NEW TRENDS IN HEADACHE AND MIGRAINE TREATMENT

Kathie Teta, RN, CPNPPANDA NeurologyAtlanta, Georgia

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

OBJECTIVES

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

OBJECTIVES

“So you think YOU’VEgot a Headache?!”

Moderate to severe pain:◦ Unilateral/bilateral◦ Throbbing/squeezing

2 of 3 cardinal features:◦ Photophobia◦ Inability to function◦ Nausea/vomiting

Exertional worsening Sound sensitivity Duration of 4 to 72 hours

Migraine without aura

Similar to migraines without aura 20 – 30 % migraneurs have aura (99% of

these have visual auras) Warning symptoms may include:

◦ Visual disturbances◦ Numbness in arm or leg◦ Difficulty speaking◦ Warning symptoms last 5 – 6 minutes and

typically are followed by headache pain

Migraine with aura

Headaches occurring on or > 15 days per month

Current or prior diagnosis of migraine Lasting on average > 4 hours per day

Chronic migraine

Obesity Lowered social economic status Stressful events Snoring Overuse of caffeine Depression Anxiety

Risk factors for chronic migraine

Use of over-the-counter medications more than 1 – 2 times per week

Overuse of abortive prescription medications

Medication overuse headache

Abdominal migraines◦ Diffuse abdominal pain, sometimes associated

with headache◦ Can last 1 – 72 hours

Benign paroxysmal vertigo◦ Usually occurs in toddlers and young children◦ Appear off balance, may refuse to walk◦ Can last minutes to hours

Cyclic vomiting◦ Occurs in school-age children◦ Forceful, frequent vomiting lasting 1 hour to 5

days

Migraine Variants

Incidence of migraine 4 -5% of young children 5 – 6% in preadolescents Increases in adolescence 18% women, 6% men as adults

AGE- AND GENDER-SPECIFIC PREVALENCE OF MIGRAINEAGE- AND GENDER-SPECIFIC PREVALENCE OF MIGRAINE

Lipton RB, Stewart WF. Neurology. 1993.

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PATHOPHYSIOLOGY OF MIGRAINE

The Migraine Process: Activation of Nerves and Blood Vessels

One Nerve Pathway, Multiple Symptoms, Multiple Manifestations of MigraineOne Nerve Pathway, Multiple Symptoms, Multiple Manifestations of Migraine

Genetic basis Strong family history of migraines

Avoid TriggersFoods:

◦ 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

Sinus infection◦ Nasal congestion◦ Nasal drainage◦ Pain over frontal or maxillary sinuses

Differential diagnoses

Cranial Parasympathetic Activation May Explain“Sinus-Like” Symptoms in Migraine

Tension headache Dull, aching, nonthrobbing Not associated with vomiting Pain or discomfort in the head, scalp, or

neck, usually associated with muscle tightness in these areas

Brain lesion Subarachnoid hemorrhage Meningoencephalitis Acute hydrocephalus Chiari I malformation Pseudotumor Cerebri

Differential diagnoses

Chiari I malformation

Diagnostic testing Imaging studies

◦ CT vs MRI 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 Lumbar puncture

◦ If concerns with papilledema

Lifestyle modifications◦ Diet

Increase water Decrease caffeine Decrease nitrates

◦ Sleep◦ Dealing with stress

Decrease use of over-the-counter medications

Phamacologic therapy

Treatment for migraines

Functional response (ability to return to normal activities)

Consistent and quick onset Prevent headache recurrence Well tolerated

Goals of Acute treatment

Cranial vasoconstriction Peripheral neuronal inhibition Modulates activity in neuroreceptors at

multiple sites along trigeminal pathway

Mechanisms of action of acute anti-migraine drugs

Acute Treatment Options for Migraines Nonspecific: (for

mild/moderate pain)◦ NSAIDs◦ Combination analgesics◦ Opioids◦ Neuroleptics/antiemetics◦ corticosteroids

Specific (for severe pain)◦ Triptans◦Ergotamine (DHE)

Oral therapies: most medications

Nasal sprays: sumatriptan, zolmitriptan, DHE

Injectable: (SQ, IM, IV) sumatriptan, DHE, injectable NSAIDs, opioids, neuroleptics

Suppositories: antiemetics, ergots, opioids

Routes of Administration

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

Triptan use

Decrease attack frequency (by 50%) duration and intensity

Improve responsiveness to acute treatment Improve function and decrease disability

GOALS OF PREVENTIVE TREATMENT

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

GUIDELINE: WHEN TO USE PREVENTIVE MEDICATIONS

Preventive Medication Groups Anticonvulsants

◦ Valproate◦ Gabapentin◦ Topiramate ◦ Zonegran◦ Neurontin

Antidepressants◦ TCAs◦ SSRIs◦ MAOIs

ß-adrenergic blockers ◦ Propranolol

Calcium channel antagonists

– Verapamil

Others – NSAIDs– Riboflavin– Magnesium– Petadolex– Feverfew

Tailor Therapy Appropriately to Comorbid ConditionsCondition Avoid

AsthmaDepression Athlete

b-Blocker

EpilepsyArrhythmiaBipolar

Tricyclic AntidepressantTCA

Peptic Ulcer Disease NSAIDs

Peripheral Vascular Disease

Ergots/Triptans

56Adapted from Silberstein S. Headache in Clinical Practice. 2002:93.

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

Preventive Treatment Options

Nonpharmacologic Therapies Tested in Clinical Trials

Behavioral Treatments

Relaxation training*

Hypnotherapy

Thermal biofeedback training*

Electromyographic biofeedback therapy*

Cognitive/behavioral management therapy*

Physical Treatments

Acupuncture

Transcutaneous electrical nerve stimulation (TENS)

Occlusal adjustment

Cervical manipulation*Proven effective in clinical trials

Adapted from US Headache Consortium Headache Guidelines. www.aan.neurology.org. 2000

Botox injections Nerve blocks Trigger point injections Nerve stimulator trials

Transcutaneous sumatriptan (battery powered)

Livodex – inhaled DHE

New Trends in Migraine Management

Referral to Pediatric Neurology Refer children and adolescents with

headaches if:◦ Poor response to acute treatment◦ Uncertainty of diagnosis◦ Unusual features ◦ Co-morbidities◦ Need for preventive treatment◦ Concerns or alarming findings on examination