Chapters Transcript Video Pediatric Headaches: Assessment and Treatment Options Thank you. Thank you. Uh It's interesting. I heard the the bell that warning bell to all come in and for a moment, I thought Santa Claus arrived. So, so I said, wow, I miss it. So, um in any case, what we're gonna do is uh talk about uh headache, how to assess the child who comes into your office, complaining about a headache. And also then what are our treatment options? Diagnostically? What needs to be done and then what are the treatment options? So let's see here. Um I'm not sure sure if people are showing disclosures, but the good news is I don't have anything to report the bad news. I don't have anything to report. So I just came here from clinic because I was in clinic starting at 8 30 I got done at 2 30. So no grants to buy time away from the office. Ok. I thought I'd start with this thing, but some of you may have seen it. I'd like to start on a light note. Can we click that on forward? Uh Hi, I'm hi, this is neurology. Returning a page. Mhm. Ok. So just so I understand you're consulting me because the patient has a brain and you don't understand it. No. No, no. That's ok. Uh, not everybody paid attention in med school. That's ok. Yeah. I'll tell you what, I'll let you know when I'm coming to see the patient you can join me and I'll show you what a physical exam looks like. Yeah. Oh. Oh. And if I see you checking reflexes with a stethoscope, I'm gonna beat you to death with it. Yeah. Ok. All right. Sorry about that. Oh, it's ok. I'm the new med student. Oh, welcome. Well, we got a couple of consoles to see this morning. Uh This one is from a doctor who forgot how to take a history and this one just says uh MRI is broken. Ok. Well, do you have everything you need? Yep. Ready to go. All right, let's go. And don't let other doctors push you around. They hate us because they ain't us. I always get a kick out of him and of course that one really cracked me up. His ones on neurology are quite, quite clever. So when I have some down time, that's what I've been doing. Looking at his videos. So let's talk a little bit about headache. You know, headache is incredibly important, not only in adults but definitely in pediatrics. It's the number one reason for referrals to pediatric neurology. You might guess that it would be epilepsy, seizures, that kind of stuff. It actually is not, uh, on a national basis. Really is headache and headache is seen. The numbers vary. Ok, quite a bit. Uh, generally it's estimated that 10% of the pediatric population suffers from headache. 1.5-1% has seizures. This is 10-20 times more common than our seizures. Um, most diagnosed headaches, it's a migraine is the key headache and you're gonna see we're really gonna focus on migraine because that really is what it's all about. Now, migraine comes in a lot of different ways, shapes and forms and oftentimes I like to explain to patients, it's kind of like buying a car right. There are Mercedes Benz and there's Kias and there's, you know, little tiny three wheel tricycles, but they're all vehicles, they all take you someplace. That's kind of how migraine is. You can get it with all the bells and the whistles or you can get it sort of just stripped down. It's not one of the top 10 diseases causing disability, 200,000 missed days of school per year and the financial impact for kids missing school, going to doctor's offices, buying drugs and parents missing work is significant. So it's obviously something that's definitely worthwhile knowing about and, and coping with to help these kids families and just patient flow through. Now, this is a video I wanna show you, I want you to listen to this boy's story and then we'll circle back to him So, so let's just pretend he just came to your office and he's gonna tell you his story. Can we click that forward, please? I want you to see us today. Well, I've been having these headaches for the past two weeks. What do your headaches feel like? Well, they've been squeezing on my head and my neck's been getting stiff. Is it more squeezing or more pounding? Both my neck keeps getting stiff. How bad are the headaches? Well, they usually last for about a day or so. Are they getting worse or staying the same? They're, they're getting worse. How long do the headaches usually last? They usually last for about till the afternoon. But then, and they say on the same day they go away and then they come back again. How often do you get them? Well, I get them about every day or so. Uh, have your headaches changed over the last two weeks since you've been getting them? Yeah, they've been, they've been getting a whole lot worse. Uh, what makes them worse? Well, I've been coughing and moving a lot and that may and when I move a lot that makes it so it hurts a lot more. Any medicines help your headaches. I've tried Advil and that doesn't work. Does light or sound bother your, your headaches? No, they haven't. Mhm. Do you ever, ever have any problem with your eyes or funny shapes or lights or before your headache comes on? Well, I get fuzzy vision and that lasted, uh, one time I got fuzzy vision and that lasted for about a minute or two. And that really freaked me out. Um, do you have any other symptoms with your headaches? I've been seeing double vision and other things. Have you had to go see a doctor for these headaches? And I went to the emergency department and they gave me a cat scan but they said that was, did anybody else in your family get headaches? Mm. No, not that I know of. Um, are you in pretty good health otherwise? Yeah, pretty good. I had these skin things and I've been given the skin medication and it's really been helping me, your mom that you're taking some thyroid medicine. Yeah, that was giving me to me by my dermatologist. Ok. I think we could probably say that wasn't given to him by his dermatologist. Right. I don't know, a dermatologist out there prescribing thyroid supplements. Um, in any case. So, um, I'm gonna circle back to him. I just kind of want you to sit and let that percolate. You know, that's the kid. What would you do? How would you approach it when we approach headache him, for example, or any child who comes in the differential is what is called primary versus secondary. All headaches can be broken into two primary versus secondary, secondary are obviously secondary to something going on. Ok. And the one that we always think about our tumors, of course, but increased endo cranial pressure, uh hemorrhages infection. And the other one that's really super important. I try to tell my students and residents, even though I haven't had a lot of them that come in with the chief complaint of headache is hypertension. Uh That's a really important one and it is absolutely mandatory in the, in our headache clinic that all kids get their blood pressure taken to make sure that that's not a factor. If it's not a secondary headache, then what we're talking about are primary headaches and primary headaches as we'll talk about in a second is a spectrum. It includes things like migraine, it includes things like tension, it includes things like chronic daily headache. So how do we take a young man who just presented his story and say, ok, which way are we turning here? Do we do C T scans and MRI scans and everyone who walks through the door contrary to what may happen in emergency departments? No, actually we don't. Ok. We start to figure out who needs scans and who doesn't need scans based on some old technique called history and physical. Ok. Uh I know, I know, I know it's really stretching back, you know, not the day and age of every instantly uh texting the doctor Google and all that