Ishaq Abu-Arafeh MBBS (Jordan), MD (Aberdeen), MRCP, FRCPCH

1. Workshops on Management of headache in Primary care Ishaq Abu-Arafeh MBBS (Jordan), MD (Aberdeen), MRCP, FRCPCH

2. Author’s affiliations Consultant in Paediatrics and Paediatric Neurology Royal Hospital for Sick Children, Glasgow, UK Forth Valley Royal Hospital, Larbert , UK Honorary Clinical Senior Lecturer University of Dundee, Dundee, UK Chairman, Child and Adolescent Committee International Headache Society

3. DISCLOSURE STATEMENT Speaker: Ishaq Abu-Arafeh Dr. Abu-Arafeh has disclosed the following relevant financial relationships. Any real or apparent conflicts of interest related to the content of this presentation have been resolved.

4. Aims • To make appropriate diagnosis based on clinical history and examination • To plan a management strategy • Appropriate use of medications for acute attacks • Rational use of preventative treatment

5. History checklist • Location of maximum pain • Quality – allow child to use his/her own words • Intensity – assessed by effect on behaviour • Duration of headache attacks • Frequency of headache attacks • Other symptoms – loss of appetite, nausea, vomiting, light and noise intolerance • Effects of activities – physical, education and pleasure

6. Physical Examination • General exam to include • Weight • Height • Head Circumference, especially in younger children • Blood pressure • Neurological examination • Cranial nerves including fundoscopy • Motor system • Co-ordination

7. Assessment of Migraine Impact

8. Case 1

9. GP letter – case 1 “Please advise on this 6 year-old girl who complains of headache for past 6 months. Her parents describe 1-2 attacks a month and each lasting the whole day. Pain is banging on the forehead and makes her lie in bed. She avoids light and noise, off her food and she feels sick. She feels better after sleep and taking paracetamol. I found no abnormalities on examination”

10. History checklist

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17. History checklist

18. Points in examination • Weight & height 50th centile • OFC 75% • Pre-pubertal • Normal BP • General exam: normal • Neurology: normal including fundoscopy • Cognitive and emotional assessment

19. What is the diagnosis?

20. Migraine without aura

21. Diagnostic criteria Migraine without aura A. At least 5 attacks fulfilling B-D B. Headache lasting 2-72 hoursin children C. Headache has at least two of the following: • Unilateral location • Pulsating quality • Moderate or severe intensity • Aggravation by walking or similar routine activity D. During headache at least one of the following • Nausea and/or vomiting • Photophobia and phonophobia

22. Salient featuresMigraine without aura • Location – bifrontal headache in at least 50% of patients • Quality - at least 60% of children can’t describe pain • Intensity - best assessed by behaviour during attacks • Duration - short attacks common; at least 10% <1 hour • Frequency – highly variable • Other symptoms • Nausea 90%, vomiting 60% - often early on • Photophobia and phonophobia can be inferred • Vasomotor changes common (mainly pallor)

23. Management issues Investigations Management of acute attack Prevention

24. Investigations None is needed No red flags

25. Management of acute attacks • Early intervention • Rest • Avoid aggravating factors (light, noise, etc) • Pain relief • Early • Appropriate dose • Appropriate route • Anti-emetic

26. Analgesia • Paracetamol - up to 20mg/kg/dose • Ibuprofen - 7.5-10 mg/kg/dose • Anti-emetics ?

27. Management issues Prevention

28. Prevention • Non-pharmacological • Diaries • Trigger avoidance • Lifestyle modifications • Regular meals • Regular sleep • Regular exercise and rest • Avoid caffeine containing drinks • Medication probably unnecessary

29. Case 2

30. GP Letter 2 “Please advise on this 10 year-old girl who complains of headache for past 9 months. Her parents describe 1 attack a week, each lasting 24 hours. Pain is banging on the side of the head and makes her lie in bed. She reports blurred vision and zigzag lines in front of eyes early in the attacks. She avoids light and noise, feels off her food and gets sick She feels better after sleep, but paracetamol rarely helps. I could find no abnormal findings on examination”

31. History checklist • Location of maximum pain and radiation • Quality • Intensity • Duration of headache attacks • Frequency of headache attacks • Other symptoms • Effects of activities

32. History checklist

33. History checklist

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38. History checklist

39. History checklist

40. What is the diagnosis?

41. Migraine with aura

42. Abilities to express symptoms by words

43. Management issues Investigations Management of acute attack Prevention

44. Investigations None is needed No red flags

45. Management of acute attacks • Early intervention • Rest • Avoid aggravating factors (light, noise, etc) • Pain relief • Early • Appropriate dose • Appropriate route • Anti-emetic

46. Analgesia • Paracetamol up to 20mg/kg/dose • Ibuprofen - 7.5-10 mg/kg/dose • Anti-emetics • Sumatriptan?

47. Management issues Prevention

48. Prevention • Diaries • Trigger avoidance • Lifestyle modifications • Regular meals • Regular sleep • Regular exercise and rest • Avoid caffeine containing drinks • Medication probably necessary

49. Preventative medications • Pizotifen: 1-2 mg per day 1 dose • Propranolol 1-2 mg/kg/day 2 doses • Topiramate 1-2 mg/kg /day 1 dose • Amitriptylline 0.25-1.0 mg/kg 1 dose How long to treat: for at least 3 months in appropriate dose before establishing efficacy – if effective treat for 6-12 months before trying off treatment Complimentary medicine

50. Case 3