Slide1: MIGRAINE IN PRIMARY CARE ADVISORS Edinburgh, 12 June 2003 1.30-5.30 pm Managing children and adolescents with migraine and other headaches


Programme: Programme Initial thoughts on key areas Epidemiology of headache in children and adolescents Burden of illness: effects on education and family and social life Impact of migraine on adolescents’ lives Presenting symptoms and diagnosis Case histories Management options for the GP Principles of care


Objectives: Objectives Promote the understanding of headache in children and adolescents Production of evidence-based guidelines for the management of headache in young people


Outputs: Outputs Academic article MIPCA newsletter for GP Slide set for educational use


Epidemiology of headache in children and adolescents: Epidemiology of headache in children and adolescents


Slide6: Patient presenting with headache Migraine/CDH low High Q1. What is the impact of the headache on the sufferer’s daily life? ETTH (50%) Q2. How many days of headache does the patient have every month? > 15  15 CDH (2-4%) Q3. For patients with chronic daily headache, on how may days per week does the patient take analgesic medications? <2 2 No medication overuse Medication overuse Migraine (15%) Q4. For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks? With aura Without aura Yes No Exclude sinister Headache (<0.1%) Consider short-lasting Headaches (<0.1%) Dowson AJ et al. Curr Med Res Opin 2002;18:414-39


Age- and gender- specific prevalence of migraine: Stewart WF et al. JAMA 1992;267:64-9. Age- and gender- specific prevalence of migraine


Headaches experienced by children - 1: Headaches experienced by children - 1 50-75% of 12-17 year-olds experience ≥1 headache per month May lead to heightened parental concern About 15% of children will experience migraine or CDH before the age of 15 Migraine Tension-type headache (TTH) Chronic daily headache (CDH) e.g. following head or neck injury in, e.g. a car crash Short, sharp headaches and cluster headache tend not to be reported Dowson AJ. Migraine: your questions answered, 2003


Headaches experienced by children - 2: Headaches experienced by children - 2 Secondary headaches Acute sinusitis or other infections / fever Eyestrain Sinister headache due to meningitis Consumption of alcohol or recreational drugs Tumour Dowson AJ. Migraine: your questions answered, 2003


Migraine without aura: Age at onset (incidence): Migraine without aura: Age at onset (incidence) Incidence per 1000 Person-Years Age at Onset Stewart WF et al. Am J Epidemiol 1991;134:1111-20. Female Male 30 25 20 15 10 5 


Incidence of migraine in children: Incidence of migraine in children Age of maximal incidence Migraine without aura (majority) Boys – 10-11 y Girls – 14-17 y Migraine with aura (minority) Boys – 5-6 y Girls – 12-13 y Stewart WF et al. Am J Epidemiol 1991;134:1111-20.


Age- and gender- specific prevalence of migraine: Stewart WF et al. JAMA 1992;267:64-9. Age- and gender- specific prevalence of migraine


Prevalence of migraine and other headaches in schoolchildren: Prevalence of migraine and other headaches in schoolchildren Epidemiological study in Aberdeen schoolchildren aged 5-15 y (n = 2,165) Prevalence of migraine = 10.6% M+A = 2.8% M-A = 7.8% TTH = 0.9% Non-specific recurrent headaches = 1.3% Prevalence increased with age Male preponderance <12 y Female preponderance ≥12 y Abu-Arefeh I, Russell G. BMJ 1994;309:765-9.


Paediatric migraine classification: What’s new?: Paediatric migraine classification: What’s new? 1.1 Migraine without aura In children below age 15, attacks may last 1-48 hours (4-72 hours for adults) 1.5 Childhood Periodic Syndromes 1.5.1 Benign paroxysmal vertigo 1.5.2 Cyclical vomiting 1.5.3 Abdominal migraine Appendix 1.5.4  Alternating hemiplegia of childhood   1.5.5  Benign paroxysmal torticollis International Headache Society Diagnostic Criteria (currently being updated)


Prevalence of CDH in children: Prevalence of CDH in children Little data on prevalence, but well recognised in clinical practice Adult prevalence about 4%: lower in children (1-2%) Medication overuse headache also reported About 1% in adults Dowson AJ et al. CNS Drugs 2003; in press.