sort of stuff, but taking a history, listen to that boy's story and we're gonna go over the features in that story, which are gonna make you lean towards primary versus secondary and then we'll go over those features in the examination which then solidify whether this is primary or secondary. If you believe this is a secondary headache, then obviously, you're gonna need to do some imaging, at least with M R or C T. So how do we do that? Well, historically, when you look at the pertinent questions, you wanna look at, first of all, the pattern of the headache, is this a headache that kind of comes and goes? You know, I had a headache last week, then I was absolutely fine. Had a headache this morning. Now, you know, tomorrow will be great and this is just a pattern of come and go. Ok. And I think all of us recognize that this come and go headache, especially spanned over time is pretty characteristic of what we tend to call migraine or you can have a headache that's just there every single day. It's going on all the time. Some days are worse than others, but it's there all the time, uh, a pattern that we tend to call chronic daily headache and usually chronic daily headache began as intermittent headache or just recurrent headache and then it morphed into it, kind of built up the tempo. And so now I got a headache every single day. Today is a two, yesterday was an eight, you know, that kind of a thing. And those are tough kids usually seen in the adolescent population. Very un uncommon to see that prior to, uh, adolescence, then you have the story of my headache is getting worse. Ok. No, it's, it was bad yesterday and it's worse today and last week it wasn't that bad. It's every day it's progressively getting worse. And that's something that we're concerned about a progressive process going on within the C N S such as increased endocrinal pressure, increased endocrinal pressure can come from obviously tumors or what about pseudotumor or what they call now? Uh idiopathic increased, uh intracranial hypertension. The next question is, how long has this been going on? Ok. Acute processes usually declare themselves with other signs and symptoms and the, the magic marker is usually six months if a headache has been going on for longer than six months. And there are no other warning facts in the history and there's nothing else on examination. The fun don't show papilloma the odds that this thing is a secondary headache is close to zero. Ok. So six months is my magic mark mom. How long's uh Johnny been having headaches? Uh They've been going on for about a year. Ok. You're going on for a year. The examination is normal. You're talking about a primary headache location. I think all of us heard in medical school, migraine kind of pounding on the side. Well, that's true in an adult. Ok, because that's what medical school teaches. You about adults in kids. That's not true in kids, it's frontal, ok. It's usually bilateral frontal and then it may swing onto the side. But, but this is where you have to, is to say where it hurt and they kind of go like this. Ok. Right on their forehead. In fact, I have this little epic note that kind of defaults so I can get through my epic char and quick. And my note actually defaults to frontal. If, if the kid doesn't have frontal, I have to go in and change it. But that's how common frontal is with migraine. Um posterior headaches, all the headaches are in the back of the head, they're getting worse again. Worrisome sign the quality migraine tends to be throbbing. Ok. But kids have a hard time describing it, especially if they're pre pubertal. It's really difficult. You know, you say, what's it feel like? Always tell the kids what's it feel like? Does it feel like a pounding? Does it feel like a stabbing? Does it feel like a squeezing or someone sitting on your head and they look at me and they go, it just hurts? Ok. I got it. We're not pushing this any further. Ok. It hurts. Ok. Um When they get a little older, then they can start expanding, it does feel like a throbbing or a pulsing or something along that lines. Time of day, migraine, primary headache can happen any time of day, the day the night. I think we all heard. If something wakes you up in the middle of the night, let's get worried about it. Well, if something wakes you up in the middle of night, my question is what time? Ok. The most common cause of waking up in the middle of night at one or two in the morning is migraine. Ok. But if you're waking up at 456, waking up in the morning with a headache, that's a worrisome sign usually indicates increased endocrinal pressure. In terms of the frequency and the duration that oftentimes helps you figure out what, how you wanna treat the headache. If they're once in a blue moon, then a board of therapy may be fine. If they're all the time then or frequent, then prophylactic therapy is gonna be um warranted. What about nausea? Vomiting? Ok. Headache and migraine, as you know, very frequently is associated with nausea and patients can vomit. Patients with increased endocrinal pressure, can vomit, ok, due to the pressure on the low brain stem, but they tend not to be nauseous. Ok. So the nausea is greater than the vomiting for primary headache and vomiting without much nausea. For secondary headache. Double vision is seen with increased endocrinal pressure. Aura, visual auras are seen with uh migraine and then last but not least photo and phonophobia. Uh very frequent concomitant with migraine, not seen with um secondary headache. So just based on these facts alone and the history that that young man gave. Ok. I wanna take a poll in the room. Ok. Uh How many think this young man has a, has a primary headache disorder? Ok. A few. How many believe he has a secondary headache disorder? Ok. A few more. Ok. All right. Now we're gonna talk about the exam on the neurologic examination. Ok. I mean, you all remember the neurologic examination from medical school and residency, you know, serial sevens, every cranial nerve in the body and 5/5 strength, all that kind of stuff. Skip it. OK. The examination for migraine is super easy. With one exception, that's the very first point. You gotta look in the back of the eye. OK? And you really, really, really, I stress the importance with the residents and even the students uh like the one I had just a few hours ago how to look in the back of the eye and to look for papilloma. I'm not gonna refract the patient. I'm not gonna tell them that they, they need a new prescription. I just want to know is there Papaloma or not like a young lady who we had today who had increased endo cranial pressure? Ok. So that's numero uno obviously, if there's papilloma, we have to be highly, highly suspicious of increased endocrinal pressure and possibly a secondary headache. Double vision double vision occurs because of increased endocrinal pressure and pressure on the six the nerve. Ok. Sick nerve is one of the longest cranial nerves in the head and easily stretched and tweaked with increased pressure. And so you develop double vision, ok? Hemi para, OK? You can do the formal exam that you learned years ago in medical school, checking in all these muscles for 5/5 strength or you can do something super simple. You have the patient hold their hands out in front of them and you just have them hold them out there. And I tell the kids just hold your hands out there like you're holding a pizza and just have them hold it out there for 20, 30 seconds. What are you looking for? You're looking for what we call a pronator drift? Ok. The earliest signs of weakness is a pronator drift. And of course, then you'll drop, obviously, if it's profound, they