Transcript Slide 1

MIGRAINE IN PRIMARY CARE ADVISORS
Edinburgh, 12 June 2003
1.30-5.30 pm
Managing children and adolescents with
migraine and other headaches
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
• Promote the understanding of
headache in children and adolescents
• Production of evidence-based
guidelines for the management of
headache in young people
Outputs
• Academic article
• MIPCA newsletter for GP
• Slide set for educational use
Epidemiology of headache in
children and adolescents
Exclude sinister
Headache (<0.1%)
Patient presenting
with headache
Q1. What is the impact of the headache
on the sufferer’s daily life?
low
ETTH (50%)
High
Q2. How many days of headache
does the patient have every month?
Migraine/CDH
 15
> 15
Consider short-lasting
Headaches (<0.1%)
CDH (2-4%)
Q3. For patients with chronic daily
headache, on how may days per week
does the patient take analgesic medications?
<2
No medication
overuse
Migraine (15%)
Q4. For patients with migraine, does the
patient experience reversible sensory
symptoms associated with their attacks?
2
Medication
overuse
Yes
With aura
No
Without aura
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.
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
• 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
Incidence per 1000
Person-Years
Migraine without aura:
Age at onset (incidence)
30
 Female
Male
25
20

15
 


10



  

5

0
5
10
15
20
25
30
Age at Onset
Stewart WF et al. Am J Epidemiol 1991;134:1111-20.
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.
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?
• 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
• 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
• 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
• 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
• Candidate drugs
– Codeine
– Temazepam
– Alcohol
– Glue sniffing
– Ecstasy
• See in clinical practice
Headache features and burden
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
‘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
‘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
• 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
• 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
• 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
• 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
• 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
• 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
Presentation
Prevalence (%)
Migraine
10.6%
Paroxysmal vertigo
2.6%
Cyclical vomiting
1.9%
Abdominal migraine
4.1%
Recurrent limb pain
2.6%
Summary of data from Aberdeen studies
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
• 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
• 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)
100
Percent of Subjects (%)
Day of migraine onset
80
60
40
20%
20
0
13%
Sun
Mon
16%
Tues
16%
Wed
13%
Thur
13%
Fri
9%
Sat
Day of week of migraine onset
33
Winner P et al. Headache 2003;43:451-7.
Adolescent migraine patients: GSK
database (n = 1,932; 12-17 y)
Percent of Subjects (%)
100
Time of migraine onset
80
60
40
18%
20
16%
18%
21%
23%
3%
0
Before
6:00
6:009:00
9:0012:00
12:0015:00
15:0018:00
After
18:00
Time of day of migraine onset
34
Winner P et al. Headache 2003;43:451-7.
Adolescent migraine patients: GSK
database (n = 1,932; 12-17 y)
Summary of migraine
symptoms
Vomiting
5%
22%
Aura
58%
Unilateral pain
60%
Nausea
74%
Pulsating pain
80%
Light / Sound sensitivity
88%
Pain aggravated by activity
0
20
40
60
80
100
Percent of Subjects (%)
35
Winner P et al. Headache 2003;43:451-7.
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.
Migraine phases
Aura
Headache
Impact
Prodrome
Time
Resolution /
recovery
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
• Total days per year of school missed
–
–
Children with migraine
Controls
7.8***
3.7
• Days per year lost due to migraine
–
–
Children with migraine
Controls
2.8
0
• Excess of school absences in children with
migraine due to:
– Co-morbidities
– Other headaches
– Prodromes and postdromes
*** p<0.0001
Abu-Arefeh I, Russell G. BMJ 1994;309:765–9.
Paediatric Migraine Disability
Questionnaire
1.
How many days in the last 3 months did you miss school or work because of
your headache?
2.
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.
3.
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.
4.
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.
5.
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
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
Percent of Subjects (%)
60%
50%
40%
30%
20%
10%
0%
Little or
None
Mild
Moderate
Severe
