• Speaker honoraria and advisory boards
• Allergan
• Avanir Pharmaceuticals
• Depomed, Inc.
• Iroko Pharmaceuticals
• National Headache Foundation
• Nautilus Neurosciences, Inc.
• Pernix Therapeutics Holdings, Inc.
• Supernus Pharmaceutical
• Teva Pharmaceutical Industries, Inc.
• Zogenix, Inc.
Christina Treppendahl, FNP-BC, AQH
Director, The Headache Center, Ridgeland, Mississippi
Headache Subspecialist
Trigeminal Autonomic Cephalalgias
• NPs should be able to distinguish between primary headache
Migraine
disorders and secondary headache disorders; confidently ruling out
secondary headache disorders and appropriately diagnosing primary
headache disorders
Migraine without Aura
Migraine with aura
Alice in wonderland
Syndrome
• NPs should be able to diagnose childhood periodic syndromes,
Familial hemiplegic migraine
migraine, posttraumatic headache and be aware of the challenges
that face this population
Sporadic hemiplegic migraine
• NPs should know the appropriate medications commonly used to
treat migraine; including acute and prevention medications, ED
treatment and hospital admission treatments for refractory migraine
• Fever
• Noncephalic infection Or Disorders of
Cranium, Eyes, Ears, Nose-Throat-Sinuses,
Teeth, Jaw
• Upper respiratory tract infection
(with or without fever)
• Otitis Media
• Pharyngitis
• Sinusitis
• CNS Infection > Meningitis: viral or bacterial
• Substance abuse:
• Cocaine or substance withdrawal
• Medication:
• Sympathomimetics (methylphenydate),
oral contraceptives, steroids
• Intoxications: lead, carbon monoxide
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
SP16.1.021
• Head or Neck Trauma
• Vascular Disorders:
•
•
•
•
•
•
• Subarachnoid hemorrhage
• Intracranial hemorrhage
Intracranial Abnormalities, Nonvascular
• High pressure CSF
• Low pressure CSF
• Postseizure
• Neoplasm > Brain Tumor
Ventriculoperitoneal shunt malformation
Hydrocephalus
Hypertension
Metabolic/Homeostatic Disorders
Psychiatric Disorder
Cluster Headache
Paroxysmal Hemicrania
SUNCT/SUNA
Hemicrania Continua
Cranial Neuralgias
Trigeminal Neuralgia
Brain stem migraine
Glossopharyngeal
Neuralgia
Tension-type headache
Occipital neuralgia
Retinal migraine
Neck-tongue syndrome
Other
Primary stabbing headache
Primary cough headache
Exertional headache
Sex headache
Hypnic headache
Thunderclap headache
Cold-stimulus headache
Ophthalmoplegic migraine
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
•
•
•
•
•
Acute-Worst Headache Ever
Abrupt Change in Headache Pattern
Head Trauma
Toxic Exposure
Focal or Generalized Neurologic
Symptoms
• Presence of a Shunt
• Presence of an Underlying Disorder
• Immunocompromised Patient
• Relentless Progression of Headache
• Systemic Symptoms: Fever, Rash,
increase Blood Pressure
• Abnormal Mental Status
• Meningismus
• Café au lait Spots, Petechiae,
Hypopigmentation
• Any Abnormality on Neurologic
Examination
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
1
History
Physical Exam
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Age <3 years
Morning or nocturnal headache
Morning or nocturnal vomiting
Headache increased by Valsalva or
straining
Explosive Onset “Thunder clap”
Progressively worsening over time
(chronic progressive pattern)
Declining school performance or
personality change
Altered mental status
Epilepsy
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
• Strongly suggests organic pathology
• There is no invariable “brain tumor
• Key signs
•
•
•
•
headache” profile
• Key symptoms
•
•
•
•
•
Nocturnal or morning headaches
Nocturnal or morning vomiting
Aggravation by Valsalva or exertion
Seizures
Neurocutaneous syndromes
Hypertension
Head Circumference >95%
Neurocutaneous markers
Meningeal signs
Papilledema
Abnormal eye movements
Motor asymmetry
Ataxia
Gait disturbance
Abnormal deep tendon reflexes
Occipital location of headache*
(bilateral or unilateral)
Papilledema
Cranial nerve palsies
Ataxia – tandem gait (walking a tightrope)
Focal signs, motor or sensory (pronator drift,
DTRs)
• Majority of brain tumors are midline
processes: medulloblastoma,
cerebellar astrocytoma,
ependymoma, pineal region tumors,
craniopharyngioma
Does anyone in your family suffer from headaches?
Medications and other medical problems?
How and when did your headaches begin?
What is the time pattern of your headache?
• Sudden first headache
• Episodes of headache
• Every day headache
• Gradually worsening headache
• Mixture
• How often does the headache occur and how long
does the headache last?
• Do you have one type of headache or more than one
type?
• Are there warning signs or can you tell that the
headache is coming?
• Location and quality of the pain?
