Transcript NEW TRENDS IN HEADACHE AND MIGRAINE TREATMENT

Kathie Teta, RN, CPNP
PANDA Neurology
Atlanta, Georgia
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1. Define concepts of a migraine headache
and migraine variants from other headache
types in the pediatric/adolescent population
2. Discuss pathophysiology of migraine
headaches
3. Discuss indications for diagnostic testing
for migraines
4. Identify appropriate treatment strategies
for acute migraine management
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5. List types of preventive versus abortive
treatments for headaches and migraines
6. Discuss when referrals to pediatric
neurology are needed for further evaluation
and management
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Moderate to severe pain:
◦ Unilateral/bilateral
◦ Throbbing/squeezing
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2 of 3 cardinal features:
◦ Photophobia
◦ Inability to function
◦ Nausea/vomiting
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Exertional worsening
Sound sensitivity
Duration of 4 to 72 hours
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Similar to migraines without aura
20 – 30 % migraneurs have aura (99% of these
have visual auras)
Warning symptoms may include:
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Visual disturbances
Numbness in arm or leg
Difficulty speaking
Warning symptoms last 5 – 6 minutes and typically
are followed by headache pain
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Headaches occurring on or > 15 days per
month
Current or prior diagnosis of migraine
Lasting on average > 4 hours per day
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Obesity
Lowered social economic status
Stressful events
Snoring
Overuse of caffeine
Depression
Anxiety
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Use of over-the-counter medications more
than 1 – 2 times per week
Overuse of abortive prescription medications
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Abdominal migraines
◦ Diffuse abdominal pain, sometimes associated with
headache
◦ Can last 1 – 72 hours
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Benign paroxysmal vertigo
◦ Usually occurs in toddlers and young children
◦ Appear off balance, may refuse to walk
◦ Can last minutes to hours
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Cyclic vomiting
◦ Occurs in school-age children
◦ Forceful, frequent vomiting lasting 1 hour to 5 days
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4 -5% of young children
5 – 6% in preadolescents
Increases in adolescence
18% women, 6% men as adults
Migraine Prevalence (%)
AGE- AND GENDER-SPECIFIC
PREVALENCE OF MIGRAINE
Lipton RB, Stewart WF. Neurology. 1993.
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Strong family history of migraines
 Foods:
◦ MSG, peanuts, chocolate, caffeine, cheese,
nitrites
 Chronobiology: sleep disturbance
 Environmental: weather changes
 Stress: school, family changes,
moving
 Physical: sports activities, heat
 Letdown: weekends, vacation, end
of projects
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Sinus infection
◦ Nasal congestion
◦ Nasal drainage
◦ Pain over frontal or maxillary sinuses
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Dull, aching, nonthrobbing
Not associated with vomiting
Pain or discomfort in the head, scalp, or neck,
usually associated with muscle tightness in
these areas
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Brain lesion
Subarachnoid hemorrhage
Meningoencephalitis
Acute hydrocephalus
Chiari I malformation
Pseudotumor Cerebri
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Imaging studies
◦ CT vs MRI
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If new onset severe headache
Hard to treat or progressive headaches
AM headaches/AM vomiting
Focal features on examination
Poor family history
Blood tests
◦ R/O causes for fatigue, possible infection, thyroid
abnormalities
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Lumbar puncture
◦ If concerns with papilledema
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Lifestyle modifications
◦ Diet
 Increase water
 Decrease caffeine
 Decrease nitrates
◦ Sleep
◦ Dealing with stress
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Decrease use of over-the-counter
medications
Phamacologic therapy
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Functional response (ability to return to
normal activities)
Consistent and quick onset
Prevent headache recurrence
Well tolerated
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Cranial vasoconstriction
Peripheral neuronal inhibition
Modulates activity in neuroreceptors at
multiple sites along trigeminal pathway
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Nonspecific: (for
mild/moderate pain)
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NSAIDs
Combination analgesics
Opioids
Neuroleptics/antiemetics
corticosteroids
Specific (for severe pain)
◦ Triptans
◦ Ergotamine (DHE)
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Oral therapies: most
medications
Nasal sprays: sumatriptan,
zolmitriptan, DHE
Injectable: (SQ, IM, IV)
sumatriptan, DHE,
injectable NSAIDs, opioids,
neuroleptics
Suppositories: antiemetics,
ergots, opioids
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Imitrex (sumatriptan) and Maxalt (rizatriptan)
– usually tier 1 on insurance formularies
Use at early onset migraine
May repeat 1X in 2 hours if needed
Maximum 2 doses in 24 hours
Should be used no more than 2 times per
week
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Decrease attack frequency (by 50%) duration
and intensity
Improve responsiveness to acute treatment
Improve function and decrease disability
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Migraine significantly interferes with patient’s
daily routine, despite acute Rx
Acute medications contraindicated,
ineffective, intolerable AEs or overused
Frequent headache (>1 - 2 attacks per week)
Uncommon migraine conditions
Patient preference
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Anticonvulsants
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Valproate
Gabapentin
Topiramate
Zonegran
Neurontin
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Antidepressants
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ß-adrenergic
blockers
◦ TCAs
◦ SSRIs
◦ MAOIs
◦ Propranolol
 Calcium channel
antagonists
– Verapamil
 Others
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NSAIDs
Riboflavin
Magnesium
Petadolex
Feverfew
Condition
Asthma
Depression
Athlete
Avoid
b-Blocker
Epilepsy
Arrhythmia
Bipolar
Tricyclic Antidepressant
TCA
Peptic Ulcer Disease
NSAIDs
Peripheral Vascular Disease
Ergots/Triptans
Adapted from Silberstein S. Headache in Clinical Practice. 2002:93.
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First line preventive treatment
◦ Corticosteroids – for daily headaches that have
been occurring for several weeks
◦ Topamax (topiramate) - consider weight/eating
habits
◦ Amitriptyline – consider mood, sleep difficulties
◦ Cyproheptadine – consider for young children
◦ Calcium channel blockers/beta blockers – consider
if mildly hypertensive
Behavioral Treatments
Relaxation training*
Hypnotherapy
Thermal biofeedback training*
Physical Treatments
Acupuncture
Electromyographic
biofeedback therapy*
Transcutaneous
electrical nerve
stimulation (TENS)
Cognitive/behavioral
management therapy*
Occlusal adjustment
*Proven effective in clinical trials
Cervical manipulation
Adapted from US Headache Consortium Headache Guidelines. www.aan.neurology.org. 2000
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Botox injections
Nerve blocks
Trigger point injections
Nerve stimulator trials
Transcutaneous sumatriptan (battery
powered)
Livodex – inhaled DHE
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Refer children and adolescents with
headaches if:
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Poor response to acute treatment
Uncertainty of diagnosis
Unusual features
Co-morbidities
Need for preventive treatment
Concerns or alarming findings on examination