MOH in children - 1: MOH in children - 1 Caffeine in cola drinks 36 children reported in a hospital tertiary care headache clinic over 5 y Mean age 9.2 y (6-18) Mean intake 11 (range 10.5-21) L cola drinks/week (1,414.5 mg caffeine) Gradual withdrawal from cola drinks led to resolution in 33 patients Three patients reverted to episodic migraine without aura Hering-Hanit, Gadoth N. Cephalalgia 2003;23:332-5..


MOH in children - 2: MOH in children - 2 12 children (aged 6-16.5 y) History of analgesic headache (3 mo to 10 y) Paracetamol (5 children) Paracetamol + codeine (6 children) Ibuprofen (1 child) Abrupt withdrawal of analgesics was effective in all but one child Symon DN. Arch Dis Child 1998;78:555-6.


MOH in adolescents: MOH in adolescents Candidate drugs Codeine Temazepam Alcohol Glue sniffing Ecstasy See in clinical practice


Headache features and burden: Headache features and burden


How childhood migraine may differ from adult migraine - 1: How childhood migraine may differ from adult migraine - 1 Attacks last 1-4 hours Frontal headache Associated nausea, vomiting and abdominal pain Associated photophobia and phonophobia Prodromes and trigger factors common Aura infrequent Most sufferers have a family history: 70% Education can be targeted through the family Dowson AJ. Migraine: your questions answered, 2003


How childhood migraine may differ from adult migraine - 2: How childhood migraine may differ from adult migraine - 2 ‘Atypical’ symptoms / migraine equivalents Sudden, brief episodes of paroxysmal vertigo Loss of balance and inability to walk Starts 2-6 y, but reported in all age groups Cyclical vomiting Every 1-2 mo, lasting about 1 day Often precipitated by travel Gastrointestinal symptoms (abdominal migraine) Paroxysmal abdominal pain without headache Older pre-adolescent children Dowson AJ. Migraine: your questions answered, 2003


How childhood migraine may differ from adult migraine - 3: How childhood migraine may differ from adult migraine - 3 ‘Atypical’ symptoms / migraine equivalents Short-lasting recurrent limb pain not due to injury Associated features of childhood migraine: Travel sickness Sleep disturbances Fearful and prone to frustration Below average strength Emotionally rigid Repressed anger and aggression Dowson AJ. Migraine: your questions answered, 2003


Paroxysmal vertigo: Paroxysmal vertigo Epidemiological study in Aberdeen schoolchildren aged 5-15 y (n = 2,165) Defined as three attacks of dizziness in 1-y period Prevalence = 2.6% Age of onset peaked at 12 y, but seen in all ages Accompanied by symptoms common in migraine Pallor, nausea, photophobia, phonophobia Family history of migraine 2X that of controls Russell G, Abu-Arefeh I. Int J Pediatr Otorhinolaryngol 1999;49 (Suppl 1):S105-7.


Cyclical vomiting: Cyclical vomiting Epidemiological study in Aberdeen schoolchildren aged 5-15 y (n = 2,165) Defined as history of unexplained vomiting Prevalence = 1.9% Age of onset 5.3 y; mean age 9.6 y Sex ratio 1:1 Mean 8 attacks/y; mean duration 20 h Travel frequent precipitator Accompanied by symptoms common in migraine Trigger factors, associated GI, sensory and vasomotor symptoms, and relieving factors Abu-Arefeh I, Russell G. J Pediatr Gastoenterol Nutr 1995;21:454-8.


