1. Treatment of Pediatric Migraine Headaches
Liz Rende DNP, RN, CPNP-PC
NAPNAP Pharmacology Update – April 28, 2017

2. Disclosures
I have no financial disclosures to report

3. Off- Label Use
Certain medications discussed are used off-label, without FDA approval
Standard of practice
If off-label, medications will be labeled as each is described

4. Objectives
After attending this presentation, participants should be able to:
Define appropriate three first-line treatments for episodic treatment of children’s migraine headaches
Define appropriate three first-line treatments for prophylactic treatment of children’s migraine headaches
Identify three key elements in the decision tree guiding the episodic, prophylactic, and/or ED management of children’s migraine headaches

5. Migraine Diagnostic Criteria & Prevalence
International Classification of Headache Criteria-3 Beta
Without Aura
With Aura
By age
3-7 years
7-11 years
15 years
prevalence
1.2%-3.2%
4%-11%
8%-23%
Gender ratio
boys>girls
boys=girls
girls>boys
50-90% of relatives also have migraine
Familial hemiplegic migraine L

6. “For a clinical problem so prevalent in children and adolescents, there is a disappointing lack of evidence from controlled, randomized, and masked trials.”

7. Goals of Treatment
Reduction of HA frequency, severity, duration, and disability
Reduction of reliance on poorly tolerated, ineffective, or unwanted acute pharmacotherapies
Improved QOL
Avoidance of acute headache medication use (MOH)
Education/promote self-management
Reduction of headache-related distress and psychological symptoms

8. Treatment… Sooner is better…. School accommodations Treat immediately
Have meds at school, with permission forms completed
Communication

9. Andrew 7yo male Headaches at school- pale, nauseated
Headaches happening about 1-2x/ month
Ibuprofen 200mg – headache is gone in 2 hours

10. Episodic Treatment Treat No More Than 2x per Week
Anti-Inflammatory effects
OTCs
Ketorolac
Triptans
Combination Products
Midrin-APAP, dichloralphenazone, isometheptene
Cafergot-Ergotamine and caffeine
Bultalbital
Antiemetics
Prochlorperazine
Promethazine
Odansetron
Lorazepam
metaclopromide
Treat No More Than 2x per Week

11. Episodic Treatment-OTC/NSAIDs
Directed at inflammation of Trigemino-vascular system
acetaminophen
Dosing: 15mg/kg
Age-4-16y
Side Effects: hepatic failure
Pearls-Limit dosing to 75mg/kg or 4G/day
ibuprofen
Dosing:7.5-10mg/kg
Age:6-12y
Side Effects: hives, dyspepsia, bleeding, renal impairment
Pearls
naproxen
Dosing:10mg/kg
Age:4-16y
Side Effects: hives, dyspepsia, bleeding, renal impairment
Pearls

12. Andrew Missed school 8yo male
Headaches at school- pale, nauseated, vomiting at school
Headaches happening about 1-2x/ month
Ibuprofen 200mg – headache is a little better, but still has to come home due to vomiting
Mom takes FMLA
disability
disability
disability
Missed school
disability

13. Episodic Treatment- RX Triptans
sumatriptan, rizatriptan, almotriptan, naratriptan, zolmitriptan, eletriptan, frovatriptan
Mechanism of Action
5-HT (1) agonist-specific action on 5-HT 1B/1D receptors
Indications- episodic migraine headache
Dosing-nasal spray, ODT, tablet, injectable
Side Effects-
facial flushing, facial tingling, chest and throat tightness
Contraindicated in:
Moderate to severe asthma
Cardiovascular disease
Costly- MedicAid
Pearls- chocolate Tootsie-Roll
Give appropriate dose, not step-wise approach

14. FDA-Approved Triptans for Kids
Almotriptan
12-17y
Onset of action min
Half-life-3hr
Rizatriptan ODT
6-17y
Onset of action:30-60min
Half-life-2-2.5hr
Zolmitriptan NS
Onset of action:10-15min
Half-life-2.5-3hr
Sumatripan/naproxen combo
Onset of action:60-240min
Half-life-2/19hr
Long-acting

15. Medication Overuse Headache
Description: Headache occurring on 15 or more days per month developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more or 15 or more days per month, depending on the medication) for more than three months. It usually, but not invariably, resolves after the overuse is stopped.

16. Andrew 11yo male Headaches at school- pale, nauseated
Headaches happening about 6-7x/ month
Rizatriptan 5mg resolves headaches within 2 hours.
Missing school at least 1x/ month

17. Too many headaches? Two-armed approach Daily prophylactic medication
Effective episodic, rescue/abortive medications

18. Headache Prophylactic Medications
Level A
Established Efficacy
Level B
Probably Effective
Level C
Possibly effective
Level U
Inadequate data
Other
? Ineffective
Not effective
valproate
amitriptyline
nortriptyline
gabapentin
lamotrigine
topiramate
venlafaxine
Llsinopril
fluoxetine
clonazepam
metoprolol
atenolol
clonidine
acetazolamide
oxcarbazepine
propranolol
nadolol
verapamil
frovatriptan (menstrual migraine)
cyproheptadine
nicardipine
???Botox, Butterbur, magnesium, riboflavin, feverfew, tizanidine, pregabalin, zonisamide ???

