Paediatric headaches
Mark Weatherall
London Headache Centre
2010
Why is this important?
• Headaches are common in children
• Headaches often cause significant
disability
– affects home life & school performance
– affects family relationships
– affects relationships with peers
Why is this important?
• Headaches in children are underrecognised, misdiagnosed, and undertreated
• Headaches may present differently in
children
• Accurate diagnosis and effective treatment
– improve quality of life
– prevent long-term disability & co-morbidity
What headaches are we
talking about?
• Migraine*
*with aura in 14-30%
• Tension-type headache
•
•
Cluster headache
Other headaches
Migraine
• ICHD-II criteria (migraine without aura)
– A recurrent headache disorder manifesting in
attacks lasting 4-72 hours*. Typical
characteristics of the headache are unilateral
location, pulsating quality, moderate or severe
intensity, aggravation by routine physical
activity, and association with nausea and/or
photophobia and phonophobia
– * In children 1-72 hours is allowed
Migraine
• Difficulties in diagnosing migraine in
children include:
– shorter duration
– more likely to be bilateral
– difficulty in describing headache features and
associated symptoms
• must often be inferred from behaviour/drawings
– evolution of the semiology of headaches over
time
Migraine
• These difficulties are not confined to the
paediatric population!
• Study comparing physician diagnoses with
ICHD-II
– 4-72 hr duration: 61.9% met criteria
– 1-72 hr duration: 71.9% met criteria
– including bilaterality & other features such as
difficulty thinking, light-headedness & fatigue:
88.4% met criteria
Other headaches
• TTH
– common but rarely debilitating
– true impact very difficult to gauge
• Cluster headache
– devastating until diagnosed
– early onset cases rare
• 18% report onset before 18 yr
• 2% report onset before 10 yr
Headaches are common
• American Migraine Prevalence &
Prevention Study
– 120 000 households
– 162 576 participants
– mailed questionnaire on HAs & Rx
– ICHD-II criteria used
– overall 1-yr prevalence migraine
• ♂ 5.6%
• ♀ 17.1%
Headaches are common
• Subgroup analysis of adolescents (12-17
yr)
– 1 yr prevalence of migraine 6.3%
• ♂ 5%
• ♀ 7.7%
– utilization of medications by this group
•
•
•
•
OTC 59.3%
prescription medication only 16.5%
OTC & prescription medication 22.1%
current prophylactic treatments 10.6%
Headaches are common
• German 3/12 prevalence study
– 2.6% migraine (ICHD-II criteria)
– 6.9% if duration criteria reduced to 30 min
– 12.6% probable migraine
– 0.7% chronic migraine
• Turkish prevalence questionnaire
– 7.8% boys
– 11.7% girls
Headaches are common
• Meta-analysis of paediatric headache
studies 2002 by AAN group
– >27 000 children
– 37-51% significant HA by age 7 yrs
– 57-82% significant HA by age 15 yrs
Impact of headaches
• Children with migraine lose on average 1½
weeks of school per year
• Impact can be assessed using validated
tools
– PedMIDAS
– PedQL
Treatment
• Accurate diagnosis
• Comprehensive treatment plan
– Explanation (and reassurance)
– Lifestyle advice
– Acute treatments
– Prophylactic treatments
– Biobehavioural therapies
Treatment
• Accurate diagnosis
– Underlying headache phenotype
• What was the headache originally like?
– Triggers
– Confounding factors
•
•
•
•
Medication overuse
Physical co-morbidities
Psychological co-morbidities
Life stresses
Treatment
• Explanation
– common problem
– physical, not just psychological problem
• genetics, pathophysiology
– treatable problem
• identifying triggers, confounding factors
• Reassurance for child and parents
– … this is not a brain tumour …
Treatment
• Acute treatment
– Goals:
• sustained pain freedom
• rapid return to normal activity
– OTC
• small trials show ibuprofen (7.5-10 mg/kg) superior
to PCT + placebo
• use early, at decent dose
• avoid overuse (≤3 days/wk)
Treatment
• Acute treatment
– Triptans
• in UK only nasal sumatriptan licensed for
adolescents
• DBPCTs in adolescents exist for almotriptan,
eletriptan, rizatriptan, sumatriptan, and zolmitriptan
• effective (but high placebo rates…) and welltolerated
• SUM/NAR database shows a linear correlation
between age & efficacy of triptans
Treatment
• Prophylactic treatments
– When to use them?
• increased headache frequency
• poor response to acute treatments
• ? severe (including hemiplegic or basilar) MA
– Goals:
• reduce headache frequency
• reduce headache-related disability
• allow eventual return to acute treatment alone (or
acute treatment + biobehavioural therapy)
Treatment
• Prophylactic treatments
– pizotifen
– beta-blockers
– tricyclics
– anticonvulsants
– others
• riboflavin (vitamin B2)*
• coenzyme Q10
• butterbur extract
* recent negative small PCRCT!
• Prophylactic treatments
– a paucity of evidence
– Cochrane review 2003 found only two trials
convincingly showing benefit of prophylactic
treatment
• Propranolol
• Flunarizine
– since then decent PCRCT for topiramate
– recent negative PCRCT for SVP MR
Treatment
• Biobehavioural therapies
– biofeedback
– relaxation training
• Treatment of co-morbidities
– physical
• sleep disorders
– psychological
• Counselling; family therapy
The future?
• Much more evidence is needed for
– Acute treatments
– Prophylactic treatments
• monotherapy
• combination therapies
– Novel treatments
• CGRP antagonists
• More interest in the subject must be
generated in 1°, 2°, and 3° care