won't even be able to lift it up, but this will pick up a very subtle weakness, very powerful screening technique. Um Then the other thing I have them do is walk, walk a straight line looking for a tax. I have all the kids stand on one ft. Uh As many of, you know, when you're five years old, you can stand on one ft for five seconds. When you're six years old, you can stand on one ft for 10 seconds. So my screening technique, even if the kid is 16, stand on one ft and then I'm sitting there 123 count. In 10 seconds. Ok. Uh And that's my screening and then abnormal reflexes. Ok? If those are normal, OK. We are talking about a normal neurologic examination and that this is a primary headache on our young friend whose video we saw, remember he was complaining a lot of double vision and I don't know if you noticed in the movie but a lot of time the, the, the, the uh interviewer was right in front of the kid. OK? And a lot of times the kid was like this, he was had his head turned and he was talking to doctor Lewis like this. OK? Um The reason he was doing that because if he looked straight at Doctor Lewis, he saw two Doctor Lewis by finding the null point which is way over here, the the image is fused and he saw one, he clearly that's a sign obviously of double vision. If we, if they asked him, did you see double right now? He'd probably say yes. OK. The other thing that was confusing, he's talked about this thing called um I got fuzzy vision. He told the emergency department. Yeah, I had this episode where I had fuzzy vision. Well, they said, oh, fuzzy vision, that must be your aura. Therefore, you must have migraine. And parenthetically his mother had migraine. And when she brought him into the clinic, she said, I think my son has migraine like I do because they said he has an aura with the fuzzy vision. Well, he didn't have an aura that wasn't fuzzy vision, that was called visual obscuration. And what that's due to is increased endocrine pressure, compressing the op nerve and compressing the ophthalmic uh artery feeding the nerve and it is transient retinal ischemia. Ok. And then all of a sudden when you get ischemia of the retina, your vision dims, right? And you kind of lose vision for a while and then it comes back. OK? And that is a sign of increasing your crow pressure. So our young friend who we heard this history clearly had signs and symptoms of a secondary headache. Uh he had AC T scan, which was normal. OK. But that doesn't mean he doesn't have increased in endocrine pressure. You noticed he was on uh a thyroid supplement by his dermatologist, right? Uh He was also on some acne medicine and he also was a generous size with a slightly high uh B M I. So he had a set up for uh pseudo tumor and lo and behold, he had an LP and that's exactly what he had. So he is a nice example of a secondary headache because he hit all of those bells and whistles. And when it came to the exam, he had diplopia and papilloma. OK. And so clearly from that off, he goes to imaging which he had the next step. LP. OK. This is um some recommendations, obtaining a scan on a routine basis is not indicated in Children with recurrent headaches and a normal examination. Again, the examination is really easy. It's what I just showed you on the previous slide. Neuroimaging should be considered if there had been a recent change in the severity of the headache. Yeah, it's getting worse. Now it's getting worse every day. It's getting worse change in the headache quality or the frequency. Yeah, it's getting worse again. Um, abnormal neurologic examination goes without saying. And interestingly enough, they also put on their coexistence of seizures. Seizures usually implies some sort of cortical irritation or brain irritation. And so you can see if you're having headaches and you're also having seizures. Is there something in there that shouldn't be in there that's irritating the cortex and causing both seizures and headaches. So, those are kind of the criteria they've been put forth for neuroimaging studies. Oops, let me go back one. Ok. So what I'm gonna do now is focus on primary headache because this is where the money is. At most of the kids. I see lots of kids with headaches because I kinda like headaches. And so everyone who doesn't like headaches send them to me. Uh, so I got a huge collection of headaches that come in on a weekly basis. Um, and most of my practice is focused on primary headache. I am operating in this clinical spectrum right here and this is a clinical spectrum. Ok. Um, it's not like Oh, I only have migraine headaches and I never have quote tension or I only have quote tension and never have migraine. There's a very well known, uh, if you will headache ologist, uh, adult neurologist up in Philadelphia at Tom Jeff Thomas Jefferson University. And by the name of Steve Silberstein, he writes quite a bit about, uh migraine and migraine management and treatment and I was at a meeting with him one time and he said there's no such thing as tension. OK? He said it's just a stripped down version of migraine. He says it's not at a, at a big meeting. And there's some truth to that because the pain pathways, whether you have tension headache or whether you have migraine headache are still kind of the mediated by the fifth cranial nerve in the trigeminal system, which is the kind of the, the pain perception system for uh the head and neck. Ok. So we have on one end of the spectrum, what we used to call in the old days, classic migraine. Now we call that migraine with aura. Then there's what we used to call in the old days, common migraine, which is uh now called just migraine without a and then you run into chronic daily headache, which by definition means that you have 15 days or more per month with headache for three months or more. So that's the formal uh I CD nine definition rebound and then tension. OK. OK. This is I like this. This is from uh Jerry Fell's book, uh Clinical Pediatric Neurology Signs and Symptoms approach. Now, this is an old version. He believe it or not, he's up to the ninth version. Now, uh Jerry's passed away, but his um pupils have taken on keeping his book moving forward. Uh And I haven't got the most recent one to see if the same lines there. But for the first five editions, when you looked up migraine headache in Jerry's book, he would say one of the few remaining neurologic disorders in which the physician cannot stumble. I love the, I love the word. Stumble on the diagnosis by imaging the brain. He said the way you make the diagnosis of migraine is with the history, history, history, family, history and associations, things like photosensitivity, phonophobia, nausea. So looking for those things extremely important and that's the clincher for migraine, not an MRI scan, which is normal, the international classification of headache disorders. Uh in 2013, put through formal criteria for childhood migraine without aura. And again, this is the quote unquote common migraine. And it's important to know that in the world of migraine, whether you're talking about Children or whether you're talking about adult auras exist in 20%. OK? 80% of people with migraine do not have aura. Uh So this, I put this one here because this is what we tend to see a lot. It means you have recurrent headaches and you have to have any two of the following four features. Notice again, this is for kids, bilateral or unilateral, frontal or temporal. Ok. Throbbin or pul which you may or may not get depending upon how um sophisticated the, the the patient is moderate or severe intensity. Well, if you're actually seeking time to see a physician, it's probably at least moderate and aggravated by physical