Not just a bad headache, migraines are complex and have particular features in the very young. As she walks through the diagnostic process in children, pediatric neurologist Samantha Irwin, MB BCh, MS, FRCPC, elucidates poorly understood elements (such as aura) and notes key questions for taking a history. She explains when workup, imaging or referral is warranted, and details the wide range of treatments, from standard and new drugs to neuromodulation devices. Learn, too, about the value of migraine prevention and the many preventive options.
well I can't see anybody. So I I saw there was about 20 or so folks. So it's nice to virtually meet you? I'm dr Irwin and I specialize in pediatric headache. Um And look forward to giving you an update here and let me see if this works Okay. My disclosures. Um I have done some consulting with various companies that make medications for migraine and those are listed here. Um None of this work directly relates to what I'm speaking with about today though. And no one involved in the planning or presentation of this activity has any relevant financial relationships with the commercial interest to disclose today. We'll review headache history and examination, will go through the diagnostic criteria and pearls for how to diagnose pediatric migraine. Um I'll outline migraine, epidemiology and path of physiology. I'll go over some common disorders we see in the clinic review diagnostic work up and then end with some treatment pearls with regards to the history examination. This is where everything starts. Um And um so I'm just gonna move the little panel with everyone's pictures. There we go. Um And I put it in kind of a hub and spoke because they all inter relate to kind of give you the either impression that this is a primary headache disorder or a secondary headache disorder that might require further work up um specific things that you know, you wanna you wanna elucidate on the history or whether or not this is someone's, you know, a sudden persistent progressive presentation, a headache or if it's something that's gradual and episodic and improving? Maybe over time. Is it the first headache, a new headache or the worst headache? Um, Was there something precipitating or preceding the onset? Want to go through the location, severity, quality, duration of pain. Whether or not there's a positional component or diurnal variation meaning as the pain worse first thing in the morning or worse in the middle of the night. Are there any exacerbating or relieving factors like rest or exercise? Sometimes paradoxically. And what are the triggers for pain? Are they classic migraine triggers? Are they a little bit atypical? You want to specifically elucidate migrants features. So things like nausea, vomiting, photo and fauna phobia. You want to try to see if there's an aura or symptoms that predate the onset or precede the onset of pain typically. Um And then you want to review any any cranial autonomic features or pre monetary or post drama features. These are phases of the head of migraine headache disorders that might come before or after the pain itself and kind of increase the overall um likelihood of this being of migrants headache disorder you want to go through if this is if there's any prior headache history specifically, if there's a change and this represents something new and you also want to touch on whether or not the patient has any episodic conditions associated with migraine specifically in the pediatric population. Things like abdominal migraine or cyclic vomiting or history of colic. Um, things that might again increase the likelihood that this is a migraine headache disorder. We always want to go through a neurologic review of systems and make sure there's no specific red flags um like double vision or kind of a whooshing sound in the ears or what's known as pulse, it'll tinnitus um are obviously any other focal deficits like trouble walking or paralysis of any any any extremities or trouble speaking in headache disorders. We do like to screen to make sure that there's nothing that can be you know, a secondary headache disorder. And sometimes what increases the likelihood of that is um systemic um symptoms or you know, inflammatory or vascular or infectious history as well as looking at the past medical history for for relevant comorbidities that I've listed their family history that might be pertinent or any sort of co use of medications or substance that might increase the risk for a secondary headache disorder. And then finally your exam. Obviously you want to do a full neurological exam to the best of your ability. The most important thing would be to, you know, look for sarah Beller signs. So trouble with with balance um with tandem gait and obviously if at all possible to do for endoscopy to look for optic nerve swelling. So this is a typical case. A 12 year old girl would present with mild intermittent headaches since she was seven. But more recently over the last six months since age 11 headaches become have become troublesome Of note. Menstruation started about three months prior. The frequency of her headaches is now described as four days per week or 16 days a month of which eight are severe. They last for two