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Paediatric headaches
Mark Weatherall
London Headache Centre
2010
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Why is this important?
Headaches are common in children
Headaches often cause significantdisability
affects home life & school performance
affects family relationships
affects relationships with peers
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Why is this important?
Headaches in children are under-recognised, misdiagnosed, and under-
treated
Headaches may present differently inchildren
Accurate diagnosis and effective treatment
improve quality of life
prevent long-term disability & co-morbidity
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What headaches are we
talking about?
Migraine**with aura in 14-30%
Tension-type headache
Cluster headache
Other headaches
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Migraine
ICHD-II criteria (migraine without aura)
A recurrent headache disorder manifesting inattacks lasting 4-72 hours*. Typical
characteristics of the headache are unilaterallocation, 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
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Migraine
Difficulties in diagnosing migraine inchildren include:
shorter duration
more likely to be bilateral
difficulty in describing headache features andassociated symptoms
must often be inferred from behaviour/drawings
evolution of the semiology of headaches overtime
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Migraine
These difficulties are notconfined to thepaediatric population!
Study comparing physician diagnoses withICHD-II
4-72 hr duration: 61.9% met criteria
1-72 hr duration: 71.9% met criteria
including bilaterality & other features such asdifficulty thinking, light-headedness & fatigue:
88.4% met criteria
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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
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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%
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Headaches are common
Subgroup analysis of adolescents (12-17yr)
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%
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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
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Headaches are common
Meta-analysis of paediatric headachestudies 2002 by AAN group
>27 000 children
37-51% significant HA by age 7 yrs
57-82% significant HA by age 15 yrs
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Impact of headaches
Children with migraine lose on average 1weeks of school per year
Impact can be assessed using validatedtools
PedMIDAS
PedQL
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Treatment
Accurate diagnosis
Comprehensive treatment plan
Explanation (and reassurance)
Lifestyle advice
Acute treatments
Prophylactic treatments
Biobehavioural therapies
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Treatment
Accurate diagnosis
Underlying headache phenotype
What was the headache originallylike?
Triggers
Confounding factors
Medication overuse
Physical co-morbidities Psychological co-morbidities
Life stresses
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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
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Treatment
Acute treatment
Goals:
sustained pain freedom
rapid return to normal activity
OTC
small trials show ibuprofen (7.5-10 mg/kg) superiorto PCT + placebo
use early, at decent dose
avoid overuse (3 days/wk)
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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
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Treatment
Prophylactic treatments
pizotifen
beta-blockers
tricyclics
anticonvulsants
others
riboflavin (vitamin B2)* * recent negative small PCRCT!
coenzyme Q10
butterbur extract
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Prophylactic treatments
a paucity of evidence
Cochrane review 2003 found only two trialsconvincingly showing benefit of prophylactic
treatment
Propranolol
Flunarizine since then decent PCRCT for topiramate
recent negative PCRCT for SVP MR
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Treatment
Biobehavioural therapies
biofeedback
relaxation training
Treatment of co-morbidities
physical
sleep disorders
psychological
Counselling; family therapy
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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 begenerated in 1, 2, and 3care
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