HEADACHE

1. HEADACHE CONTINUITY LECTURE SAMATHA MADHAVARAPU PGY -1

2. EPIDEMIOLOGY • Significant health problem for children and adolescents. • Up to 75% of children report having a significant headache by the time they are 15 years of age • 10.6% of children between 5 and 15 years had migraine

3. Meta-analysis of pediatric headache • 3-7 Years : (1.2% to 3.2% )Slightly male predominance • 7-11 Yrs : 4–11% Equal male and female predominance. • 11- 15 years of age: 18–23% Female predominance • 15 – 19 Yrs : 28% had migraine, Females, migraine without aura common • 81% of adolescents with migraine had a positive family history.

4. TTHs have been less well studied than migraine • Migraine has a genetic component • Degree of inheritance as high as 90% in first- or second-degree relatives • TTHs are generally considered mild recurrent headaches (previously called muscle contraction headache,idiopathic headache, and tension headache • Impact of headaches • 1989 National Health Interview Survey found that within a 2-week period, 975,000 children had a migraine, resulting in 164,454 missed school days.

5. International Classification of Headache Disorders (ICHD-II). Primary Headaches Secondary Headaches • Directly attributed to a neurologic basis • Migraine • Tension-type headaches (TTHs) • Cluster headaches • Other primary neuralgias • Attributed to a specific non-neurologic cause. • Infectious • Vascular • Traumatic • Toxic • Including medications and overuse of medications • Mass lesion

6. Evaluation • After the detailed history and medical examination, it should be possible to determine whether the patient has a primary or secondary headache • The first step in evaluating a child with headache is to rule out secondary causes

7. Detailed Headache History • Length of time the child has had headaches • Severity • Quality :Throbbing, pulsating, tightness, pressure, squeezing, sharp, stabbing, dull • Location :frontal, temporal, occipital, unilateral, bilateral • Duration : number of minutes, hours, or days • Frequency : number per month, time interval between headaches • The effect on the child’s quality of life and disability • Any aura before headaches • Presence of Nausea/ vomitting

8. History contd • Time of onset: specific time of day, night-time waking, relationship to particular activity/ menses • Precipitating factors: foods, odors/ perfumes, stressors • Ameliorating factors: sleep, exercise, quiet, dark room • Associated factors: photophobia, phonophobia • Lifestyle factors: sleep pattern, exercise; diet: caffeine intake, chocolate, aged cheeses, processed meats, monosodium glutamate, nuts, and pickles • Personality change: crying, rocking, holding head, decreased activity/eating in younger children; withdrawal in older children • What does the child/adolescent think is causing the headache? • Prior treatment: response to past treatment, frequency of use of over-the-counter or prescription medications, use of herbs, vitamins, supplements, or alternative therapies • Activities; changes in school attendance or performance; smoking, alcohol, or other substance abuse Detailed review of systems

9. History contd • Medical History : trauma, infection, allergies, ventriculo-peritoneal (VP) shunt placement , epilepsy, atopic disorders, diabetes mellitus, depression or other psychiatric disorders • Family History : headaches in first- and second-degree relatives • Social History : Changes or stressors in the home, school, or outside the home or school should be obtained

10. Physical Exam • Conducting a physical examination is important, with an emphasis on the neurologic examination. • Include a thorough search for potential sources of secondary headache. • Increased intracranial pressure • Sinusitis • Dental disease • Abnormalities of the cervical spine • Temporomandibular joint disorders

11. Secondary headache causes • Head or neck trauma • Cranial or cervical vascular disorder • Nonvascular intracranial disorder • High-pressure headaches • Low-pressure headaches • Substance use/abuse or withdrawal • Includes medication overuse headaches • Infection • Brain abscess • Meningitis • Encephalitis • Disorders of homeostasis or facial pain extending from • Cranium • Neck • Eyes • Ears • Nose • Sinuses • Teeth • Mouth • Psychiatric disorders

12. MIGRAINE Migraine without aura, previously called common migraineor hemicrania simplex • Recurrent headache disorder • Attacks last 4–72 hours. • Typical characteristics • More often bilateral, orbital, or frontotemporal, • Pulsating quality • Moderate or severe intensity • Aggravation by routine physical activity • Association with nausea, photophobia, phonophobia , unexplained paroxysmal abdominal pain • GI symptoms • 60-85% of migrainous children