• Pounding*
• Squeezing
• Stabbing
• Other
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
SP16.1.021
• CHRONIC NONPROGRESSIVE or CHONIC DAILY
HEADACHE
• Frequent or constant headache
• Chronic Migraine ≥15 headache days per month,
each headache lasting >4 hours if untreated and >
4 month history
• Neuro exam normal
• Psychological factors and anxiety about underlying
organic causes
respiratory tract
Infection*
•
• ACUTE-RECURRENT
• recurrent headaches separated by symptomfree intervals
• CHRONIC PROGRESSIVE – most ominous
• Gradual increasing frequency and severity of
• MIXED – Migrainous acute-recurrent headaches
superimposed upon a chronic daily headache
background
headache
• Pathological correlate is increasing intracranial
•
pressure
Pseudotumor cerebri, brain tumor,
hydrocephalus, chronic meningitis, brain
abscess, or subdural collections
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
• These patients are prone to
• They can develop any
develop intracranial tumors
due to the absence of tumor
suppressor genes:
• Neurofibromatosis, types 1 and 2
(NF1 and NF2)
• Sturge-Weber syndrome
• Tuberous sclerosis (TS)
• Ataxia-telangiectasia (A-T)
• Von Hippel-Lindau disease (VHL)
primary CNS neoplasm:
• Optic gliomas
• Meningiomas
• Acoustic schwannomas (acoustic
neuromas)
• Subependymal giant cell
astrocytomas
• Hemangioblastoma
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
•
•
•
•
• ACUTE
• single episode of head pain without prior history
• “first and worst” – febrile illness related to upper
• Accompanying symptoms?
•
•
•
•
•
• Nausea
• Vomiting
• Dizziness
• Numbness
• Weakness
• Other
Alleviating or aggravating factors?
• Activities
• Medications
• Foods
• Sleep
• Position
What do you do when you get a headache? Stop
activities?
Do the headaches occur under any special
circumstances or at any particular time?
Do you have other symptoms between headaches?
What do you think might be causing your headaches?
FIVE KEY NEUROLOGICAL
EXAMINATION ELEMENTS
COMPREHENSIVE HEADACHE
EXAMINATION
• Cervical spine examination
• Skull: palpation of bones and muscles, listen for
bruits
• Ears: external auditory meatus occlusion and
motion
• Temporomadibular joint: palpation, range of
motion
• Nerves: Palpation of supraorbital, trochlear, and
occipital nerves as well as cranial nerves IX –XII
• Eyes: palpation and inspection
• Sinuses: modified Muller’s Maneuver
• Evaluation for increased intracranial pressure
•Winner,
Teeth:
inspection, percussion, palpation
P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
• Carotid arteries; listen for bruits
•
•
•
•
•
Optic nerve discs – papilledema
Eye movements – 3rd or 6th nerve palsy
Pronator drift
Tandem gait
Reflexes
2
WWW.AAN.ORG
• Routine EEG not recommended
• Afebrile – routine labs and Lumbar puncture are not recommended
• Neuroimaging on a routine basis is not indicated in children with
recurrent headaches and a normal neurological examination
• Neuroimaging should be considered in children with a history of:
• Recent onset of severe headache
• Change in the type of headache
• Neurological dysfunction
• Neuroimaging should be considered in children with an abnormal
neurological examination (e.g., focal findings, signs of increased
intracranial pressure, significant alteration of consciousness) and/or the
coexistence of seizures
• Infant Colic
• Benign Paroxysmal Torticollis
• Benign Paroxysmal Vertigo
• Cyclic Vomiting Syndrome
• Abdominal Migraine
> 5-6 weeks
> 5-6 months
> 2-5 years
> 5 years
> 7 years
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
• A recent meta-analysis revealed that infants with colic have a higher likelihood of
•
•
•
•
•
•
developing migraine
Mothers with migraine have been found to be 2.5 x more likely to have infants with
colic than mothers that do not have migraine
Fathers with infant colic have a higher likelihood of developing migraine
“Colic” implies abdominal discomfort but trials of GI-oriented therapies have been
negative
Possibly experiencing headaches due to increased sensitivity to stimuli, just as
migraineurs do > expressed as crying
Rapid brain development and visual perception in the first few weeks > onset of
colic begins after 2 weeks
Circadian biology > 3 months of age, endogenous melatonin secretion allows for
sleep consolidation at night > colic usually resolves > sleep can terminate a
migraine attack
Gelfand, AA. Episodic Syndromes That May Be Associated With Migraine: A.K.A. “the Childhood Periodic Syndromes”. Headache. 2016; 55: 1358-1364.
•
•
•
•
•
•
•
•
•
•
Underdiagnosed > only 2.4% of pediatricians are aware of BPT
It is the rarest of the pediatric syndromes
Periodic, stereotyped bouts of torticollis during infancy
Age of onset is typically around 5-6 months, may begin as early as 2 months
Attacks may last only minutes but they typically last hours to days
Disorder begins to improve by age 2 and resolves by age 3-4
Associated symptoms: irritability, drowsiness, pallor, vomiting, ataxia, or tortipelvis
Occasional motor delays reported > improves
Family history of migraine (often) or CACNA1A gene mutations associated with FHM (rare)
Differential diagnosis: GE reflux, idiopathic torsional dystonia, complex partial seizures,
congenital or acquired lesions (posterior fossa and craniocervical junction), trochlear
dysfunction
• Diagnostic yield of brain MRI and EEG are quite low
• Treatment not established or required > reassurance of parents
Gelfand, AA. Episodic Syndromes That May Be Associated With Migraine: A.K.A. “the Childhood Periodic Syndromes”. Headache. 2016; 55: 1358-1364.
SP16.1.021
• Excessive, frequent crying in a baby who appears to be otherwise
healthy and well fed.
• Diagnostic criteria
• Recurrent episodes of irritability, fussing or crying from birth to 4 months of
age, fulfilling criterion B
• Both of the following:
•
• Episodes last for ≥3 hours per day
• Episodes occur on ≥3 days per week for ≥3 weeks
Not attributed to another disorder
The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33(9) 629-808.
