Transcript Document

Update In Management Of
Childhood Headache
Topics
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Headache as a public health issue
Types of pediatric headache (ICHD – HIS)
Challenges in pediatric headache
Pathway of pediatric headache management
Assessment in pediatric headache
Clinical management of pediatric headache
Clinic tools in pediatric headache
Why is it a Relevant Public Health
Issue: Magnitude of the Problem
• Headache is very frequently reported among
children, even more frequently than among
adults.
• It can have a strong impact on school
performance, being major cause of absence from
school, and widely affecting other daily activities
• Individual and societal costs of headache
disorders in children and adolescents are due to
their high incidence and lifetime prevalence.
Why is it a Relevant Public Health
Issue: Magnitude of the Problem
• the lifetime prevalence of headache disorders ranges
from 70% to 80% in children of 13–15 years of age.
• Headache affects 3% to 8% of children aged ≥3 years,
19.5% of children aged 5, and 37% to 51.5% of children
aged 7, with an higher frequency in males before
puberty, and in females after puberty.
• Headaches in infancy and early childhood are rare,
and in children younger than 3 years are more likely to
have an organic cause (secondary headaches)
The International Classification of Headache
Disorders, 3rd edition (beta version)- International
Headache Society 2013
Common Headache Disorders in
Primary Care
Type
Definition
Migraine
Usually episodic, occurring in 12 – 16% of general
population, with female to male ratio of 3:1
Tension-type
Headache
Usually episodic, affecting > 80% of people from time to
time, in at least 10% it recurs frequently, and in 2 – 3% of
adults and some children it is chronic, occurring on more
days than not
Cluster Headache
Intense and frequently recurring but short-lasting
headache, affecting up to 3 in 1000 men and up to 1 in
2000 women
A chronic daily headache syndrome occurring in up to
Medicationoveruse Headache 30% of adults, 5 women to each man, and 1% of children
and adolescents; it is a secondary headache but it occurs
as a complication of a pre-existing headache disorder,
usually migraine or tension-type headache
2004 International Headache Society classification of
headache disorders: Criteria for pediatric migraine without aura
A. 5 attacks fulfilling features B–D
B. Headache attack lasting 1 to 72 hours
C. Headache has at least 2 of the following 4 features:
• 1. Either bilateral or unilateral (frontal/temporal) location
• 2. Pulsating quality
• 3. Moderate to severe intensity
• 4. Aggravated by routine physical activities
D. At least 1 of the following accompanies headache:
• 1. Nausea and/or vomiting
• 2. Photophobia and phonophobia (may be inferred from their
• behavior)
Conclusions: CGs resulted definitely of low-moderate
quality and non “homogeneous”. Further major efforts are
needed to update the existing CGs according to the
principles of evidence based medicine.
Pediatric headache: Challenges
• Diagnosis of headache in children is often surprisingly
poor and not adequately investigated.
• No adequately sensitive and specific diagnostic
criteria.
• In Pediatric Emergency Department, children are
diagnosed and treated by healthcare professionals who
if are not expert in pediatric neurology, might risk to
undergo inappropriate, unnecessary and harmful
neuro-radiological investigations.
Pediatric Headache: Consult and Referral Guidelines
Child Neurology Division at Children’s National Medical Center
Provider’s initial
evaluation may include:
Provider should instruct
family on basic first line
treatment for headache
including:
Provider may consider
testing in patients who:
Provider may consider
initiating referral to
child neurology when:
Provider may instruct
families to bring the
following to the
evaluation:
Asking about common
symptoms seen in
primary headaches..to
classify them
Considering other
common causes of
headaches e.g. sinusitis
– post-traumatic –
allergic – ophthamic
problems – depression
Lifestyle modification
for prevention of
headache e.g. hydration
– sleep – 3 healthy well
balanced meals
Abortive therapy for
headahces: ibuprofen –
triptans
Preventive therapy for
frequent headaches e.g.
amitriptyline cyprohepatidine
* Neuro-imaging if:
Headache < 6 months
not responding to
lifestyle measures and
first line treatment
Headache + abnormal
neurological exam
Absent family history
of headache
Headache with
prominent confusion or
vomiting
Headache awakening
child from sleep
repeatedly
Family history of predisposing CNS disease
* Specific testing for
headache plus other
symptoms
New severe headache
of acute onset
Headache with focal
neurological signs or
papilledema
Recurrent headache
for 6 months not
responding to standard
medical treatment
Headache resulting in
missed school days or
worsening of school
participation
Headache calendar for
at least one month
Complete list of
medications used for
treatment of headache
Copies of previous
testing
Patient presents with headache
Complete history, physical and neurological examination –
use screening tools to identify psycho-social problems
No red flags
Classify headache
There are red flags
Begin neuro-imaging
Consult ped. neurologist
If urgent refer to pediatric neurologist or
neurosurgeon
Begin headache
treatment
Begin appropriate treatment
in consultation with
subspecialist
Keep an ongoing log of date,
time, situation, treatment,
response for headache
Keep an ongoing log of date,
time, situation, treatment,
response for headache
Assessment: Questions to ask in the History
Question
Details
How many
headache types?