Cyclical vomiting: Prognosis: Cyclical vomiting: Prognosis Medium term prognosis for 26 sufferers identified from clinical records 50% had continuing cyclical vomiting and/or migraine headaches 50% were currently asymptomatic Prevalence of past or present migraine headaches: 46% for patients with cyclical vomiting 12% for matched controls Dignan F et al. Arch Dis Child 2001;84:55-7.


Abdominal migraine: Abdominal migraine Epidemiological study in Aberdeen schoolchildren aged 5-15 y (n = 2,165) Defined as history of severe headache and/or severe abdominal pain Prevalence = 10.6% (migraine) and 4.1% (abdominal migraine) Accompanied by features typical of migraine Trigger and relieving factors, demographic and social characteristics Abu-Arefeh I, Russell G. Arch Dis Child 1995;72:413-7.


Abdominal migraine: Prognosis: Abdominal migraine: Prognosis 7-10 year prognosis in 54 patients with abdominal migraine Abdominal migraine resolved in 61% 70% of cases had history of migraine 52% current 12% previous In matched controls, only 20% had current or previous history of migraine Data support concept of abdominal migraine as a migraine precursor Dignan F et al. Arch Dis Child 2001;84:415-8.


Recurrent limb pain: Recurrent limb pain Epidemiological study in Aberdeen schoolchildren aged 5-15 y (n = 2,165) Prevalence of recurrent limb pain = 2.6% Accompanied by features typical of migraine Trigger and relieving factors and associated symptoms Abu-Arefeh I, Russell G. Arch Dis Child 1996;74:336-9.


Overview of prevalence data: Overview of prevalence data Summary of data from Aberdeen studies


Consequences of ‘atypical’ symptoms: Consequences of ‘atypical’ symptoms Symptoms are frequently misunderstood Blamed on stress or malingering True cause (migraine) often missed by parents and GPs ‘Adult’ type symptoms develop as the child moves into adolescence Dowson AJ. Migraine: your questions answered, 2003


Personality traits of children with headache: Personality traits of children with headache 57 children with M+A, M-A and TTH Children exhibited Emotional rigidity Tendency to repress anger and aggression No link to: Sociodemographic factors Duration of headache Characteristic of migraine patients Lanzi G et al. Cephalalgia 2001;21:53-60.


Emotional and behavioural problems: Emotional and behavioural problems Psychiatric co-morbidity in children with primary headaches aged 6-18 y (migraine and TTH): Depression Anxiety Somatisation 33% of children required psychiatric therapy for these conditions Just U et al. Cephalalgia 2003;23:206-13.


Adolescent migraine patients: GSK database (n = 1,932; 12-17 y): Adolescent migraine patients: GSK database (n = 1,932; 12-17 y) Day of week of migraine onset Sun Mon Wed Fri 13% 20% 16% 16% 13% 13% 9% 0 20 40 60 80 100 Percent of Subjects (%) Tues Thur Sat Winner P et al. Headache 2003;43:451-7. Day of migraine onset


Adolescent migraine patients: GSK database (n = 1,932; 12-17 y): Adolescent migraine patients: GSK database (n = 1,932; 12-17 y) 3% 18% 16% 18% 21% 23% 0 20 40 60 80 100 Percent of Subjects (%) Before 6:00 6:00- 9:00 9:00- 12:00 12:00- 15:00 15:00- 18:00 After 18:00 Time of day of migraine onset Winner P et al. Headache 2003;43:451-7. Time of migraine onset


Adolescent migraine patients: GSK database (n = 1,932; 12-17 y): Adolescent migraine patients: GSK database (n = 1,932; 12-17 y) 88% 80% 74% 60% 58% 22% 5% 0 20 40 60 80 100 Percent of Subjects (%) Pain aggravated by activity Light / Sound sensitivity Pulsating pain Nausea Unilateral pain Aura Vomiting Winner P et al. Headache 2003;43:451-7. Summary of migraine symptoms


Impact on children: Impact on children Significant impairment of well-being and functional ability Play behaviour affected -1 to +1 days of attack Hamalainen M et al. IJCP 2002;56:704-9.


