Management of Pediatric Headaches

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Management of Pediatric Headaches

• Paul Winner DO, FAAN, FAAP, FAHS
• Palm Beach Headache Center
• Clinical Professor of Neurology
• Nova Southeastern University
• www.DrWinner.org
• Disclosure Speaker, Research, Consultant for
• A-Z, GSK,Ortho McNeil, Merck, Pfizer, Allergan
• Off label Medication use with be discussed

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Management of Pediatric Headache Issues

• Diagnosis
• Evaluation
• Treatment

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Migraine vs Tension-type / IHS
Migraine Criteria

• ? 5 attacks lasting 472 hours (30 minutes7
  days)
• ? 2 of the following
• Unilateral (bilateral)
• Pulsating (not pulsating)
• Moderate or severe intensity (mild or moderate)
• Aggravation by routine physical activity (not)
• ? 1 of the following
• Nausea and/or vomiting (no nausea/vomiting)
• Photophobia and phonophobia (one or neither)
• No evidence on history or examination of disease
  that might cause headaches

Adapted from The International Classification of
Headache Disorders. Cephalalgia. 2004
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Diagnostic criteria ICHC -II Migraine without
aura

• Notes
• 3. In children, attacks may last 1-72 hours
  (although the evidence for untreated durations of
  less than 2 hours in children requires
  corroboration by prospective diary studies).
• 5. Migraine headache is commonly bilateral in
  young children an adult pattern of unilateral
  pain usually emerges in late adolescence or early
  adult life.
• 6. Migraine headache is usually frontotemporal.
  Occipital headache in children, whether
  unilateral or bilateral, is rare and calls for
  diagnostic caution many causes are attributable
  to structural lesions.
• 8. In young children, photophobia and phonophobia
  may be inferred from their behaviour.

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Proposed Criteria for Pediatrics

• At least 5 attacks
• Duration 1 to 72 hours
• Two of the following
• Bifrontal/bitemporal or unilateral
  location
• Pulsating / throbbing quality
• Moderate to severe intensity
  (numerical scale, faces scale)
• Aggravated by physical activity
• One of the following
• Nausea and/or vomating
• Two of five symptoms (photophobia,
  phonophobia, difficulty thinking,
  lightheadedness, or fatigue)
• May be inferred from their behaviour
• 0 to 10 scale or faces scale can be used

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A Look at the Future Solutions?

• Recognition - Case based headache
  diagnoses
• Picturing Drawing based diagnoses
• Allodynia Criteria
• Disability Better assess degree
• Quick Screen - Diagnostic tools
• Continued Research
• - Prospective diary studies
• - Longitudinal studies
  
  
  

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Childhood Periodic Syndromes
1.3.1 Cyclical vomiting 1.3.2 Abdominal
migraine 1.3.3 Benign paroxysmal vertigo of
childhood
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1.3.1 Cyclical Vomiting

• Description Recurrent episodic attacks, usually
  stereotypical in the individual patient, of
  vomiting and intense nausea. Symptom-free between
  episodes. Complete resolution of symptoms between
  attacks.
• Diagnostic criteria
• A.  At least 5 attacks
• B.  Episodic attacks of vomiting and intense
  nausea, stereotypical in the individual patient
  from 1 hour to 5 days.
• C. . Peak vomiting intensity at least 4
  emeses/hour.
• D. Symptom free between attacks
• E. History and physical examination do not
  show signs of gastrointestinal disease.

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1.3.2 Abdominal Migraine

• Description An idiopathic recurrent disorder
  seen mainly in children of episodic midline
  abdominal pain manifesting in attacks lasting
  1-72 hours with normality between episodes. The
  pain is of moderate to severe intensity and
  associated with vasomotor symptoms, nausea and
  vomiting.
• Diagnostic Criteria
• A.   At least 5 attacks fulfilling B-E.
• B.   Attacks of abdominal pain lasting 1-72
  hours (untreated or unsuccessfully treated)
• C.   Abdominal Pain has all of the following
  characteristics
• 1.     Midline location, periumbilical or
  poorly localized
• 2.     Dull or just sore quality
• 3.     Moderate or severe pain intensity
• D.  During abdominal pain at least 2 of the
  following
• 1.     Anorexia
• 2.     Nausea
• 3.     Vomiting
• 4.     pallor
• E.   History and physical examination do not
  suggest gastrointestinal or renal disease or such
  disease is ruled out by appropriate
  investigations.

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Migraine
1.2 Migraine with aura
1.2.1 Typical aura with migraine headache
1.2.2 Typical aura with non-migraine
headache 1.2.3 Typical aura without
headache 1.2.4 Familial hemiplegic
migraine 1.2.5 Sporadic hemiplegic
migraine 1.2.6 Basilar type migraine
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1.2.4 Familial hemiplegic migraine

• B. Aura consisting of fully reversible MOTOR
  WEAKNESS and gt1 of
• 1. Fully reversible visual symptoms including
  positive and/or negative features
• 2. Fully reversible sensory symptoms including
  positive and/or negative features
• 3. Fully reversible dysphasic speech
  disturbance
• D. At least one 1st or 2nd degree relative
  fulfils these criteria

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Risk Factors/Suspected Causes of Frequent
Headache

• Frequency of migraines(gt4/mo)
• Overuse of medications, esp. analgesics /-
  caffeine
• Depression
• Stress or traumatic life events
• Personality traits (e.g., neuroticism, type A)
• Hypertension
• Dietary triggers (caffeine)
• Obesity
• Low education/socioeconomic status
• Head injury
• Snoring

• Adapted with permission from Walter Stewart, MD,
  MPH. Scher AI, et al. Pain. 200310681-89.

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Chronic Daily Headache
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4.8 New daily-persistent headache

• Description Headache that is daily and
  unremitting from very soon after onset (within 3
  days at most). The pain is typically bilateral,
  pressing or tightening in quality and of mild to
  moderate intensity. There may be photophobia,
  phonophobia, or mild nausea.
• Diagnostic criteria
• A. Headache for gt 3 months fulfilling criteria
  B-D
• B. Headache is daily and unremitting from
  onset or from lt 3 days from onset¹

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Treatment of Pediatric Headaches
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Acute Treatment

• Analgesics
• NSAIDs
• Triptans (5-HT agonists)
• Antiemetics
• Opiates

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Preventive Treatment

• Anticonvulsants
• Antidepressants
• Beta blockers
• Calcium channel blockers
• Serotonin agents

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Pediatric Headache Issues

• Diagnosis ICHD-II a step in the right direction
  for the Pediatric Population
• Improve Diagnostic tools
• Expanded Treatment Options
• Continue Research
• - Prospective diary studies/Longitudina
  l studies
• - Acute and Preventative
  Clinical trials
•