Susan LeCates, MSN, CNP
Family Nurse Practitioner
Neurology Department / Headache Center
Cincinnati Children’s Hospital Medical Center

Disclosure
The content of my presentation will include discussion of unapproved or investigational uses of medication for acute and preventative treatment of migraine headache in children

Objectives
• Understand diagnosis of primary headache in children using the International Classification of
Headache Disorders (ICHD-3)
• Develop an appropriate treatment plan for children diagnosed with migraine headaches
• Recognize when to refer children with migraine headaches

Migraines are Common
• There are 28 million people in the world with
Migraine
• Migraines occur at all ages
Migraine headaches in children and adolescents are often under recognized or NOT taken seriously
Headache 1993;33:29-35

Migraine Prevalence in Childhood
>
3 to 7 year olds

Migraine Prevalence in Childhood
=
7 to 11 year olds

Migraine Prevalence in Childhood
<
11 to 15+ year olds

Pediatric Migraine Impact
• Migraine - Top 5 most prevalent childhood disorders
• Headache - 3 rd ranked illness - related cause of school absence
• Pediatric migraine - $36 billion impact in USA
• WHO Survey - rates severe migraine with quadriplegia as one of the Most Disabling chronic disorders

What is the Key to Diagnosing
Migraine?
• Accurate Diagnosis
• Effective Communication

International Headache Society
(IHS)
• Classification system for headache diagnosis developed in 1988
• International Classification of Headache
Disorders 3 rd Edition (ICHD-3)

Headache Classification
1. Primary: Headache is the Problem
2. Secondary: Symptom of Underlying Disorder
3. Painful cranial neuropathies, other facial pains and other headaches

Diagnosing Migraine

Migraine without Aura
ICHD-3, 2013
• At least 5 attacks
• Last 4 -72 hours untreated (2 - 72 for children under 18 years of age)
• Two of four characteristics
– Unilateral location (commonly bilateral in kids)
– Pulsating quality
– Moderate or severe intensity
– Aggravated by routine activity

Migraine without Aura
ICHD-3, 2013
• During the HA at least one of the following:
– Nausea and/or vomiting
– Photophobia and phonophobia (may be inferred by child’s behavior)
• Not attributed to another disorder

Migraine with Aura
ICHD-3, 2013
• Criteria same as Migraine without Aura but also have:
– Focal neurological symptom usually developing over 5-20 minutes and lasts less than 60 min
– Visual, Sensory, Speech, Motor, Brainstem,
Retinal
– At least 2 attacks
– Headache begins during the aura or follows aura within 60 minutes

The Visual Aura

The Sensory Aura http://www.youtube.com/watch?v=iZ-RzRUynAE&feature=player_embedded

Chronic Migraine
ICHD-3, 2013
• Headache occurring on 15 or more days per month for > 3 months, which has the features of migraine headache on at least 8 days per month
• Often results from unresolved status migrainosus
• Not attributed to another disorder

Status Migrainosus
ICHD-3, 2013
• Present attack meets criteria for migraine without aura and is typical of other attacks
• Both of the following
– HA > 72 hours
– Severe intensity
• Not attributed to another disorder
• Interruption during sleep and short lasting relief due to medication are disregarded

Challenges of Treating Pediatric
Migraine
• Diagnosis and assessment of symptoms is complicated by the inability of children to articulate their complaints
• Other infectious, allergic, or gastrointestinal disorders of childhood may mimic symptoms of migraine
• Lack of research conducted in children and adolescents

If It Isn’t Migraine What Is It?

Headache Attributed to Infection of Nose or Paranasal Sinuses
ICHD-3, 2013
• Frontal HA with pain in one or more regions of face, ears or teeth
• Clinical, nasal exam, CT and/or MRI imaging and/or lab evidence of acute or acute-on-chronic rhinosinusitis
• Simultaneous onset of headache and facial pain
• Headache and/or facial pain resolve within 7 days after successful treatment

Episodic Tension-Type
ICHD-3, 2013
• At least 10 attacks (more than once but less than 15 days/mos)
• HA lasting from 30 minutes to 7 days
• At least 2 of the following:
– Pressing/tightening quality
– Mild or moderate intensity
– Bilateral location
– Not aggravated by routine physical activity

Episodic Tension-Type
ICHD-3, 2013
• Both of the following:
– No nausea or vomiting (anorexia may occur)
– Photophobia or phonophobia
• Not attributed to another disorder