activity. I mean, do they go out and ride their BMX or skateboard or roller skate or do they go into a dark room and turn off the lights and put a pillow over their head? Ok. So, physical activity, what do they do with it when they get a bad headache? And then any one of the two following, which would include nausea and, or vomiting and photo and, or phonophobia. So, pretty easy when you look for those features in the history, pretty easy to make a diagnosis of migraine. Ok. So what about migraine? Let's talk a little bit about the path of physiology so that we can then understand how to treat it, right? So, the diagnosis pretty straightforward. Now, let's talk about a little of the path of fizz. This is a genetic disorder. Ok. The vast majority of these kids, I asked the moms say, well, who else has headache? And you know, more than likely moms could say, oh, well, I have migraine or my mother had a migraine or my sister gets really bad headaches. I always ask the question who in the family has headaches? I don't ask who has migraine because a lot of people don't really understand what migraine is. So, I just wanna know someone who's having headaches. I've had. Mom said no, no one has migraine in our family. You've never had a headache? Mom? Well, yeah, I get them with my cycle. But that's it. Well, guess what that's called menstrual migraine. Ok. So you, we have to get away from people assuming they really know and understand migraine and just say, what about headaches? Who, who all in the family and more than likely you're gonna always find someone and if I really have to push it hard, I said, what about the dog? Does a dog complain of headaches? I mean, someone to give me a, give me a, throw me a bone here, huh? But it's very high to get that and what the genetic tendency is. And for certain types, especially the, the complicated hemiplegic migraines, we actually have the genes, they're actually channelopathy. Ok. Uh, so it's not for all of them, but we do have some gene markers for some of the headaches. So, we clearly know there's gene genetic basis here. And so what is this genetic basis? Doing? Well, it's, it's instilling sensitivity. The brain is more sensitive and these individuals to tweak that circuit that I'm gonna show you in a second and causes the pain. Ok. And so there are a lot of things that can tweak the circuit, right? All of these things here can be it triggers for people who have migraine. Um The biggest one for people just in general is stress and the biggest stress for kids is school. There's no surprise that during the school year, the incidence of the headaches goes up, summer comes the incidence of the headache goes down. Ok. Yeah, that just ebbs and flows that way. And you just say, yeah, that's a pattern that we see with Children with migraine is reinforced. That's it. But that doesn't mean that, you know, dismisses it. It's still how we're gonna deal with this. Ok. Um Also hormonal, why is it that in young Children migraine is more common in boys, less than say 12 years of age. Then soon as you hit puberty, boys kind of average out maybe improve a little bit. Girls take off like a rocket and then 20% of young women, ok, have migraine in the adult world. 20 of young women have migraine. And then later on in life, the incidence of migraine in those women drops down to the incidence of men. Well, clearly it's there's hormonal influences. We, we definitely know that. So that doesn't mean you can make them go away. That's just part of life. But understanding this and explaining it to the families can actually take you quite a long way. They uh I I get it now. OK. OK. Last but not least is what about the migraine pain? Well, the migraine pain circuit is this one right here. OK. So it's this trigeminal circuit. So here's the trigeminal uh nua in the brain stem, there's the inner innervation to the meningeal blood vessels. Then there's the feedback back into this is the trigeminal nerve right here. The feedback into this trigeminal system. OK. If this gets tweaked and out of sorts, then this system here gets triggered to cause migraine perception which runs up and then spreads throughout. But it, these blood vessels, what happen here is they get destabilized and they become, they vasodilate as many of you recognize from old teachings. But the reason they vasodilate is because of central causes not just because their blood vessels behaving badly. Ok. So all of a sudden these leaky blood vessels leak out noxious things like C G R P or uh cap 38. OK. So there's all these no noxious polypeptides that get sent out that cause pain and then that signal gets sent back in. Now, it's interesting to note that um one of the things that can stabilize that circuit is serotonin. Ok. So, serotonin stabilizes these, these dilated blood vessels that are leaking and causes vehicles of constriction. It inhibits neuronal uh transmission in the brain stem and also the feedback into the brain stem. So, serotonin is a very important mediator and stabilizer of this circuit isn't it interesting that Triptans IMAX max salt packs. All of these Triptans are all serotonin agonist. And the reason they're serotonin egos because they're acting on this system to try to reestablish um a balance. Ok. Now, enter into the, let's, let's come to the modern days. That's all old stuff. Um What about calcitonin gene related pet? This is the hottest ticket item out there, especially in the adult world in the pediatric world. I'm talking to you about it. Unfortunately, all this stuff is off label. All of the stuff is not FDA approved. Ok. But I think we need to know about because the future is here. OK. With C G R PC G R P has been found, it's a neuropeptide, OK? And it's found as you can read here, it's releasing results in vasodilation. Now, we already said vaso dilatation is a bad guy and neurogenic inflammation. Ok? And these things, these receptors are all over within that that pathway and they've measured C G R P levels which go up in migraine intact and actually infusion of C G R P will precipitate a migraine uh in migraine prone patients. So C G R P is gigantically important and the regulator for C G R P. Guess what? Serotonin. Ok. So serotonin can kind of regulate the release of C G R P. So now all of a sudden all these pieces are starting to come together as we as kind of modern science molecular biology, you know, neuro inflammatory peptides are all slowly understood. So now we recognize that migraine really is a disease of the brain and the balance within the hypothalamus and the trigeminal system, vasoactive neuropeptide such as C G R P substance P this pac 38. Ok. Um uh which is another neuroactive peptide. All of these things get released, they cause inflammation and pain perception and they're all regulated by serotonin. As you see in the last bullet, uh serotonin inhibits the trigeminal nerve and vaso constricts, the blood vessel. So it stabilizes this neuropeptide war that's happened during a migraine attack. So with all of that, so that's a path of physiology. Now, what can we do from a therapeutic standpoint? Well, we have to understand that migraines come, you know, once in a blue moon having them every day. And obviously, the approach is gonna be different, right? So if you're having them, you know, once in a while, a board of therapy is perfectly fine. Uh and a board of therapy may be as simple as over the counter medications. There's a lot of studies out there that show that Ibuprofen and Tylenol work quite well for childhood migraine. Ok. Obviously, the ones that come to see us don't but, but a lot of kids are moms are self medicating the kids and taking care of it. On