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?
Dr Sue Lipscombe
Dr John Millar
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
• 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
• 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
• 633 students returned questionnaires
• Age range 13 to 18+
• 43% of students said they had suffered
one or more attacks of migraine
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
60%
50%
40%
30%
20%
10%
0%
No
Yes
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
18+
17
other family
migraineurs?
Ever had migraine
16
15
<15
0%
10%
20%
30%
40%
50%
Students differentiating headache
type
90%
80%
70%
60%
50%
40%
30%
20%
currently have migraine
10%
0%
yes
no
Students differentiating headache
type
80%
70%
60%
50%
Other types of
headache
40%
30%
20%
10%
0%
No
Yes
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?
60%
50%
40%
30%
20%
10%
0%
No
yes
In students with migraine
• 40% of attacks appeared to be tied
directly to pressure from schoolwork.
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
70%
60%
50%
40%
30%
20%
10%
0%
No
Yes
Impact
• In the older age group, where
schoolwork was an important pressure,
86% felt their attacks got better in the
holidays
Impact of migraine
70%
60%
50%
40%
migraines
interfering with
exams
30%
20%
10%
0%
No
Yes
Migraine occurrence
get better in
hols
during hols
after exams
0%
20%
40%
60%
80%
100%
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
60%
50%
40%
30%
Yes
20%
10%
0%
<15
15
16
17
18+
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
Acute medications
Analgesic-based therapies
•
•
•
•
Paracetamol
Aspirin
NSAIDs
Effective in about 50% of patients for mildmoderate 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)
• Double blind, randomised, placebocontrolled, 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
Sumatriptan 25, 50 and 100 mg (302
adolescent patients)
Headache severity (mild or no pain) 0-240 minutes post first dose
100%
Placebo
25mg
50mg
100mg
% of Patients
80%
(25, 50,100)
*
60%
(25, 50,100)
*
(50)
*
40%
20%
0%
0
60
120
180
240
Time (Minutes)
*p<0.05
versus placebo
Linder SL, Winner P. Med Clin North Am 2001;85:1037-53.
Rizatriptan 5 mg in adolescent
migraineurs
70
NS
66
Patients (%)
60
2-h headache
relief
56
2-h pain-free
50
NS
32
40
28
30
20
10
0
Riza 5 mg
n = 296
Placebo
Riza 5 mg
Placebo
Winner P et al. Headache 2002;42:49-55
Pain relief at 2 hours in adolescents:
Weekdays versus weekends
% of Patients
80
61
(n=114)
65*
(n=31)
66
(n=118)
60
36
(n=28)
40
Placebo
Rizatriptan 5 mg
20
0
Weekdays
* p<0.05 vs. placebo
Weekends
73
Winner P et al. Headache 2002;42:49-55
Adverse events prior to second dose
in adolescents
% Patients
Rizatriptan 5 mg
(n=149)
Any adverse event
Placebo
(n=147)
34%
35%
22%
24%
3%
2%
Dizziness
5%
5%
Dry mouth
5%
3%
3%*
8%
3%*
8%
Any drugrelated event
Common adverse events (  3%)
Asthenia/fatigue
Nausea
Somnolence
* p<0.05 versus placebo
74
Winner P et al. Headache 2002;42:49-55
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
100
80
% of attacks treated
88
85
79
75
70
69
59
60
52
2-H HR* 5 mg
2-H PF# 5mg
2-H HR* 2.5mg
2-H PF# 2.5mg
40
20
0
N=120 N=120
Adolescents
N=13898N=20835
Adults
*Moderate or severe attacks
# All attacks
Linder SL et al., 51st Annual Meeting of the AAN, April 1999
Nasal spray sumatriptan
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
* p0.05 vs. placebo
† p=0.059 vs. placebo
100%
*
66
%
80%
60%
40%
41
%
53
%
2h
47
%
*
56
%
2h
1h
64
%
*
56
%
2h
1h
†
63
%
2h
1h
1h
20%
0%
Placebo
n=130
5 mg
n=127
10 mg
20 mg
n=133
n=117
Sumatriptan nasal spray
Winner P et al. Pediatrics 2000;106:989-997
Headache free (severity score 0) 0-2
hours after first dose
% of Patients
60
Sumatriptan 20mg
Sumatriptan 10mg
Sumatriptan 5mg
Placebo
40
1
20
0
0
30
60
90
120
Time after administration (minutes)
1p<0.05,
20mg versus placebo
Winner P et al. Pediatrics 2000;106:989-997
Most common adverse events*
Sumatriptan nasal spray (mg/dose)
Placebo
5
10
20
n=131
n=128
n=133
n=118
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%
<1%
2%
4%
* Adverse event >3% in any group
†Temperature (warmth), burning/stinging sensations, or paresthesia
Winner P et al. Pediatrics 2000;106:989-997
Study 2: Headache relief at
1 and 2 h
66%
70%
50%
67%
57%
60%
**
**
*
*
53%
47%
47%
67%
38%
39%
33%
40%
29%
24%
30%
20%
10%
1h
2h
1h
2h
1h
2h
0%
Sumatriptan 10 mg
* p < 0.05 vs. placebo
** p < 0.001 vs. placebo
Placebo
Sumatriptan 20 mg
Active 1h
Both
Active 2h
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
*
70
64%
60
50
41%
40
30
20
10
0
Placebo
* p=0.022
Sumatriptan 10mg
Long-term safety and tolerability study in
adolescent migraineurs
Design:
Long-term, open-label, multiple-attack,
multicentre, outpatient
Treatments:
Start with sumatriptan nasal spray 10mg
and either up titrate to 20mg or down
titrate to 5mg
Patients:
518 Patients (12-17 years old) enrolled;
437 treated at least one attack
85
Percent of Attacks (%)
Headache relief at 2 h post dose
100
76%
72%
80
60
40
20
0
10 mg
n=1938
20 mg
n=1261
Sumatriptan nasal spray (mg/dose)
Statistical comparisons were not made per protocol.
86
Consistency of response
Headache relief rates 2 h post dose, by dose/attack number
10mg
Percent of Patients (%)
100
80
20mg
60
40
20
0
1
3
5
7
9
11 13 15 17 19 21 23 25 27
Attack number
87
Data presented for those attacks treated by  10 subjects
Overall incidence of AEs including and
excluding taste disturbance (by attack)a
Percent of Attacks (%)
100
Including taste disturbance
80
Excluding taste disturbance
60
39%
37%
40
15%
20
15%
0
10 mg
20 mg
Sumatriptan nasal spray (mg/dose)
a Incidences
for attacks treated with one or two doses of study medication
88
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
•NNT varies with the placebo response
•Problematic in areas where a variable placebo
rate is likely, e.g. migraine
NNT
Mean pl ot
25
NNT75%
NNT25%
NNT55%
15
5
-5
-15
-25
.1
.2
.3
.4
PLACEBO RESPONSE
.5
Migraine treatments for children
Prophylactic medications
Preventative treatment
• Propranolol
(Inderal):
• Cyproheptadine
(Periactin):
• Nortriptyline
(Pamelor):
• Divalproex sodium
(Depakote):
Initial dosage
• 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
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
–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
• 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
Basic principles
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
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
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
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.
Exclude sinister
Headache (<0.1%)
Patient presenting
with headache
Q1. What is the impact of the headache
on the sufferer’s daily life?
low
ETTH (>50%)
High
Migraine/CDH
 15
> 15
Consider short-lasting
Headaches (<0.1%)
CDH (1-2%)
Q3. For patients with chronic daily
headache, on how may days per week
does the patient take analgesic medications?
<2
Q2. How many days of headache
does the patient have every month?
Migraine (10-12%)
Q4. For patients with migraine, does the
patient experience reversible sensory
symptoms associated with their attacks?
2
Yes
No medication
overuse
No
Medication
Without aura
With aura
overuse
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Diagnosis of migraine in
pre-adolescent children
Look for:
• Family history
• Paroxysmal vertigo
Younger children
• Cyclical vomiting
• Paroxysmal abdominal pain
Older children
• 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 adolescent
children
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
Management individualised for each
patient
• Behavioural therapy recommended for all
– Minimise trigger factors
– Regular lifestyle and meals
• Acute therapy recommended for all
– Paracetamol (± anti-emetics) and ibuprofen firstline
– Introduce aspirin when >16 years
– Nasal spray triptan second-line
• Avoid prophylaxis if possible
– Refer if thought necessary
Restrictions on antimigraine drugs
in the UK
• 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
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
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)
Behavioural/complementary therapies
Paracetamol
Aspirin/NSAID
Paracetamol plus anti-emetic
Initial consultation
Initial treatment
Paracetamol
Aspirin/NSAID
Paracetamol plus anti-emetic
Nasal spray / oral triptan
Rescue
Copyright MIPCA 2003, all rights reserved
Nasal spray / oral
triptan
Initial
treatment
Initial
treatment
Paracetamol
Aspirin/NSAID
Paracetamol plus anti-emetic
Nasal spray / oral triptan
If unsuccessful
Follow-up treatment
Nasal spray / oral triptan
Frequent headache
(i.e. 4 attacks per month)
Migraine
Chronic daily
Headache (CDH)?
Copyright MIPCA 2003, all rights reserved
Consider referral
Implementation of guidelines
• Primary care headache team
– GP, practice nurse, ancillary staff and sometimes
pharmacist (core team)
– Pharmacist
– School nurses / staff
Associate team
– Optician
members
– Dentist
– Specialist physician (additional resource)
Primary care
Teachers
School nurse
School staff
Optician
Pharmacist
Practice
nurse
Specialist
care
Ancillary
staff
Primary care
physician
Physician with expertise
in headache:
GP; PCT; specialist
Nurse practitioner
Dentist
Patient/Parent/Peer
Associate team
Core team
Copyright MIPCA
2003, all rights
reserved