1. Diagnosis and Treatment of Pediatric Migraine Susan LeCates, MSN, CNP Family Nurse Practitioner Neurology Department / Headache Center Cincinnati Children’s Hospital Medical Center

2. Disclosure The content of my presentation will include discussion of unapproved or investigational uses of medication for acute and preventative treatment of migraine headache in children

3. Objectives Understand diagnosis of primary headache in children using the International Classification of Headache Disorders (ICHD-3) Develop an appropriate treatment plan for children diagnosed with migraine headaches Recognize when to refer children with migraine headaches

4. Migraines are Common There are 28 million people in the world with Migraine Migraines occur at all ages NOT Migraine headaches in children and adolescents are often under recognized or NOT taken seriously Headache 1993;33:29-35

5. Migraine Prevalence in Childhood 3 to 7 year olds >

6. Migraine Prevalence in Childhood 7 to 11 year olds =

7. Migraine Prevalence in Childhood 11 to 15+ year olds <

8. Pediatric Migraine Impact Migraine - Top 5 most prevalent childhood disorders Headache - 3 rd ranked illness - related cause of school absence Pediatric migraine - $36 billion impact in USA WHO Survey - rates severe migraine with quadriplegia as one of the Most Disabling chronic disorders

9. What is the Key to Diagnosing Migraine? Accurate Diagnosis Effective Communication

10. International Headache Society (IHS) Classification system for headache diagnosis developed in 1988 International Classification of Headache Disorders 3 rd Edition (ICHD-3)

11. Headache Classification 1. Primary: Headache is the Problem 2. Secondary: Symptom of Underlying Disorder 3. Painful cranial neuropathies, other facial pains and other headaches

12. Diagnosing Migraine

13. Migraine without Aura ICHD-3, 2013 At least 5 attacks Last 4 -72 hours untreated (2 - 72 for children under 18 years of age) Two of four characteristics –Unilateral location (commonly bilateral in kids) –Pulsating quality –Moderate or severe intensity –Aggravated by routine activity

14. Migraine without Aura ICHD-3, 2013 During the HA at least one of the following: –Nausea and/or vomiting –Photophobia and phonophobia (may be inferred by child’s behavior) Not attributed to another disorder

15. Migraine with Aura ICHD-3, 2013 Criteria same as Migraine without Aura but also have: –Focal neurological symptom usually developing over 5-20 minutes and lasts less than 60 min –Visual, Sensory, Speech, Motor, Brainstem, Retinal –At least 2 attacks –Headache begins during the aura or follows aura within 60 minutes

16. The Visual Aura

17. The Sensory Aura http://www.youtube.com/watch?v=iZ-RzRUynAE&feature=player_embedded

18. Chronic Migraine ICHD-3, 2013 Headache occurring on 15 or more days per month for > 3 months, which has the features of migraine headache on at least 8 days per month Often results from unresolved status migrainosus Not attributed to another disorder

19. Status Migrainosus ICHD-3, 2013 Present attack meets criteria for migraine without aura and is typical of other attacks Both of the following –HA > 72 hours –Severe intensity Not attributed to another disorder Interruption during sleep and short lasting relief due to medication are disregarded

20. Challenges of Treating Pediatric Migraine Diagnosis and assessment of symptoms is complicated by the inability of children to articulate their complaints Other infectious, allergic, or gastrointestinal disorders of childhood may mimic symptoms of migraine Lack of research conducted in children and adolescents

24. If It Isn’t Migraine What Is It?

25. Headache Attributed to Infection of Nose or Paranasal Sinuses ICHD-3, 2013 Frontal HA with pain in one or more regions of face, ears or teeth Clinical, nasal exam, CT and/or MRI imaging and/or lab evidence of acute or acute-on-chronic rhinosinusitis Simultaneous onset of headache and facial pain Headache and/or facial pain resolve within 7 days after successful treatment

26. Episodic Tension-Type ICHD-3, 2013 At least 10 attacks (more than once but less than 15 days/mos) HA lasting from 30 minutes to 7 days At least 2 of the following: –Pressing/tightening quality –Mild or moderate intensity –Bilateral location –Not aggravated by routine physical activity