the other hand, if the kids are starting to have more than two headaches a week then we're starting to talk about maybe a significant impact. How well can the child continue to go to school? How well can the parents take off work or take them to the doctor? There's now starting to become an impact. And it's generally suggested that once in the adult world, believe it or not, if you're having one or more headaches a week, they suggest you go on prophylactic medication for us. It's usually we put it at somewhere around two and a lot of times, you know, they're not as severe as it is in the adult. And what we look at is what's called the headache burden. And the burden is not just the frequency but it's also severity. So, you know, I have kids coming in, they have, you know, three or four headaches a week but on a scale of 0 to 10, the pain scale, you know, they're kind of like two or three. It doesn't really bother them that much. They can kinda, you know, manage it themselves. Um, ok. So that has an impact, probably moderate. But you can also have a child who has maybe two headaches a week but the headache lasts for three days. They're on their back, they can't go to school, they're off to the, er, that has a little bit more of an impact. So we have to factor in not only the frequency but also how severe it is. Ok. So how do you, what are the tools in our tool belt. OK. I want to show all these so I wanna make a comment. Uh Hopefully we'll have enough time to make a comment on all of these as well because these are important to bear in mind. I mean, as physicians, I think, you know, the first thing you, you talk about a disorder, a disease, first thing you run to is ok. What drug do I use? You know, where do you want me to send this to CV S Walmart Walgreens? Ok. We gotta remember that's one avenue of approach pharmacologic therapy. But there are other approaches including behavioral therapies, relaxation, cognitive behavioral therapy, herbal supplements. This is a biggie in my clinic. Every kid that comes in for headache gets started on a supplement and I'll talk to you about that in a second. And of course, then there are the physical therapies. Ok. Um Probably the big one in the adult world is Botox. Now, that's a hard one for us to get in pediatrics because it's not Botox is approved in kids for cerebral palsy and you know, dystonia, believe it or not, it's not approved for headache, it is in adults but not in kids. So there are some things acupuncture, there's a couple of other things we'll touch on just quickly there. But I first wanna uh talk about the traditional pharmacology. Oops, I'm not sure what I did here. Oh, there we go. So in the world of traditional pharmacology. There's the acute management. Ok. What do I do? I got a headache right now. And doc, prophylactic therapy, doc, I get a lot of headaches. What are you gonna do about this? Ok. Um, and in the world of acute therapy they're analgesics, right? And the most common ones are obviously the O T CS, there's anti medics. I think we're all familiar with Fenner and actually the role that Fenner may have not just as an anti uh uh a medic, but also as a dopa agonist and it affecting that whole pathway of pain. And then there's the abortive treatments and an abortive. I'm talking about our trip fans, then there's prophylaxis. So in the world of analgesics, I think you're all familiar with Tylenol, Ibuprofen, Napro tool, gotta be careful with it, but it can actually work quite well for acute migraine. Then there's the other things that are below that line, the fin, the codeines, the Demerol, the oxy, the more obviously things we wanna stay away from. Ok. Not a big fan of fin you had its flair, especially in the adult world in the past. Uh There's one kid that I have on it um because it seems to help her and the mom's absolutely convinced it helped her and she really basically wouldn't leave the office unless I gave her and I said, ok, fine. Um but generally stay away from things uh under the red dots um and like I said, there's plenty of evidence to support the use of Tylenol and Ibuprofen. One of the things that we tend to do is we tend to underdose Children. Ok. So I had a kid today who uh has migraine and mom was treating him with Ibuprofen. And um he was a big guy. He's kind of a chunky guy. He weighed 33 kg and she was giving him 200 mg of Ibuprofen. And, and she said, well, that's what the, the back of the um bottle says on the, on the uh children's. I said, well, you know, if you 10 milligram per kilo, Ibuprofen, a guy who weighs 33 kg, he should be taking more than that. He should be taking 300 mg. So when you do use these substance, make sure you're given appropriate and I just use 10 per kilo with uh for any of the O T CS makes it super easy. Um And, and, and make sure they're getting enough. I mean, I always tell him, I said, look, if you were complaining about a headache and he gave you a baby aspirin and you said it didn't work. Would you say aspirin doesn't work? You'd say no man, give me more. So same thing here with kids. Let's be sure we dose them appropriately based on their weight, not just with the back of um you know, the box says, OK, now what about the trip cans. So those are, those are your O T C analgesics. What about trip downs? Again? We talked about the trip cans being serotonin and agonous. Ok. It works on the nerves and the blood vessels to stabilize things. We already talked about the fact that it constricts the blood vessels so they stop leaking. Ok. It stops the kind of the transmission within the brain stem. We tend not to use trip dance because of the vasoconstrictive effect. We tend not to use um the trip dances in complicated migraine such as hemiplegic migraine. Um because of the concern that this could lead to a stroke, but those are really uncommon in kids. And so it's really not much of an issue. One of the things that you may have heard in the past and it's under fiction here. OK. Um Is that uh there's an increased risk of the serotonin syndrome when you use uh a trip tan with an S S R I or an S N R I fact it's false. OK. That is fiction. And uh there's a little um disclaimer there which kind of kind of supports that. So that was a big thing, especially when the Trip Dance came out. Oh, my gosh, don't use it with anyone on S S R I. Well, I don't know about your clinic but in my clinic, everyone's on an S S R I, including the faculty and staff. OK. Oh, you've worked at M US. C too, huh? Ok. So the Triptans, there's a whole slew of them, right? Every one of us is familiar with, obviously Suma Triptan, which is the oldest one or IMAX. Then there's a Z or Z. The other one that's real popular here is R Triptan or Max. So Rhiza Trip trip and I have the shortest half life. Uh They also come in pediatric friendly forms. Um So they're easy to give to kids. Intermediate ones include a merge and rack uh rail packs and then long acting ones. Uh you include um uh frova and actually emerge is a longer acting one Aerts one that's intermediate. But in any case, we tend not to use those in kids because most kids have relatively short uh duration to their headaches. Um Also once you start using things other than Sumatriptan or Rhiza Trip, you're gonna start to get into problems with insurance. Ok. Treatment with trip. Hands. Are there side effects? Yeah, there can be a little bit of side effects but they're relatively short lived. Ok. Some the most common one is you can kind of feel uh flush in the face. Um Occasionally it's more common in adults get a little tight in your chest. Um Kids tolerate these things real well. Actually, probably the most common side effect that I get including the