Slide37: Impact Time Migraine phases Prodrome Aura Headache Resolution / recovery


Impact on children: Impact on children Significant impairment of well-being and functional ability Play behaviour affected -1 to +1 days of attack QOL and coping ability impaired Impact from headache frequency and duration No impact from headache severity Ability to function during attacks School – 39.5% of normal Home – 33.7% of normal Ability to function between attacks  somatic complaints, stress and psychological symptoms compared to controls Potential for long-term sequelae Hamalainen M et al. IJCP 2002;56:704-9. Frare M et al. Headache 2002;42:953-62.


Impact on education: Impact on education Total days per year of school missed – Children with migraine 7.8*** – Controls 3.7 Days per year lost due to migraine – Children with migraine 2.8 – Controls 0 Excess of school absences in children with migraine due to: Co-morbidities Other headaches Prodromes and postdromes Abu-Arefeh I, Russell G. BMJ 1994;309:765–9. *** p<0.0001


Paediatric Migraine Disability Questionnaire: Paediatric Migraine Disability Questionnaire How many days in the last 3 months did you miss school or work because of your headache? How many days in the last three months was your productivity at school or work reduced by half or more because of your headaches? For example, completing schoolwork, homework or job related activities. How many days in the last three months did you not do your chores or after school activities because of your headaches? For example, unable to clean the house / yard, work on the computer, watch TV or listen to the stereo. How many days in the last 3 months was your productivity in chores or after school activities reduced by half or more because of your headaches? For example, difficulty cleaning the house / yard, working on the computer, watching TV or listening to the stereo. How many days in the last 3 months did you miss family, social or leisure activities because of your headaches? For example, parties, sports or attending social or school clubs like band or boy scouts / girl scouts.


The MIDAS Questionnaire: The MIDAS Questionnaire


Definition of grades: Definition of grades Four MIDAS grades were defined: Grade I (score 0–5): ‘not urgent’ and limitations to activities are ‘minimal or infrequent’ Grade II (score 6–10): treatment need and limitations to activities are ‘mild’ Grade III (score 11–20): treatment need and limitations to activities are ‘moderate’ Grade IV (score 21+): treatment need and limitations to activities are ‘severe’ Generate easy-to-remember scores


Paediatric Migraine Disability Assessment: Paediatric Migraine Disability Assessment Percent of Subjects (%)


Natural history of childhood headaches: Natural history of childhood headaches 32 patients with migraine without aura investigated over a 5-y period M-A persisted in 56.2% Converted to migrainous disorder or unclassifiable headache in 9.4% Converted to ETTH in 12.5% Resolved in 18.8% Camarda R et al. Headache 2002;42:1000-5.


Does migraine interfere with adolescent studying and examination? : Does migraine interfere with adolescent studying and examination? Dr Sue Lipscombe Dr John Millar


Introduction: Introduction Adolescence is a time of bodily and mental change Pressures from peers, teachers and parents are at their zenith Hormonal changes may herald first migraine attack Studies and examinations are critical at this age.


Objectives: Objectives To analyse frequency and impact of migraine on adolescents To see if students recognised their condition To see if they knew help was available To assess the effect of their migraine To educate pupils and staff


Methods: Methods Comprehensive talks to students from five schools, two in Brighton and three in Northern Ireland Staff, pupils and parents were invited to all evening meetings Questionnaires were distributed and collected immediately after talks


Results: Results 633 students returned questionnaires Age range 13 to 18+ 43% of students said they had suffered one or more attacks of migraine


Results: Results 14% said they currently suffered regular migraine attacks Of these nearly all had a family member who also suffered


Students who have ever had migraine: Students who have ever had migraine


Students could distinguish migraine from other headaches: Students could distinguish migraine from other headaches In any of the age groups only 26% said they’d never had a headache


Relationship between those that have migraines and their families: Relationship between those that have migraines and their families


Students differentiating headache type: Students differentiating headache type 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% yes no currently have migraine


Students differentiating headache type: Students differentiating headache type


Importance of schoolwork: Importance of schoolwork The older the child the more important schoolwork seemed to be an important pressure This did not correlate with any increase in children with migraine; i.e. pressure alone didn’t seem to cause migraine


Does schoolwork pressure cause attacks?: Does schoolwork pressure cause attacks?