A. Recurrent attacks in a young child, fulfilling criteria B and C
B. Tilt of the head to either side, with or without slight rotation, remitting spontaneously
after minutes to days
C. At least one of the following associated symptoms or signs:
1. Pallor
2. Irritability
3. Malaise
4. Vomiting
5. Ataxia
D. Normal neurological examination between attacks
E. Not attributed to another disorder.
The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33(9) 629-808.
3
•
•
•
•
•
•
•
Abrupt, recurrent attacks of vertigo that last seconds to hours > usually less than 5 minutes
Accompanying symptoms: nystagmus, ataxia, nausea/vomiting, or pallor and in some cases, headache
A.
A disorder characterized by recurrent brief attacks of vertigo, occurring without warning and resolving spontaneously, in
otherwise healthy children. Symptoms may include dizziness, pallor, perspiration, nausea/vomiting, nystagmus,
photophobia, phonophobia, fear and sleepiness after an episode.
B.
C.
At least five attacks fulfilling criteria C and D
Child may appear scared/attacks usually resolve with sleep
Must have normal audiometric and vestibular functions between attacks
If alterations of mental status are present > order EEG (benign occipital epilepsy)
MRI brain and c-spine and rule out metabolic disorders
Parent’s observation of unsteadiness is sufficient to infer vertigo since children may have difficulty
articulating this
D.
At least one of the following associated symptoms or signs:
1.
2.
3.
4.
5.
• Onset is between 2 and 5 years of age and resolves typically by 5 or 6 years > may persist into young
adulthood
• Family history of migraine was seen in 70% and several studies have noted a much higher prevalence of
migraine as an adult in this population versus the general population
• A patient that had BPT, then BPV, then HPM was found to have a CACNA1A gene mutation
Vertigo occurring without warning, maximal at onset and resolving spontaneously after minutes to hours without loss of
consciousness
E.
F.
Nystagmus
Ataxia
Vomiting
Pallor
Fearfulness
Normal neurological examination and audiometric and vestibular functions between attacks
Not attributed to another disorder
Drigo P, Brain and Development , 23 (2001) 38-41.
The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33(9) 629-808.
• A 2 year old female awoke from sleep, looked fearful, and was
• Recurrent episodic attacks of frequent, severe vomiting.
• Attacks are stereotyped and predictable – morning & monthly.
• Last hours to days.
pale and unsteady. She had four episodes in 24 hours and
each lasting 5 minutes. The third time she said she felt “funny
and spinny.” She tried to grab her mom’s legs and did not
want to be put down on the floor.
• Testing: EEG, MRI, Metabolic Panel, CK were all normal
• She had one episode a month for 3 months. The frequency
slowly decreased and by 3 years old she had no more
attacks.
Completely well between attacks.
• Family history of migraine is common, more develop migraine than the
general population
• Prevalence estimated at 2%
• Mean onset of age is 5 yo (childhood -typically resolves by teens) or *25
adults
• Rule out secondary causes: gastrointestinal, urologic, and inborn errors of
metabolism
The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33(9) 629-808.
A.
At least five attacks of intense nausea and vomiting, fulfilling criteria B and C
B.
Stereotypical in the individual patient and recurring with predictable periodicity
C.
All of the following:
1. Nausea and vomiting occur at least four times per hour
2. Attacks last >1 hour and up to 10 days
3. Attacks occur >1 week apart
D.
Complete freedom from symptoms between attacks
E.
Not attributed to another disorder
• Gastrointestinal pathology – GI specialist
• Urologic disorders – Ureteropelvic Junction Obstruction >
hydronephrosis > abdominal ultrasound
• Autonomic seizures – Altered mental status > EEG
• Cannabinoid hyperemesis syndrome > UDS
• Metabolic disorders > Mitochondrial dysfunction > metabolic geneticist
• Consider if there is any degree of abnormality between attacks
• Presence of encephalopathy with attacks
• Attacks are precipitated by illness, fasting, high fat or high-protein meals
• Blood tests: quantitative plasma amino acid analysis, plasma acylcarnitine profile, plasma
total and free carnitine, lactate, pyruvate, ammonia, glucose, electrolytes
• Urine tests: urine ketones urine organic acids, quantitative orotic acid, urine acyloglycines,
urine porphobilinogen
The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33(9) 629-808.
SP16.1.021
Gelfand, AA. Episodic Syndromes That May Be Associated With Migraine: A.K.A. “the Childhood Periodic Syndromes”. Headache. 2016; 55: 1358-1364.
4
• Hydration: oral or IV with glucose
• Antiemetic:
• Ondansetron
> 0.3-0.4 mg/kg IV or 4-8 mg ODT
• Promethazine > 0.25-0.5 mg/kg/dose
• Metoclopramide > 1-2 mg/kg/ up to 10 mg BID
• Prochlorperazine > 2.5-5 mg BID
• Sedation:
• Lorazepam
> 0.05-0.1 mg/kg up to 5 mg
• Diphenhydramine
> 0.25-1 mg/kg
• Triptans: Sumatriptan IN 5 mg, SC ~0.07 mg/kg, Oral
Gelfand, AA. Episodic Syndromes That May Be Associated With Migraine: A.K.A. “the Childhood Periodic Syndromes”. Headache. 2016; 55: 1358-1364.
Most common childhood periodic syndrome
Prevalence is estimated at 4.1% among 5-15 year olds
School-aged children > onset 7
Mean attack frequency is 14 episodes per year
Mean attack duration is 17 hours
Rarely persists into adulthood > evolution into typical migraine headache (70%)
Diagnosis excluded if: Mild symptoms not interfering with daily activities, non-midline
abdominal pain, symptoms consistent with food allergy or other GI disease, attacks
less than 2 hours, or persistence of symptoms between attacks
• No GI pathology or renal disease is identified > well between attacks
• Migraine treatments have proven success > sumatriptan NS, IV DHE (refractory), and
migraine prevention
Migraine
prevalence peaks
in the 25-55 age
range
• < 40 kg: 40 mg
• 40-60 kg: 80 mg
• > 60 kg: 125 mg
A.