side effect. I got just a few two hours ago from a kid is it knocks me out. They're not supposed to really make you that sleepy. But I got a lot of kids come in while I take it, it just knocks me out. I fall asleep and then when I wake up, my headache is gone. Ok. That's fine. You know, sleep and rest is one of the treatments that we use contra indicated. If you have uncontrolled hypertension, that's one area that I really back off on again. Another super important reason to take the blood pressure of anyone with headaches, whether they're new patient or a return patient and heart disease. I look at that, uh, pretty carefully as well and the complicated headaches already talked about hemiplegic. We tend not to go there but even with Basler or some of these funny sort of, we, we kind of rethink. It doesn't mean I necessarily wouldn't go there, but I definitely wouldn't just recommend it across the board. Ok. So that's the acute management. I think you're probably all pretty well familiar with how to acutely manage the headaches. What about prevention? Well, there's a lot of things on this list here. Does anyone know, um, what the oldest medication that's been used? Oldest medication that was first used for the treatment of migraine or headaches in Children? What's that? No, before propranolol. What's that Perry Acton older than that? Gunshot to the head? I'll take care of it. Um, uh, PHENobarbital, PHENobarbital, if you go back to old textbooks on neurology and you look at pediatric migraine PHENobarbital was a treatment. Isn't that interesting? PHENobarbital? And guess what we use tend to use nowadays to pyro. Isn't that interesting? We can also use valproic acid. Isn't that interesting? We also can use gabapentin. All of those drugs are anti epileptic drugs, right. That's how they first got marketed. Is there a relationship between migraine and epilepsy? The answer is yes. Ok. And so a lot of the uh drugs that came out for treating epilepsy kind of crossed over Topamax is classic. It came out, it was being pushed big league for the treatment of epilepsy. And the next thing better than sliced bread, right? Uh I remember going to conferences where they're pushing this stuff and um all of a sudden one time it started creeping out, hey, this stuff may be pretty good with headache. Well, guess what more Topamax is used and prescribed nowadays for headache than for seizures because it's a great uh headache drug. It's OK for seizures and I'm not a big fan of it, but I use a heck of a lot of it for headaches. So, um it's interesting how antiepileptics which started out with PHENobarbital. And then all of a sudden we circle back and we're using antiepileptics, but other things are on this list. Cypert was mentioned and actually can work quite well in young Children. I'm a fan of cy heine and little kids. Um Propranolol is has been used uh successfully. The big problem with propranolol is that, you know, it has a slight increase increase in, uh, depression and we got enough depressed kids out there also. It can slow down on your physical tolerance. And we want a kid keeps kids active and out there running, burning off calories, not, you know, sitting inside eating Twinkies. Ok. So, um, do I use propranolol? Yeah, occasionally. But my big that I use are the antiepileptics which is mainly to pyro and then the tricyclics. Ok. Although I've really moved away from the tricyclics. I used to use a lot of them. I used to use a lot of ale. I really, I am leaning a lot more towards uh toy. Ok. Calcium channel blockers are pretty big in the adult world. There's a lot of good literature on flura which is a calcium channel blocker and pediatric migraine. The problem is the drug is not um approved in the United States. You can't get it here. Um So the closest thing we have to it is uh pneumo. Um I haven't had a whole lot of luck. The only, the only, the only headache uh form that I use a calcium channel blocker on routinely is hemiplegic migraine because the most common cause of hemiplegic migraine is a calcium channel uh defect. Ok. And so I will use it in that situation. But otherwise I'm sort of in the tricyclics and antiepileptics. Occasionally. Cypert. So can be quite effective. But the biggest problem with it is weight gain and it's very sedating. It also has a relatively short half life. So, it's a drug which only last in your system about eight hours. Right. And so people are saying in here take this at night and you only have to take it at night and won't make you sleep in the day. But it also is not working during the day. Right. So, it's, uh, when you think about the pharmacology of it um to use it properly, you need to do at least B ID. Um And theoretically T ID, but that's almost impossible for everyone. OK. Let's see if we can make this go forward there. We are. OK? So now I want to talk about C G R P blockers because this is, this is where it's at and for any of you in the room who do have headaches, you're probably on these C G R P blockers. The first one to get approved was in May of 2018 something by a trade name called uh A. OK. Uh And this is AC G R P receptor blocker because it's a monoclonal antibody. And what you do is you get a monthly injection. These are little um self injecting things. It's like everything you see nowadays on TV, everything has a monoclonal antibody. I mean, I was just in the the room uh next door where the vendors are and there is uh a monoclonal antibody for R S V as it blew my mind. So I, I hadn't heard of that one, but in any case, the point is is that there are a number of these monoclonal antibodies out there. Um A and I is probably the other one you may have seen advertised on TV. They work really well. I just had a kid two days ago who was able to get because his mom's a nurse and she works for, um, a family doc who gets lots of free samples as pediatricians. We don't get free anything. Um, so, you know, I couldn't give it out if I had it. But he, um, he's mom brings it home for him and he gets him, he went from daily headaches the last three months to no headaches for the past two weeks. Uh, it, it was dramatic. Um, so these things work super well and I think in the adult world I, I listen to a lot of what's going on in the adult world. These are hot topics. We just need to know about them. They're not available for most kids because you have to be 18 or older. If you want to pay for this stuff out of pocket, it runs $700 a month. Ok. For one injection. Some of them actually cost 1000 bucks a month. So very expensive. So there are four of them now out there. They, they work great. I can't say much more about them. There was a second dot down is a is superior. In a study, aig was superior to toy when studied directly for a adherence, efficacy and tolerability. And it's interesting, the long term study looking at toy, a lot of people just got tired of it. They got tired of the side effects and they got themselves off of it where these things have a very low side effect profile. There are new oral agents out there which also work at the C G R P. They're called G pants. OK. So you bro pant. Uh The biggest one is probably a re that's also goes under the name of Nerc may have seen that advertised on TV. OK. Nerd Tech is an interesting one because it can be used acutely like IMAX or you can use it every other day as a preventative. OK. Um I don't have a lot of experience with this because again, it's not sanctioned under 18. Um but I think the future is out there in this realm of medication. Ok. So we got just a few minutes left. I wanna kind of polish off here. That's kind of traditional pharmacology where we're at and where I think we're going in the