hours. She describes them as on both sides of her temples and has throbbing quality. She notes that she gets nauseous as well as feels sensitive to certain smells, what we call Osma phobia. She denies aura, she denies cranial autonomic features. Um And any pre monetary or post trauma symptoms. There is a family history of migraine in her mother and maternal grandmother and no one in the family has aura with regards to episodic syndromes, which I'll describe later that those are absent and her pediatric migraine markers are positive for motion sickness. She has an unremarkable medical history in her examination, including endoscopy, is normal. So in this case you probably guessed it, but the diagnosis would be chronic migraine without aura. Um And and the specific things of note is that even though the headache duration might sound short to you if you're seeing this patient in your office two hours, you probably remember you know that four hours is more typical for migraine. Two hours is accepted in the I. C. H. D. Criteria for migraine, which is the international classification for headache disorders that we use by temporal pain might catch people as well wait. This is tension type headache actually bilateral pain is more common. Pediatric migraine than unilateral pain. Doesn't typically start to lateral eyes till late teens, early adulthood with regards to associated symptoms, you only need to have one of nausea or vomiting to meet criteria. You don't need both. Um, but if you're having sensitivity symptoms, you do need to have photo phobia and fauna phobia, but you don't need both. So if you have nausea, that's all you need. You don't need the other symptoms to make the diagnosis. Osma phobia, smell sensitivity can be particular help, particularly helpful for differentiating migraine. The pre manacles sort of monarch monarchy period is a common time for worsening for pediatric migraine. So that would be quite typical. And the support of features are that, you know, episodic syndromes um, might be present and pediatric migraine markers like motion sickness as I mentioned, might might be present. Those don't help you make the diagnosis. I want to be clear on that. It just helps support the case for migraine. So, to review the actual diagnostic criteria, someone needs to have five attacks each lasting 2 to 72 hours. Um, and the attacks must have um any two of these features and any one of these features and then I just circled here that the time is shorter in pediatrics. The pain is offered bilateral and pediatrics and the sensitivity symptoms can be inferred in pediatrics and don't need to be explicitly endorsed with regards to epidemiology. Migraine is very common. It's a common cause of headache. It's a common cause of disability and it's a common cause of school absences, About 12% overall. Um, is the prevalence of Migraine, although that ranges from about 7-17% between males and females. There is a predilection for females after puberty to have migraine more often, whereas that's relatively stable pre puberty. This is just a chart that shows um kind of the prevalence over time and how there's that the big upswing in kind of the one year period prevalence of migraine between the ages of zero and 20. So this is often a time when migraine is emerging, Chronic Migraine is less common. It happens in about .6% of those less than 12 and between .8 and 1.8 of adolescents. Um, and about 2% of adults um, by way of reference. Um, uh, epilepsy occurs in about 1% of the population, so this is about twice as common. The evolution of episodic to chronic migraine happens in about 2.5% a year. The cut off for chronic migraine is 15 days a month, so about 2.5% of folks a year are going to transition to that more chronic debilitating pattern. With regards to migraine path of physiology. We know migraines, a complex genetic disorder of the brain. It involves calcitonin, gene related peptide and you've probably heard that word a lot more in the last four years. Um, as it's now felt to be a major, a major mediator of a pediatric migraine. The vascular theory is now considered neither sufficient nor necessary to cause migraine, Interestingly, about 40% of migrants are misdiagnosed as having sinus headache. I mentioned that only just so you don't get caught in that diagnostic trap of thinking that a headache is sinus if it's kind of bi temporal or by frontal. Oftentimes, you know, folks will say, well, migraine is just something psychologic, it's not real. There's been two studies to try to kind of tease this apart. One was a behavioral trial in middle schoolers that he was looking at, you know, a number of friends and friend groups and there was found to be an equal number of friends and those with migraine versus without. And those with migraine were not described as more sensitive rather as leaders are popular amongst their peers. In another study of youth with chronic daily headaches, um, there were no more, they were found to be no more likely to have a psychiatric disorder than their peers. Although there was one important thing to to mention about that study that those who did have co morbid psychiatric illness had higher related headache disability and poor quality of life. So that