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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
Dowson AJ. Migraine: your questions answered, 2003
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
Dowson AJ. Migraine: your questions answered, 2003
How childhood migraine may differ from adult migraine - 2
‘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
Dowson AJ. Migraine: your questions answered, 2003
How childhood migraine may differ from adult migraine - 3
‘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
Dowson AJ. Migraine: your questions answered, 2003
Paroxysmal vertigo
• Epidemiological study in Aberdeen schoolchildren aged 5-15 y (n = 2,165)
• 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
• Epidemiological study in Aberdeen schoolchildren aged 5-15 y (n = 2,165)
• 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
• Epidemiological study in Aberdeen schoolchildren aged 5-15 y (n = 2,165)
• 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
• Epidemiological study in Aberdeen schoolchildren aged 5-15 y (n = 2,165)
• 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
Dowson AJ. Migraine: your questions answered, 2003
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
Adolescent migraine patients: GSK database (n = 1,932; 12-17 y)
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
Winner P et al. Headache 2003;43:451-7.
Time of migraine onset
35
Adolescent migraine patients: GSK database (n = 1,932; 12-17 y)
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
Winner P et al. Headache 2003;43:451-7.
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
Winner P et al. Pediatrics 2000;106:989-997
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
Winner P et al. Pediatrics 2000;106:989-997
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
Sumatriptan nasal spray (mg/dose)
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
Sumatriptan nasal spray (mg/dose)
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
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
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%)
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
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
ParacetamolAspirin/NSAID
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
ParacetamolAspirin/NSAID
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
Copyright MIPCA 2003, all rights reserved
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
Copyright MIPCA 2003, all rights reserved