A separate history is needed for each type
Time questions
Why consulting now? - How recent in onset? Time from onset to
peak? - Usual time of onset? (season, month, menstrual cycle,
week, hour of day) - How frequent and what temporal pattern
(episodic or daily and/or unremitting)?- How long lasting?
Character
questions
Intensity of pain? – nature and quality of pain? – site and spread
of pain? – associated symptoms?
Cause questions
Predisposing and/or trigger factors? – aggravating and/or
relieving factors? – family history?
Response questions What does the patient do during the headache? – how much is
activity (function) limited or prevented? – what and how
medications?
State of health
between attacks
Completely well or residual or persisting symptoms? – concerns,
anxieties, fears about recurrent attacks and/or their cause?
Assessment: Focused physical examination
• Vital signs: BP, pulse, resp., temp.
• Extra-cranial structures: carotid
arteries, sinuses, scalp arteries,
cervical paraspinal muscles
• Neck examination; flexion versus
lateral rotation for meningeal
irritation.
Focused neurological examination
• A focused neurological examination: abnormal signs in
headache due to acquired disease or a secondary headache.
• Examination should include at least the following evaluations:
• Awareness and consciousness, presence of confusion, and
memory impairment
• Ophthalmological examination: pupillary symmetry and
reactivity, optic fundi, visual fields, and ocular motility
• Cranial nerve examination: corneal reflexes, facial sensation
and facial symmetry
• Symmetry of muscle tone, strength
• Sensation
• Plantar response(s)
• Gait, arm and leg coordination
Causes for Concern? www.icsi.org.
2013 by Institute for Clinical Systems
Improvement
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Warning signs of possible disorder other than primary headache
are:
Subacute and/or progressive headaches that worsen over time (months).
A new or different headache or a statement by a headache patient that "this
is the worst headache ever."
Any headache of maximum severity at onset.
Persistent headache precipitated by a Valsalva maneuver such as cough,
sneeze, bending or with exertion (physical or sexual).
Evidence such as fever, hypertension, myalgias, weight loss or scalp
tenderness suggesting a systemic disorder.
Neurological signs e.g. meningismus, confusion, altered levels of
consciousness, impairment of memory, papilledema, visual field defect,
cranial nerve asymmetry, extremity drifts or weaknesses, clear sensory
deficits, reflex asymmetry, extensor plantar response, or gait disturbances.
Seizures.
Radiologic Evaluation: MRI without contrast unless imaging
study needed urgently, then do CT without contrast*
• Suspected primary headache BUT migraine complicated by focal
neurological symptoms or signs, or concerning change in frequency or
severity
• Headache with signs of increased intracranial pressure (ICP) or abnormal
neurological signs
• Severe headache of abrupt onset (thunderclap headache) - CT
preferred*
• Headache attributed to infection - CT prior to LP*
• Headache attributed to trauma - CT preferred*
• Occipital headache - MRI preferred due to limitation of CT to view
posterior fossa (eg. Chiari Malformation)
• *CT can be obtained urgently in most communities and can give
adequate information to identify intracranial bleeding or increased
ventricular size.
Neuro-imaging (Quality of evidence: B)
1. Computed tomography (CT) scanning is usually not
indicated in a child with recurrent headaches.
Consider when the following are present:
1. Acute “worst headache of life” (WHOL)
2. Thunderclap headache
3. New focal neurological deficit is currently present on
examination with acute headache
4. Intractable vomiting
5. Papilledema
6. Fever
Neuro-imaging (Quality of evidence: B)
2. Magnetic resonance imaging (MRI)
1. If one of more red flags (Several red flags
may be more predictive of underlying
neurological etiology) and/or concern for a
tumor or other structural abnormality.
2. In a child with a majority of headaches
occurring only at nighttime.