next year or two or three. Um So I wanna next look at herbals and supplements. OK. We are, we meaning me are a big fan of supplements and the big one that I like is a riboflavin. OK. Vitamin B two and the other one which is kind of up there with it is magnesium. Ok? And as I always tell my patients and as my students and residents get nauseated every time I open my mouth about this, two of my nurses in my North Charleston office, that's all they're on for their recurrent headaches and they swear by it. Ok. I've had lots of success and luck with the uh, supplementation. This is megavitamin therapy. Ok. So you start at 100 to 400 mg. Ok. Um, my nurses are 200 but they're kind of petite. I think most kids should be 100 if they're before 10, 200 if they're kind of 10 to 15, 300 if they're 15 and if they're a middle linebacker, 400. Ok. So, um, you can use, this is megavitamin therapy. It works really well. There is this stuff here called Micro leaf. Um, I'm not pushing it but I have been using it a lot in the clinic because it's kind of one stop shopping. It has riboflavin magnesium and then it has an herbal in it. Fever. Few. Ok. And the roll of fever for you, we can always discuss but uh that's not really why I use it. I use it because of the magnesium and the riboflavin. This is a pediatric form. There is an adult form that's been out for years. They then came out with this pediatric form which actually is a little bit more palatable for the kids to take. And it's usually two tabs. Once a day, the bottles, say twice a day. But again, it's a supplement so you can just do it once a day. Two tablets. Um, I use a lot of this now. It's on Amazon. Uh, easy to buy. I had a lady today I was talking about it. She picked up her phone and before I'd finished all my sentences, she goes, I have it come to me on Amazon. Ok. Can't, it can have better impact than that, right? The only thing I wish I got is a kickback from the company, but I don't. So that would, I'd have to disclose that though. So I wanna be pure. Um ok, so that's the herbals and supplements. I think the bottom line Ribo flavor magnesium. Every kid with headache comes in and sees me, they get that. They get that spiel. Then if it's more severe than that, then we talk about traditional pharmacology. What are our other options that are out there? Well, I mentioned uh physical therapies. Botox is the biggie in the adult world is hard to pull off in the P D world. There are a number of neuromodulatory uh devices that work on stimulating um the uh the uh peripheral nerves um and they kind of look kind of cool. They kinda sort of work. Um I'm not convinced of the efficacy. The one that's been around the most is the top one. The Phalle I'm gonna skip the next slide. This just talks about Botox but the bottom line is Botox does work. Ok. Um Definitely for chronic headache, definitely for tension headache, definitely in the adult. Um and in the kids, um I think it has a lot of promise. These are the neuromodulatory advice. My favorite is uh phal because it makes the kids look like wonder woman. Um I think that's pretty cool. This is a vagal nerve stimulator where they're stimulating the Vegas nerve. Uh This one just came out. Uh This company is pushing this like a cheap coat. Um So there are a number of these things out there. They're still kind of being searched at, they're um expensive. The Phal is about 300 bucks for the unit. OK. This one you need to renew packs. Uh So they're not exactly super cheap. Uh Again, this is kind of more of last resort and then last, but not least are the behavioral treatments. And I think the big one here is cognitive behavioral therapy. OK. Um There are a lot of biofeedback techniques that can be effective, but the most important one is bio um cognitive behavioral therapy. We I send a lot of kids for C BT. Uh And there, it's been shown a number of times that this can actually play a role. And actually the American Academy of Neurology actually came out with, believe it or not almost 20 years, 20 plus years ago, a statement saying that there was great a evidence for relaxation therapy, biofeedback and cognitive behavioral therapy in the, uh, treatment and prevention of migraine. That was a pretty big step for those guys. I don't know if you hang out with any adult neurologist. I try to avoid it at all times. Um, because they're not exactly the most fuzzy group in the world. Um, but for them to come out and make this kind of holistic statement, I thought it was pretty impressive. Ok, so I think I need to curtail it because I think there's a Q and A, I got 12 questions on the line so far. Ok. Ok. Here we go guys, there we go. OK. 6:00. Huh? Uh which prevent uh a preventive migraine med should a general practitioner try before referral to a neurologist? Um Well, definitely, I think, I think the bottom line was magnesium and riboflavin. Huh? Super easy. No side effects. Will it work? Maybe? Will it not work? Maybe? But again, no downside. So I definitely would do either pure riboflavin or you know, try like the micro leaf? Ok. After that, then I personally am a big fan of low dose to pram. Ok. I know people can be um kind of cautious about Parma because it is the anti seizure drug. But the dose that you use the toy, I start out at the dose of available which is 15 mg. It comes in a little 15 mg Sprinkle. I start adolescents on that. 15 mg is what we give to babies with seizures, ok? And so I re I reassure the family, hey, it's safe. We give it to newborns with seizures but 15 mg and then you can double it up to 30. I think if you're gonna get bang for the buck with pram, you usually see it before 60 mg. OK. So I kind of just take it up and I think you should feel comfortable with Tom. Uh you can start the kit on top. I'll get a lot of kids coming in now who've been started on to, to and then they send them in for uh further neurologic assessment. And that's a great way because then I can assess, hey, is this drug doing anything? Do we have any bang for the buck? OK. How um do you choose a trip? Is there an algorithm you run through in your head or is it typically come down to a form in insurance coverage? Unfortunately, it is the form in the insurance coverage? OK. That really is the issue. The the trip that I tend to use are IMAX because not because I think it's the best thing out there, but it is well covered. It's the first one that was approved. It comes as an injection, it comes as a nasal spray which works quite well. And of course it comes in three sizes of pills, 25 50 and 100. So I usually use that one. Um, the next one is Mac Salt because max salt comes as a melt tab as a five and a 10 mg. So the kids can stick it in the mouth and it kind of melts in their mouth. Um, so those are the two and those seem to be the best covered. Uh, in my experience here in South Carolina. How significant are assimilating scatomas? Um Well, they're, they're really cool is what they are. Um, the scintillating scatomas are absolutely classic for migraine. There's only one disorder on this planet that occurs in humans which causes the sinti schema. And guess what that is migraine. So if you get someone who comes in and say, hey, I get headaches before that I get these wavy lines or spots, boom, you got the diagnosis. Those aren't seizures, those aren't MS, those aren't any of that. So that is migraine. So, scintillating scatomas. Nice. The problem is they're not real common. Ok. Auras in general are 20% and in kids it's, I don't know, they, they say kids, it's 20% in my personal experience. I think it's even less than that. I don't get a lot of scatomas out there and definitely not the scintillating ones. Should