In students with migraine: In students with migraine 40% of attacks appeared to be tied directly to pressure from schoolwork.


Impact: Impact Amongst the migraineurs two thirds felt that their migraines significantly interfered with their ability to study and undergo examinations


Impact of migraine interfering with studies: Impact of migraine interfering with studies


Impact: Impact In the older age group, where schoolwork was an important pressure, 86% felt their attacks got better in the holidays


Impact of migraine: Impact of migraine


Migraine occurrence: Migraine occurrence


Treatment: Treatment In spite of the obvious impingement of migraine on their lives, less than half of all students had seen any sort of medical professional. They were therefore unlikely to be receiving optimal care Need for early treatment The school nurse may play an important role in the education of children and their parents about headache


Sought professional advice: Sought professional advice


Conclusions: Conclusions Students and parents need educating about migraine After can recognise and seek help Migraine is common in this age group: 14% After education students can identify migraine from other headaches The impact of migraine in this age group is large


Migraine treatments for children: Migraine treatments for children Acute medications


Analgesic-based therapies: Analgesic-based therapies Paracetamol Aspirin NSAIDs Effective in about 50% of patients for mild-moderate pain Anti-emetics may also be helpful Pain is less of a problem when nausea/vomiting eliminated Farkas V. Cephalalgia 1999;19 (Suppl);24-6. Lewis DW. Am Fam Physician 2002;65:625-32.


Acute migraine treatment (ibuprofen or paracetamol): Acute migraine treatment (ibuprofen or paracetamol) Double blind, randomised, placebo-controlled, crossover study Children (n = 88); ages 4.0 to 15.8 y Ibuprofen Paracetamol Placebo Ibuprofen and paracetamol found to be 3 and 2 X more effective than placebo, respectively Ibuprofen 2 X more likely than paracetamol to abort migraine within 2 h Hamalainen ML et al. Neurology 1997;48:103-7


Oral triptans: Oral triptans


Sumatriptan 25, 50 and 100 mg (302 adolescent patients): Sumatriptan 25, 50 and 100 mg (302 adolescent patients) *p<0.05 versus placebo (50) * Headache severity (mild or no pain) 0-240 minutes post first dose Linder SL, Winner P. Med Clin North Am 2001;85:1037-53.


Rizatriptan 5 mg in adolescent migraineurs: Rizatriptan 5 mg in adolescent migraineurs 0 10 20 30 40 50 60 70 Riza 5 mg Placebo Riza 5 mg Placebo NS66 56 NS32 28 Patients (%) 2-h headache relief 2-h pain-free n = 296 Winner P et al. Headache 2002;42:49-55


Pain relief at 2 hours in adolescents:Weekdays versus weekends: Pain relief at 2 hours in adolescents: Weekdays versus weekends * p<0.05 vs. placebo 61 (n=114) 66 (n=118) 36 (n=28) 65* (n=31) 0 20 40 60 80 % of Patients Weekdays Weekends Placebo Rizatriptan 5 mg Winner P et al. Headache 2002;42:49-55


Adverse events prior to second dose in adolescents: Adverse events prior to second dose in adolescents % Patients Rizatriptan 5 mg (n=149) Placebo (n=147) Any adverse event 34% 35% Any drug - related event 22% 24% Common adverse events ( ³ 3%) Asthenia/fatigue 3% 2% Dizziness 5% 5% Dry mouth 5% 3% Nausea 3% * 8% Somnolence 3% * 8% * p<0.05 versus placebo Winner P et al. Headache 2002;42:49-55


