Management of Headaches in Children & Adolescents · management of headaches including lifestyle...
Transcript of Management of Headaches in Children & Adolescents · management of headaches including lifestyle...
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22nd Annual Northeast Regional Nurse Practitioner Conference – May 6-8, 2015
Management of Headaches in Children andAdolescentsEvie Stacy, MS, APRN
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D I S C L O S U R E S
• There has been no commercial support or sponsorship for this program.
• The planners and presenters have declared that no conflicts of interest exist.
• The program co-sponsors do not endorse any products in conjunction with any educational activity.
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A C C R E D I TAT I O N
Boston College Connell School of Nursing Continuing Education Program is accredited as a provider of continuing nursing education by the American Nurses Association Massachusetts, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
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22nd Annual Northeast Regional Nurse Practitioner Conference – May 6-8, 2015
S E S S I O N O B J E C T I V E S
• Summarize the assessment of headaches in children and adolescents.
• Discuss treatment strategies for management of headaches including lifestyle changes and pharmacological interventions.
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Management of
Headaches in
Children & Adolescents Evie Stacy, MS, APRN
Pediatric Neurology
Dartmouth Hitchcock Clinic
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Objectives
Review the assessment of headaches in children and
adolescents
Discuss management of headaches including non-
pharmacological and pharmacological treatment
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No Disclosures to report
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Prevalence 37-51 % of children report headaches
56 % boys and 74% girls between ages of 12 and 17 report having a headache in the past month
Pre pubertal boys > girls
After puberty girls > boys
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Headache Consequences
Third most common cause of school absenteeism
Most common reason to seek neurology consultation
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Migraine
50% of adults with migraine seek medical attention
ONLY 10 % of the 7 % of children with migraine
actually receive a migraine diagnosis
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Why we don’t identify children
with migraine
Parents deny their own migraine
Parents with migraine deny the symptoms in their child
School nurses rarely elicit a migraine history
Signs & symptoms of pediatric migraine may differ from
adult migraine
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Assessment of Headache Do you have more than one type of headache?
How did the headaches begin?
When did the headaches begin?
Are the headaches intermittent, progressive, or stay the
same?
How often does each headache occur?
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Assessment of Headache Are there any special circumstances of triggers?
Are there any warning signs?
Where is the pain located”
What is the severity of pain? (0-10)
What are the characteristics of the headache?
Are there any associated symptoms?
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Assessment of Headache What do you do during the headache?
Does anything make your headache better?
Does anything make your headache worse?
Do the symptoms continue between headache?
Are there any other medical issues?
Are you taking any medication?
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Assessment of Headache Would I know that you had a headache if I saw you?
Is there a family history of headaches?
WHAT DO YOU THINK IS THE CAUSE OF YOUR
HEADACHES?
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Assessment of Headache Medical History
Family History
90% have a close relative with migraine
1 parent 40% chance
2 parents 75%
School Performance/Attendance
Peer Relations
Home stress/ issues
Substance Use including caffeine
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Physical Exam Mental Status Exam
Neurological Exam
Cranial nerves
Motor function
Sensory function
DTRs
Gait
Pronator Drift
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Fundoscopic Exam
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Physical Exam
Babinski reflex
Cerebellar function
Romberg
Gait
Palpate head, TMJ, sinuses, cervical muscles
Assess for “hot” head
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Lab Studies
CBC, electrolytes, LFTs, thyroid, ferritin, UA
Consensus is that labs are “uniformly unrevealing”
Consider labs if you suspect something else
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Lumbar puncture
No studies support its role in managing headaches
But useful in diagnosing pseudotumor cerebri
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EEG
Not useful in the routine evaluation of recurrent
headache
It does not provide etiology, improve diagnostic yield, or
distinguish migraines from other types of headaches
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EEG
Do an EEG if you are suspicious of a seizure disorder
24 hour EEG vs. Sleep Deprived
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Neuroimaging
CT scan vs. MRI
Not recommended in children with a recurrent
headache and a normal neurological exam
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Neuroimaging Consider with abnormal neurological exam i.e. focal
findings, S & S of increased intracranial pressure,
significant alteration in consciousness, confusion, co-
morbid seizures, papilledema, abnormal eye
movements, motor or gait dysfunction
Reassurance
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Neuroimaging
Recent onset of severe headaches, change in the type
of headaches, or if associated features suggest
neurological dysfunction
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Causes of Headaches No biological markers or accurate tests to confirm the
diagnosis
History of trauma
Diagnosis is based on
Medical history
Physical exam including neuro exam
Appropriate tests
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Migraine without Aura
Common migraine
60-85 % of all migraine
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Pediatric Migraine without
Aura A. At least 5 attacks fulfilling B-D
B. Headache attack lasts 1-72 hours
C. Headache has at least 2 of the following:
1. Unilateral location, may bilateral, frontal/temporal (not
occipital)
2. Pulsing quality
3. Moderate to severe intensity
4. Aggravated by routine physical activity
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Pediatric Migraine without
Aura D. During the headache, at least 1 of the following
1. Nausea and/or vomiting
2. Photophobia or phonophobia
E. Not attributed to another disorder
Adapted from: Classification & diagnostic criteria for
headache disorders, cranial neuralgia and facial pain.