B.
C.
D.
E.
F.
At least five attacks of abdominal pain, fulfilling criteria B–D
Pain has at least two of the following three characteristics:
Midline location, periumbilical or poorly localized
Dull or ‘just sore’ quality
Moderate or severe intensity
During attacks, at least two of the following:
1. Anorexia
2. Nausea
3. Vomiting
4. Pallor
Attacks last 2-72 hours when untreated or unsuccessfully treated
Complete freedom from symptoms between attacks
Not attributed to another disorder. (In particular, history and physical examination do not show signs of
gastrointestinal disease)
1.
2.
3.
The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33(9) 629-808.
Gelfand, AA. Episodic Syndromes That May Be Associated With Migraine: A.K.A. “the Childhood Periodic Syndromes”. Headache. 2016; 55: 1358-1364.
Approximately
10% of pediatric
population has
migraine
age)
• Propranolol > 10-20 mg TID <35 kg, 2—40 mg tid > 35 kg
• Aprepitant > 2x/week:
Gelfand, AA. Episodic Syndromes That May Be Associated With Migraine: A.K.A. “the Childhood Periodic Syndromes”. Headache. 2016; 55: 1358-1364.
•
•
•
•
•
•
•
There are over 36
million migraine
sufferers in the
US (age 12 and
older)
• Avoid fasting and irregular sleep schedules
• Riboflavin (vitamin B2) > 400 mg divided BID
• Coenzyme q10 (coq10) > 10 mg/kg/day (max 200 mg) divided BID
• L-carnitine > 50-100 mg/kg/day (max 4 g) divided BID
• Amitriptyline > 1mg/kg nightly (over 5 years of age)
• Cyproheptadine > 0.25-0.5 mg/kg/d divided bid or nightly (under 5 years of
Female to Male
Ratio of 3:1after
puberty
1 in 4 households
has at least 1
migraine sufferer
By age
3-7 years
7-11 years
15 years
Prevalence
1.2-3.2%
4-11%
8-23%
Gender Ratio
boys > girls
boys = girl
girls > boys
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
SP16.1.021
5
Percentage of Females with Migraine
27%
Migraine tends to run in families
26%
22%
There is a 50% chance of having migraine if one
parent suffers from migraine.1,2
20%
12%
10%
A combination of genetic and environmental factors are
likely to play a role in the development of migraine.3
8%
Age 6 - 11
Age 12 - 17
Age 18 - 29
Age 30 - 39
Age 40 - 49
Age 50 - 59
Age 60+
Modified from Lipton RB et al. Headache. 2001;41:646-657.
1. Sandor PS et al. Headache. 2002;42:365-377.
2. Montagna P. Cephalalgia. 2000;20:3-14.
3. Stewart WF et al. Ann Neurol. 1997;41:166-172.
Headache
Headache is the 3rd ranked illness-related cause of school absence
No
10% Children with migraine missed at least 1 day of school over
a 2-week period from migraine
Nearly 1% missed 4 days of school over a 2-week period from
migraine
National Health Interview Survey (1989), Headache 1993;33:29-35
Red Flag
Warning Signs
Primary Headache
Yes
Secondary Headache
Atypical Features
Diagnosis
Further Investigation
Dodick DW. Adv Stud Med. 2003;3:S550-S555.
“RED FLAGS”
S
SYSTEMIC Symptoms (fever, weight loss) or Disease (malignancy)
N
NEUROLOGIC Signs or Symptoms
O
ONSET sudden (acute or thunderclap headache)
O
ONSET after age 50 years
P
PREVIOUS HEADACHE HISTORY (new or different )
P
PROGRESSIVE
P
PRECIPITATION BY VALSALVA (cough, bend)
P
POSTURAL
P
PREGNANCY
Sinus
Tension
Stress
Dodick DW. Adv Stud Med. 2003;3:S550-S555.
SP16.1.021
6
At least five attacks fulfilling criteria B–D
Duration: 2 to 72 hours*
C. Characterized by ≥2 of the following
pain features
A.
B.
1.
2.
3.
4.
D.
Bilateral
Throbbing (85%)
Moderate to severe
Aggravated by movement
One of the following
1. Nausea (74%) and/or Vomiting (30%)
2. Photophobia (81%) and Phonophobia (77%)
E.
Not attributable to another disorder
A complex of neurological symptoms that are
visual (90%), sensory and/or language
Begins 5 to 60 minutes before pain starts and last
up to 1 hour
Confusion, lightheadedness, and difficulty
concentrating can also accompany the aura
Only 1 in 5 migraine sufferers experience aura
The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33(9) 629-808.
A. At least two attacks fulfilling criteria B & C
B. Aura consisting of visual, sensory and/or speech/language symptoms,
each fully reversible, but not no motor, brainstem or retinal
symptoms
C. At least two of the following four characteristics:
1. At least one aura symptoms spreads gradually over ≥5 minutes, and/or two or
more symptoms occur in succession
2. Each individual aura symptoms lasts 5-60 minutes (3X60)
3. At least one aura symptoms is unilateral (aphasia is regarded as unilateral)
4. The aura is accompanied, or followed within 60 minutes, by a headache
D. Not better accounted for by another ICHD-3b diagnosis, and transient
ischemic attack has been excluded
The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33(9) 629-808.
