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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
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 - - 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
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Sinus vs. Migraine
Pain over sinus can be due to firing of 2nd branch of
CN V
So… N/V/ photo/Phono/ relief with sleep/ Pallor
plus sinus tenderness :
MIGRAINE NOT SINUS
SN(O)OP: Red Flags
Systemic Symptoms Neurologic Symptoms Onset is abrupt (Older patient at onset for adults only) Previous Headache history is different
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
Treat attacks at first twinge Treat attacks with high doses of medication Don’t wait until sure it’s a migraine Involve school nurse and teacher
STEP VS STRATIFIED CARE
Start
Start
A B C A B C
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Acute Treatment
Analgesics: Aspirin, Acetaminophen, Ibuprofen,
Naproxen Sodium
Use higher doses!
Mixed drugs
Midrin, Fioriset, Esgic Gone out of favor risk of medication overuse
Adjunctive treatment
Antiemetics anxiolytics
5-HT Agonists
Route important Is there recurrence after dosing? Onset vs. duration
Dihydroergoatamine
Can be given IV , IN, (or inhaled)
Sumatriptan
Po, SQ, IN Multiple sizes give maximum flexibility Treximet- Imitrex 85 plus naproxen 500
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Zolmatriptan
PO, Melt and IN 2 po doses, but 1 IN dose
Eletriptan
Po only
Almotriptan
Pill only
Naratriptan and Frovatriptan
Slow in, long lasting May have a role in menstrual migraine prophylaxis May have role in bounce back headache
Rescue Meds
Have a role in Ed or Infusion Center setting IV MG IV Fluids IV Steroids IV DHE IV Metochlopromide IV Valproate Match intensity to severity More disabled- use triptans GET IT RIGHT FIRST TIME
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Initial Considerations
Match intensity to severity More disabled- use triptans GET IT RIGHT FIRST TIME
Preventative strategies
Avoid Triggers Assess Coping skills Assess Disability
Absenteeism Presenteeism
Prevention Approaches
Cognitive Behavioral Therapy Biofeedback Relaxation Hypnosis Acupuncture Medications
Prevention Drugs: Principles
Who needs them?
Absenteeism Presenteeism Disability after retraining proper use of triptans Start low and go slow Realistic expectations
Prevention drugs: Which to choose?
Pick drug you are familiar with Pick drug that will give an extra bonus Pick drug that will not exacerbate another problem Pick drug whose side effects will be tolerated by an INDIVIDUAL patient / family
Amitriptyline
Start low: 10 mg . Increase weekly ? EKG Weight gain, hard to wake up, dry mouth
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Cyproheptadine
Start low 4 mg Hard to wake up, weight gain
Gabapentin
Start low 900 mg Fuzzy sensorium, compliance a problem
Pregabalin
Start low, but move fast Brain fuzziness, weakness
Topiramate
Start slow 15-25 mg Weight loss, eye pain, dryness, subtle learning
problems
Propranolol
Start slow 20 mg Foggy, no exercise tolerance, depression, asthma
exacerbation
Valproate
Start slow 500 mg Hair loss, fogginess
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Verapamil
Start slow 40 mg Constipation , Orthostatic hypotension
New treatments for next 5 years
Magnet ( next 2 years) Cefaly ( now) Sphenocath (now) Inhaled DHE (asthma inhaler)(??) CGRP Monoclonal Antibody (5 years) (game
changer)
Magnet Cefaly Video
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Spenocath Inhaled DHE
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