Pediatric Migraine JA C K GL A D ST EIN , M . D PR O FESSO R O F - PDF document

Pediatric Migraine JA C K GL A D ST EIN , M . D PR O FESSO R O F PED IA T R IC S A N D N EU R O L O GY U O F M A R Y L A N D SC H O O L O F M ED IC IN E N JA A P C O N FER EN C E O C T O B ER 201 5 Kids vs. Adults  Bilateral  Shorter Duration  Bad describers- less throbbing 1

Do kids get allodynia? Migraine Summary  Hershey Poster AHS:  Acute and recurrent  Severe  As kids get older more allodynia  Unilateral or Bilateral  Girls > boys  Usually No Aura  Hair more than anywhere else  Autonomic Symptoms  Family history, relief with sleep Migraine Physiology  Genetically Susceptible  Trigger happens  Decrease of Serotonin in MDR and Trigeminovascular system  Open 5ht1-D receptor Physiology 2 MIGRAINE If autonomic symptoms : TENSION If not: 2

Sinus vs. Migraine SN(O)OP: Red Flags  Pain over sinus can be due to firing of 2 nd branch of  S ystemic Symptoms CN V  N eurologic Symptoms  O nset is abrupt  So… N/V/ photo/Phono/ relief with sleep/ Pallor  (O lder patient at onset for adults only) plus sinus tenderness :  P revious Headache history is different  MIGRAINE NOT SINUS For all Migraine Patients  Weak Brain needs extra nurturing  Sleep More and more regularly  Eat Breakfast  Drink Water  Exercise  Deal with Stress For All migraine patients STEP VS STRATIFIED CARE  Treat attacks at first twinge Start  Treat attacks with high doses of medication  Don’t wait until sure it’s a migraine  Involve school nurse and teacher A C A Start B B C 3

Acute Treatment Mixed drugs  Analgesics: Aspirin, Acetaminophen, Ibuprofen,  Midrin, Fioriset, Esgic Naproxen Sodium  Gone out of favor  Use higher doses!  risk of medication overuse Adjunctive treatment 5-HT Agonists  Antiemetics  Route important  Is there recurrence after dosing?  anxiolytics  Onset vs. duration Dihydroergoatamine Sumatriptan  Can be given IV , IN, (or inhaled)  Po, SQ, IN  Multiple sizes give maximum flexibility  Treximet- Imitrex 85 plus naproxen 500 4

Zolmatriptan Eletriptan  PO, Melt and IN  Po only  2 po doses, but 1 IN dose Almotriptan Naratriptan and Frovatriptan  Pill only  Slow in, long lasting  May have a role in menstrual migraine prophylaxis  May have role in bounce back headache Rescue Meds  Match intensity to severity  Have a role in Ed or Infusion Center setting  IV MG  More disabled- use triptans  IV Fluids  IV Steroids  GET IT RIGHT FIRST TIME  IV DHE  IV Metochlopromide  IV Valproate 5

Preventative strategies Initial Considerations  Avoid Triggers Match intensity to severity  Assess Coping skills More disabled- use triptans  Assess Disability GET IT RIGHT FIRST TIME  Absenteeism  Presenteeism Prevention Drugs: Prevention Approaches Principles  Cognitive Behavioral Therapy  Who needs them?  Biofeedback  Absenteeism  Presenteeism  Relaxation  Disability after retraining proper use of triptans  Hypnosis  Start low and go slow  Acupuncture  Realistic expectations  Medications Prevention drugs: Which to choose? Amitriptyline Pick drug you are familiar with  Start low: 10 mg . Increase weekly Pick drug that will give an extra bonus  ? EKG Pick drug that will not exacerbate another problem Pick drug whose side effects will be tolerated by an INDIVIDUAL patient / family  Weight gain, hard to wake up, dry mouth 6

Cyproheptadine Gabapentin  Start low 4 mg  Start low 900 mg  Hard to wake up, weight gain  Fuzzy sensorium, compliance a problem Pregabalin Topiramate  Start low, but move fast  Start slow 15-25 mg  Brain fuzziness, weakness  Weight loss, eye pain, dryness, subtle learning problems Propranolol Valproate  Start slow 20 mg  Start slow 500 mg  Foggy, no exercise tolerance, depression, asthma  Hair loss, fogginess exacerbation 7

Verapamil New treatments for next 5 years  Start slow 40 mg  Magnet ( next 2 years)  Cefaly ( now)  Sphenocath (now)  Constipation , Orthostatic hypotension  Inhaled DHE (asthma inhaler)(??)  CGRP Monoclonal Antibody (5 years) (game changer) Magnet Cefaly Video  <iframe width="560" height="315" src=https://www.youtube.com/embed/0Rh3btp7Rx w  frameborder="0" allowfullscreen></iframe> Spenocath Inhaled DHE 8

CGRP monocloncal antibody Summary  Diagnosis Easy  Stratified Care  Use Triptans Early and Often  Get comfortable with a triptan and two prevention meds  Refer when not sure 9