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Diagnosis and Treatment of
Pediatric Migraine
Susan LeCates, MSN, CNP
Family Nurse Practitioner
Neurology Department / Headache Center
Cincinnati Children’s Hospital Medical Center
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
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
Migraines are Common
• There are 28 million people in the world with
Migraine
• Migraines occur at all ages
Migraine headaches in children and
adolescents are often under recognized or NOT
taken seriously
Headache 1993;33:29-35
Migraine Prevalence in Childhood
>
3 to 7 year olds
Migraine Prevalence in Childhood
=
7 to 11 year olds
Migraine Prevalence in Childhood
<
11 to 15+ year olds
Pediatric Migraine Impact
• Migraine - Top 5 most prevalent childhood
disorders
• Headache - 3rd 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
What is the Key to Diagnosing
Migraine?
• Accurate Diagnosis
• Effective Communication
International Headache Society
(IHS)
• Classification system for headache
diagnosis developed in 1988
• International Classification of Headache
Disorders 3rd Edition (ICHD-3)
Headache Classification
1. Primary: Headache is the Problem
2. Secondary: Symptom of Underlying Disorder
3. Painful cranial neuropathies, other facial pains
and other headaches
Diagnosing Migraine
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
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
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
The Visual Aura
The Sensory Aura
http://www.youtube.com/watch?v=iZ-RzRUynAE&feature=player_embedded
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
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
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
If It Isn’t Migraine What Is It?
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
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
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
Medication-Overuse Headache
ICHD-3, 2013
• Analgesics at least 15 days/mos
for > 3 mos
• Daily low dose medication use
worse than high dose use once
a week
• Triptans at least 10 days/mos for
> 3 mos
• Caffeine can also be culprit
• HA has developed or markedly
worsened during analgesic
overuse
• Headache resolves or reverts to
previous pattern within 2 months
after stopping analgesics
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
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
Episodic Syndromes that may be
Associated with Migraine
ICHD-3, 2013
1. Benign Paroxysmal
Vertigo
4. Recurrent gastrointestinal
disturbance
2. Abdominal Migraine
5. Benign Paroxysmal
Torticollis
3. Cyclical Vomiting
Syndrome
6. Others: motion/car
sickness; sleep
disturbances; recurrent
unexplained fever
Headache Warning Signs
Ferrari, 1998
• Sudden change in headache symptoms
• Sudden, substantial increase in frequency
• Abnormal neurological examination
• Aura < 5 minutes or > 60 minutes
• Aura always on same side
• Aura without headache
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
Additional Headache Diagnostic Testing
Abnormal HA Evaluation:
• Blood work
• CT/MRI
• EEG
• LP
So How Do You Treat Pediatric
Headaches?
• Acute
• Preventative
• Biobehavioral
Goals of Acute Treatment
• 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
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
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)
Acute Migraine Treatment
No Narcotics!
• Use of opioids prevents reversal of established migraine and
central sensitization (Jakubowski et al. Headache 2005; 45:85061)
– 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
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
Management of Intractable Acute
Migraines
When do you Refer for Intravenous Acute
Headache Treatment?
• Acute / Non-responsive to home abortive
treatment
• Chronic Migraine - Impaired functioning
• Chronic Migraine - Acute exacerbation
Acute Headache Treatment Algorithm
D5 ½ NS bolus 20 mL / kg
(MAX Dose = 1000 mL)
Ketorolac (Toradol) 0.5 mg / kg
(MAX Dose = 30 mg)
Metoclopramide
(Reglan) 0.25 mg / kg
(MAX Dose = 20 mg)
Prochlorperazine
(Compazine) 0.15 mg / kg
(MAX Dose = 10 mg)
Headache Free
YES, Discharge Home
NO, Admit
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
Migraine Preventative Treatment
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
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)
Botox (onabotulinumtoxin A)
• Injected directly into overactive muscles
• Reduces contractions, relaxes muscles
Preventative Treatment Principles
• Criteria to Start:
– Frequency >1 week and/or
– Disability from HA
• Full response to medication not
seen until on full dose for at least
6-8 weeks
• Purpose is to prevent not cure
migraines
• Slowly wean medication after
treatment goal (3-4 HA/month) for
4-6 months
• Never expect a lifetime of
preventative treatment
• Start low and go slow when
increasing dose to limit side
effects
• No medications FDA approved for
migraine prevention in children
Biobehavioral Treatment
(“Healthy Habits”)
Common Headache Triggers
(Riback, P., 2000)
• Stress (23%)
• Sleep Deprivation (16%)
• Hunger (11%)
• Heat (11%)
• Bright Lights (9%)
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
Healthy Eating Habits
• Regular meals and snacks
• Encourage regular intake of
fruits, vegetables, and dairy
• Food triggers uncommon in
children
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
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
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
When to Refer for Specialty Care?
Child Psychologist
• Lifestyle changes
• Stress management
• Learn coping strategies for chronic pain
• Teach Biofeedback-Assisted Relaxation
Techniques
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
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
Website Resources for Headache
•
American Council for Headache Education (ACHE)
www.achenet.org
•
American Headache Society
www.ahsnet.org
•
Cincinnati Children’s Hospital Med Center
www.cincinnatichildrens.org
•
National Headache Foundation
www.headaches.org
•
American Migraine Foundation
http://www.americanmigrainefoundation.org
Questions?