means migraine plus depression or anxiety pertains a worse outcome. Just to review the path of physiology in more of a schematic. We know that there can be a change in homeostasis or so called migraine trigger that might be hunger dehydration, stress changes in sleep which might alter the dura vasculature, leading to the release of neuro inflammatory peptides of which one is C. G. R. P. Um in the trigeminal vascular nucleus. These peptides interact with the hypothalamus, the thalamus and various other cortical regions to produce the symptoms of migraine. And that's the pathway that we refer to. When we refer to migraine. You can see it here into schematics, seeing sort of you know external um input leading to changes in um your inflammatory peptide release and changes in vascular resulting vasculature resulting in pain. So what do we see? We see chronic migraine most often we see a lot of post traumatic headache and new daily persistent headache or chronic headaches that start on a on a day that's remembered and persist as unrelenting thereafter. We see you know a little bit of episodic migraine not as often. Um We see some kind of more pediatric specific disorders like primary stabbing headache. Um And episodic syndromes that I have alluded to a few times including abdominal migraines cyclic vomiting syndrome. Um Amongst you know other things like border collies and benign paroxysmal vertigo. We see visual snow which is a persistent visual dysfunction that can happen in those with migraine and then more more rarely we see secondary headaches but that's what we're always trying to rule out things like high pressure headaches or idiopathic intracranial hypertension, low pressure headaches like spontaneous intracranial hypertension and brain tumors, which is obviously everybody's biggest worry. And then much more rarely we see trigeminal autonomic, several al jas, that's that hard word to say. That is typically presents with pain on one side of the face, with, with associated symptoms on that same side, like drooping of the eye, tearing of the eye running of the nose, flushing of the face etcetera. Migraine is far and away. The most common thing we see and we'll spend the rest of the time talking about that today. I just wanted to mention aura because I think or a trip trips people up trips people up fair amount. Um it is um it's present in the minority. About 25-30% of migrant workers have aura. The clinical presentation will help you differentiate it from a. T. I. A. Or a stroke or a seizure in that or a typically evolves slowly. It doesn't come on as an abrupt acute onset. The duration is long, it's typically five minutes to 60 minutes, not just a matter of seconds it's often positive, not negative, meaning that it's either it's tingling in the hand. Um or it's kind of scary temas and skin relations and vision verse paralysis or verse vision loss. Um The headache is confusing because it can come before, during or after the aura. So you can't really hang your hat on that one. Um but I do want you to consider the premonitory phase if symptoms occurring pre headache are not aura. So sometimes people will say they feel, you know fatigued or their vision, you know. Um I might just go a little bit like blurry for a few seconds. Um or their stomach hurts, you know, or they get cravings for things. Those will be more likely to be kind of premonitory phase than an aura. Visual auras, the most common sensory being second, which is tingling and numbness. Language, aura is the third most common and then much more rarely or motor brain stem in retinal auras um which which involved weak weakness, brainstem or as a constellation of different brain stem findings and and retinal aura is is typically a mon ocular visual change. The importance of aura, especially in in terms of primary care and pediatrics is that it does increase the stroke risk for women who have aura, that risk is still small, but it is about two times those without aura. And it's it's further increased by by using estrogen containing contraception. So in our clinic we recommend using low dose estrogen if someone is female and has migraine with aura, these are some examples of what aura might look like. Just so when you're asking the question you can try to get this to be, you know, you can try to see if this is what you're hearing with regard to the syndromes associated with migraine, the episodic syndrome associated with migraine. I touched on these a little bit a few times now and I just wanted to give you the diagnostic criteria for them and kind of how they present. Um These slides will be made available to you so I won't read them verbatim but I have given you the typical kind of age of onset for these um conditions as well. Nicholas is a head tilt, it's not subtle. I tell families they would typically see their doctor um paroxysmal vertigo. Kids look scared off balance and start vomiting. And then the recurrent gi disturbance disorders like abdominal migraine and cyclic vomiting present typically with kind of recurrent stereotyped attacks without another cause. Um And where kids are well in between. There's a few other things that are in the appendix of the headache disorder criteria. Kind of um compendium