be inferred from the child’s behavior

• Not attributed to another disorder

17 year old male

Frequent headaches that began in august (with school)

2-3/month, 1 hour to 5 days

Global, squeezing, moderately intense, did not interfere with his activity

No nausea, vomiting, phonophobia, but had photophobia

Worked 4 nights/week at fast food establishment to save money for college

PMH, FH, SH and ROS were benign, general and neurologic exam were normal

What was the most likely diagnosis?

What diagnostic studies were indicated?

What management options were appropriate?

Tension Type Headache

30 minutes to 7 days,

bilateral, pressing/tightening (non-pulsatile)

mild to moderate intensity,

not aggravated by physical exertion

Associated with:

lack of associated features

may have pericranial muscle tenderness

nausea/vomiting do not occur

no more than 1 of photophobia/phonophobia and it is not prominent


Most common type worldwide

Rarely interferes with function

Infrequently present if episodic

Most common reasons buying OTC meds

Little known about pathogenesis of tension-type headache

1-year prevalence ranges from 40-80%

Slightly more common in females


Differential: episodic migraine, cervicogenic headache, and secondary causes of headache

If presents with chronic tension type headache: neuroimaging is warranted to rule out space occupying lesions

Cervicogenic HA-strictly unilateral headache


Treatment-lifestyle changes (stress reduction and management, relaxation therapy, massage, cognitive behavioral therapy

Abortives: NSAIDS, combination products with caffeine if caffeine naïve

Preventatives if > 10 days/month, amitriptyline or nortriptyline


What was the most likely diagnosis?

What diagnostic studies were indicated?

What management options were appropriate?

13 year old female

March 2011: flu-like illness (mom thought), headaches began and have been daily

Bilateral, continuous moderate pain, she had difficulty describing quality (feel tightening, throbbing, pulsating, worse with movement)

Some nausea, photophobia and phonophobia, but they were not prominent

No autonomic features

No systemic or neurologic symptoms

13 year old female

Labs from nearly 2 years ago, mono positive, and then a year after the fact West Nile Virus was positive

MRI, MRA, MRV all were negative

Hematologic workup was negative

LP was normal pressure, no infection

13 year old female

What diagnosis could this be?

What needs done in this patient?

What treatment is suggested in this patient?

New Daily Persistant Headache

Subacute onset over 72 hours of daily unremitting headache

Resemble CTTH, or CM, but is chronic at onset

Diagnosis of exclusion: neuroimaging, hematologic workup required to rule out secondary causes

May resolve on own or be refractory to treatment


Most common in adolescents/young adults

~10% of patients in tertiary headache clinics

Underlying etiology unknown (30% report recent flu-like illness at time of onset)

Two clinical subtypes-

benign self limited form

refractory form resistant to aggressive therapy


Bilateral, continuous moderate pain(can be mild or severe)

Tightening/throbbing/pulsating, and may be aggravated by physical exercise

Migraine features (N/V/P/P) but typically not most prominent features

No associated trigeminal autonomic features (lacrimation/conjunctival injection)

No systemic or neurologic symptoms


Differential includes CTTH, CM and secondary causes of headaches

Can resemble spontaneous intracranial hypotension (dural tear or leak) if positional component overlooked in history

Can resemble pseudotumor cerebri (idiopathic intracranial hypertension)


Labs: CBC (rule out chronic anemia or infection), TSH (rule out hypothyroidism), CRP/ESR (rule out temporal arteritis)

MRI brain: space occupying lesion, hydrocephalus,

MRI w/GAD: spontaneous intracranial hypotension

MRV: cerebral venous sinus thrombosis

LP: increased/decreased CSF pressure or chronic meningitis


Treatment- no known effective acute or prophylactic therapy

Standard acute/preventative for CTTH, CM could be attempted on trial and error basis

Doxycycline, Singulair have been used

Beware: Medication overuse headache complicating picture


What diagnosis could this be?

What needs done in this patient?

What treatment is suggested in this patient?

14 year old male, eye pain

Sharp excruciating right sided orbital and temporal pain

Tearing, reddening of eye, ringing in right ear

About 20 minutes, 8 times/day, but 1 lasted 3 hours

He feels agitated, awakening nightly during baseball season every year

Nausea occurs, and so does photophobia

Between episodes has lesser pain and takes 800 mg ibuprofen regularly which helps

14 year old male, eye pain

What is his diagnosis?

What investigations need done?

How would you treat this entity?

