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Update In Management Of Childhood Headache Topics • • • • • • • 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 • 1. 2. 3. 4. 5. 6. 7. 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