Zolmitriptan for adolescent migraine: Demographics: Zolmitriptan for adolescent migraine: Demographics 49,784 migraine attacks treated TOTAL 350 migraine attacks treated in adolescents 38 adolescents patients recruited Average age: 14.3 ± 1.7 y 52.6% females Age at onset: 9 ± 3 y Average attacks per month: 4 ± 2 Mean hours missed from school/work due to typical migraine attack: 6 ± 9 hours Linder SL et al., Presented at the 51st Annual Meeting of the AAN, April 1999


Headache response and pain-free rates: 2.5 and 5 mg zolmitriptan: Headache response and pain-free rates: 2.5 and 5 mg zolmitriptan 70 52 88 75 79 59 85 69 0 20 40 60 80 100 Adolescents Adults 2-H HR* 5 mg 2-H PF# 5mg 2-H HR* 2.5mg 2-H PF# 2.5mg N=120 N=20835 N=120 N=13898 *Moderate or severe attacks # All attacks % of attacks treated Linder SL et al., 51st Annual Meeting of the AAN, April 1999


Nasal spray sumatriptan: Nasal spray sumatriptan


Controlled studies in adolescents: Controlled studies in adolescents Two placebo-controlled studies 782 patients aged 12-17 y Study 1: Sumatriptan nasal spray (5mg, 10mg, 20mg) and placebo nasal spray 510 patients treated one attack USA Study 2: crossover study with sumatriptan 10 or 20 mg and placebo 8-17 y Finland


Study 1: Headache relief 1 h and 2 h postdose: Study 1: Headache relief 1 h and 2 h postdose 0% 20% 40% 60% 80% 100% 41% 53% 47% * 66% 64% * 56% † 63% * 56% Placebo n=130 5 mg n=127 10 mg n=133 20 mg n=117 * p0.05 vs. placebo † p=0.059 vs. placebo Sumatriptan nasal spray 1 h 2 h Winner P et al. Pediatrics 2000;106:989-997 1 h 1 h 1 h 2 h 2 h 2 h % of patients


Headache free (severity score 0) 0-2 hours after first dose: Headache free (severity score 0) 0-2 hours after first dose 1p<0.05, 20mg versus placebo 1 0 20 40 60 0 30 60 90 120 Time after administration (minutes) % of Patients Sumatriptan 20mg Sumatriptan 10mg Sumatriptan 5mg Placebo Winner P et al. Pediatrics 2000;106:989-997


Most common adverse events*: Total 18% 35% 38% 40% Disturbance of taste 2% 19% 30% 26% Nausea 8% 9% 5% 11% Vomiting 2% 5% 3% 5% Triptan sensations† 2% 3% in any group †Temperature (warmth), burning/stinging sensations, or paresthesia Winner P et al. Pediatrics 2000;106:989-997


Study 2: Headache relief at1 and 2 h: 0% 10% 20% 30% 40% 50% 60% 70% Sumatriptan 10 mg Sumatriptan 20 mg Both Placebo Active 1h Active 2h Study 2: Headache relief at 1 and 2 h * p < 0.05 vs. placebo ** p < 0.001 vs. placebo % of patients


Controlled study in pre-adolescents: Controlled study in pre-adolescents 7-12 years old with migraine resistant to OTCs Randomised, double-blind, crossover trial in one German centre Two attacks treated: 1 with sumatriptan 10 mg 1 with placebo


Headache relief at 2 h: Headache relief at 2 h * p=0.022 * % of patients 64% 41% 0 10 20 30 40 50 60 70 Placebo Sumatriptan 10mg


Long-term safety and tolerability study in adolescent migraineurs: Long-term safety and tolerability study in adolescent migraineurs


