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Headache Treatment in Children, Menstruation, Pregnancy and Lactation, Elderly, Renal Disease

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Headache Treatment in Children, Menstruation, Pregnancy and Lactation, Elderly, Renal Disease Headache Treatment in Children, Menstruation, Pregnancy and Lactation, Elderly, Renal Disease Andrew D. Hershey, MD, PhD Director, Headache Center Cincinnati Children’s Hospital Medical Center Professor of Pediatrics and Neurology University of Cincinnati, College of Medicine Objectives • Discuss unique aspects of headache treatment in special populations –Children –Menstruation – Pregnancy and Lactation –Elderly – Renal Disease Children • Unique aspects of headache treatment in children – Developmentally appropriate intervention – Integration of family and school •Treatment – Acute pediatric issues – ED and inpatient management – Preventative therapy –Biobehavioral therapy ® American Headache Society “Unique” aspects of children • Family-centered interview – Child is the patient • “Only you know what the headache feels like” • Parental observation without parental interpretation – Unified treatment plan • Patient and parent to agree – Young child – parent provides the treatment – Teenager – resistant to parental pressure “Unique” aspects of children • Family-centered interview – Tools to utilize • Questionnaire • Disability assessments – PedMIDAS, PedsQL •Drawings • School letters • Calendars and diaries – Expectations discussed • Headache gone within 1 hour and back to normal • 1-2 headaches per month without missing activities • Limited long-term use of medication Diagnosis ® American Headache Society Classification of Headache International Classification of Headache Disorders – 2nd Edition, Cephalalgia, 2004 • Primary headache disorders – Migraine – Tension-type headache – Cluster headache and other trigeminal autonomic cephalalgias – Other primary headaches Migraine Without Aura International Classification of Headache Disorders – 2nd Edition, Cephalalgia, 2004 • At least 5 attacks • Last 4 - 72 hours untreated – 2 - 72 hours in children under 15 years old – 1-72 if diary confirmation Migraine Without Aura International Classification of Headache Disorders – 2nd Edition, Cephalalgia, 2004 • Two of four characteristics – Unilateral location – Pulsating quality – Moderate or severe intensity – Aggravated by routine physical activity ® American Headache Society Migraine Without Aura International Classification of Headache Disorders – 2nd Edition, Cephalalgia, 2004 • One of two associated symptoms – Nausea and/or vomiting – Photophobia and phonophobia • Not attributed to another disorder Migraine Without Aura International Classification of Headache Disorders – 2nd Edition, Cephalalgia, 2004 • Footnotes – Sleep is included in duration – 1- 72 hours allowed for children with diary – Commonly bilateral in children, adult pattern emerging in adolescents – Usually frontotemporal, occipital requires further evaluation – Photo and phonophobia may be inferred in young children Drawings • Useful as adjuvant to history and questionnaires • Difficult to standardize • More useful for younger children ® American Headache Society Drawings Drawing – Girl, Age 4 Drawings – Girl, Age 6 ® American Headache Society Drawing – Boy, Age 11 Drawing – Girl, Age 12 Drawing – Girl, Age 14 ® American Headache Society Drawing – Girl, Age 20 Neuroimaging Neuroimaging - Meta-analysis Maytal, 1995; Medina, 1997; Dooley, 1990; Wober-Bingel, 1996; Chu, 1992; Lewis, 2000 • 605 of 1275 patients imaged – 62% with migraine – 22% with tension-type headache – 2% with mixed headache • CT in 116 MRI in 483 • 16% (97) abnormal - – 79 incidental, non-surgical, non-medical (Chiari, arachnoid cyst, sinus disease, occult vascular, pineal cyst) ® American Headache Society Neuroimaging - Meta-analysis Maytal, 1995; Medina, 1997; Dooley, 1990; Wober-Bingel, 1996; Chu, 1992; Lewis, 2000 • Significant problems found – 2.3% (14) surgical lesions –0.7% (4) medical lesions –1.7% (10) tumors • ALL with abnormal neurological exams Treatment ® American Headache Society Practice Parameter •Main Results – 5 acute agents • Ibuprofen and Nasal Sumatriptan effective – 12 Preventative agents • Flunarizine “probably” effective (not in US) • 5 without sufficient evidence – Cyproheptadine, amitriptyline, divalproex sodium, topiramate, and levetireacetem • Conflicting data on 2 – Propranolol and trazadone Acute Treatment ® American Headache Society Abortive Therapy Goals US Headache Consortium • Treat attacks rapidly and consistently without recurrence • Restore the patient’s ability to function • Minimize the use of back-up and rescue medications • Optimize self-care and reduce use of resources • Cost-effective • Minimal or no adverse events Abortive Therapy Management US Headache Consortium • Educate patients and participate in management • Migraine specific