Medication-Overuse Headache
ICHD-3, 2013
• Analgesics at least 15 days/mos for > 3 mos
• Daily low dose medication use worse than high dose use once a week
• Triptans at least 10 days/mos for
> 3 mos
• Caffeine can also be culprit
• HA has developed or markedly worsened during analgesic overuse
• Headache resolves or reverts to previous pattern within 2 months after stopping analgesics

Medication-Overuse Headache
Vasconcellos, et al, 1997
Retrospective review of pts > 4 HA/wk
• N = 98, mean age = 12.1
Frequency of HA per month
– Initial = 27.5
– After 1 mo. without analgesics = 7.3
– After 2 mo. without analgesics = 5.4
(P<0.0001)
Daily use of analgesics may reduce the effectiveness of preventative HA meds

Acute headache attributed to traumatic injury to the head
ICHD-3, 2013
• Traumatic injury to the head has occurred
• Headache is reported to have developed within 7 days after one of the following:
– 1. the injury to the head
– 2. regaining of consciousness following the injury to the head
– 3. discontinuation of medication(s) that impair ability to sense or report headache following the injury to the head
• Either of the Following:
– Headache has resolved within 3 months after the injury to the head
– Headache has not yet resolved but 3 months have not yet passed since the injury to the head
• Not attributed to another disorder

Episodic Syndromes that may be
Associated with Migraine
ICHD-3, 2013
1. Benign Paroxysmal
Vertigo
4. Recurrent gastrointestinal disturbance
2. Abdominal Migraine
5. Benign Paroxysmal
Torticollis
3. Cyclical Vomiting
Syndrome
6. Others: motion/car sickness; sleep disturbances; recurrent unexplained fever

Headache Warning Signs
Ferrari, 1998
• Sudden change in headache symptoms
• Sudden, substantial increase in frequency
• Abnormal neurological examination
• Aura < 5 minutes or > 60 minutes
• Aura always on same side
• Aura without headache

When to Get an MRI in Kids
• Presence of any of the “Warning Signs/Red
Flags”
• No family history of headaches
• Age less than 5 years old
• Persistent occipital headache

Additional Headache Diagnostic Testing
Abnormal HA Evaluation:
• Blood work
• CT/MRI
• EEG
• LP

So How Do You Treat Pediatric
Headaches?
• Acute
• Preventative
• Biobehavioral

Goals of Acute Treatment
• Treat attacks rapidly and consistently without recurrence
• Restore patient’s ability to function
• Minimize the use of rescue medications
• Optimize self-care and reduce use of resources
• Cost-effectiveness
• Minimal or no adverse events

Acute Migraine Treatment
• Over-the-Counter Medication
– Ibuprofen most effective in children
Dosage: 10 mg/kg (Hamalainen, et al, 1997)
– Naproxen sodium (Aleve) may be substituted for ibuprofen
– Aspirin and Excedrin are other options (> 16 years)
• 24-32 ounces of sports drink for vascular rehydration at
HA onset
Early Treatment = Successful Treatment

Faster Onset of Action :
– Almotriptan (Axert)
– Eletriptan (Relpax)
– Rizatriptan (Maxalt, Maxalt-MLT)
– Sumatriptan (Imitrex-tablet, NS, SQ,)
– Sumatriptan + Naproxen sodium (Treximet)
– Zolmitriptan (Zomig, Zomig-ZMT, nasal spray)
Slower Onset of Action :
– Frovatriptan (Frova)
– Naratriptan (Amerge)

Acute Migraine Treatment
No Narcotics!
• Use of opioids prevents reversal of established migraine and central sensitization (Jakubowski et al. Headache 2005; 45:850-
61)
– Patients with migraine were given parenteral sumatriptan and ketorolac
– 71% were pain free and without allodynia within 60 minute of ketorolac infusion
– In contrast to the responders (9/9), non-responders (1/19) had treated their migraine with opioids

Medication Overuse Prevention
• Limit analgesic use to 2-3 days a week
• Triptan use limited to 6 headaches a month
• Limit: No more than 2 doses of medication per headache- need IV acute tx if HA persists

Management of Intractable Acute
Migraines

When do you Refer for Intravenous Acute
Headache Treatment?
• Acute / Non-responsive to home abortive treatment
• Chronic Migraine - Impaired functioning
• Chronic Migraine - Acute exacerbation