Cluster Headache

Excrutiating strictly unilateral headache, last about 1 hour (15min-3hours), and may recur up to 8/day usually seasonal

Associated with cranial autonomic symptoms ipsilateral to pain, can be bilateral

20% have CCH when headaches continue for more than 1 year without remission of > 4 weeks

Cluster Headache

Co-Morbid: Tobacco use, OSA

MRI brain: intracranial lesions particularly in pituitary and parasellar regions

Treatments:

100% oxygen

Intranasal or parenteral triptans

Corticosteroids

Verapamil

Cluster Headache

Prototypical TAC-Trigeminal Autonomic Cephalgias; first division of trigeminal nerve, accompanying ipsilateral autonomic features (lacrimation/ conjuctival injection/rhinorrhea)

80% have cluster 1-3 months, typically 1-2 times per year with remissions in between

Nocturnal attacks typical, but daytime attacks occur, usually near same time daily

Cluster Headache

Triggers: alcohol and high altitude

Strictly unilateral, maximal around or above orbit, may begin or become referred to the temporal, lower facial, or occipital region

Extremely severe, piercing, boring, stabbing peaking within 3-5 minutes lasting average 1 hour (15 min- 3 hour)

Cluster Headache

> 90% agitation

Autonomic features: lacrimation, rhinorrhea, conjunctival injection, ptosis, miosis, facial or periorbital edema

Autonomic features may be bilateral, but are prominent ipsilateral to pain

Cluster Headache

Migrainous symptoms (N/V/P/P)

Can have unilateral Photo/phonophobia

Interparoxysmal pain and allodynia (abnormal pain response to normal stimulus) may occur in more than 1/3 of patients with any of the TACs

Medication Overuse may be responsible the interparoxysmal pain

Cluster Headache

PE may show persistant Horner syndrome if had recurrent attacks for years

MRI brain: special attention to pituitary and parasellar regions for mimickers of TACs

Overnight polysomnography if features of OSA are present

Cluster Headache

Treatment

Acute- 100% oxygen 7-15L/min with closed facemask for 15 minutes

Triptans-sumatriptan 6mg SC, sumatriptan 20 mg NS, zolmitriptan 5 mg NS

Short term prevention- steroid taper 60 mg decrease by 10 mg every 2-3 days

Occipital nerve blockade 2.5 mL bupivacaine with 20 mg methylprednisolone

Cluster Headache

Preventatives

Verapamil 80 mg TID up to 320 mg TID (check ECG after each dose increase).

Long term side effects: gingival hyperplasia, constipation, and peripheral edema)

Cluster Headache

What else could be his diagnosis?



13 year old with migraine

Headaches since she was 6, diagnosed with migraine and nothing seems to be helping

Pain is all day long, sharp, stabbing, usually around the temples, mostly on left side

Both eyes get red, ears ringing bilaterally

Sensitive to light and sound out of the left ear and eye

Nausea present, no vomiting

Ibuprofen helps but it comes back


PMH, FH, SH, ROS and physical exam all normal

When asked about all day long headache, she said it came and went throughout the day

Further questioning revealed that is came and went around 20-30 minutes, but happened 8-20 times per day

In between she was head pain free


What could be her diagnosis?



Paroxysmal Hemicrania

Similar to CH however shorter and more frequent attacks

MRI brain with coronal GAD sequences of pituitary for all suspected paroxysmal hemicrania

Responds rapidly AND completely to indomethacin


Slight female predominance

Late adolescence to early adulthood mean age 36 (1 year -81 years reported)

Typically unilateral (bilateral reported though)

Located maximally in V1 region, however may occur in parietal and temporal regions


Severe intensity, throbbing, pressure, stabbing or boring

Attacks 2-30 minutes, 1-40/day, average 5-15/day


Autonomic features: ipsilateral lacrimation, nasal congestion most common, but can inlude rhinorrhea, conjunctival injection, eyelid edema, ptosis, miosis, forehead or facial sweating (>50% of patients), ear fullness sensation in 30% of patients

Migraine features: Photophobia/phonophobia 66% of patients, may be unilateral


Nausea/vomiting 33% of patients

Motion sensitivity 50%

Agitation/Restlessness in 80%

Spontaneous attacks, no nocturnal predominance

Differential: cluster headache, trigeminal neuralgia, SUNCT syndrome, and hemicrania continua


Dull inter-ictal pain, may resemble hemicrania continua, but hemicrania continua exacerbations are longer lasting with less autonomic features

Secondary causes have been reported with lesions in pituitary and posterior fossa

Treatment: Indomethacin


Titrate up to 75 mg TID, protect mucosal lining due to gastric side effects, if poorly tolerated cox-2 inhibitors, ASA, topiramate, or gabapentin may be tried

Occipital nerve blockade may help

May last years or decades

Some have spontaneous remission


What else could be her diagnosis?