Attack
Prodrome
)
Mood Change
(23%
SP16.1.021
(77%
)
Mild Headache
(74%
(22%
-24
Tiredness
)
Nausea
)
GI Symptoms
Kelman L. Headache. 2004;44:865-872.
Kelman L. Cephalalgia. 2005;26:214-220.
Lipton RB et al. Headache. 2001;41:638-645.
(81%
)
Phonophobia
)
Vomiting
(41%
(19%
)
GI Symptoms
Mood Change
(5%)
(4%)
(30%
Aura
Migraine-Related Symptoms
(26%
)
Neck Pain/Tightness
Food Cravings
Yawning
Postdrome
Photophobia
Fatigue
0
)
Osmophobia Headache
Throbbing (85%)(30%
)
Unilateral (60%)
Neck Pain
(75%
)
Cranial Autonomic Sx
(56%
4
) Time (hours)
– 72
96 – 120
7
• Rare form of migraine in children > may be observed in adolescents and young adults
• Repeated attacks of monocular (unilateral) visual disturbance, including scintillations,
•
•
•
•
•
scotoma, or blindness, associated with a migraine headache
Extremely rare cause of transient monocular visual loss > appropriate investigations
are required to exclude other causes of transient monocular blindness >
ophthalmological evaluation, MRI with special views of the orbit and an MRA
Evaluation for hypercoagulable states, embolic sources, and vascular disruption
(carotid dissection) must be considered
Unlike the “descending curtain” of amaurosis fugax, affected patients will report brief
(seconds to minutes), sudden monocular black or gray “outs,” or bright, blinding
episodes (photopsia) of visual disturbance before, after, or during the headache
Pain is often retro-orbital and ipsilateral to the visual disturbance
Neurological examination is normal between episodes
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
A. At least 2 attacks fulfilling criteria b & c
B. Aura consisting of fully reversible monocular positive and/or negative
visual phenomena (e.g., scintillations, scotomata, or blindness)
confirmed during an attack by either or both of the following:
1. Clinical visual field examination
2. The patient’s drawing (made after clear instruction) of a monocular field defect
C. At least 2 of the following three characteristics:
1. The aura spreads gradually over ≥5 minutes
2. Aura symptoms last 5-60 minutes
3. The aura is accompanied, or followed within 60 minutes, by headache
• Not better accounted for by another ICHD-3b diagnosis, and other
causes of amaurosis fugax have been excluded
The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33(9) 629-808.
Stress (89%)
Bright lights (38%)
Female hormones (65%)
Alcohol (38%)
Not eating (57%)
Smoke (36%)
Weather changes (53%)
Sleeping late (32%)
Physical exhaustion or traveling (53%)
Heat (30%)
Sleep disturbance (50%)
Food (27%)
Perfume or odors (44%)
Exercise (22%)
Kelman L. The triggers or precipitants of the acute migraine attack. Cephalalgia. 2007;27:394-402.
Increase water intake
Good sleep hygiene
Exercise
Many medications used for the treatment of
headache in children are only FDA approved for
patients ≥ 18 y/o
Weight loss
Eat a healthy diet
• Avoid food triggers
• Avoid MSG, artificial sweeteners, preservatives
Minimize caffeine
SP16.1.021
Many medications used for treatment of headache
do not have FDA approval for treatment of
headache.
8
• No evidence to support the use of Butalbital-containing products or opioids in migraine – these
drugs are not recommended as best practice by the American Headache Society or the
National Headache Foundation and there is a preponderance of evidence that supports the
notion that they exacerbate migraine pathophysiology and promote transformation of episodic
migraine to chronic migraine
• Nonspecific
• ASA – Reye’s Syndrome avoid if febrile or concern for an underlying metabolic disorder
• Acetaminophen
• Ibuprofen
• Naproxen sodium
• Diclofenac (CAMBIA – FDA approved in adults)
• Ergots
• Dihydroergotamine (DHE)
• Antiemetics
• Promethazine (Phenergan)
• Prochlorperazine (Compazine)*
• Metoclopramide (Reglan)*
• Ondansetron (Zofran)
•
•
•
•
•
•
•
•
Sumatriptan – 6 yo – 0.06 mg/kg up to 6 mg sc x 1 dose
Sumatriptan/Naproxen Sodium – Fixed does – Treximet - 12 yo
Rizatriptan – 6 yo – 5 mg < 40 kg, 10 mg > 40 kg
Zolmatriptan NS – 12 yo 2.5-5 mg first dose, up to 10 mg in 24 hours
Almotriptan – 12 yo 6.25 -12.5 mg, up to 25 mg in 24 hours
Eletriptan – 20 mg and 40 mg
Naratriptan – 1 – 2.5 mg
Frovatriptan – 2.5 mg
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
• Concern: The combination of triptans with antidepressants pose an
If acute treatment still inadequate:
increased risk of serotonin syndrome.
• Truth: It does not.
• Try additional therapies such as using ice or heat, resting, going to a quiet room,
etc.
