1. Paediatric headaches Mark Weatherall London Headache Centre 2010

2. Why is this important? Headaches are common in children Headaches often cause significant disability –affects home life & school performance –affects family relationships –affects relationships with peers

3. Why is this important? Headaches in children are under- recognised, misdiagnosed, and under- treated Headaches may present differently in children Accurate diagnosis and effective treatment –improve quality of life –prevent long-term disability & co-morbidity

4. What headaches are we talking about? Migraine* * with aura in 14-30% Tension-type headache Cluster headache Other headaches

5. Migraine ICHD-II criteria (migraine without aura) –A recurrent headache disorder manifesting in attacks lasting 4-72 hours*. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity, and association with nausea and/or photophobia and phonophobia –* In children 1-72 hours is allowed

6. Migraine Difficulties in diagnosing migraine in children include: –shorter duration –more likely to be bilateral –difficulty in describing headache features and associated symptoms must often be inferred from behaviour/drawings –evolution of the semiology of headaches over time

7. Migraine These difficulties are not confined to the paediatric population! Study comparing physician diagnoses with ICHD-II –4-72 hr duration: 61.9% met criteria –1-72 hr duration: 71.9% met criteria –including bilaterality & other features such as difficulty thinking, light-headedness & fatigue: 88.4% met criteria

8. Other headaches TTH –common but rarely debilitating –true impact very difficult to gauge Cluster headache –devastating until diagnosed –early onset cases rare 18% report onset before 18 yr 2% report onset before 10 yr

9. Headaches are common American Migraine Prevalence & Prevention Study –120 000 households –162 576 participants –mailed questionnaire on HAs & Rx –ICHD-II criteria used –overall 1-yr prevalence migraine ♂ 5.6% ♀ 17.1%

10. Headaches are common Subgroup analysis of adolescents (12-17 yr) –1 yr prevalence of migraine 6.3% ♂ 5% ♀ 7.7% –utilization of medications by this group OTC 59.3% prescription medication only 16.5% OTC & prescription medication 22.1% current prophylactic treatments 10.6%

11. Headaches are common German 3/12 prevalence study –2.6% migraine (ICHD-II criteria) –6.9% if duration criteria reduced to 30 min –12.6% probable migraine –0.7% chronic migraine Turkish prevalence questionnaire –7.8% boys –11.7% girls

12. Headaches are common Meta-analysis of paediatric headache studies 2002 by AAN group –>27 000 children –37-51% significant HA by age 7 yrs –57-82% significant HA by age 15 yrs

13. Impact of headaches Children with migraine lose on average 1½ weeks of school per year Impact can be assessed using validated tools –PedMIDAS –PedQL

14. Treatment Accurate diagnosis Comprehensive treatment plan –Explanation (and reassurance) –Lifestyle advice –Acute treatments –Prophylactic treatments –Biobehavioural therapies

15. Treatment Accurate diagnosis –Underlying headache phenotype What was the headache originally like? –Triggers –Confounding factors Medication overuse Physical co-morbidities Psychological co-morbidities Life stresses

16. Treatment Explanation –common problem –physical, not just psychological problem genetics, pathophysiology –treatable problem identifying triggers, confounding factors Reassurance for child and parents –… this is not a brain tumour …

17. Treatment Acute treatment –Goals: sustained pain freedom rapid return to normal activity –OTC small trials show ibuprofen (7.5-10 mg/kg) superior to PCT + placebo use early, at decent dose avoid overuse (≤3 days/wk)

18. Treatment Acute treatment –Triptans in UK only nasal sumatriptan licensed for adolescents DBPCTs in adolescents exist for almotriptan, eletriptan, rizatriptan, sumatriptan, and zolmitriptan effective (but high placebo rates…) and well- tolerated SUM/NAR database shows a linear correlation between age & efficacy of triptans

19. Treatment Prophylactic treatments –When to use them? increased headache frequency poor response to acute treatments ? severe (including hemiplegic or basilar) MA –Goals: reduce headache frequency reduce headache-related disability allow eventual return to acute treatment alone (or acute treatment + biobehavioural therapy)

20. Treatment Prophylactic treatments –pizotifen –beta-blockers –tricyclics –anticonvulsants –others riboflavin (vitamin B2)* * recent negative small PCRCT! coenzyme Q10 butterbur extract

21. Prophylactic treatments –a paucity of evidence –Cochrane review 2003 found only two trials convincingly showing benefit of prophylactic treatment Propranolol Flunarizine –since then decent PCRCT for topiramate –recent negative PCRCT for SVP MR

22. Treatment Biobehavioural therapies –biofeedback –relaxation training Treatment of co-morbidities –physical sleep disorders –psychological Counselling; family therapy

23. The future? Much more evidence is needed for –Acute treatments –Prophylactic treatments monotherapy combination therapies –Novel treatments CGRP antagonists More interest in the subject must be generated in 1°, 2°, and 3° care