13. Phases of Migraine attack • Premonitory phase or prodrome : may precede the headache phase by up to 24 hours • irritability, elation or sadness, talkativeness or social withdrawal, an increase or decrease in appetite, food craving or anorexia, water retention, and/or sleep disturbances • Aura: focal cerebral dysfunction that immediately precedes or coincides with the headache onset • Only 10-20% of children with migraine experience an aura

14. Phases of Migraine • Aura: precedes the headache by less than 30 minutes and lasts for 5-20 minutes • Motor auras last longer • Children are often unaware or unable to describe • pictorial cards • The visual aura is the most common form in children, • blurred vision, fortification spectra (zigzag lines), scotomata (field defects), scintillations, black dots, kaleidoscopic patterns of various colors, micropsia, macropsia (distortion of size), and metamorphopsia ("Alice in Wonderland" syndrome). moving or changing shapes

15. other auras include attention loss, confusion, amnesia, agitation, aphasia, ataxia, dizziness, vertigo, paraesthesia, or hemiparesis. • Actual headache phase : usually shorter in children, 30 min- 48hrs. less severe • Postdrome : patient may feel either elated and energized or exhausted and lethargic

16. MIGRAINE • Migraine with aura (classic migraine) • Aura consists of visual, sensory, or speech symptoms. • Gradual development • Duration ≤1 hour • Complete reversibility • In addition to the aura, the headache will have symptoms of migraine without aura. • Chronic migraine • Frequent headaches (≥15 times per month for the previous 3 months) • Presence of migraine features • Cannot be attributed to a secondary cause

17. Status migrainosus: severe form of migraine . Headache continuous for over 72 hours. Hydration imp for those with vomiting. Iv dihydroergotamine/ valprote is treatment. • Familial hemiplegic migraine : autosomal dominant form of migraine with aura • prolonged hemiplegia accompanied by numbness, aphasia, and confusion. precede, accompany, or follow the headache. headache is usually contralateral to the hemiparesis

18. Basilar migraine • Subtype of migraine with aura. • Occipital headache. • Disturbances in function originating from the brain stem, occipital cortex, and cerebellum • Ataxia • Bilateral paresthesias • Deafness • Decreased level of consciousness • Diplopia • Dizziness • Drop attacks • Dysarthria • Fluctuating low-tone hearing loss • Tinnitus • Unilateral or bilateral vision loss • Vertigo • Weakness

19. Cyclic vomiting syndrome • Migraine-associated cyclic vomiting syndrome (periodic syndrome) • Recurrent periods of intense vomiting separated by symptom-free intervals • Rapid onset at night or in the early morning. Nausea, anorexia, abd pain, pallor, headache, photo/phonophobia. • Begins when the patient is a toddler and resolves in adolescence. family history of migraine • Respond to antimigraine drugs

20. TTH s • Generally considered mild recurrent headaches • Many features are the opposite of those of migraine. • TTHs can be subdivided based on frequency. Infrequent, episodic Frequent, episodic Chronic • Diffuse in location • Having a pressing quality • No secondary causes are identified

21. Cluster headache • histamine headache • severe and unilateral, sudden onset • typically are located at the temple and periorbital region • ipsilaterallacrimation, nasal congestion, conjunctival injection, miosis, ptosis, and lid edema • few moments to 2 hours • grouping of headaches, usually over a period of several weeks. • at least 5 attacks occurring from 1 every other day to 8 per day and no other cause for the headache. • Distribution - First and second divisions of the trigeminal nerve

22. Danger Signs and Symptoms of Life Threatening Conditions that Can Present with a Headache • History: No family history in presence of other signs & symptoms Lack of response to medical therapy Early morning pain, with/without headache Night time awakening with pain Persistant vomiting Increased pain with coughing/bowel movt/voiding Chronic progressive pain Worst headache that has ever had Personality change (depression &migraine indicate temporal lobe tumor)

23. Physical exam • Age <3yrs • Known risk for intracranial pathology V-P shunt malfunction Neurofibromatosis Tuberous sclerosis • Abnormal Neurologic exam Seizures, lethargy, ataxia hemiparesis, abn reflexes, diplopia, papilledema, meningeal signs

