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“Top Neurology Cases” Ohsui.E “Top Neurology Cases” OHSUi.e. Headache, etc. Doernbecher Annual Review DATE: October 3, 2019 BY: Kaitlin Greene, MD Director, Pediatric Headache OHSU Department of Pediatrics, Division of Pediatric Neurology Disclosures OHSU• None Outline: • Case 1: Headache • Case 2: Seizure • Case 3: Stroke OHSU• Discussion and Questions! 33 Case 1: Headache • Goals: • Review indications for imaging in patient presenting with headache • Review diagnostic criteria for migraine and migraine with aura in children and adolescents • Outline approach to acute and preventive treatment of headaches OHSU• Be comfortable prescribing a triptan! Case 1: Headache • 13 year old girl presenting with worsening headaches • When did headaches start? • Six months ago Age 8 • Short (~1 hour), infrequent (<1x/month), typically triggered by illness or dehydration, improved with ibuprofen • Over the past two years, frequency gradually increased to OHSU2x/month, then 4x/month, then to 2x/week by about 6 months ago Case 1: Headache • What are the headaches like? • Location: Mostly front, sometime back, sometimes more on one side or the other • Quality: Pressure (throbbing when severe) • Severity: Usually moderate, at least 2/month severe • What are the associated features • “Sensory sensitivity”: Light, sound, smell OHSU• Nausea when severe • Sees “flashes of light” for a few seconds with more severe headaches Itsoktobeweird.com Case 1: Headache • PMH: None • Family history: • Mom with “stress headaches” (Gets sensitive to light/noise, has to lie down) • Younger sister gets headaches when sick • Medications: • Ibuprofen 200 mg as needed for headache • Exam: Wt 50 kg. Normal including fundoscopic OHSUexam. Case 1: Headache - Diagnosis • What is the diagnosis? Migraine! With Aura? • BUT first have to answer two questions: 1. Are there any “red flags” to necessitate further work up? 2. Does she meet diagnostic criteria for migraine or migraine with aura based on the International Classification of OHSUrd headache disorders, 3 edition (ICHD-3)? Case 1: Headache - Diagnosis • Are there any “red flags”/indications for additional work up? • “SSNOOPP” • Systemic symptoms (i.e. fever, rash, neck stiffness) • Secondary risk factors (i.e. medical co-morbidities, history of cancer, immunosuppression) • Neurologic signs or symptoms: focal symptoms or focal findings on exam • Onset: sudden, abrupt, maximum at onset (“thunderclap”) • Older patient: age >50 (OR younger patient: age <6) OHSU• Progression and Prior headache history: major change in frequency, severity or clinical features, new headache type or pattern (<6 months headache history) Dodick Adv Stud Med 2003 Case 1: Headache - Diagnosis • Does she meet criteria for migraine without aura (1.1) based on the ICHD-3 1? A. ≥5 attacks fulfilling criteria B-D B. Headache attacks lasting 2-72 hours (untreated or unsuccessfully treated) C. Headache has at least two of the following four characteristics 1. Unilateral location (More often bilateral in children2) 2. Pulsating quality 3. Moderate or severe intensity 4. Aggravation by or causing avoidance of routine physical activity D. During headache at least one of the following: 1. Nausea and/or vomiting OHSU2 Photophobia and phonophobia (Can be inferred from behavior) E. Not better accounted for by another diagnosis Comment: “Migraine headache is usually frontotemporal. Occipital headache in children is rare and calls for diagnostic caution.” 1ICHD-3 Cephalalgia 2018; 2deGrauw et al., Headache 1999 Case 1: Headache - Diagnosis • What about occipital headaches? Is it rare? Does it call for diagnostic caution? • Study 1: 432 children in the ED for • Study 2: 150 children in the ED HA1 for HA2 • 18/277 with discharge diagnosis (6%) • 2/150 (1.3%) had occipital had “life-threatening headache” headache and both had brain • 3/18 occipital, 15/18 unable to tumors localize • 2/150 (1.3%) had brain tumors but OHSU• 17/18 had headaches for <2 months did NOT have occipital headache • 18/18 (100%) had objective • 4/4 (100%) with brain tumors had neurological signs abnormal neurologic examinations 1Conicella et. al., Headache 2008; 2Lewis and Qureshi, Headache, 2000 Case 1: Headache - Diagnosis • Of children newly referred to Neurology and Headache Clinics, 6-16% have occipital headache1, 3 • Children with occipital headache are more likely to get scanned BUT not more likely to find anything wrong!2, 3 • In children with solely occipital headache, 91% were scanned (RR 4.9, 1.2-21) OHSU• No significant difference in abnormal findings on MRI 1deGrauw et. al., Headache 1999, 2Bear J et. al., AAN Abstract 2014, 3Eidlitz-Marcus et. al., Pediatric Neurology 2014 Case 1: Headache www.ohsu.edu • Occipital headache: Does it call for diagnostic caution? • Depends on the