kathie teta, rn, cpnp panda neurology atlanta, georgia
TRANSCRIPT
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.
Mig
rain
e P
reva
lenc
e (%
)
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