24. Imaging • If abnormalities on the neurologic examination cannot be explained by medical history, then neuroimaging may be required to identify a medically or surgically treatable cause of the headaches. • The decision to perform neuroimaging on a child with headache is made based on the history and physical. • Neuroimaging in children with recurrent headache but a normal examination routinely is not recommended • Neuroimaging should be considered for children with headaches with abnormal neurologic examinations and/or seizure, recently occurring severe headaches, change in headaches, or associated neurologic dysfunction

25. Treatment Approach • In patients with secondary headaches, the treatment goal is to address the underlying cause. • Headaches should resolve once the underlying cause is addressed. • Treatment of primary headache disorders in children must be 3-fold. • Acute therapy • Preventive therapy • Biobehavioral therapy • Clear goals of treatment must be discussed with the patient and parents

26. Short-term therapy • To ameliorate episodic headache and return to N baseline. • NSAIDS: Ibuprofen, Naproxen Mainstay for the acute treatment of childhood headaches and migraines Good tolerability, Effective in clinical trials. Proper use of ibuprofen needs: Initiation of rapid treatment Proper dosing Avoidance of overuse; limited to ≤3 times per week

27. When NSAIDs are ineffective or not completely effective, switch to migraine-specific therapy

28. Triptans • 5-HT1B-1D agonist migraine-specific medications • Relieve not only pain but also nausea, vomiting, photophobia, and phonophobia. • Sumatriptan, zolmitriptan, rizatriptan • Use of these drugs for migraine relief in children has not been formally approved. • Sumatriptan nasal spray (especially in the teenage population) has been among the most extensively studied; sumatriptan subcutaneous in small doses for severe migraine can be considered. Use in persons <8 y not recommended • Two treatment methods • Rescue therapy or Stepwise treatment within an attack. • Starts with NSAID at the onset & if it fails, use triptan • Step wise Rx: Mild /moderate pain: NSAID Severe headache: triptan

29. Dihydroergotamine (DHE) • Long history of usefulness in migraines • Frequently used in the emergency management of childhood headaches • Breaks status migrainosus or prolonged migraines in children • Has significant adverse effects, including vomiting • The effect may be enhanced if patients are premedicated with dopamine antagonists

30. Dopamine antagonists (prochlorperazine, metoclopramide) • Used for nausea and vomiting effects of migraine headaches • Combines an antiemetic effect but also a direct antimigraine effect because of antidopamine action • Dopamine antagonists should be given intravenously. • Their utility is limited by extrapyramidal side effects. • It is suggested that prochlorperazine can be used to break an acute episode of status migrainosus. • Best given with rehydrating fluids in the emergency room setting

31. Prophylactic treatment • Second component • Started when headache becomes frequent / disabling • Goal: minimize the effect & number of headaches • Having >2–3 headaches per month typically warrants treatment • For all prophylactic medications, titrate doses slowly to an effective level • This may be a lengthy process (weeks, months) • Migraine preventives: flunarizine, gabapentin , riboflavin , metoprolol.

32. Antiepileptics • Only divalproate sodium and topiramate are currently approved for the prevention of migraines in adults; they are not approved for children • Divalproate: Has not been formally approved for use in migraine in persons <16 y . safe use younger than that age has been reported • Topiramate : initial studies point to good efficacy and tolerability • Antidepressants : • Most widely used tricyclic antidepressant for headache prevention is amitriptyline. • First recognized in the 1970s as an effective migraine therapy

33. Amitriptyline was found to be effective in 50–60% of children in a cross-over study comparing amitriptyline with propranolol and cyproheptadine • There are no placebo-controlled studies with amitriptyline. • Titrate slowly over 8-10 weeks to minimize somnolence • Cannot be formally recommended for individuals <12 y • Nortriptyline : Potential for increased arrhythmias Regular EKG is needed. SSRI s not yet studied, , not as effective as more global decrease in neurotransmitter reuptake inhibition is needed to treat childhood headache disorders

34. Cyproheptadine • An antihistamine that has been used for migraine prevention in children more than in adults. • Antihistamine with antiserotonergic effects • May have some calcium channel–blocking properties • Tends to be well tolerated • Increased weight gain is the most significant side effect. • Because weight gain is substantial, use of this medication tends to be limited to younger children