Headache relief at 2 h post dose: Headache relief at 2 h post dose n=1938 n=1261 Statistical comparisons were not made per protocol. 76% 72% 0 20 40 60 80 100 Percent of Attacks (%) 10 mg 20 mg Sumatriptan nasal spray (mg/dose)


Consistency of responseHeadache relief rates 2 h post dose, by dose/attack number: Consistency of response Headache relief rates 2 h post dose, by dose/attack number 10mg 20mg Data presented for those attacks treated by ³ 10 subjects 0 20 40 60 80 100 1 3 5 7 9 11 13 15 17 19 21 23 25 27 Attack number Percent of Patients (%)


Overall incidence of AEs including and excluding taste disturbance (by attack)a: a Incidences for attacks treated with one or two doses of study medication Overall incidence of AEs including and excluding taste disturbance (by attack)a 39% 15% 37% 15% 0 20 40 60 80 100 Percent of Attacks (%) 10 mg 20 mg Sumatriptan nasal spray (mg/dose) Including taste disturbance Excluding taste disturbance


Perspective on the triptans: Perspective on the triptans Oral triptans struggle to show significant benefit over placebo High placebo response Too slow onset of action for attacks that are relatively rapid to resolve? Nasal spray triptans show significant benefit for adolescent and pre-adolescent migraineurs Faster onset of action Greater overall effect Need for studies with nasal spray zolmitriptan


Placebo response and NNT: Placebo response and NNT NNT varies with the placebo response Problematic in areas where a variable placebo rate is likely, e.g. migraine


Migraine treatments for children: Migraine treatments for children Prophylactic medications


Preventative treatment: Preventative treatment Propranolol (Inderal): Cyproheptadine (Periactin): Nortriptyline (Pamelor): Divalproex sodium (Depakote): 1-2 mg/kg 10 mg bid 0.2-0.4 mg/kg 4 mg HS 0.5 mg/kg 10 mg HS 10 mg/kg bid Initial dosage


Divalproex sodium : Divalproex sodium Migraine: n = 42 Age: 7 to 16 y Dosage range: 15 – 45 mg/kg/day After 4 months: 50% HA reduction - 78.5% 75% HA reduction - 14% 100% HA reduction - 9.5% Well-tolerated - AE’s: GI upset, weight gain, somnolence, dizziness, tremor Caruso J, Brown W, Headache 2000;40:672-676


Non-pharmacological treatments: Non-pharmacological treatments Non-pharmacological treatments Education Biofeedback effective1 Relaxation effective1,2 Stress management effective2 Sleep Eliminate triggers Exercise Magnesium prophylaxis may show promise2 1.Hermann C et al. Pain 1995;60:239-56. 2. McGrath PJ et al. Pain 1992;49:321-4. 3. Wang F et al. Headache 2003;43:601-10.


Evidence-based evaluation of migraine medications: Evidence-based evaluation of migraine medications Duke database Grade A: evidence from multiple controlled clinical trials Grade B: some evidence from clinical studies Grade C: no objective evidence Most evidence on acute and prophylactic medications for paediatric migraine is Grade B/C No definitive advice possible Matchar DB et al. Neurology 2000;54. Ramadan NM et al. Neurology 2000;54.


Management of children with headache: Management of children with headache


Slide97: Follow the MIPCA guidelines for migraine: Screening, provision of information and patient and parent buy-in Differential diagnosis (key feature) Tailoring of care to the individual patient Proactive follow-up Primary care headache team Basic principles Dowson AJ et al. Curr Med Res Opin 2002;18:414-39


Investigations : Investigations Practice parameter for children and adolescents with recurrent headaches EEG not routinely recommended Neuro-imaging not indicated for patients with normal neurological exam Use for those with: Abnormal neurological exam Physical findings that suggest CNS disease Lewis DW et al. Neurology 2002;59:490-8.


Investigations : Investigations Practice parameter for children and adolescents with recurrent headaches Prediction of space-occupying lesions: Headache <1 mo duration No family history of migraine Abnormal neurological exam Gait abnormalities Seizures Lewis DW et al. Neurology 2002;59:490-8.