27. Episodic Tension-Type ICHD-3, 2013 Both of the following: –No nausea or vomiting (anorexia may occur) –Photophobia or phonophobia Not attributed to another disorder

28. Medication-Overuse Headache ICHD-3, 2013 Analgesics at least 15 days/mos for > 3 mos Triptans at least 10 days/mos for > 3 mos HA has developed or markedly worsened during analgesic overuse Headache resolves or reverts to previous pattern within 2 months after stopping analgesics Daily low dose medication use worse than high dose use once a week Caffeine can also be culprit

29. Medication-Overuse Headache Vasconcellos, et al, 1997 Retrospective review of pts > 4 HA/wk N = 98, mean age = 12.1 Frequency of HA per month –Initial = 27.5 –After 1 mo. without analgesics = 7.3 –After 2 mo. without analgesics = 5.4 (P<0.0001) Daily use of analgesics may reduce the effectiveness of preventative HA meds

30. Acute headache attributed to traumatic injury to the head ICHD-3, 2013 Traumatic injury to the head has occurred Headache is reported to have developed within 7 days after one of the following: –1. the injury to the head –2. regaining of consciousness following the injury to the head –3. discontinuation of medication(s) that impair ability to sense or report headache following the injury to the head Either of the Following: –Headache has resolved within 3 months after the injury to the head –Headache has not yet resolved but 3 months have not yet passed since the injury to the head Not attributed to another disorder

31. Episodic Syndromes that may be Associated with Migraine ICHD-3, 2013 Episodic Syndromes that may be Associated with Migraine ICHD-3, 2013 4. Recurrent gastrointestinal disturbance 5.Benign Paroxysmal Torticollis 6.Others: motion/car sickness; sleep disturbances; recurrent unexplained fever 1.Benign Paroxysmal Vertigo 2. Abdominal Migraine 3. Cyclical Vomiting Syndrome

32. Headache Warning Signs Ferrari, 1998 Sudden change in headache symptoms Sudden, substantial increase in frequency Abnormal neurological examination Aura 60 minutes Aura always on same side Aura without headache

33. When to Get an MRI in Kids Presence of any of the “Warning Signs/Red Flags” No family history of headaches Age less than 5 years old Persistent occipital headache

34. Additional Headache Diagnostic Testing Abnormal HA Evaluation: Blood work CT/MRI EEG LP

35. So How Do You Treat Pediatric Headaches? Acute Preventative Biobehavioral

36. Treat attacks rapidly and consistently without recurrence Restore patient’s ability to function Minimize the use of rescue medications Optimize self-care and reduce use of resources Cost-effectiveness Minimal or no adverse events Goals of Acute Treatment

37. Acute Migraine Treatment Over-the-Counter Medication –Ibuprofen most effective in children Dosage: 10 mg/kg (Hamalainen, et al, 1997) –Naproxen sodium (Aleve) may be substituted for ibuprofen –Aspirin and Excedrin are other options (> 16 years) 24-32 ounces of sports drink for vascular rehydration at HA onset Early Treatment = Successful Treatment

38. Acute Migraine Treatment Faster Onset of Action: –Almotriptan (Axert) –Eletriptan (Relpax) –Rizatriptan (Maxalt, Maxalt-MLT) –Sumatriptan (Imitrex-tablet, NS, SQ,) –Sumatriptan + Naproxen sodium (Treximet) –Zolmitriptan (Zomig, Zomig-ZMT, nasal spray) Slower Onset of Action: –Frovatriptan (Frova) –Naratriptan (Amerge)

39. Acute Migraine Treatment No Narcotics! Use of opioids prevents reversal of established migraine and central sensitization (Jakubowski et al. Headache 2005; 45:850- 61) –Patients with migraine were given parenteral sumatriptan and ketorolac –71% were pain free and without allodynia within 60 minute of ketorolac infusion –In contrast to the responders (9/9), non-responders (1/19) had treated their migraine with opioids

40. Medication Overuse Prevention Limit analgesic use to 2-3 days a week Triptan use limited to 6 headaches a month Limit: No more than 2 doses of medication per headache- need IV acute tx if HA persists