context! • In children presenting to the ED (or clinic) with NEW headache and ABNORMAL exam, caution is warranted regardless of location of headache OHSU• BUT in a child with a normal neurologic exam and a headache phenotype consistent with migraine, occipital head pain location alone is not necessarily associated with pathology Case 1: Headache - Diagnosis • What about aura? “Flashes of light for a few seconds” 1.2 Migraine with aura1: A. At least two attacks B. ≥ 1 of the following fully reversible symptoms: • Visual, sensory, speech/language, motor, brainstem, retinal C. At least 3/6 characteristics: • Aura symptom spreads gradually over ≥5 minutes • ≥2 aura symptoms occur in succession • each individual aura symptom lasts 5-60 minutes • ≥ 1 aura symptom is unilateral • ≥ 1aura symptom is “positive” • aura is accompanied, or followed within 60 minutes, by OHSUheadache • Why does it matter? • Women with migraine with aura have a 2-fold increased risk of stroke more w/high-dose estrogen OCPs and smoking 1ICHD-3 Cephalalgia 2018 Case 1: Headache – Treatment • Acute treatment: Decrease the duration and severity of the attack • Inadequate acute treatment optimization associated with a higher risk of developing chronic migraine within one year in adults1 • Preventive treatment: Decrease the frequency of attacks over time OHSU• Consider when bothersome headache is occurring >1 day per week or >4 days per month iStock.com Lipton Neurology 2015 Case 1: Headache – Acute Treatment • First-line: NSAIDs or Tylenol • Acetaminophen and ibuprofen both studied down to age 41 • Both superior to placebo • Ibuprofen 2x more likely to abort migraine at 2h • Consider longer-acting NSAID • Naproxen less likely to cause medication overuse headache and may have some preventive OHSUbenefit2,3 1 Hamalainen Neurology 1997; 2 Lipton Neurology 2015; 3 Cady Headache 2014 Case 1: Headache – Acute Treatment • Second-line: Triptans (5-HT1B/1D agonists) • Generally very safe and well-tolerated in children with healthy vessels! • Contraindications: • Underlying intracranial or cardiac vascular disease (including moyamoya, prior stroke, ischemic heart disease) • Uncontrolled hypertension • WPW OHSU• Specific aura types (hemiplegic migraine and brainstem aura) Case 1: Headache – Acute Treatment • Four triptans now FDA-approved for pediatric migraine Triptan Forms Dose Approval <40 kg >40 kg Almotriptan PO 6.25 mg 12.5 mg 12-17 yo (2009) Rizatriptan MLT, tab 5 mg 10 mg 6-17 yo (2011) Sumatriptan/naproxen PO 10/60 mg – 85/500 mg 12-17 yo (2015) (sumatriptan (Sumatriptan alone: 25 mg (<40 kg) – 50 OHSUalso NS and SQ) mg (>40 mg) Zolmitriptan NS 2.5 mg 5 mg 12-17 yo (2015) FDA.gov; Lewis et. al., Pediatrics 2007; Ho et. al., Cephalalgia 2012; Hewitt et. al., Headache 2013; Linder et. al., Headache 2008 Case 1: Headache – Acute Treatment • Triptan pearls: • Better to take early when pain is MILD (53% pain free at 2h)1 • BUT okay to take when mod/sev (38% pain free at 2h) • Take with naproxen! • Higher 2h pain-free rate, lower 24h recurrence (adults)2 • No need to re-dose • Safe but no evidence for better efficacy • Limit to <10 days per month to decrease risk of OHSUmedication overuse3 • Choose the formulation that makes the most sense! • PO, MLT, NS, SQ 1 Goadsby, Cephalalgia, 2008; 2 Brandes et. al., JAMA 2007; 3 De Felice Ann Neurol 2010 Case 1: Headache –Preventive Treatment • Topiramate is the only FDA-approved preventive treatment in children based on two positive RCTs • What about CHAMP? • Why?? • Very high placebo-response rate, perhaps related to active co-interventions • Frequent visits with providers • Optimization of acute OHSUtreatment • Patients with very refractory migraine or continuous headache excluded Findings from CHAMP (Powers et al NEJM 2017) Case 1: Headache OHSU Case 1: Headache - Treatment • Recommend discussing lifestyle modification and discussion of modifiable risk factors (Level B) • Recommend discussion of role or preventive treatments in those with frequent headaches, migraine-related disability and medication overuse (Level B) • Recommend informing families of placebo response rates in trials and that majority of preventives are not OHSUsuperior to placebo, with shared decision making about pros/cons of short-term treatment trials (Level B) Case 1: Headache – Preventive Treatment • First-line: Lifestyle modifications! • “Regularity” seems to be key – regular exercise, regular meals, regular fluid intake, regular sleep • Among teens, significantly higher odds of presenting to the ED OHSUwith headache in Jan and Sept Kedia et. al., Cephalalgia 2013; CDC 2018 Case 1: Headache – Preventive Treatment OHSU• Headachereliefguide.com Case 1: Headache – Preventive Treatment • Second-line: Over-the-counter medications/supplements • Riboflavin 200
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