things like alternating hemiplegic childhood colic and vestibular migraine. Those don't get, you know, a home in the actual criteria diagnostic criteria but they live in the appendix and then some other markers like motion sickness, periodic sleep disorders and cold stimulus, headache or brain freeze. Um are things that are associated with migraine and help build the case. So the work up this is on everyone's mind when you see a patient with headache. Typically no diagnostic is work up beyond the history and physical exam In a child with a normal exam uh and history consistent with migraine less than 3% will have neuropathology and typically those who do have neuropathology still have an abnormal exam or some features on exam that are abnormal, except occipital headache in Children in and of itself is no longer considered a red flag. It used to be and it used to be something that would catch people's attention. Um but but it's no longer considered to be a red flag in and of itself. Um uh So you want to identify triggers and preempt a migraine if you can. So if there's, you know, a consistent trigger like menses or travel, you want to look for contributing factors um like stimulants, caffeine medication overuse you want to treat when pain is mild. It's more effective than treating late. You want to maximize the dose and how patients try acute treatments at least 2-3 times once is not sufficient. We know these medicines aren't perfect. So one time trial is not going to be, we're not going to be effective For prevention, starts slow, go low, start low, go slow to avoid med failure and kind of cycling through medications. Um consider a preventive. If someone's having 4-6 headache days a month or severe headaches on three days a month and try a preventive for at least eight weeks before assessing response. Set realistic goals and I can't emphasize this enough headache treatments aren't going to work tomorrow and they aren't going to be perfect. Um they should reduce headache by about 50% and about 50% of patients when treatments are used consistently for three months, acute treatments should reduce pain In 2/3 and lead to pain freedom in about 1/3 and that's by two hours. So again not immediate and not perfect in terms of acute treatments, we think of them in four categories. We have analgesics and we prefer. Nsaids, migraine specific medications like triptans or newer things that I'll touch on in a moment. Mhm. If nausea is problematic, consider something like Zafran and consider a Rescuer bridge options um If they're needed, if the headache is very problematic And always be sure to kind of counsel about medication overuse. Um so that you don't run into that problem later on. That's using simple analgesics for 15 days a month or tripped in opioids or combos on 10 days a month. So what should you give? An otherwise healthy adolescent adolescent who is migraine is a home aborted plan um For mild to moderate. You wanna help them take an analgesic such as ibuprofen or naproxen for moderate to severe headache. You want to add a triptan, you want to counsel them for less than nine days a month. There are four approved triptans in pediatrics and I listed them here as well as the doses they come in different routes and that can be helpful. Um You know for different scenarios. Obviously you want to consider an anti nausea medication. We typically use Zafran and you want to add a rescue therapy like a dopamine antagonist. We typically use composite which is parable Benadryl Up to three doses per week. After doing a screening, you might consider a bridge if needed if the headache is very problematic Or additional rescue treatments. A typical bridges Naproxen which can be used twice a day in the short term, 1-4 weeks during periods of worsening migraine. And then you might want to consider a new migraine specific therapy. As these become kind of more commonplace, you'll see them more in your practice and might consider them down the line. So what is new and when to use them? We use them when triptans either can't be used or have been tried and don't work or the patient is asking for a non acute or after a non medication based acute option. These are the newer treatments here. Um G pants is the class that is known as you bro, japan and japan. These are C G R P receptor antagonists. The other names are readily and New tech and these medications have been available for just over a year now there's Di Tan's which the one in this class is limited an Which is a five HT or a serotonin one f agonist. You'll recall that triptans also work on serotonin but they work on three different receptors, one of which is the blood vessel receptor which is why they're contraindicated in so many conditions with vascular changes. The Dayton solved that problem by not touching the vessels. The problem with the titans though is that there's a driving restriction for eight hours. Um and it's a controlled substance. So I find very little use for this class in my my patient population and haven't actually prescribed it since it's been available. And then there's two devices specifically marketed for the acute treatment of migraine, Toribio and bolivian. Um I'll show you what those look like on the next slide but