Newer Version? Other Cognitive Models

Headaches in Children: Assessment & Treatment

Steven Leber, MD, PhD Division of Pediatric Neurology Departments of Pediatrics & Neurology University of Michigan Fall Update in Family Medicine October 19, 2017 Disclosures

• No financial disclosures • Very limited evidence-based data • Some off-label medication discussion • I may use some brand names for medications; generics are fine for everything I mention Objectives Participants should be able to: • Be able to diagnose a migraine and differentiate from other types of headaches • Be able to recognize migraine variants • Be able to prescribe appropriate migraine abortives and preventatives • Be able to know when to refer a patient to Pediatric Neurology and when to order brain imaging Headaches Case 1

A 15-year-old student, in the office for a pre- football practice screening exam, complains of frequent diffuse, nonthrobbing headaches that may last several days. They seem to be brought on by stress. Case 2

An 8-year-old girl comes in because she vomited three times this morning. She has had no change in bowel habits but has woken up two nights this week because of progressively severe headaches. Differential diagnosis of headaches

• Progressive headache • Worsens with recumbency • Wakes at night, present 1st thing in the a.m. • Mental status changes • Nausea and vomiting • Papilledema • VIth nerve palsies (false localizing) • Infants: macrocephaly, bulging fontanelle • "Sunsetting" Differential diagnosis of headaches

Primary headaches Secondary headaches Migraine Depression Tension-type headache Sinus disease Cluster Tumor or other mass lesion Hydrocephalus, pseudotumor Meningitis Subarachnoid hemorrhage Seizures TMJ dysfunction / teeth clenching Visual problems (very rare cause) Sleep disturbances Hypertension Caffeine withdrawal Tension-type headaches • Constant • Diffuse, band-like • Aching, tight • Relieved with minor analgesics • No nausea or vomiting • Increases with stress Case 3 An 11-year-old girl has bifrontal, throbbing headaches associated with nausea. They last 2-3 hours, have no clear precipitant, are exacerbated by noise and exertion, and are moderately severe. She sometimes sees "sparkles" during the headaches. They occur 1-2 times per month. She gets car sick and gets “ice-cream headaches.” She has a history of colic as a baby. Her mother gets similar headaches. The examination is normal. Migraine with aura • 10-15% of migraineurs have aura • Not consistently present • Usually 10-25 minutes • Headache usually contralateral to side of symptoms • Visual symptoms most common, but can be sensory, motor, language, cognitive, or cerebellar/cranial nerve Migraine with aura

• Visual symptoms most common • Sensory, motor, language, cognitive, & cerebellar/cranial nerve aura also occur Migraine with aura

• Headache – Usually throbbing, unilateral or bilateral, and frontal or temporal – Gradual onset (minutes to an hour) – Duration usually 2-6 hours (can last days) – Increased by activity – Sometimes stops when vomiting occurs Migraine with aura

• Sleep (even brief nap) relieves • Anorexia, nausea, vomiting • Allodynia • Photophobia, phonophobia Migraine without aura • More variable than migraine with aura • Visual symptoms may occur • Personality change, dizziness, malaise, and nausea more common • Headache may be unilateral and pounding, but often difficult to describe • Duration: a few hours to several days • Nausea and vomiting do not herald the end of the headache Triggers • Stress • Head trauma • Particular foods (fairly uncommon) • Cold (ice-cream headaches) • Menstrual cycle and oral contraceptive pills • Changes in sleep habits • Missing meals • Odors Epidemiology • Cumulative incidence of migraine in Americans – 43% of women – 18% of men • About equal in boys and girl until puberty, the prevalence explodes in girls – 3% at age 5 – 7% at age 8 – 11% at age 10 Epidemiology Epidemiology

Stewart et al. 1991 PMID: 1746521 Per 1000 person-years Underdiagnosis of migraine

• About half of the 28 million pts with migraine in the U.S. are undiagnosed • Of pts dx’d by primary care physicians with migraine, 98% agreement when evaluated by panel of migraine experts • When PCP dx’d non-migraine HA, expert panel dx’d migraine 82% of the time • 28% of pts in this series received non-migraine dx by PCPs Headaches in College Students • 51% of students had at least one headache per month • Majority are migraines and interfere with their activity