Slide100: Patient presenting with headache Migraine/CDH low High Q1. What is the impact of the headache on the sufferer’s daily life? ETTH (>50%) Q2. How many days of headache does the patient have every month? > 15  15 CDH (1-2%) Q3. For patients with chronic daily headache, on how may days per week does the patient take analgesic medications? <2 2 No medication overuse Medication overuse Migraine (10-12%) Q4. For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks? With aura Without aura Yes No Exclude sinister Headache (<0.1%) Consider short-lasting Headaches (<0.1%) Dowson AJ et al. Curr Med Res Opin 2002;18:414-39


Slide101: Look for: Family history Paroxysmal vertigo Cyclical vomiting Paroxysmal abdominal pain Recurrent episodes of limb pain Nausea, photophobia and phonophobia may be absent Age of onset may be younger in boys than in girls Diagnosis of migraine in pre-adolescent children Younger children Older children


Slide102: Look for: Family history Frontal headache Relatively short-lasting headache Nausea, photophobia and phonophobia usually present Typically, the patient goes to bed due to photophobia and phonophobia, sleeps and wakes up several hours later with the attack resolved In girls, initial attacks may be associated with the menarche Diagnosis of migraine in adolescent children


Slide103: Behavioural therapy recommended for all Minimise trigger factors Regular lifestyle and meals Acute therapy recommended for all Paracetamol (± anti-emetics) and ibuprofen first-line Introduce aspirin when >16 years Nasal spray triptan second-line Avoid prophylaxis if possible Refer if thought necessary Management individualised for each patient


Slide104: Migraleve (buclizine / paracetamol / codeine) 10-14 y: half adult dose Paramax (paracetamol / metoclopramide) 12-19 y: half adult dose Voltarol Rapid (NSAID) Over 14 y: ≥50% of adult dose Other acute medications (including triptans) not recommended Sumatriptan nasal spray likely to be launched in 2003 Restrictions on antimigraine drugs in the UK


Follow-up procedures: Follow-up procedures Instigate proactive long-term follow-up procedures Monitor the outcome of therapy Headache diaries Impact questionnaires (MIDAS/HIT) Make appropriate treatment decisions


Slide106: Detailed history, patient education and buy-in Diagnostic screening and differential diagnosis Assess illness severity Attack frequency and duration Pain severity Impact (MIDAS or HIT questionnaires) Non-headache symptoms Patient history and preferences Intermittent mild-to-moderate migraine (+/- aura) Intermittent moderate-to severe migraine (+/- aura) Paracetamol Aspirin/NSAID Paracetamol plus anti-emetic Paracetamol Aspirin/NSAID Paracetamol plus anti-emetic Nasal spray / oral triptan Nasal spray / oral triptan Initial consultation Initial treatment Rescue Rescue Behavioural/complementary therapies Copyright MIPCA 2003, all rights reserved


Slide107: Paracetamol Aspirin/NSAID Paracetamol plus anti-emetic Nasal spray / oral triptan Initial treatment Follow-up treatment Nasal spray / oral triptan If unsuccessful Frequent headache (i.e. 4 attacks per month) Consider referral Chronic daily Headache (CDH)? Migraine Initial treatment Copyright MIPCA 2003, all rights reserved


Implementation of guidelines: Implementation of guidelines Primary care headache team GP, practice nurse, ancillary staff and sometimes pharmacist (core team) Pharmacist School nurses / staff Optician Dentist Specialist physician (additional resource) Associate team members


Slide109: Pharmacist Teachers School nurse School staff Optician Dentist Patient/Parent/Peer Primary care physician Practice nurse Physician with expertise in headache: GP; PCT; specialist Nurse practitioner Ancillary staff Primary care Specialist care Associate team Core team Copyright MIPCA 2003, all rights reserved