lhc paediatric headaches

8/12/2019 LHC Paediatric Headaches

1/23

Paediatric headaches

Mark Weatherall

London Headache Centre

2010


2/23

Why is this important?

Headaches are common in children

Headaches often cause significantdisability

affects home life & school performance

affects family relationships

affects relationships with peers


3/23

Why is this important?

Headaches in children are under-recognised, misdiagnosed, and under-

treated

Headaches may present differently inchildren

Accurate diagnosis and effective treatment

improve quality of life

prevent long-term disability & co-morbidity


4/23

What headaches are we

talking about?

Migraine**with aura in 14-30%

Tension-type headache

Cluster headache

Other headaches


5/23

Migraine

ICHD-II criteria (migraine without aura)

A recurrent headache disorder manifesting inattacks lasting 4-72 hours*. Typical

characteristics of the headache are unilaterallocation, pulsating quality, moderate or severe

intensity, aggravation by routine physical

activity, and association with nausea and/or

photophobia and phonophobia

* In children 1-72 hours is allowed


6/23

Migraine

Difficulties in diagnosing migraine inchildren include:

shorter duration

more likely to be bilateral

difficulty in describing headache features andassociated symptoms

must often be inferred from behaviour/drawings

evolution of the semiology of headaches overtime


7/23

Migraine

These difficulties are notconfined to thepaediatric population!

Study comparing physician diagnoses withICHD-II

4-72 hr duration: 61.9% met criteria

1-72 hr duration: 71.9% met criteria

including bilaterality & other features such asdifficulty thinking, light-headedness & fatigue:

88.4% met criteria


8/23

Other headaches

TTH

common but rarely debilitating

true impact very difficult to gauge

Cluster headache

devastating until diagnosed

early onset cases rare

18% report onset before 18 yr

2% report onset before 10 yr


9/23

Headaches are common

American Migraine Prevalence &Prevention Study

120 000 households

162 576 participants

mailed questionnaire on HAs & Rx

ICHD-II criteria used

overall 1-yr prevalence migraine

5.6%

17.1%


10/23


Subgroup analysis of adolescents (12-17yr)

1 yr prevalence of migraine 6.3%

5%

7.7%

utilization of medications by this group

OTC 59.3% prescription medication only 16.5%

OTC & prescription medication 22.1%

current prophylactic treatments 10.6%


11/23


German 3/12 prevalence study

2.6% migraine (ICHD-II criteria)

6.9% if duration criteria reduced to 30 min

12.6% probable migraine

0.7% chronic migraine

Turkish prevalence questionnaire

7.8% boys

11.7% girls


12/23


Meta-analysis of paediatric headachestudies 2002 by AAN group

>27 000 children

37-51% significant HA by age 7 yrs

57-82% significant HA by age 15 yrs


13/23

Impact of headaches

Children with migraine lose on average 1weeks of school per year

Impact can be assessed using validatedtools

PedMIDAS

PedQL


14/23

Treatment

Accurate diagnosis

Comprehensive treatment plan

Explanation (and reassurance)

Lifestyle advice

Acute treatments

Prophylactic treatments

Biobehavioural therapies


15/23

Treatment

Accurate diagnosis

Underlying headache phenotype

What was the headache originallylike?

Triggers

Confounding factors

Medication overuse

Physical co-morbidities Psychological co-morbidities

Life stresses


16/23

Treatment

Explanation

common problem

physical, not just psychological problem

genetics, pathophysiology

treatable problem

identifying triggers, confounding factors

Reassurance for child and parents this is not a brain tumour


17/23

Treatment

Acute treatment

Goals:

sustained pain freedom

rapid return to normal activity

OTC

small trials show ibuprofen (7.5-10 mg/kg) superiorto PCT + placebo

use early, at decent dose

avoid overuse (3 days/wk)


18/23

Treatment

Acute treatment

Triptans

in UK only nasal sumatriptan licensed for

adolescents DBPCTs in adolescents exist for almotriptan,

eletriptan, rizatriptan, sumatriptan, and zolmitriptan

effective (but high placebo rates) and well-

tolerated SUM/NAR database shows a linear correlation

between age & efficacy of triptans


19/23


20/23

Treatment


pizotifen

beta-blockers

tricyclics

anticonvulsants

others

riboflavin (vitamin B2)* * recent negative small PCRCT!

coenzyme Q10

butterbur extract


21/23


a paucity of evidence

Cochrane review 2003 found only two trialsconvincingly showing benefit of prophylactic

treatment

Propranolol

Flunarizine since then decent PCRCT for topiramate

recent negative PCRCT for SVP MR


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Treatment

Biobehavioural therapies

biofeedback

relaxation training

Treatment of co-morbidities

physical

sleep disorders

psychological

Counselling; family therapy


23/23

The future?

Much more evidence is needed for

Acute treatments


monotherapy

combination therapies

Novel treatments

CGRP antagonists

More interest in the subject must begenerated in 1, 2, and 3care

lhc paediatric headaches

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