15 year old excruciating pains

4 year history of headaches behind right eye that last all day

Severe to excruciating, stabbing on right temple/eye, tearing in right eye, injection in right eye

Able to trigger it combing hair occasionally, but not always

Nothing over the counter seemed to help

Amitriptyline had been tried unsuccessfully


Further questioning revealed he had pain that came and went throughout day

The longest pain was 3 minutes and the shortest pain was 5 seconds of stabbing

He estimated the range of episodes throughout the day were around 60-70 times/day

PMH/FH/SH/ ROS and exam were normal


What could be his diagnosis?



SUNCT Syndrome

Short lasting Unilateral Neuralgiform Headache attacks with Conjunctival Tearing

Strictly unilateral, severe, stabbing, shooting, lancinating, burning, V1 distribution occur with conjunctival injection and tearing

5 - 240 seconds, in between attacks pain free

Frequent up to 200/day attacks

Slight male predominance

Age 35-65 years (10-77 years)

Natural history-last years, decades or lifelong

SUNCT Syndrome

Migrainous features are not uncommon especially unilateral photophobia

Autonomic symptoms are frequently seen including rhinorrhea, nasal congestion, eyelid edema, ptosis, miosis, facial redness, conjunctival tearing obviously

May be triggered by tactile stimuli, most commonly mastication and trigeminal innervated areas

SUNCT Syndrome

Brain MRI looking at pituitary, parasellar region, and brainstem in all patients with suspected SUNCT syndrome

Anticonvulsants: lamotrigine, gabapentin, topiramate, and carbamazepine.

Parenteral lidocaine: effective in most

Surgical procedures- mixed results

Percutaneous trigeminal ganglion rhizolysis

Trigeminal root microvascular decompression

Hypothalamic deep brain stimulation

SUNCT Syndrome

What else could be his diagnosis?



14 year old girl with stabbing pain

4 month headache history

Occasional stabbing in random locations, most in temple and frontal area that lasted 1-10 seconds, and up to 10 a day, then some days without any pain

No migraine features

No autonomic features

Occasionally would have a true migraine, lasting hours, worse with movement, associated with N/V/P/P responds to naproxen

14 year old girl with stabbing pain

What could be her diagnosis?



Primary Stabbing Headache

Alias: ophthalmodynia periodica, ice pick headache, jabs and jolts syndrome, idiopathic stabbing headache

Ultra short paroxysms of stabbing pain (1-10s) unilateral ophthalmic division most common, however anywhere on head may occur, 1-50 times throughout day and evening

Onset 12-70 (mean 47 years), female predominance


Differential includes SUNCT (attacks longer) or Trigeminal Neuralgia (more V2/V3) or secondary causes

Frequent attacks: indomethacin is treatment of choice as preventative

Frequently associated with migraine (40%), tension type headache and the TACs

Secondary causes: meningiomas, pituitary tumors, giant cell arteritis, cranial and ocular trauma, herpes zoster, and elevated intraocular pressure


Frequently associated with migraine (40%), tension type headache and the TACs

Secondary causes: meningiomas, pituitary tumors, giant cell arteritis, cranial and ocular trauma, herpes zoster, and elevated intraocular pressure


Usually unilateral

Attacks from 1-50 attacks/day

Most attacks throughout day and evening

Differential includes SUNCT (attacks longer) or Trigeminal Neuralgia (more V2/V3) or secondary causes


Investigations usually not necessary unless suspicious for secondary causes

Prophylaxis rarely required

Indomethacin 25-75mg TID

Melatonin 3-12 mg/day

Gabapentin 400 mg BID


What else could be her diagnosis?


How or would you treat this entity?

Tests used

Used DSM-IV to make diagnosis

CBCL-child behavior checklist age weighted

YSR-youth self report

SCARED-the screen for Child Anxiety Related Disorders

CDI-Children’s Depression Inventory

CPRS-R; Conner’s Parent Rating Scale-Revised

CBCL-child behavior checklist

Filled out by parents to assess emotional/behavioral

problems of children and adolescents

Identifies two types of problems- internalizing and

externalizing

Internalizing- anxiety, depression, social withdrawal, and

somatic complaints

Externalizing- aggression and antisocial behavior

SCARED-screen for childhood anxiety related

disorders Self administered

41 questions over last three months of feelings of anxiety

Score >39 indicates clinical impairment

CDI-children’s depression inventory

Derived from Beck’s depression Scale

Assesses severity of depression symptoms in prior two

weeks

Age 7-17

19 points or higher discriminates risk for depression

CPSR-Conner’s Parent Rating Scale

Self administered

80 questions about behavior during last month

Ages 3-17

Scores> 65 indicate clinical impairment

Results

Children with headaches had significant internalizing and

externalizing problems compared with control 63% and

27%

No difference between migraine and tension type found

26% had positive comorbidity with the headache of

anxiety and mood disorders.