35. β-Blockers have a long history of use for preventing childhood headaches. • Propranolol was found to provide mixed responsiveness when used for childhood headaches. • .Tolerated best with a titration of the dose over 1-2 wk. • They cause a decrease in blood pressure. • There is a risk for exercise-induced asthma. • They can result in depressive effects

36. Calcium-channel blockers • Flunarizine Baseline headache frequency was significantly reduced in flunarizine-treated children. not scheduled to be approved in the United States • Verapamil:drug has not been FDA approved for use in migraine

37. Biobehavioral therapy • Essential for children to maintain a lifetime response to the treatment and management of their headaches . • Treatment adherence Clear understanding by the patient and parent about the importance of the treatment is essential. • Biofeedback-assisted relaxation therapy • For children, single-session biofeedback-assisted relaxation therapy has been demonstrated to be learned quickly and efficiently • Relaxation techniques with biofeedback of either cutaneous temperature with a finger probe or muscular contraction with an electromyography (EMG) needle are very helpful as adjunct therapy or can even prevent headache on their own in the older child granted that an adequate cooperation can be obtained. • Recommended treatment is 2-3 times a week for 4-8 weeks. Usually, a physical therapist or sometimes a psychologist with cognitive-behavioral skills performs this technique.

38. Lifestyle changes • Adequate fluid hydration, with limited use of caffeine • Regular exercise • Adequate nutrition through regular meals and a balanced diet • Adequate sleep • The patient and parents must understand that these objectives are lifetime goals that can control the effect of migraines and minimize the use of medication. • Lifestyle changes may result in an overall long-term improvement in quality of life and may reverse any progressive nature of the disease.

39. When to refer • Headaches that do not respond routinely to acute treatment • Headaches that are increasing in frequency, severity, or duration • Headaches in which the features acutely change • Side effects of medications that limit increasing the medication to an effective dose • Psychological factors that interfere with management • Disability that impairs functioning

40. Follow up • Important to assess regularly the morbidity of headaches and effectiveness of treatment • Regular measurement of both disability and quality of life are helpful in assessing treatment strategies and improvement in outcomes. • Disability • Pediatric Migraine Disability Assessment (PedMIDAS) uses a patient-based disability scale. • Quality of Life • Pediatric Quality of Life Inventory version 4.0 (PedsQL 4.0) uses both parent and child input. • Evaluates functioning in health, emotional, social, and school domains • Headaches have been found to substantially affect emotional development and school functioning.

41. PEDMIDAS Developed to assess migraine disability in pediatric and adolescent patients validated for ages 4 to 18 Pedmidas score Disability grade 0 to 10 little/none 11 to 30 mild 31 to 50 moderate > 50 severe

42. A 16-year-old girl who is new to your practice complains of a nearly constant headache for the past year. She describes the pain as a band around her head that often is throbbing and is worse during the middle of the day. She denies nausea or vomiting but reports occasional fatigue. There is no family history of headaches. She has missed more than 20 days of school this year because of the headache, and she is struggling to maintain a C average. She admits to hating school and does not participate in extracurricular activities because she "doesn't like anything." Findings on her physical examination, including complete neurologic and funduscopic evaluation, are normal.Of the following, the BEST next step in the management of this girl's headaches is to

43. Of the following, the BEST next step in the management of this girl's headaches is to • advise her to keep a headache diary and return in 2 months • obtain a lumbar puncture • obtain computed tomography scan of the brain • prescribe oral sumatriptan • refer her for psychosocial evaluation and counseling

44. A 14-year-old girl who has a 1-year history of migraine headaches presents to the emergency department with a severe headache that she calls "the worst headache of my life. " The headache occurred suddenly after she lifted a heavy box. Her mother says that the girl has been holding her head stiffly. On physical examination, she appears in severe pain and has meningismus. Other findings on the physical examination are normal.Of the following, the MOST appropriate initial course of action is

45. Of the following, the MOST appropriate initial course of action is • emergent noncontrast head computed tomography scan • intravenous administration of ceftriaxone • intravenous administration of dihydroergotamine • lumbar puncture • oral administration of sumatriptan