Curry and Green, J Amer Acad Nurse Practitioners 2007; 19: 378 n=104 Case 4

A 16-year-old student comes to you complaining that the medicine she takes for her seizures is not working. Her spells consist of sudden onset of blindness, and progress to ataxia, vertigo, paresthesias of all four extremities, and loss of consciousness. She always develops severe vomiting and a posterior headache. The EEG report she brings with her describes high voltage occipital slow waves and an occasional occipital spike. Case 5 An 8-year-old boy complained of blurred vision during a soccer game, then went blind. His symptoms resolved by the time he got to the emergency room. He had no headache or vomiting. Case 6 A 2-year-old girl suddenly falls to the floor and lies awake, but motionless, pale, and looking extremely frightened. Her astute mother notes nystagmus. Migraine variants

• Complicated migraine (migraine w/ nonvisual aura) • Ocular migraine • Ophthalmoplegic migraine • Basilar migraine • Acute confusional migraine • Migraine aura without headache • Hemiplegic migraine • Trauma-induced migraine • Benign paroxysmal vertigo • Paroxysmal torticollis • Cyclic vomiting

Migraine variants

• Status migrainosus • Migrainous infarction • Cardiovascular disease Bigal, M. E. et al. Neurology 2009;72:1864-1871

Case 7a

An 11-year-old girl has bifrontal, throbbing headaches associated with nausea. They last 2-3 hours, have no clear precipitant, are exacerbated by noise and exertion, and are moderately severe. They occur 1-2 times per month. She gets car sick and gets “ice-cream headaches.” Her mother gets similar headaches. The examination is normal. Case 7b

The same student returns, now 12 years old, with identical headaches. Now, however, they are occurring twice per week. Case 7c

She now develops a headache similar in quality to her previous ones but more severe. In addition, it has lasted three days. She is taken to the emergency room and is felt to be slightly dehydrated because of anorexia and vomiting. Treatment • Natural history • Reassurance • Avoidance of precipitants • Sleep • Abortive • Prophylactic • Behavioral Abortive medications

• Better if used at onset of headache • Acetaminophen, ibuprofen, naprosyn, ASA, caffeine, combinations • Midrin (isometheptene, acetaminophen, caffeine) • Fioricet (butalbital, acetaminophen, caffeine) • Chlorpromazine (Thorazine) • Narcotics: risk of addiction in patients with chronic or frequent headaches, but occasionally useful in selected patients with infrequent migraines • “Triptans” Triptans

• Block release of inflammatory peptides into walls of dural vessels • Avoid in • basilar and other complicated migraines – risk of stroke?? • Hypertension • Pregnancy • Hx of stroke or MI Tritptans • 7 triptans • Oral, melts, nasal sprays, injections • 2 FDA-approved for kids (≥ 12 y.o.) • Rizatriptan (Maxalt) 6-17 y.o.’s • Almotriptan (Axert) • Zolmitriptan (Zomig) nasal spray • Sumatriptan/naproxen combinations (Treximet) • Side effects • Chest, throat tightness • Drowsiness, dizziness, nausea • Bad taste (nasal spray) Prophylactic medications • Indications: frequency >1-2 times/week; severity; complicated migraines • Often use for 6-12 months, then attempt taper • ß-adrenergic antagonists • Cyproheptadine (Periactin) • Amitriptyline, nortriptyline • Calcium channel blockers • NSAIDs (ASA, naproxen, indomethacin)??? • Anticonvulsants (topiramate, valproate) Nortriptyline

• Effective at much lower doses than used for depression – Typically 1020 30 mg Qhs – Occasionally 25 50 75 • 1-2 month latency • Baseline EKG? • Interactions with SSRI’s Nortriptyline • Potential side effects – Sleepiness – Dry mouth – Orthostatic lightheadedness – Weight gain (5% of patients) – Arrhythmias • Trachycardia • Increased PR interval, QRS duration, QT interval – Mood changes Cyproheptadine (Periactin)

• Drug of choice for young children • Also for thin teens who cannot sleep • Dosage forms – 2 mg/5 mL liquid – 4 mg tablet • Typical dosage – 2-4 mg/day ÷ BID (occasionally all HS) – Advance slowly as tolerated up to 8-16 mg/day if needed Cyproheptadine (Periactin)

• Common side effects – Sleepiness – Weight gain Topiramate

• Brand name: Topamax • Anti-epileptic • Dosage forms – 25, 50, 100, 200 mg tablets – 15, 25 mg sprinkle capsules – 6 mg/ml suspension (by pharmacy) Topiramate