One out of three headache patients needed particular therapy with emotional and

behavioral problems

Headache Toolbox

Proven Behavioral Therapies

Relaxation training

Temperature biofeedback (hand warming) combined with relaxation

training

Electromyographic (EMG) biofeedback (for muscle tension

reduction

Cognitive Behavior Therapy

Complementary Therapies

Accupuncture/accupressure

Chiropractic therapy

Hypnosis and physical therapy

Cognitive Behavioral Therapy

Highly effective

Average rate of reduction in headaches compared to

controls 68% vs. 20%

Improvement was seen in baseline coping skills, social

support, physiologic measures at rest and in response to

stress.

Noncompliance

Prevalent in headache patients

Simplifying medication strategies

Screening and management of psychiatric co-morbidities

Enabling patient to have self-efficacy and take ownership

of their headaches is key

Website for relaxation: www.dawnbuse.com

Natural Remedies for headaches

LipiGesic- sublingual feverfew/ginger appears safe and

effective as first line abortive in migraine patients at the

onset of a pre-severe migraine (most common side effect

is nausea of gagging)

Exercise-systematic review on the literature concluded it

was promising but adherence to headache research

guidelines in a study needed.

�Natural Remedies for headaches

Thirty studies reviewed on 6 nutraceuticals

Butterbur-showed reduction and liver toxicity

Riboflavin-400 mg showed marked reduction

Ginkgolide B-60-80 mg showed marked reduction

Magnesium- 300 mg showed marked reduction

Coenzyme Q10- 100 mg showed marked reduction

Polyunsaturated fatty acids-Marine ester concentrate- showed

marked reduction

Studies showed strong evidence but level of evidence is still low in

all-more studies are needed.

When to Refer to Headache Specialist

When not responding to OTC medications, preventatives or abortives

Frequency of headache increasing or disability increasing

When something other than migraine suspected, but uncomfortable treating it

When you would like help with the time-consuming patient

When patient has chronic migraine or chronic daily headache

When to Refer to Headache Specialist

Headache specialist requested by parent/patient

Role of Pediatric Headache specialist-

Taking time to establish proper diagnosis

Get patient on a good preventative

Get patient on good rescue medication

Decreasing headache disability

Returning improved pediatric patient to their primary care provider

References

Baillie LE, Gabriele JM, Penzien DB. A systematic review of behavioral headache interventions with an aerobic exercise component. Headache 2014;54(1): 40-53.

Penzien DB. Stress management for migraine: recent research and commentary. Headaches 2009;49(9):1395-1398.

Rains JC, Penzien DB, Lipchick GL. Behavioral facilitation of medical treatment of headache: implications of noncompliance and strategies for improving adherence. Headache 2006;46 (suppl 3):S142-S143.

Seng EK, Holroyd KA. Behavioral migraine management modifies behavioral and cognitive coping in people with migraine. Headache 2014;54(9):1470-1483.

Cady RK, Goldstein J, Nett R, et al. A double blind placebo controlled pilot study of sublingual feverfew and ginger (LipiGesic M) in the treatment of migraine. Headache 2011;51(7):1078-1086.

Oelkers-Ax R, L eins A, Parzer P, et al. Butterbur root extract and music therapy in the prevention of childhood migraine: and explorative study. Eur J Pain 2008;12(3):301-313.

Brujin J, Duivenvoorden H, Passchier J, et al. Medium-dose riboflavin as a prophylactic agent in children with migraine: a preliminary placebo controlled randomized, double-blind, cross-over trial. Cephalalgia 2010;30(12):1426-1434.

Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013;33(9):665-671.

Orr SL, Ventkateswaran S. Nutraceuticals in the prophylaxis of pediatric migraine: evidence-based review and recommendations. Cephalalgia 2014:34(8):568-683

Werder DS, Sargent JD. A study of childhodd headache using biofeedback as a treatment alternative. Headache 1984;24(3):122-126.

Arruda MA, Guidetti V, Galli F, et al. Primary headaches in childhood—a population-based study. Cephalalgia 2010;30(9):1056-1064.

Wojaczynska-Stanek K, Koprowski R, Wrobel Z, Gola M. Headache in children’s drawings. J. Child Neurol 2008;23(2):184-191.

Lewis D, Ashwal S, Hershey A, et al. Practice parameter: pharmacological treatment of migraine headache in children and adolescent: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology 2004;63(12):2215-2224.

Lewis DW, Ashwal S, Dahl G, et al. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002;59(4):490-498.

Any questions?

[email protected]

480-412-7473

Nurse Manager Lynn Bevans, RN

480-412-7435 (direct line)

mailto:[email protected]

it’s not all about migraine!az-ns.org/presentations/its-not-all-about-migraine.pdf13 year old with...

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