Headache Classification Committee of the International
Headache Society 2004
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Pediatric Migraine without
Aura Early prodromal features
Mood changes
Irritability
Lethargy/ fatigue
Yawning
Food cravings
Increased thirst
Behavior change
Withdrawal from activity
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Pediatric Migraine without
Aura May have a gradual onset
Escalates over minutes to hours
Lasts 2-72 hours
Frontal, bi temporal, retro orbital, unilateral
Pounding, pulsing or throbbing quality
May increase with physical activity
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Pediatric Migraine with Aura Visual disturbances, distortions before or as the
headache begins
Smell
Aura is an inconsistent feature in children
Other migraine symptoms
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Pediatric Migraine with Aura A. At least 2 attacks fulfilling Criteria B
B. At least 3 of the following:
1. One or more fully reversible aura symptoms indicating
focal cortical and/or brain stem dysfunction
2. At least one aura developing gradually over more than
4 minutes or two or more symptoms occurring in
succession
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Pediatric Migraine with Aura 3. No auras lasting > 60 minutes
4. Headache follows less than 60 minutes
Adapted from: Classification and diagnostic criteria for headache disorder, cranial neuralgia and facial pain. Headache Classification Committee of the International Headache Society 2004
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Pediatric Migraine with Aura Visual disturbance, distortions, or obscurations before
or as the headache begins
Ask the child to draw what they see
Alice in Wonderland syndrome- usually no headache
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Complicated Migraine More unusual neurologic symptoms
May mimic an ischemic attack
Usually occurs in an individual with history of migraine
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Ophthalmoplegic Migraine Transient paresis of eye movements
Onset 5-12 years of age
Occurs during an otherwise typical migraine
Pain is ipsilateral to the eye involved
Aura, nausea and vomiting
Usually a 3rd nerve palsy but all 3 cranial nerves of
EOM can be involved
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Retinal Migraine
Most common aura is scotomas- sensation of seeing
scintillating lights caused by ischemia of contralateral
occipital cortex
Caused by ischemia of the retinal artery
Occurs in children with pre-existing migraines
Transient monocular blindness
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Hemiplegic Migraine Unilateral weakness of the face and arm
Motor deficit may be preceded by numbness or tingling
Weakness may precede, accompany, or follow head pain
Right sided weakness can be accompanied by aphasia
Rare in children, may be a familial hemiplegic migraine
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Basilar Artery Migraine Occurs primarily in adolescent girls
Recurrent stereotypic attacks caused by temporary
dysfunction of the brain stem & cerebellum
Sx ataxic gait, dysarthric speech, vertigo & tinnitus,
visual complaints, alternating hemiplegia, impairment of
consciousness, parasthesias of the face, arms or legs
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Basilar Artery Migraine Sudden loss of postural tone, loss of consciousness,
cardiac arrhthymias
Followed by a severe headache usually localized to the
occipital region
Strong family history of migraine
May progress to a more typical migraine syndrome
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Acute Confusional Migraine Agitated confusion, disorientation, & combativeness
May last several minutes to hours
Usually too confused to complain of a headache
Deep sleep after
EEG may show disorganized pattern if done during or
shortly after
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Migraine Triggers
Sleep deprivation/excess
Missed meals/ Delayed meals
Emotional stress
Menstrual cycle
Weather changes/ seasonal changes
Travel through time zones
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Migraine Triggers Red wine, beer, dark alcohol
MSG
Tyramine
NutraSweet
Chocolate
Aged cheeses
Processed meats
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Tension Type Headache Bilateral pressing tightness on the cranium or sub
occipital region
Non throbbing
Mild to moderate intensity
Not usually accompanied by nausea or vomiting
Not aggravated by activity
Lasts 30 minutes to 7 days
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Cluster Headache Rare < age 10
Males : Females 9:1
Severe unilateral orbital or supraorbital, and/or
temporal pain lasting 1-180 minutes untreated
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Cluster Headache Associated with
