Paediatric headaches

Mark Weatherall
London Headache Centre
2010
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

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

What headaches are we
talking about?
Migraine*
*with aura in 14-30%

Tension-type headache

Cluster headache
Other headaches
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
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
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
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
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%
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%
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
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
Impact of headaches
Children with migraine lose on average 1
weeks of school per year
Impact can be assessed using validated
tools
PedMIDAS
PedQL
Treatment
Accurate diagnosis
Comprehensive treatment plan
Explanation (and reassurance)
Lifestyle advice
Acute treatments
Prophylactic treatments
Biobehavioural therapies
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
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
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)

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
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)
Treatment
Prophylactic treatments
pizotifen
beta-blockers
tricyclics
anticonvulsants
others
riboflavin (vitamin B2)* * recent negative small PCRCT!
coenzyme Q10
butterbur extract
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
Treatment
Biobehavioural therapies
biofeedback
relaxation training

Treatment of co-morbidities
physical
sleep disorders
psychological
Counselling; family therapy
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