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It's Not All About Migraine!

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It's Not All About Migraine! It’s not all about Migraine! ERIC HASTRITER, MD FAHS BANNER PEDIATRIC SPECIALISTS CARDON CHILDREN’S MEDICAL CENTER DECEMBER 6TH, 2016 MY PROCESS THE SAGA CONTINUED Program Disclaimer: The accuracy and utility of the materials presented are based on the International Classification of Headache Disorders, 2nd edition (ICHD- II), statements made will be evidence-based, the limitations being due to the nature of trials in children, most of the evidence comes from adult studies but clinical evidence across the pediatric headache community will be discussed Conflict of Interest: There is no conflict of interest at this time Objectives Describe a typical diagnostic path used by neurologists obtaining proper primary headache diagnosis other than migraine Understand the utility of preventative or abortive medications, diagnostic tests, and psychological/bio-behavioral approaches in management of diagnosis Discuss the timing of when to refer to a specialist Migraine Criteria- ICHD-II At least 5 attacks, lasting 1 to 72 hours Headache has at least 2 of the following: • Unilateral location, may be bilateral, frontotemporal (not occipital) • Pulsating quality (throbbing) • Moderate or severe pain intensity • Aggravated by routine physical activity • at least 1 of the following: Nausea and/or vomiting. Photophobia and phonophobia may be inferred from the child’s behavior • Not attributed to another disorder 17 year old male Frequent headaches that began in august (with school) 2-3/month, 1 hour to 5 days Global, squeezing, moderately intense, did not interfere with his activity No nausea, vomiting, phonophobia, but had photophobia Worked 4 nights/week at fast food establishment to save money for college PMH, FH, SH and ROS were benign, general and neurologic exam were normal What was the most likely diagnosis? What diagnostic studies were indicated? What management options were appropriate? Tension Type Headache 30 minutes to 7 days, bilateral, pressing/tightening (non-pulsatile) mild to moderate intensity, not aggravated by physical exertion Associated with: . lack of associated features . may have pericranial muscle tenderness . nausea/vomiting do not occur . no more than 1 of photophobia/phonophobia and it is not prominent Tension Type Headache Most common type worldwide Rarely interferes with function Infrequently present if episodic Most common reasons buying OTC meds Little known about pathogenesis of tension-type headache 1-year prevalence ranges from 40-80% Slightly more common in females Tension Type Headache Differential: episodic migraine, cervicogenic headache, and secondary causes of headache If presents with chronic tension type headache: neuroimaging is warranted to rule out space occupying lesions Cervicogenic HA-strictly unilateral headache Tension Type Headache Treatment-lifestyle changes (stress reduction and management, relaxation therapy, massage, cognitive behavioral therapy Abortives: NSAIDS, combination products with caffeine if caffeine naïve Preventatives if > 10 days/month, amitriptyline or nortriptyline Tension Type Headache What was the most likely diagnosis? What diagnostic studies were indicated? What management options were appropriate? 13 year old female March 2011: flu-like illness (mom thought), headaches began and have been daily Bilateral, continuous moderate pain, she had difficulty describing quality (feel tightening, throbbing, pulsating, worse with movement) Some nausea, photophobia and phonophobia, but they were not prominent No autonomic features No systemic or neurologic symptoms 13 year old female Labs from nearly 2 years ago, mono positive, and then a year after the fact West Nile Virus was positive MRI, MRA, MRV all were negative Hematologic workup was negative LP was normal pressure, no infection 13 year old female What diagnosis could this be? What needs done in this patient? What treatment is suggested in this patient? New Daily Persistant Headache Subacute onset over 72 hours of daily unremitting headache Resemble CTTH, or CM, but is chronic at onset Diagnosis of exclusion: neuroimaging, hematologic workup required to rule out secondary causes May resolve on own or be refractory to treatment New Daily Persistant Headache Most common in adolescents/young adults ~10% of patients in tertiary headache clinics Underlying etiology unknown (30% report recent flu-like illness at time of onset) Two clinical subtypes- . benign self limited form . refractory form resistant to aggressive therapy New Daily Persistant Headache Bilateral, continuous moderate pain(can be mild or severe) Tightening/throbbing/pulsating, and may be aggravated by physical exercise Migraine features (N/V/P/P) but typically not most prominent features No associated trigeminal autonomic features (lacrimation/conjunctival injection) No systemic or neurologic symptoms New Daily Persistant Headache Differential includes CTTH, CM and secondary causes of headaches Can resemble spontaneous intracranial hypotension (dural tear or leak) if positional component overlooked in history Can resemble pseudotumor cerebri (idiopathic intracranial hypertension) New Daily Persistant Headache Labs: CBC (rule out chronic anemia or infection), TSH (rule out hypothyroidism), CRP/ESR (rule out temporal arteritis) MRI brain: space occupying lesion, hydrocephalus, MRI w/GAD: spontaneous intracranial hypotension MRV: cerebral venous sinus thrombosis LP: increased/decreased CSF pressure or chronic meningitis New Daily Persistant Headache Treatment- no known effective acute or prophylactic therapy Standard acute/preventative for CTTH, CM could be attempted on trial and error basis Doxycycline, Singulair have been used Beware: Medication overuse headache complicating picture New Daily Persistant Headache What diagnosis could this be? What needs done in this patient? What treatment is suggested in this patient? 14 year old male, eye pain Sharp excruciating right sided orbital and temporal pain Tearing, reddening of eye, ringing in right ear About 20 minutes, 8 times/day, but 1 lasted 3 hours He feels agitated, awakening nightly during baseball season every year Nausea occurs, and so does photophobia Between episodes has lesser pain and takes 800 mg ibuprofen regularly which helps 14 year old male, eye pain What is his diagnosis? What investigations need done? How would you treat this entity? Cluster Headache Excrutiating strictly unilateral headache, last about 1 hour (15min-3hours), and may recur up to 8/day usually seasonal Associated with cranial autonomic symptoms ipsilateral to pain, can be bilateral 20% have CCH when headaches continue for more than 1 year without remission of > 4 weeks Cluster Headache Co-Morbid: Tobacco use, OSA MRI brain: intracranial lesions particularly in pituitary and parasellar regions Treatments: . 100% oxygen . Intranasal or parenteral triptans . Corticosteroids . Verapamil Cluster Headache Prototypical TAC-Trigeminal Autonomic Cephalgias; first division of trigeminal nerve, accompanying ipsilateral autonomic features (lacrimation/ conjuctival injection/rhinorrhea) 80% have cluster 1-3 months, typically 1-2 times per year with remissions in between Nocturnal attacks typical, but daytime attacks occur, usually near same time daily Cluster Headache Triggers: alcohol and high altitude Strictly unilateral, maximal around or above orbit, may begin or become referred to the temporal, lower facial, or occipital region Extremely severe, piercing, boring, stabbing peaking within 3-5 minutes lasting average 1 hour (15 min- 3 hour) Cluster Headache > 90% agitation Autonomic features: lacrimation, rhinorrhea, conjunctival injection, ptosis, miosis, facial or periorbital edema Autonomic features may be bilateral, but are prominent ipsilateral to pain Cluster Headache Migrainous symptoms (N/V/P/P) Can have unilateral Photo/phonophobia Interparoxysmal pain and allodynia (abnormal pain response to normal stimulus) may occur in more than 1/3 of patients with any of the TACs Medication Overuse may be responsible the interparoxysmal pain Cluster Headache PE may show persistant Horner syndrome if had recurrent attacks for years MRI brain: special attention to pituitary and parasellar regions for mimickers of TACs Overnight polysomnography if features of OSA are present Cluster Headache Treatment . Acute- 100% oxygen 7-15L/min with closed facemask for 15 minutes . Triptans-sumatriptan 6mg SC, sumatriptan 20 mg NS, zolmitriptan 5 mg NS . Short term prevention- steroid taper 60 mg decrease by 10 mg every 2-3 days . Occipital nerve blockade 2.5 mL bupivacaine with 20 mg methylprednisolone Cluster Headache Preventatives . Verapamil 80 mg TID up to 320 mg TID (check ECG after each dose increase). Long term side effects: gingival hyperplasia, constipation, and peripheral edema) Cluster Headache What else could be his diagnosis? What investigations need done? How would you treat this entity? 13 year old with migraine Headaches since she was 6, diagnosed with migraine and nothing seems to be helping Pain is all day long, sharp, stabbing, usually around the temples, mostly on left side Both eyes get red, ears ringing bilaterally Sensitive to light and sound out of the left ear and eye Nausea present, no vomiting Ibuprofen helps but it comes back 13 year old with migraine PMH, FH, SH, ROS and physical exam all normal When asked about all day long headache, she said it came and went throughout the day Further questioning revealed
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