• Screen for exacerbating/interfering factors such as caffeine or acute medication
overuse
•
•
•
•
•
• Chronic daily headache and a secondary disorder in which acute medications used
excessively causes headache in a headache-prone patient
• History of analgesic use more than two to three days per week in a patient with
chronic daily headache
• Most commonly occurs in people with primary headache disorders like migraine,
cluster, or tension-type headaches using less effective or nonspecific medications
resulting in inadequate treatment response and redosing
• Headaches become refractory to both pharmacological and non-pharmacological
Change dose or formulation
Treat early while headache is mild
Add adjunctive therapy (e.g. NSAID)
Try dihydroergotamine (DHE 45) (nasal spray, injection)
Add preventive therapy
• Simple analgesics: Common medications such as aspirin, acetaminophen, NSAIDS
(ibuprofen, naproxen, indomethacin,) may contribute to rebound headaches especially
when the patient exceeds the recommended daily dosages. These medications cause
MOH when used 15 or more days per month
• Combination pain relievers: Over-the-counter pain relievers that contain a
combination of caffeine, aspirin and acetaminophen or butalbital commonly cause
medication overuse headache as well. All of these medications are high risk for the
development of medication-overuse headache if taken for 10 or more days per month
prophylactic treatments, and also reduces the efficacy of acute abortive therapy for
migraines
• Triptans and Ergotamines: Triptans and Ergotamines also have a moderate risk of
• Most effective method treatment is discontinuation of the medication that is overused
• Opioids: Oxycodone, tramadol, butorphanol, morphine, codeine, and hydrocodone
and a combination of pharmacological, non-pharmacological, behavioral and physical
therapy interventions
• Use of certain classes of acute medications such as opioids, barbiturate-containing
analgesics and butalbital, aspirin and caffeine is associated with increased risk of
chronic migraine
https://americanmigrainefoundation.org/medication-overuse-headache/
SP16.1.021
causing medication overuse headache when used for ten or more days per month
among others cause MOH when used 10 or more days per month
• Caffeine use: Caffeine intake of more than 200mg per day increases the risk of MOH
https://americanmigrainefoundation.org/medication-overuse-headache/
9
Reduce attack
frequency, severity,
and duration
Improve function and
reduce disability
Reduce use of acute
medication and
potential for
medication overuse
headache
Improve
responsiveness to
treatment of acute
attacks
• Start at a low dose and titrate slowly to avoid/minimize side effects
• Give each preventive medication an adequate trial, at least 2 months at a therapeutic
dose
• Avoid interfering, contraindicated, or overused medications
• Reevaluate therapy on a regular basis; follow-up is important.
• Discuss contraception with women in childbearing age and the potential risk of
medication with pregnancy.
• Involve patients in their care to improve adherence.
• Address comorbid conditions and try to choose the fewest medications to manage
multiple problems where possible.
• Choose a drug based on efficacy, patient’s/parents preferences, headache profile, the
drug’s side effects, and the presence comorbid conditions.
Ramadan NM et al. Evidence-based guidelines for migraine headache in the primary care setting: pharmacological management for prevention of migraine. Accessed November 17, 2005.
First line:
Initial Dose
Anticonvulsants
Topiramate
0.5-1mg/kg/day
Valproic acid
250 mg/day
Zonisamide
1-2 mg/kg/day
Levetiracetam
250 mg/day
Antihistamines
Cyproheptadine
0.2 mg/kg/day
Second Line:
Antidepressants
Amitriptyline
0.25-0.5 mg/kg (Max 10 mg)
Nortriptyline
10 mg
Antihypertensives
Propranolol
10 mg
If two or more preventives have failed:
Botulinum toxin
Onabotulinum toxin A
155 units
Dose Range
2-3 mg/kg/day
250-1000 mg/day
4-6 mg/kg/day
250-1500
Medical
0.2-0.4 mg/kg/day
School
10-75 mg/day
10-75 mg/day
1-4 mg/kg/day divided TID
• Acute treatment
• Preventive treatment
• Develop strategy, including accommodations, to
keep child in school.
• If not in school, develop strategy to transition child
back into school
• Established the ability to treat headaches in school.
Headache must be treated as a medical
emergency!
• Biobehavioral treatment strategies for anxiety
155-200 units
Hickman, C, et. al. Prevention for Pediatric and Adolescent Migraine. Headache. 2016; 55: 1371-1381.
Take A Proactive Approach
Provide a letter of accommodations for the school nurse and teachers
describing the symptoms, rescue treatment plan, and hydration &
restroom needs
Recommend parent and child review the plan with teachers and school
nurse
Headaches can limit ability to concentrate and learn
37% of children with migraine report performing poorly
during a headache1
Discuss expectations for school attendance
Evaluate headache disability at each visit
Consider recommendation for a 504 Plan
1Headache
SP16.1.021
1997;37:269-276.
10
Section 504 is a federal law that falls under Americans with Disabilities Act
No one with a disability can be excluded from participating in federally funded programs or activities,
including school.
Disability is defined as a physical or mental impairment which substantially limits one or more major life
activities, i.e. learning, writing, walking, hearing, seeing
Reinforce to student & parents that the student
may have to learn to function presence of pain
Work with student, parents, and school to
develop school reintegration plan
No school excuses
Avoid homebound schooling
The 504 Plan is a plan developed to ensure that a child who has a disability identified under the law and
is attending an elementary or secondary educational institution receives accommodations that will ensure
their academic success and access to the learning environment
Referral for to psychology for pain
management and coping strategies
• Headache is the 3rd leading cause of referral to a pediatric ED
• The most common etiology of headache presenting to the ED is viral infections with
Child is afraid to tell teacher when has
a headache
School does not understand importance
of acute headache treatment
School nurse, teachers, or administrators
do not believe the student
fever. Migraine headache accounts for 1/3 of these referrals. Serious neurological
disorders such as meningitis, shunt malfunction, hydrocephalus are diagnosed in
6.6% of the referrals and the neurological examination in these patients is
typically abnormal indicating the need for further work-up and neuroimaging.
• Thorough evaluation should be done to determine etiology (primary vs secondary
headache) before specific therapy is initiated. Note: even a patient with a previous
diagnosis of migraine should still have a full evaluation to eliminate possible
secondary cause for the present headache.