41. Management of Intractable Acute Migraines

42. When do you Refer for Intravenous Acute Headache Treatment? Acute / Non-responsive to home abortive treatment Chronic Migraine - Impaired functioning Chronic Migraine - Acute exacerbation

43. Acute Headache Treatment Algorithm

44. What Happens if the Acute Refractory Headache Doesn’t Break? Admit for Inpatient Treatment using: Pharmacological agents: IV DHE IV Valproate sodium IV Magnesium IV Steroids IV fluids Others

46. Migraine Preventative Treatment

47. Goals of Migraine Prevention Reduce HA attack Frequency, Severity and Duration Improve Responsiveness to TX of Acute Attacks Improve Function and Reduce Disability Improve Quality of Life Educate Patient/Family to become Active Participants in HA Management

48. Common Preventative Medications Antidepressants –Amitriptyline (Elavil) Anticonvulsants –Topiramate (Topamax) –Valproic Acid (Depakote) –Levetiracetam (Keppra) Antiserotonergic –Cyproheptadine (Periactin) Neutraceuticals -Vitamin B2 (Riboflavin) -Coenzyme Q10 -Vitamin D3 Botulinum toxin A (Botox)

49. Botox (onabotulinumtoxin A) Injected directly into overactive muscles Reduces contractions, relaxes muscles

50. Preventative Treatment Principles Criteria to Start: –Frequency >1 week and/or –Disability from HA Purpose is to prevent not cure migraines Never expect a lifetime of preventative treatment Start low and go slow when increasing dose to limit side effects Full response to medication not seen until on full dose for at least 6-8 weeks Slowly wean medication after treatment goal (3-4 HA/month) for 4-6 months No medications FDA approved for migraine prevention in children

51. Biobehavioral Treatment (“Healthy Habits”)

52. Common Headache Triggers (Riback, P., 2000) Stress (23%) Sleep Deprivation (16%) Hunger (11%) Heat (11%) Bright Lights (9%)

53. Daily Fluid Intake Recommend 2-3 liters daily –Provide letter for school giving kids permission to carry water/sports drink bottle at school and use restroom as needed Eliminate Caffeine Diuretic Addictive Caffeine-Withdrawal Headache

54. Healthy Eating Habits Regular meals and snacks Encourage regular intake of fruits, vegetables, and dairy Food triggers uncommon in children

55. Healthy Sleep Habits Recommend 8-9 hours –No Naps Keep regular sleep schedule –Do not oversleep more than 2-3 hours on weekend, especially on Sunday –Avoid naps Establish a bedtime routine to help child fall asleep

56. Exercise Three times a week for 20-30 minutes Hydrate before, during, and after exercise –May need 32 ounces before and after exercise to prevent dehydration triggered headache –Sports drink is best Do not exercise before bedtime

57. School Issues: Proactive Approach –Provide School Letter with Acute Headache Treatment Plan, Hydration/Restroom Needs –Recommend Parent/Child Review Headache Tx Plan with Teachers –Discuss Expectations for School Attendance with Headache –Evaluate Headache Disability at Each Visit

58. When to Refer for Specialty Care?

59. Child Psychologist Lifestyle changes Stress management Learn coping strategies for chronic pain Teach Biofeedback-Assisted Relaxation Techniques

60. Child Neurologist/Headache Specialist Any concern about a secondary cause of headaches (unless it is sinus disease) Headaches that do not meet ICHD-II criteria Headaches unresponsive to treatment interventions Transient neurological signs during headache episodes

61. Conclusions Migraine headaches are common and may often be under-recognized - Think Migraine! Diagnosis should rely on standardized criteria Imaging should be guided by “warning signs” with specific criteria used as suggestions Multi-modal treatment may be necessary: Acute Preventative Healthy Habits Pain Management Consider referral for Headache Specialty Care

62. Website Resources for Headache American Council for Headache Education (ACHE) www.achenet.org www.achenet.org American Headache Society www.ahsnet.org Cincinnati Children’s Hospital Med Center www.cincinnatichildrens.org www.cincinnatichildrens.org National Headache Foundation www.headaches.org American Migraine Foundation http://www.americanmigrainefoundation.org

63. Questions?