migraine in primary care advisors edinburgh, 12 june 2003 1.30-5.30 pm managing children and...

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

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

Stewart WF et al. JAMA 1992;267:64-9.

Age- and gender- specific prevalence of migraine

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


Migraine without aura: Age at onset (incidence)In

cid

ence

per

100

0P

erso

n-Y

ears

Age at Onset

Stewart WF et al. Am J Epidemiol 1991;134:1111-20.

FemaleMale

30

25

20

15

10

5

0 5 10 15 20 25 30

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.

Stewart WF et al. JAMA 1992;267:64-9.

Age- and gender- specific prevalence of migraine

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 auraHering-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



‘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



‘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


Paroxysmal vertigo


• 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


• 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


• 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


• 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


Personality traits of children with headache

• 57 children with M+A, M-A and TTHChildren 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.

33

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

Per

cen

t o

f S

ub

ject

s (%

)

Tues Thur Sat

Winner P et al. Headache 2003;43:451-7.

Day of migraine onset

34


3%

18% 16% 18% 21% 23%

0

20

40

60

80

100

Pe

rcen

t o

f S

ub

jec

ts (

%)

Before6:00

6:00- 9:00

9:00-12:00

12:00-15:00

15:00-18:00

After18:00

Time of day of migraine onset


Time of migraine onset

35


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


Summary of migraine symptoms

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.

Imp

act

Time

Migraine phases

Prodrome

Aura

Headache Resolution / recovery

Impact on childrenSignificant 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 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

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

0%

10%

20%

30%

40%

50%

60%

Little orNone

Mild Moderate Severe

Pe

rcen

t o

f S

ub

jec

ts (

%)

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

0%

10%

20%

30%

40%

50%

60%

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

0% 10% 20% 30% 40% 50%

<15

15

16

17

18+

other familymigraineurs?Ever had migraine

Students differentiating headache type

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

yes no

currently have migraine

Students differentiating headache type

0%

10%

20%

30%

40%

50%

60%

70%

80%

No Yes

Other types ofheadache

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?

0%

10%

20%

30%

40%

50%

60%

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

0%

10%

20%

30%

40%

50%

60%

70%

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

0%

10%

20%

30%

40%

50%

60%

70%

No Yes

migrainesinterfering withexams

Migraine occurrence

0% 20% 40% 60% 80% 100%

after exams

during hols

get better inhols

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

0%

10%

20%

30%

40%

50%

60%

<15 15 16 17 18+

Yes

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 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)

• 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

Sumatriptan 25, 50 and 100 mg (302 adolescent patients)

0%

20%

40%

60%

80%

100%

0 60 120 180 240Time (Minutes)

% of Patients

Placebo

25mg

50mg

100mg

*p<0.05 versus placebo

*(25, 50,100)

(50)*

(25, 50,100)*

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

0

10

20

30

40

50

60

70

Riza 5 mg Placebo Riza 5 mg Placebo

NS66

56

NS32

28

Pat

ien

ts (

%)

2-h headache relief

2-h pain-free

n = 296Winner P et al. Headache 2002;42:49-55

73

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

% o

f P

atie

nts

Weekdays Weekends

Placebo

Rizatriptan 5 mg

Winner P et al. Headache 2002;42:49-55

74

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%)

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

• 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

70

52

88

7579

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=20835N=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

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

0%

20%

40%

60%

80%

100%

41%

53%47%

*66% 64% *

56%

†63%*

56%

Placebon=130

5 mgn=127

10 mgn=133

20 mgn=117

* p0.05 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

% o

f p

atie

nts

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 120Time after administration (minutes)

% o

f P

atie

nts

Sumatriptan 20mg Sumatriptan 10mg Sumatriptan 5mg Placebo


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%

Sumatriptan nasal spray (mg/dose)

Most common adverse events*

Placebo 5 10 20n=131 n=128 n=133 n=118

* Adverse event >3% in any group†Temperature (warmth), burning/stinging sensations, or paresthesia


0%

10%

20%

30%

40%

50%

60%

70%

Sumatriptan 10 mg Sumatriptan 20 mg Both

Placebo Active 1h Active 2h

Study 2: Headache relief at1 and 2 h

* p < 0.05 vs. placebo** p < 0.001 vs. placebo

39%

57%

1h

24%

47%*

1h

29%

53%*

1h

47%

66%

2h

33%

67%**

2h

38%

67%**

2h

% o

f pa

t ien

t s

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

* p=0.022

*

% o

f pa

t ien

t s

64%

41%

0

10

20

30

40

50

60

70

Placebo Sumatriptan 10mg

85

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

86

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

Pe

rce

nt

of

Att

ack

s (

%)

10 mg 20 mg


87

Consistency of responseHeadache relief rates 2 h post dose, by dose/attack number

10mg

20mg

Data presented for those attacks treated by 10 subjects

0

20

40

60

80

100

1 3 5 7 9 11 13 15 17 19 21 23 25 27

Attack number

Per

cen

t o

f P

atie

nts

(%

)

88a 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

100P

erce

nt

of

Att

acks

(%

)

10 mg 20 mg


Including taste disturbance

Excluding taste disturbance

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

Mean plot

NNT55%

NNT25%

NNT75%

.5.4.3.2.1

25

15

5

-5

-15

-25

NNT

•NNT varies with the placebo response

•Problematic in areas where a variable placebo rate is likely, e.g. migraine

Migraine treatments for children

Prophylactic medications

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 dosageInitial dosage

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

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


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.

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%)


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

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

• 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

• 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

• 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-inDiagnostic screening and differential diagnosisAssess illness severity

Attack frequency and durationPain severityImpact (MIDAS or HIT questionnaires)Non-headache symptomsPatient history and preferences

Intermittentmild-to-moderate migraine

(+/- aura)

Intermittentmoderate-to severe migraine

(+/- aura)

ParacetamolAspirin/NSAID

Paracetamol plus anti-emetic


Paracetamol plus anti-emeticNasal spray / oral triptan

Nasal spray / oraltriptan

Initial consultation

Initial treatment

Rescue

Rescue

Behavioural/complementary therapies

Copyright MIPCA 2003, all rights reserved


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 dailyHeadache (CDH)?

Migraine

Initial treatment


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

Pharmacist

TeachersSchool nurseSchool staff

Optician

Dentist

Patient/Parent/Peer

Primary care physician

Practice nurse

Physician with expertise in headache:

GP; PCT; specialistNurse practitioner

Ancillarystaff

Primary care Specialist care

Associate team Core team


migraine in primary care advisors edinburgh, 12 june 2003 1.30-5.30 pm managing children and...

Documents

management of headache

days of headache

understanding of headache

chronic daily headache

gp slide set

gp principles of care

educational use slide

adolescents burden of