• A sudden, severe (“thunderclap”) onset to the headache is suggestive of
subarachnoid hemorrhage (SAH) which is rare in children and has three primary
causes:
• Arteriovenous malformation (AVM) (Cavernous angioma, venous angioma, capillary telangiectasia,
and true AVM)
• Aneurysm (berry, giant, traumatic, and mycotic)
• Other causes: coagulopathy, sickle cell anemia, sympathomimetic intoxication, and leukemia
• In the event of a “thunderclap” headache a CT is always warranted and if negative,
an LP
mustof Pediatric
be conducted
rule
out
a small,
undetected
Kabbouche,
MK. Management
Migraine Headache in the to
Emergency
Room
and Infusion
Center. Headache.
2016; 55: 1365-1370. bleed.
• Occipital location of head pain must be considered strongly indicative of an organic
pathology, specifically posterior fossa tumors (not visible on CT)
• Patients with serious underlying conditions had clear, objective neurological signs
including papilledema, ataxia, hemiparesis, or abnormal movements
• The best way to keep migraine patients out of the emergency department is
• Prochlorperazine (Compazine) – 0.15 mg/kg/dose – maximum dose10 mg IV
• Metoclopramide (Reglan) – 0.13-0.15 mg/kg/dose – maximum dose 10 mg IV over 15 minutes
• Ketorolac (Toradol) – 0.5 mg/kg/dose – maximum dose 30 mg IV
• To decrease recurrence, give with prochlorperazine
• 1. to educate them about migraine and triggers to avoid with lifestyle modification and
• Sumatriptan (Imitrex) – 0.06 mg/kg/dose SC (not within 24 hours of DHE)
• Dihydroergotamine (DHE 45) – always given 30 minutes after antiemetic to minimize GI side
• 2. to make sure they have a migraine-specific attack medication, like triptans
• 3. to make sure they are offered prevention if headaches are frequent, disabling or if they
• Sodium Valproate (Depacon) – 15-20 mg/kg IV push (over 5 minutes) while receiving a fluid
biobehavioral
training)
therapies (cognitive-behavioral therapy, biofeedback, and relaxation
have an adverse effect on quality of life
• Never give a child opioids to manage headache – strong evidence that it will
increase likelihood of transforming to CM – can lead to dependence
• Early aggressive IV therapy can be very effective in breaking the attack and allowing
the child to return to normal functioning
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
Kabbouche, MK. Management of Pediatric Migraine Headache in the Emergency Room and Infusion Center. Headache. 2016; 55: 1365-1370.
SP16.1.021
effects including nausea, vomiting and abdominal discomfort
load
• Followed by an oral dose (15-20 mg/kg) 4 hours after the injection
• Magnesium Sulfate –
• Insufficient evidence
• Beneficial in patients with migraine with aura
• Beneficial in patients with low ionized magnesium levels
• Dexamethasone (Decadron) – Combined with any of the above as a one time dose to
decrease rate of recurrence
Kabbouche, MK. Management of Pediatric Migraine Headache in the Emergency Room and Infusion Center. Headache. 2016; 55: 1365-1370.
11
• About 7% of pediatric patients fail to respond to treatment in the ED and
• Head Injury accounts for the largest number of emergency
• Low dose DHE protocol
• Motor vehicle accidents, bicycle accidents, sports-related injury and
will admission for further therapies with DHE
• to prevent GI side effects including nausea, vomiting and abdominal discomfort –
given every 6 hours with metoclopramide 5-10 mg/dose given 30 prior to each DHE
dose x maximum of 16 doses
• Age 6-9 – 0.1 mg dose of DHE
• Age 9-12 – 0.15 mg dose of DHE
• Age 12-16 – 0.2 mg dose of DHE
• HIGH DOSE DHE protocol
• Prochlorperazine 0.13-0.15 mg/kg 30 minutes prior to the DHE dose x 3 doses then
replaced by different antiemetic to prevent extrapyramidal reactions
• DHE 0.5 – 1 mg per dose every 8 hours until headache freedom
department visits by children
child abuse
• Begins within 24 hours to weeks following head injury
• Constellation of symptoms: vertigo, dizziness, difficulty
concentrating, memory disorders, depression, altered school
performance, behavior disorders, and sleep alteration
• Phenotype: similar to migraine, tension-type headache, CDH,
mixed headache, & cluster
• Minor head injury: headaches usually resolve in 2-3 months
• < age 9 and weighing less than 30 kg – 0.5 mg
• > 9 and weighing greater than 30 kg – 1 mg
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
Winner, P, Lewis, DW, Rothner, AD. Headache in Children and Adolescents. 2008.
• Up to 3.8 million sport-related
• A concussion is a traumatic brain injury that may be caused by a
blow to the head, face, neck or elsewhere on the body with an
“impulsive” force transmitted to the brain
concussions every year
• 10% young athletes ever year
• Up to 50% playing collision
sports have concussion
symptoms –
only 10% report them
• 7.6 million athletes participate in
high school sports; 44 million in
non-scholastic sports
New Engl J Med 2007
What is the most common symptom after concussion?
1.
2.
3.
4.
5.