• Effective at much, much lower doses than typically used for seizures – Typical adult dose 50 mg BID (reasonable AED for 18 mo boy) – Fewer side effects • Build up gradually over one month • Usually ÷ BID ; occasionally, just HS Topiramate • Side effects – “Body” •  appetite, weight •  sweating • Paresthesias • Metabolic acidosis • Kidney stones • Acute glaucoma – “Brain” • Sleepiness • Confusion, word-finding difficulty • Mood changes CHAMP study 11/16

• Primary outcome (50% reduction in HA days) – Amitriptylline: 52% – Topiramate: 55% – Placebo: 61% • Similar (60/60/60) for all secondary outcomes • Terminated early for futility Which preventative? First line (my preference, not evidence-based)

• Notriptyline – 1st choice, daily headaches • Amitriptyline – thin, insomnia • Cyproheptadine – young, thin, insomnia • Topiramate – overweight • Verapamil – complicated migraine (e.g., basilar) Which preventative? Backup

• Propranolol (Inderal) • Gabapentin (Neurontin) • Valproate (Depakote) • Alternative meds – Butterbur (Petadolex) – Magnesium, riboflavin, feverfew (MigreLief) – Melatonin Nonpharmacological treatment

• Go to school! Live your life as if you don’t have headaches! • CBT • Exercise • Fluids • Biofeedback / relaxation / hypnosis Case 8 A 17-year-old girl has had a headache that “never goes away” for the last six months. She had occasional migraines in the past. She uses sumatriptan 2-3 times per day. Chronic headaches • 20% of migraineurs develop chronic headaches Chronic headaches

• Often tension-like or mixed tension-type and migrainous • Postconcussive syndrome • Dizziness. myalgia, and fatigue common • May be accompanied by nausea and vomiting • Increased by stress • School absence a big problem • Look for abuse, depression, psychosocial stress • Rx: psychologic counseling (individual and family), prophylactics, biofeedback • Avoid analgesics Pseudotumor cerebri • Idiopathic (“benign”) intracranial hypertension • Increased intracranial pressure with normal imaging, normal CSF • Cause usually identified in pts < 6 y.o.; usually idiopathic in older children • Symptoms of increased ICP, HA worse with coughing, vague dizziness, visual obscurations; may have diplopia due to VIths • Young children may only be irritable or having bulging fontanels • Venous sinus thrombosis can mimic Pseudotumor cerebri - causes • Drugs • Head trauma – Steroids (especially • Infections withdrawal) – Otitis media – OCPs – Sinusitis – Tetracycline • Metabolic disorders – Vitamin A – Adrenal insufficiency – Thyroid replacement – DKA • Systemic disorders – Hyperthyroidism – Guillain-Barré – Hypoparathyroidism – Iron-deficiency – Pregnancy – Vitamin A, D deficiency – Leukemia Pseudotumor cerebri

• Diagnosis – LP • Treatment – LP with large needle – Acetazolamide – Diuretics – Steroids – Lumboperitoneal shunt – Optic nerve sheath fenestration Evaluation of headache • Blood-pressure • Head circumference • Sinus, temporalis tenderness • Neurological examination, including funduscopy • Evaluation for depression When to image? • Abnormal neurological examination • Headaches improve with sitting up • Headaches frequently wake at night • or are present first thing in a.m. • Rapidly progressive course • Change in severity or quality of headache • (migraineurs can have tumors!) When to refer to neurologist? • Abnormal neurological examination • Associated seizure • Associated change in mental status • Progressive headache not responding to routine Rx • Headaches commonly at night or present upon awakening • Headaches worsening with recumbency • Onset after traumas • Analgesic abuse

How would you evaluate and treat?

• 12 y.o. girl with bad migraines every 3 weeks How would you evaluate and treat?

• 5 y.o. boy with migraines 2-3 times per week How would you evaluate and treat?

• 15 y.o. girl with basilar migraines, syncope every 2 weeks How would you evaluate and treat?

• 15 y.o. girl with menstrual migraines, regular menses How would you evaluate and treat?

• 9 y.o. boy with infrequent migraines, suddenly worse and now almost daily x 2 weeks How would you evaluate and treat?

• 13 y.o. girl with 6 months of daily headaches with migrainous features; depression; school absence