Paediatric headaches

1. Paediatric headaches Mark Weatherall London Headache Centre 2010

2. Why is this important? • Headaches are common in children • Headaches often cause significant disability • affects home life & school performance • affects family relationships • affects relationships with peers

3. Why is this important? • Headaches in children are under-recognised, misdiagnosed, and under-treated • Headaches may present differently in children • Accurate diagnosis and effective treatment • improve quality of life • prevent long-term disability & co-morbidity

4. What headaches are wetalking about? • Migraine* *with aura in 14-30% • Tension-type headache • Cluster headache • Other headaches

5. Migraine • ICHD-II criteria (migraine without aura) • A recurrent headache disorder manifesting in attacks lasting 4-72 hours*. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity, and association with nausea and/or photophobia and phonophobia • * In children 1-72 hours is allowed

6. Migraine • Difficulties in diagnosing migraine in children include: • shorter duration • more likely to be bilateral • difficulty in describing headache features and associated symptoms • must often be inferred from behaviour/drawings • evolution of the semiology of headaches over time

7. Migraine • These difficulties are not confined to the paediatric population! • Study comparing physician diagnoses with ICHD-II • 4-72 hr duration: 61.9% met criteria • 1-72 hr duration: 71.9% met criteria • including bilaterality & other features such as difficulty thinking, light-headedness & fatigue: 88.4% met criteria

8. Other headaches • TTH • common but rarely debilitating • true impact very difficult to gauge • Cluster headache • devastating until diagnosed • early onset cases rare • 18% report onset before 18 yr • 2% report onset before 10 yr

9. Headaches are common • American Migraine Prevalence & Prevention Study • 120 000 households • 162 576 participants • mailed questionnaire on HAs & Rx • ICHD-II criteria used • overall 1-yr prevalence migraine • ♂ 5.6% • ♀ 17.1%

10. Headaches are common • Subgroup analysis of adolescents (12-17 yr) • 1 yr prevalence of migraine 6.3% • ♂ 5% • ♀ 7.7% • utilization of medications by this group • OTC 59.3% • prescription medication only 16.5% • OTC & prescription medication 22.1% • current prophylactic treatments 10.6%

11. Headaches are common • German 3/12 prevalence study • 2.6% migraine (ICHD-II criteria) • 6.9% if duration criteria reduced to 30 min • 12.6% probable migraine • 0.7% chronic migraine • Turkish prevalence questionnaire • 7.8% boys • 11.7% girls

12. Headaches are common • Meta-analysis of paediatric headache studies 2002 by AAN group • >27 000 children • 37-51% significant HA by age 7 yrs • 57-82% significant HA by age 15 yrs

13. Impact of headaches • Children with migraine lose on average 1½ weeks of school per year • Impact can be assessed using validated tools • PedMIDAS • PedQL

14. Treatment • Accurate diagnosis • Comprehensive treatment plan • Explanation (and reassurance) • Lifestyle advice • Acute treatments • Prophylactic treatments • Biobehavioural therapies

15. Treatment • Accurate diagnosis • Underlying headache phenotype • What was the headache originally like? • Triggers • Confounding factors • Medication overuse • Physical co-morbidities • Psychological co-morbidities • Life stresses

16. Treatment • Explanation • common problem • physical, not just psychological problem • genetics, pathophysiology • treatable problem • identifying triggers, confounding factors • Reassurance for child and parents • … this is not a brain tumour …

17. Treatment • Acute treatment • Goals: • sustained pain freedom • rapid return to normal activity • OTC • small trials show ibuprofen (7.5-10 mg/kg) superior to PCT + placebo • use early, at decent dose • avoid overuse (≤3 days/wk)

18. Treatment • Acute treatment • Triptans • in UK only nasal sumatriptan licensed for adolescents • DBPCTs in adolescents exist for almotriptan, eletriptan, rizatriptan, sumatriptan, and zolmitriptan • effective (but high placebo rates…) and well-tolerated • SUM/NAR database shows a linear correlation between age & efficacy of triptans

19. Treatment • Prophylactic treatments • When to use them? • increased headache frequency • poor response to acute treatments • ? severe (including hemiplegic or basilar) MA • Goals: • reduce headache frequency • reduce headache-related disability • allow eventual return to acute treatment alone (or acute treatment + biobehavioural therapy)

20. Treatment • Prophylactic treatments • pizotifen • beta-blockers • tricyclics • anticonvulsants • others • riboflavin (vitamin B2)* * recent negative small PCRCT! • coenzyme Q10 • butterbur extract

21. Prophylactic treatments • a paucity of evidence • Cochrane review 2003 found only two trials convincingly showing benefit of prophylactic treatment • Propranolol • Flunarizine • since then decent PCRCT for topiramate • recent negative PCRCT for SVP MR

22. Treatment • Biobehavioural therapies • biofeedback • relaxation training • Treatment of co-morbidities • physical • sleep disorders • psychological • Counselling; family therapy

23. The future? • Much more evidence is needed for • Acute treatments • Prophylactic treatments • monotherapy • combination therapies • Novel treatments • CGRP antagonists • More interest in the subject must be generated in 1°, 2°, and 3° care