19. Antihistamines Cyproheptadine (Periactin) Oldest kids HA treatment
Mechanism- competes with histamine for H-1 receptor sites, serotonin antagonist
SE-Drowsiness, weight gain
Dosing-2-4mg 1-2X/day

20. Antidepressants-tricyclics
nortriptyline or amitriptyline
Nortriptyline-fewer side effects, costs less
50-60% effective
Mechanism- inhibits norepinephrine and serotonin re-uptake
SE-drowsiness, dry mouth
Dosing-start at 10mg/day, increase to 30-50mg/day
Contraindicated for anyone with arrhythmias, may prolong Q-T interval
EKG?
OFF-Label

21. Antidepressants-SSRIs
Fluoxetine, paroxetine, sertraline HCL
Not innocuous, taper must be slow
Mechanism- Decreases serotonin re-uptake
SE- drowsiness, weight gain
Dosing-Start low, go slow
Sertaline:25-50mg, paroxetine 25mg, Fluoxetine (liquid)
BLACK BOX WARNING
OFF-Label

22. Antihypertensives OFF-Label Beta blocker-propranolol, atenolol
Mechanism-reduces vascular resistance, lowers B/P
SE-Fatigue, sleep disturbances, depression, dizziness
Dosing-max-1-2mg/kg/day
Calcium channel blocker-verapamil
Dosing-4-8mg/kg/day, divide in 3 doses
OFF-Label

23. Anticonvulsants OFF-Label Depakote (Valproate Acid)
Mechanisms: ?inhibits Ca+ channels; interacts with 5-HT; reduces neurogenic inflammation in peripheral TVS
SE-Drowsiness, weight gain, hair loss, pancreatitis, thrombocytopenia, associated with neural tube defects
Dosing-start at 10mg/kg/day
Available as ER- 1x/day dosing
Disadvantages-frequent blood levels, CBC, LFT’s
OFF-Label

24. Anticonvulsants OFF-Label Topamax (topiramate)
Mechanisms: blocks Ca+ channel and Na+ channels, carbonic anhydrase activity, enhances GABA effects ( inhibitory)
SE-rash, acute angle glaucoma (rare- red eyes, eye pain, visual complaints), weight loss, word finding difficulties, cognitive and /or memory difficulties
Dosing-Max 5-9mg/kg/ day, though typical dosing is 2-3mg/kg/ day
Start at 15-25mg QHS; average is 100mg
OFF-Label

25. Placebo Effect Preventive Pearls 60% 40% 30% 20%
Even when they work, not guaranteed to get rid of all headaches
Efficacy defined……
May take 4-8 weeks to notice effect
“Two-fers”
Meds do not take place of other interventions
20%
60%
40%
30%
Placebo Effect

26. Andrew-Day 3
12yo male
Headaches at school and at home- pale, nauseated
Headaches happening about 3-4x/ month
Amitriptyline 25mg QHS
Has treated headache
Day 1-rizatriptan and Zofran- minimal improvement
Day 2-riatriptan, odantseron, diphenhydramine and naproxen
Headache still present; unable to go to school

27. What do I do (next…..) OTC medications Prescribed medications
Combined “cocktails”

28. Acute Treatment at Home
The “Headache Cocktail”
Triptan, antiemetic, OTC
Add-on medications
diphenhydramine
Mg+
Co-Enzyme Q-10
Vitamin B2
Migralief
Butterbur-SE

29. Acute Migraine Treatment in ED
Acute Treatment at ED
Acute Migraine Treatment in ED
Sumitriptan 4-6mg SQ
Antiemetics + DHE 0.5-1mg IV
Prochlorperazine
Metoclopramide 20mg IV
Ketorolac 30mg-60mg IM
Magnesium 1-2GM IV
Valproate mg IV
Corticosteroids –dexamethasone 10-24mg IV)
0.9 % Saline bolus with:
Ketorolac 0.5mg/kg (max 30 mg) IV
prochlorperazine 0.15mg/kg IV (max 30mg)
+/- dexamethasone
+/- magnesium infusion
Valproate 15-20mg/kg
Dihydroergotamine (DHE)
intranasal /iv Oxytocin ?
Lack of controlled trials

30. Special situations Asthma Cardiovascular disease Sickle Cell disease
Connective tissue disease:
Marfans’; Loeys-Dietz
Menstrual-related migraine
Status Migrainosus

31. Opioids?

32. Take a Massage and Call Me in the Morning
Complementary & Alternative Therapies
Take a Massage and Call Me in the Morning
Non-Drug therapies
***FLUIDS***
Dietary Interventions
Headache Diary
Environmental Adjustments
Herbal/Vitamin Therapies
Acupuncture/Acupressure
Biofeedback
Aromatherapy
Chiropractic manipulations

33. “For prevention, it is essential to prescribe a sound rhythm in life, for work and rest, mealtimes, and sleep.”Dr. Bo Bille
THE END