Acute Headache Treatment Algorithm
D5 ½ NS bolus 20 mL / kg
(MAX Dose = 1000 mL)
Metoclopramide
(Reglan) 0.25 mg / kg
(MAX Dose = 20 mg)
Ketorolac (Toradol) 0.5 mg / kg
(MAX Dose = 30 mg)
Prochlorperazine
(Compazine) 0.15 mg / kg
(MAX Dose = 10 mg)
Headache Free
YES, Discharge Home NO, Admit

What Happens if the Acute Refractory
Headache Doesn’t Break?
Admit for Inpatient Treatment using :
Pharmacological agents:
• IV DHE
• IV Valproate sodium
• IV Magnesium
• IV Steroids
• IV fluids
• Others

Migraine Preventative Treatment

Goals of Migraine Prevention
• Reduce HA attack Frequency, Severity and Duration
• Improve Responsiveness to TX of Acute Attacks
• Improve Function and Reduce Disability
• Improve Quality of Life
• Educate Patient/Family to become Active Participants in HA Management

Common Preventative Medications
Antidepressants
– Amitriptyline (Elavil)
Anticonvulsants
– Topiramate (Topamax)
– Valproic Acid (Depakote)
– Levetiracetam (Keppra)
Antiserotonergic
– Cyproheptadine (Periactin)
Neutraceuticals
-Vitamin B2 (Riboflavin)
-Coenzyme Q10
-Vitamin D3
Botulinum toxin A (Botox)

Botox (onabotulinumtoxin A)
• Injected directly into overactive muscles
• Reduces contractions, relaxes muscles

Preventative Treatment Principles
• Criteria to Start:
– Frequency >1 week and/or
– Disability from HA
• Full response to medication not seen until on full dose for at least
6-8 weeks
• Purpose is to prevent not cure migraines
• Slowly wean medication after treatment goal (3-4 HA/month) for
4-6 months
• Never expect a lifetime of preventative treatment
• No medications FDA approved for migraine prevention in children
• Start low and go slow when increasing dose to limit side effects

Biobehavioral Treatment
(“Healthy Habits”)

Common Headache Triggers
(Riback, P., 2000)
• Stress (23%)
• Sleep Deprivation (16%)
• Hunger (11%)
• Heat (11%)
• Bright Lights (9%)

• Recommend 2-3 liters daily
– Provide letter for school giving kids permission to carry water/sports drink bottle at school and use restroom as needed
• Eliminate Caffeine
• Diuretic
• Addictive
• Caffeine-Withdrawal Headache

Healthy Eating Habits
• Regular meals and snacks
• Encourage regular intake of fruits, vegetables, and dairy
• Food triggers uncommon in children

Healthy Sleep Habits
• Recommend 8-9 hours
– No Naps
• Keep regular sleep schedule
– Do not oversleep more than 2-3 hours on weekend, especially on Sunday
– Avoid naps
• Establish a bedtime routine to help child fall asleep

Exercise
• Three times a week for 20-30 minutes
• Hydrate before, during, and after exercise
– May need 32 ounces before and after exercise to prevent dehydration triggered headache
– Sports drink is best
• Do not exercise before bedtime

– Provide School Letter with Acute
Headache Treatment Plan,
Hydration/Restroom Needs
– Recommend Parent/Child Review
Headache Tx Plan with Teachers
– Discuss Expectations for School
Attendance with Headache
– Evaluate Headache Disability at
Each Visit

When to Refer for Specialty Care?

Child Psychologist
• Lifestyle changes
• Stress management
• Learn coping strategies for chronic pain
• Teach Biofeedback-Assisted Relaxation
Techniques

Child Neurologist/Headache Specialist
• Any concern about a secondary cause of headaches
(unless it is sinus disease)
• Headaches that do not meet ICHD-II criteria
• Headaches unresponsive to treatment interventions
• Transient neurological signs during headache episodes

Conclusions
• Migraine headaches are common and may often be under-recognized Think Migraine!
• Diagnosis should rely on standardized criteria
• Imaging should be guided by “warning signs” with specific criteria used as suggestions
• Multi-modal treatment may be necessary:
Acute Preventative Healthy Habits Pain Management
• Consider referral for Headache Specialty Care

Website Resources for Headache
• American Council for Headache Education (ACHE) www.achenet.org
• American Headache Society www.ahsnet.org
• Cincinnati Children’s Hospital Med Center www.cincinnatichildrens.org
• National Headache Foundation www.headaches.org
• American Migraine Foundation http://www.americanmigrainefoundation.org

Questions?