their options instead of medications for the acute treatment of pain. Now rubio is on the left, it's an armband that connects to your smartphone. It works by something called conditioned pain modulation which is a mechanism that um uh stimulates the nerve fibers in the patient's arm in a non painful way. But by doing so it activates the pain centers in the brain so they can shut down the central migraine switch. Um it's 45 minute treatment sessions and it's it seems to be pretty well tolerated livi on on the other side is an external nerve stimulator for both the trigeminal and occipital nerve. So it's kind of a combined action um that's used for the acute treatment of migraine uh and is newer but seems to have promising results. What about prevention? Um So the most important thing is lifestyle regularity and you want to set expectations that are reasonable but also try to get teens on the right track. So things like regular sleep. Um trying to uh make sure there's no big swings in sleep or variation and sleep patterns. Regular exercise exercise is a particular area of interest of mine. Um And I'll note just for for you guys that it's been shown to be equivalent to pyramid and non inferior and additive to amitriptyline when studied in migraine populations. So exercise is of utmost importance. Um for pain regulation in adolescence, regular meals, ideally not skipping meals, Adequate hydration, which I use a reference is about one ounce per kilogram. And these all can be found on the website headache relief guide dot com. And that could be a nice resource to give families when you're seeing them in office, cognitive behavioral therapy is another kind of main treatment that we have. One that's evidence based to be effective and doesn't have any side effects. It's to recognize errors in patients thought process and encourage more helpful and realistic ways of thinking and it reduces distress and improves treatment adherence. There's been multiple trials to show that it's been helpful. A pivotal trial in Jama showed that CBT Plus Ami Triple in was more effective than any triple in education. And there's been some other kind of more specific cbc trials showing that it's effective for the headache population to reduce headache frequency. Um And also to lead to sustained improvement. Of note in the 2019 pediatric guidelines. CBT and Ami Triple in combined is the only therapy that was given level a evidence with regards to preventive treatments. We really use expert opinion and we extrapolate from the adult guidelines because there aren't many guidelines to to guide the pediatric treatment preventive treatment strategy. Um of note, 38% of patients need a preventive but only about 15% use one. Um so, so there's definitely a gap there in terms of need and use The Champ study is is a major study in the pediatric Migraine space done in 2017. Um and it effectively compared a trip to link into pyramid to placebo and found that all were equivalent with regards to headache reduction. And there was obviously a lot more side effects in the medication arms of the of the trial. So since the champ trial, we've we've tried to provide treatment that's evidence based for efficacy but with the favorable side effects similar to placebo. Because of this trial, the new guidelines that I touched on in 2019 really show only high quality evidence for AmI trip to lean and CBT and CBT in that paper was outlined to something that should be considered first line in pediatric migraine. There is no level a preventive medications and kids and two. Pyramid is the only FDA labeled medication and use from 12 plus and there's nothing licensed yet less than 12. So what do we use? We typically start with nutraceuticals because these have been studied and have low side effects or side effects similar to placebo which is what we're trying to achieve. Um And will often start one of rival flavin melatonin Co. Q 10 or magnesium. Um A particular note. We start these as medicines so we use one at a time for a three month treatment trial and measured response rather than combining them. Lab door dot com is an independent website that assesses quality of supplements and can be helpful for your patients. And then in terms of pharmaceuticals we extrapolate from the adult data. Um and I've just highlighted here the medications that do have pediatric trials to support use what's new in pediatric preventive treatments. Um Newish because some of this is not new. Um We also do nerve blocks for pediatric migraine to help with refractory headache disorders. We use devices for the prevention similar to the way we use them for the acute treatment. We sometimes use Botox. We use the C. G. R. P. Monoclonal antibody class um as well as CTRP oral antagonist every day. Um And sometimes we admit patients for factory treatment. We're sorry for factory headaches with regards to nerve blocks. We typically block the greater occipital nerve. Um it's helpful and about two thirds of folks with pediatric chronic migraines. The benefit can last up 5-16 weeks and it's pretty low risk. Um We did a retrospective review of pediatric patients with chronic headache disorders. Um And overall as mentioned benefit was seen um you know and at least half