Lumbar
Puncture
1. Mandatory in febrile patients with nuchal
rigidity but no alteration in consciousness, signs
of increased intracranial pressure, or lateralizing
features
2. Indicated with measurement of opening
pressure in case of suspected subarachnoid
hemorrhage (WHOL and Thunderclap
headache), acute or chronic meningitis,
pseudotumor cerebri, or neuroborreliosis
3. patient’s mental status is altered, papilledema
is present, or focal findings are evident, cranial
imaging is warranted before lumbar puncture
Electroencephalogram
(EEG) (Quality of
evidence: D)
Of limited use in the routine evaluation of
headache in children
May be warranted if headache is momentary
and is associated with altered consciousness
or abnormal movement,
Referral
• Reasons for Referral/Consultation (by phone or online
immediately)
1. Red Flags in the History
2. Red Flags in the Physical
3. Significant Abnormality on Radiologic Evaluation
• Materials to send the pediatric neurologist at the time of referral
or consultation:
1. Copies of medical records with dictated letter
2. Laboratory reports and imaging studies or CD's
3. Complete list of medications, prescription and over-the-counter
4. Two-month calendar diary of date, time, severity, duration,
other symptoms, triggers, and treatment for headaches
CLINICAL
MANAGEMENT
Behavioral Modification
• All children need to be counseled on behavior
modification as “headache hygiene” maintaining
healthy habits to prevent headaches. These
include:
1. Fluids: Drink enough fluid (6 to 8 glasses per day)
and avoid caffeine.
2. Sleep: 8 to 10 hours of sleep each night and go to
bed at the same time each night and awaken at
the same time each day keep a regular sleep
schedule
CLINICAL
MANAGEMENT
Behavioral Modification
3. Nutrition: Consume balanced meals at regular hours and do not
skip meals. Triggers are different for each individual. Possible
food triggers: aged cheese, artificial sweeteners, caffeine,
chocolate, citrus fruits, cured meats (packaged lunchmeats,
sausage, pepperoni), nuts, onions, and salty foods.
4. Exercise/stretching: At least 45 minutes of aerobic activity and 5
to 10 minutes of stretching every day.
5. Stress: Stress is the number one trigger for children. Consider
stress management, counseling, or relaxation techniques.
6. Electronics overuse: Limit use of electronics to less than 2 hours
per day and none 2 hours prior to bedtime
CLINICAL
MANAGEMENT
Acute / Abortive Headache - General recommendations
1. Create a treatment plan for home/school acute management
a. Always include a component of non-pharmacologic options
b. Always have fluid replacement as part of first line treatment
c. Always have a first line medication to take at onset and a second line to take 2
hours later for persistent headache
d. First line therapy should not contain a sedating medication and child can
return back to school work
e. Second line therapy may contain a sedating medication and child should rest
and avoid activity when possible
2. The key is to treat with an adequate dose at onset of aura or headache
3. If using a triptan: it is most effective to take at onset of headache
4. Start with monotherapy and progress to combinations as needed
5. Abortive treatment should be limited to only 2 to 3 times per week. Pay particular
attention to prescribing NSAIDS for extended periods, as this will increase
medication overuse headaches (i.e. rebound headache)
Non-Pharmacologic Options
• Non-pharmacologic options
1. Fluid replacement: Sports drink without caffeine ,
coconut water, or plain water
2. Rest
3. Darken room
4. No televisión, cell- phone, etc.
5. Aromatherapy
6. Massage
7. Relaxation techniques and biofeedback
modalities
8. Warm or cold packs
Relaxation Techniques and Bio-behavioral Modalities
The combination of biofeedback and relaxation
treatments provides the child/adolescent with
objective data to evaluate their response
While all children with migraines may benefit
from these therapies, they are reserved
primarily for children with disabling
headaches.
Relaxation Techniques and Bio-behavioral Modalities
• Relaxation treatments include progressive muscle
relaxation, diaphragmatic or deep breathing, and guided
imagery. Generally, children must be at least 7 years old
before they can comprehend the concepts involved in
these techniques
• Biofeedback frequently is used as an adjunct to
relaxation training. Two different techniques can be used
with children and adolescents:
• Electromyographic activity, in which an electrical
discharge in the muscle fiber indicates skeletal tension
• Peripheral skin temperature monitoring measures
vasomotor mechanisms. As the child relaxes, the skin
temperature rises.
NEUROLOGY 2004;63:2215–2224
Recommendations for the acute treatment of migraine
in children and adolescents.
• 1. Ibuprofen is effective and should be considered for
the acute treatment of migraine in children (Level A).
• 2. Acetaminophen is probably effective and should be
considered for the acute treatment of migraine in
children (Level B).