agents in poor responders to NSAIDs or combination medications • Non-oral route for patients with significant nausea and vomiting • Consider a rescue medications for severe migraines • Guard against medication-overuse headaches Abortive Therapy Management US Headache Consortium • Group 1: Pronounced statistical and clinical benefit • Group 2: Moderate statistical and clinical benefit • Group 3: Statistical, but not proven clinical OR clinical, but not proven statistical • Group 4: Proven statistical or clinical ineffective • Group 5: Statistical or clinical benefit unknown ® American Headache Society Group 1 Group 2 Group 3 Group 4 Group 5 Acet + ASA Acet + cod PO Butalbital, ASA + Acetamenophen Dexamethasone IV +caffeine PO Butalbital +ASA caff PO PO Hydrocortizone IV ASA PO +caff+cod Ergotamine PO Chlorpromazine Ibuprofen PO Butorphanol IM Ergot + caff PO IM Naproxen sodium Chlorpromazine IM, Metoclopramide IM, Granisetron IV PO IV PR Lidocaine IV Diclofenac K, PO Naratriptan PO Ergot + caff Rizatriptan PO Flurbiprofen PO Sumatriptan SC, IN, Isometheptene PO PO Ketorolac IM Zolmitriptan PO Lidocaine IN Meperidine IM, IV Butorphanol IN Methadone IM DHE SC, IM, IV Metoclopramide IV DHE IN Naproxen PO Prochlorperazine IV Prochlorperazine IM, PR Non-specific agents Treatment of Migraine - Abortive Hamalainen et al, 1997 • Ibuprofen vs Acetaminophen – Children over 8 yo, 88 children studied • Met IHS criteria, previous therapy unsatisfactory, >2 HAs/month, > 2 hours –Excluded • Renal, heptatic, CV disease, coagulation defect, severe allergy/asthma, drug allergies, daily medication ® American Headache Society Treatment of Migraine - Abortive Hamalainen et al, 1997 • Ibuprofen vs Acetaminophen – Double-blind, randomized, placebo-controlled, three way crossover • Acetaminophen dose - 15 mg/kg • Ibuprofen dose - 10 mg/kg Treatment of Migraine - Abortive Hamalainen et al, 1997 • Ibuprofen vs Acetaminophen – Pain free • 1 hour – Ibuprofen 2.9 times placebo • 2 hours – Acetaminophen 2.0 times placebo – Ibuprofen 3.5 times placebo Ibuprofen 2.2 times acetaminophen Ibuprofen Lewis, 2000 • Ibuprofen at 7.5 mg/kg/dose • 2 hour response Ibuprofen Placebo Pain-free 71% 43% Improved 62% 28% Recurrence 18% 36% Rescue Med 40% 44% ® American Headache Society Ibuprofen Lewis, 2000 Pain-free Improved 80% 70% 60% 50% 40% 30% Percentage 20% 10% 0% Placebo Ibuprofen Triptans Treatment of Migraine - Abortive • Triptans (alphabetical) – Almotriptan (Axert) – Eletriptan (Relapax) – Frovatriptan (Frova) – Naratriptan (Amerge) – Rizatriptan (Maxalt) – Sumatriptan (Imitrex) – Zolmitriptan (Zomig) ® American Headache Society Triptan Comparison Almo-25 Ele-40 Ele-80 Frova-2.5 Nara-2.5 Riza-10 Suma-NS Suma-50 Suma-SC Zolmi-2.5 0% 10% 20% 30% 40% 50% 60% 70% 70% 80% 90% 90% 100% 100% Triptan side effects • Tingling • Dizziness • Warm/hot sensation • Bad taste (nasal spray) • Injection site reaction •Chest tightness •Jaw tightness Pediatric Triptans ® American Headache Society Almotriptan • Pain free response – Time Almo Placebo – 1 hour 35% 22% – 2 hour 63% 39% • Side effects – 2% with nausea – 0.2% with chest pain Eletriptan Winner et al., 2007 • Multi-center, double-blind, parallel-group, placebo-controlled • 12 to 17 year olds • 40 mg dose • Primary end-point – 2-hour headache response • 274 patients, 267 evaluated – 138 eletriptan –129 placebo Eletriptan Winner et al., 2007 ® American Headache Society Eletriptan Winner et al., 2007 Rizatriptan Winner et al, 2000 •5 mg • 12 to 17 years old • Double-blinded, placebo-controlled, parallel- group, single-attack • 66% pain relief at 2 hours vs 50% placebo • 32% headache free at 2 hours vs 28% placebo Rizatriptan Winner et al, 2000 70 60 50 40 Placebo 30 5 mg 20 10 0 Weekends Weekdays ® American Headache Society Rizatriptan Ahonen et al., Neurology 2006 • Double-blind, placebo-controlled three way crossover trial • Ages 6 to 17 years old –5 mg for weight 20-39 kg – 10 mg for weight 40 kg or more • Primary end-point, headache relief at 2 hours Rizatriptan Ahonen et al., Neurology 2006 Sumatriptan Hamalainen et al, 1997 • Sumatriptan • Double-blind, randomized, placebo- controlled, two-way crossover •N = 23 • 50 mg 6-12 yo, 100 mg >12yo • Visual Analog Scale • 30 and 60 minute time points ® American Headache Society Sumatriptan Hamalainen et al, 1997 • Sumatriptan • 22% vs 9% became pain free (not sign) • 30% vs 22% obtained some relief (not sign) • 13 vs 2 patients preferred sumatriptan Sumatriptan Nasal Ueberall and Wenzel, 1999 • Double-blind, randomized, placebo- controlled, crossover • Age 6.4 to 9.8 • 20 mg dose • 4 point pain scale • Sleep in 2 hours = responders • 86% improved in 2 hours vs. 43% placebo Sumatriptan Nasal Winner et al, 2000 • Double-blind, randomized, placebo- controlled • Age 12 to 17 • N = 510 • 5, 10, 20 mg dose • Most common adverse event = bad taste ® American Headache Society Sumatriptan
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