pediatricians be prescribing trip hands or antiepileptics or is this for the neurologist? I think it's fine for the pediatrician. I have no problem at all, as long as you're comfortable with it. Ok. Um, and again, it's, you're only gonna get comfortable by doing it a couple of times. Can you comment on chronic sinusitis and allergic, uh, chronic allergic rhinitis and their relationship to headaches of this form of migraine? Also, that's an interesting question. There was a number of years ago. I can't remember, I believe it came out and I can't remember if it was Lancet or New England journal, but a, a major, a major journal. OK. And the title is there is no such thing as Sinus Headache. OK. Of course, every E N T guy was like ripping their shirt heresy, you know. Um but the point is, can you have sinus disease? Trigger migraine? Yes. OK. Can you have stressful situations? Trigger migraine? Yes. OK. So there is a relationship because it can trigger migraine. Um But it's not, it, it's not in place of migraine. OK. The, in the old days again, we used to say there were sinus headaches, there was migraine, there was tension headaches. We used to break these things up into all these little categories. Well, that's not true. It's all one big umbrella because now we understand the path of physiology of pain perception. And then the question is, how do you feed into that pain pathway? Do you suggest that the PC P order imaging before referral to you? So, which is the best to work up for secondary causes. OK. So let me talk about imaging. Do not image. OK? If you think this is a primary headache, do not image. OK? Otherwise on the other end, when I see this kid with the normal scan because it'll be like doctor uh Glen, I mean, you know, we forgot how to do an exam. So let's just go order an MRI that's something you do in the E D. OK? Um You guys are pediatricians, you're gonna take a look at the kid. You're gonna take a history, you're gonna look in the back of the eye. Um And you're gonna say, hey, I think this is primary, I just think this is secondary if there's concern of secondary. Sure image, the best way to image is MRI, right? So we cut down on the radiation exposure to kids, but generally speaking, I don't think an M R uh scanning is necessary. I see way too many scans are magnesium tablets and B six used for prophylaxis used for, are you for? It just disappeared. So I guess you can you talk about um blocks? OK. I don't do blocks anything with needles. You don't want me doing? Ok. Um So I stay away from them. I personally try to stay away from money. I don't inflict it on anyone else can blocks be helpful. The answer is yes they can. OK. But again, it's, it's more of an acute treatment. What really is the underlying cause? What's irritating the gang. Ok. Um, why is the block necessary? Do I refer patients for blocks? Yeah, I do for those really tough ones that just aren't responding. Ok. Here we are our magnesium tablets and vitamin B, they don't want me to read that one. That's ok. Oh, there it's the second one. Down. Our magnesium tablets and vitamin B six used for, uh, used for prop, I assume. Go for migraines. Uh, good for migraine. Um Not exactly sure what the question is, but the bottom line is magnesium tablets and B six, there's no real efficacy to B six, but definitely the magnesium. Ok. And in the world of magnesium, usually 200 to 400 mg, please tell us the trick of seeing the back of the eye or the closest I usually get is a blood vessel. We're getting close. Ok. So that, that's good. It means you see the barn. Ok. And you know, the horse is gonna get in there. Um, the bottom line is practice. Ok. Um And I look at, you know, I watch the students and the residents, you know, and a lot of times they'll grab the ophthalmoscope and you know, they kind of put it up to their. First of all, you know, the patient is, let's say the patient is you your face and me. So your left eye is right here, your right eye is here and they'll take it because they're generally right handed right eyed, they'll take the ophthalmic goat, they'll put it in front of their right eye and then they'll come in on the patient. So all of a sudden the right eye is to the left eye, the nose is to the nose. Bad idea. Ok. Um, and the other thing they'll do is they'll get the ophthalmoscope and the patient will be here and they'll kind of be looking like this. Ok? You gotta get it, you gotta get intimate, you gotta get dirty, you gotta get in their face. OK? I put my hand on the kid's head. I come in from the right eye to right eye, left eye to left eye. I put my, the thymo up to my right eye, put my hand on the kid's head. Have them pick, I always name a target, have them look at that piece of paper, have them look at that hand dispenser, hold their head and then I come in so that I see the blood vessel. OK? And then I just rotate a bit and then I can look directly onto the desk. Try it, it works really, really well. Uh Don't just boom, come straight in on them. It can be very intimidating. OK? Um OK. Is colic and infants also a migraine any way to know or treat. Um usually not. OK? Uh Early, the earliest that you get for a migraine variant is something called um torticollis, infant torticollis. So colic usually isn't up there. Um Two more. OK. Um Always learned a history taking to ask about motion sickness and ice cream. OK. Um I like ice cream, by the way. Um uh So motion sickness, interesting question. It's interesting you ask that my mentor was fixated on motion sickness. Um He would always ask, does the kid have motion sickness kid who has migraine? If you start asking that you're gonna find out. The answer is yes. A lot of the times is there a relationship between motion sickness and migraine? The answer is, yeah, there there can be. And sometimes when you're trying to build a case that this looks like migraine asking that question. Also, you can look like super smart. Oh Is your child have motion because oh God, he can't write at all, you know. So you know, so you know the other question that can be associated with migraine is leg cramps, nocturnal leg cramps. What we as pediatricians tend to call growing pains? Ok. High frequency of quote growing pains in kids with migraine, high frequency of uh history of uh motion sickness ice cream. Um No, the ice cream headaches are usually because of the stimulation of the nerves in the back of the throat, triggering. Uh That whole Wow, that feels like a stab and stab in the head. Where do you send kids for C BT? Good question. We don't have any near us, neither do we. Um It's hard. OK. There is a website. This is, this is worthwhile. There's a website that one of our residents who is a neuropsychiatry resident he gave to us and I use it all the time in the clinic. Um There's a magazine out there called Psychology Today. You can Google it. And if you go to their home page up at the top, they'll, it'll say therapy and you click on therapy and then there's a drop down. What are you looking for? You're looking for, you know, marriage counseling. Uh What, what are you looking for? C BT? You click on C BT the drop down. What age put in the age drop down? What's the zip code? Bang. It kicks up people who will see a kid for C BT in a circle around that zip code very, very helpful. Ok. Now the problem with it is it's usually for patients who have insurance. Ok, third party insurance. And the challenge is at least for many of our patients they don't and so it can be very difficult. So then we have to lean on County Mental Health or if they're close to M US C going downtown to uh I O P. Thank you very much. I'm kind of being pulled off stage. Mhm. Published Created by