6.
http://www.cdc.gov/concussion/
Physical &
Postural
Cognitive
Emotional
Hypothalamic
“Dizziness”
Cognitive complaints
Headache/neck pain
Feeling mentally “foggy”
Irritability
Altered sleep-wake
Headache
Nausea/vomiting
Feeling slowed down
Sadness/Depression
cycles/circadian
Sensitivity to light/noise
Answers questions slowly
Personality change
rhythms
Visual problems
Difficulty concentrating
Anxiety/panic
Thermoregulation
Fatigue
Forgetful of recent events
More emotional
Diabetes insipidus
Dazed, stunned
Repeats questions
Less emotion (apathy)
Autonomic
Dizzy, balance problems
Drop academic performance
Nausea
Depression/anxiety
Poor sleep
SP16.1.021
dysfunction
12
• Most common symptom after minor head trauma
• 94% of athletes with concussion
• 90% of general public with TBI history
• 98% of soldiers with TBI during final 3 months of deployment
• Headache (any phenotype) within 7 days
• Of injury to the head
• After regaining consciousness after head injury
• Discontinuation of medications masking headache
• 33% meet criteria for chronic PTH
1. Kirk C et al. Dev Med Child Neurol. 2008;50(6):422–425.;
2. Marar M et al. Am J Sports Med. 2012; 40:747–755.
3. Theeler et al. Headache 2010;50:1262-1272
ICHD3b. Cephalalgia 2013;33:629-808.
Moderate/severe trauma
• At least one of the following:
• LOC > 30 min
• GCS < 13
• Altered level of awareness > 24h
• Imaging evidence of TBI
(intracranial hemorrhage and/or
brain contusion)
• Persistent headache
Mild trauma
• No moderate/severe features
• One or more of the following:
• Transient confusion or
•
disorientation
• Nausea/vomiting
• Cognitive symptoms
• “Dizziness”
ICHD3b. Cephalalgia 2013;33:629-808.
Glasgow Coma Scale
Score
Eye opening
spontaneously
4
To speech
3
• GCS < 15 + mild behavior
• Chronic subdural hematoma
• Hydrocephalous
• Structural lesion (unrelated to
Verbal response
trauma)
Motor response
Maximum score
SP16.1.021
• Context
• Timing
• Factors
Persists for > 3 months after injury
• Retro- or anterograde amnesia
• Two or more mTBI symptoms
ICHD3b. Cephalalgia 2013;33:629-808.
abnormality:
• MRI brain to rule out:
• Meets criteria for post-traumatic headache
To pain
2
none
1
orientated
5
confused
4
inappropriate
3
incomprehensible
2
none
1
Obeys commands
6
Localizes to pain
5
Withdraws from pain
4
Flexion to pain
3
Extension to pain
2
none
1
15
• Headache frequency
• Obesity
• Medication overuse
• Caffeine
• Snoring/sleep apnea
• Depression
• Stress
Bigal ME, Lipton RB. Headache 2006;46:1334-1343.
13
• Psychiatry consultation
• Cognitive behavioral therapy
• Sleep hygiene
• Autonomic disruptions
• OnabotulinumtoxinA injections
• Peripheral nerve block
• Massage
• Physical therapy
• Acupuncture
• Retrospective chart review
• Prophylactic
• Adolescent concussion patients in pediatric clinic (16-month period)
• Chronic post-traumatic headache of 3-12 months’ duration
• Results
• 70.1% met criteria for probable medication overuse headache (analgesics
only)
• After discontinuing, 68.5% had headaches resolve or improve to pre-injury
patterns
Excessive Use of Analgesics by Concussed Adolescents Contributes to Chronic Post-traumatic
Headaches
Heyer G et al. Pediatr Neurol. 2014; 50: 464–468.
• Triptans
• 70% relief in 2h vs
•
42% for nontriptans
Similarly effective in
blast vs non-blast
Erickson. Headache 2011;51:932-944
SP16.1.021
• Amitriptyline/Nortriptyline 25-50mg/daily
• Topiramate 100mg/daily
• Propranolol LA 80mg/daily
• Sodium valproate ER 500mg/daily
• OnabotulinumtoxinA
• Abortive
• Triptans
• NSAIDs
• Opioids
• Combination medications
• APAP
Erickson. Headache 2011;51:932-944
Yerry. Headache 2015;55:395-406.
• Headache at 1 month
• Headache at 1 year
• Headache at 3 months
• Headache at 4 years
• 31-90%
• 47-78%
• 8-35%
• 24%
Evans RW. Neurol Clin 2014.
14
• Baseline: Back to School First
Athlete is back to their regular school activities, is no longer experiencing symptoms from the injury
when doing normal activities, and has the green-light from their health care provider to begin the return
to play process.
• Step 1: Light aerobic activity
Begin with light aerobic exercise only to increase an athlete’s heart rate. This means about 5 to 10
minutes on an exercise bike, walking, or light jogging. No weight lifting at this point.
• Step 2: Moderate activity
Continue with activities to increase an athlete’s heart rate with body or head movement. This includes
moderate jogging, brief running, moderate-intensity stationary biking, moderate-intensity weightlifting
(less time and/or less weight from their typical routine).
• Step 3: Heavy, non-contact activity
Add heavy non-contact physical activity, such as sprinting/running, high-intensity stationary biking,
regular weightlifting routine, non-contact sport-specific drills (in 3 planes of movement).
www.MississippiMigraineCenter.com
www.facebook.com/TheHeadacheCenter
American Headache Society: www.AmericanHeadacheSociety.org
American Migraine Foundation www.americanmigrainefoundation.org
National Headache Foundation: www.Headaches.org
www.Migraine4kids.org.uk
• Step 4: Practice & full contact
www.Migraine.com
• Step 5: Competition
www.MigraineTrust.org
Young athlete may return to practice and full contact (if appropriate for the sport) in controlled practice.
Young athlete may return to competition.
http://www.cdc.gov/headsup/basics/return_to_sports.html
SP16.1.021
15