Conjunctival injection
Lacrimation
Nasal congestion
Rhinorrhea
Miosis
Ptosis
Eyelid edema
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Daily Persistent Headache Recurrent headaches averaging 15 days per month
No serious underlying pathology
Physiology is not well defined
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Daily Persistent Headache Associated with
Stress
Anxiety
Depression
Chronic somatic complaints
Familial patterns
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Daily Persistent Headaches Mixed headaches
Treatment
Behavioral strategies
Avoid overuse of medication
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Post Traumatic Headache Severe headache
Impaired memory
Poor concentration
May occur within days or weeks of the trauma
Migraine-like quality
Symptoms may or may not equal injury
Can subside spontaneously
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Space Occupying Lesions
Headache < 1 month duration
Early AM headache that improves with getting up
Absence of family history of migraine
Abnormal neurological examination
Gait abnormality
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Non Pharmacological
Treatment Reassurance
Lifestyle
Sleep
Nutrition
Water
Exercise
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Non Pharmacological
Treatment
Stress management
Cognitive Behavioral Treatment
Guided Imagery
Relaxation
Biofeedback
Massage
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Supplements
Magnesium
Vitamin B 2 (Riboflavin)
Coenzyme Q10
Fish oils
Butterbur Associated with elevated LFTs
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Pharmacological Treatment
Prophylactic versus Rescue Medications
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Rescue Medications
Acetaminophen 10-15 mg/
Ibuprofen 10 mg/kg
Naproxen 10 mg/kg
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Rescue Medications Butalbital 50 mg/Acetaminophen 325/caffeine 40 mg
Acetaminophen/Dichloralphenazone 325/100/65 Midrin
Acetaminophen/Aspirin/caffeine 250/250/65 Excedrin
Migraine > 15 years
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Rescue Medications
Sumatriptan (Imitrex)
SC 0.06 mg/kg up to 6 mg
Nasal spray 5 or 20 mg
Tablets 25mg, 50mg or 100 mg
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Rescue Medications Rizatriptan (Maxalt) Tablets and ODT
5 and 10 mg tablets
Zolmitriptatan (Zomig) Tablet, ODT, and nasal spray
2.5 mg and 10 mg
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Nasal Spray Blow nose
Water and mint ready
Nose to toes
Hold in to the count of 60
Should not blow nose
Use the water and mint
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Contraindications for Triptans Symptoms consistent with ischemic heart disease
Uncontrolled hypertension
Hemiplegic or basilar migraine
Use of another 5HT agonist
MAOI in the past 2 weeks
Hypersensitivity to a triptan
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Antiemetics
Ondansetron (Zofran) ODT 4-8 mg
Metoclopramide (Reglan) 5-10 mg
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Prophylactic Medications Cyproheptadine (Periactin) 2 mg BID or 4 mg QHS
Propranolol (Inderal) 1 mg/kg up to 10 mg BID
TCAs
Amitriptyline 0.25-0.5 mg
Nortriptyline 0.25-0.5 mg
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Prophylactic Medications Gabapentin (Neurontin) start at 100 mg
Topiramate (Topamax) up to 50 mg BID
Divalproex (Depakote) 10 mg/kg
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Evaluation Headache Diary
Work with the family to identify triggers
AVOID overuse of medication
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Psychosocial Aspects of
Headache School year
Reflection of what is happening at home
Relation to menstrual cycle (drop in estrogen)
Recurrent abdominal pain
Combination of school absenteeism and poor concentration may lead to school failure
Depression and anxiety
Social competence
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Migraine Personality
Perfectionistic
Internalizes stress
Sensitive
Cautious
Restrained
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References
Headache Classification Subcommittee of the International
Headache Society. The International Classification of Headache
Disorders. Cephalalgia, 24 (2004).
Practice Parameter: Evaluation of children and adolescents with
recurrent headaches. Report of the Quality Standards
Subcommittee of the American Academy of Neurology and
Practice Committee of the Child Neurology Society 2002.
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References
Practice Parameter: Pharmacological treatment of migraine
headache in children and adolescents. Report of the American
Academy of of Neurology Quality Standards Subcommittee and
the Practice Committee of the Child Neurology Society. 2004.