• 3. Sumatriptan nasal spray is effective and should be
considered for the acute treatment of migraine in
adolescents (Level A).
• 4. There are no data to support or refute use of any
oral triptan preparations in children or adolescents
(Level U).
• 5. There are inadequate data to make a judgment on
the efficacy of subcutaneous sumatriptan (Level U).
Developing Home / School Use Headache
Action Plan
Has child failed
adequate dose
of ibuprofen
1st line: Fluid replacement: 24 to 32 ounces PLUS ibuprofen
NO PLUS non-pharmacological options
2nd line: if symptoms persist after 2 hours administer
dihydrophenhydramine
YES
Has child failed
adequate dose
of naproxyn
1st line: Fluid replacement: 24 to 32 ounces PLUS naproxyn
NO PLUS non-pharmacological options
2nd line: if symptoms persist after 2 hours administer
dihydrophenhydramine
YES
Has child failed
adequate dose of
triptan or
contraindicated
1st line: Fluid replacement: 24 to 32 ounces PLUS triptan
NO PLUS non-pharmacological options
2nd line: if symptoms persist after 2 hours repeat triptan and
NSAID and /or dihydrophenhydramine
YES
Has child failed
adequate dose of
triptan and NSAID
or triptan
contraindicated
1st line: Fluid replacement: 24 to 32 ounces PLUS NSAID
NO PLUS triptan PLUS non-pharmacological options
2nd line: if symptoms persist after 2 hours repeat triptan and
dihydrophenhydramine
CLINICAL
MANAGEMENT
Preventive Therapy - General recommendations
1. Life-style behaviors and stress management are the safest
preventatives
2. Start preventive if 3-4 headaches or more / month with
significant disability (i.e. missed school, missed school
related activities, etc). The goal of preventive treatment is
to decrease headache frequency to < 1-+2 per month, with
decreased disability for a sustained period of time (4-6
months)
3. When choosing a preventative Consider child’s age, weight,
and comorbidities. Side –effect profile of medications.
CLINICAL
MANAGEMENT
Preventive Therapy - General recommendations
4. Titration tips
a. Start low and go slow—you want to optimize effectiveness and
decrease possible side effects experienced
B. During titration, you do not need to reach “maintenance” dose if
patient has improvement/resolution of headaches.
C. Improvement typically is observed after weeks or possibly
months of treatment, rather than within days6.
5. Discontinuation tips
a. All meds should be weaned by approximately 25% every 2
weeks, unless side-effects are considered adverse or patient on
lowest dose.
Recommendations for preventive therapy of migraine
in children and adolescents.
• 1. Flunarizine is probably effective for preventive
therapy and can be considered. (Level B).
• 2. There is insufficient evidence to make any
recommendations concerning the use of
cyproheptadine, amitriptyline, divalproex
sodium, topiramate, or levetiracetam (Level U).
• 3. Recommendations cannot be made
concerning propranolol or trazodone for
preventive therapy as the evidence is conflicting
(Level U).
• 4. Pizotifen and nimodipine (Level B) and
clonidine (Level B) did not show efficacy and are
not recommended.
Provider Tools
1. Headache Intake Questionnaire:
This tool can be given to patients for them to complete
while in the waiting or exam rooms. Providers then can
use this information during their visit.
2. Headaches in Children Caregiver Education:
This handout can be given to families and patients as
headache education
3. Headache Diary:
For patients to fill out to keep track of their headaches,
any patterns, and frequency of headaches. Can be
given to patients for them to complete while in the
waiting or exam rooms.
Headache Intake Questionnaire
Preventive Caregiver Education
1. Instruct parent/caregiver and patient about measures to help
prevent headaches such as:
• a. Fluids
• b. Sleep
• c. Nutrition
• d. Exercise/stretching
• e. Electronics overuse
2. Instruct parent/caregiver and patient about keeping a headache
diary
3. Instruct parent/caregiver and patient about medications, including
optimal scheduling of rescue and preventative medications
4. Manage expectations of the parent/caregiver and patient, including
informing them that changes are often seen after a period of time
such as weeks or months, rather than days
Headache Diary
Follow up
• When to see your patient back in your clinic:
Category
New onset headaches
Frequency
follow-up in 2 to 4 weeks
Children with high frequency headaches follow-up in 4 to 6 weeks
(>8 headaches per month) and new
changes to treatment plan
Children with low frequency headaches
(<8 headaches per month) and new
changes to treatment plan
follow-up in 8 to 12 weeks
Children with no changes and stable
follow–up in 10 to 12 weeks,
up to 1 year