and sometimes more in our practice we use lidocaine as well as methylprednisolone um to block the greater acceptable nerve and we do it every three months. The specific devices that are approved for preventive treatment of migraine include TMS or transcranial magnetic stimulation cheerfully and VNS or gamma core. Um Two of those are approved in kids the VMS and the TMS. Um And they all have different treatment protocols but they have a preventive side and and they often also have an acute treatment protocol for use Botox is approved for chronic migraine and adults. Um And this is a table from the kind of pivotal trial the preempt trial that showed how it worked to improve headache In those with chronic migraine who are adult age. There was a randomized control trial impedes it didn't meet its efficacy. Endpoint both Botox and placebo um led to reduction and headache. Um Of note here, I've just listed the kind of the difference in headache days per month. Um from the adult trials below with regards to the C. G. R. P. Monoclonal antibody class. These are the home injections given once a month. We know that C. G. R. P. Is involved in migraine. It seems to be increased during migraine And when the trigeminal nerve is activated. Things like triptans blocks E. G. R. P. If you give C. G. R. P. You can trigger a migraine and those who have a history of of same um There seems to be increased inter inter levels of crp and those with chronic migraine and when you give small molecule CTRP antagonists it can abort an attack. So multiple lines of evidence to suggest that it's it's helpful. It is a potent beso dilator and it also has a role in metabolism and other kind of off target effects which we have to counsel patients about. There are four of them and the overall effect is similar to oral medication so they're not magic. Um But they do seem to be better tolerated and sometimes work faster. These are the names of them. You've probably seen these in your practice or patients have patients on them. Um um A VK joviality and by petty the therapeutic gain is listed there on the side just so you can see that they don't uh they don't kind of you know work in an extraordinary fashion compared to oral medications. Um But as I said they're better tolerated and sometimes can work faster. The therapeutically gain is compared to Botox and chronic migraine into pyramid below. Just for your reference, when do we use them? We use them when patients have headache you know somewhat frequently at least eight days a month if they're pedes midas or disability. Score is very high if they failed. Other preventive and if they're post puberty I've listed some kind of contraindications and monitoring for things. We look out for. We studied it in our clinic here. The use of C. G. R. P. Retrospectively in those with refractory and difficult to manage headache. Um This was a patient population with either N. D. P. H. Persistent post traumatic headache Um in folks who were having you know at least about 27 headache days a month and often continuous headache. And up to two thirds of the patient population that was studied it led to a significant reduction and headache frequency by about two days and functional improvement. Um uh In about one third and the side effects were for the most part minimal constipation seems to be a specific side effect that we screen for. Um And obviously pain at the site. So what can you expect? As I mentioned a similar effect to medications but they do work um a little bit better in those with medication overuse a little bit better and those with significant comorbidities they work when other treatments fail. Um And they can kind of increase their effectiveness over time. They may be faster than oral medications. They often have less side effects. They're more migraine specific and there is this kind of sub population that seems to be a super responder um having 100% improvement, headache. The side effects most importantly constipation as I mentioned. Um And I've listed other kind of off target effects there below. Um One that's come up kind of in um pharmacy vigilance, post post marketing um seems to be you know vascular contraindications. So patients who have Renault's phenomenon or specifically kind of painful distal extremities with ulceration, it would be contraindicated in those patients. And then finally we have inpatient options for those with the most refractory headaches. These will be patients that you will have referred to our clinic um because nothing is working and we might offer them things like Dhe thor's and thor's in depth with Connor lidocaine to finish. And I'm sorry for all the disruptions with the audio here. Migraine is not just a severe headache, it's a complex sensory processing disorder. I hope you can become familiar with the diagnostic criteria and consider premonitory phase first aura when making the diagnosis of aura just because of the implications of that identify red flags and the need for imaging and or referral acute treatment is more effective when taken early and one pain is mild. Um So try to recommend that patients take that at that time. Um Know the reasons for tripped and use and how to use them. Consider combining triptans with Nsaids are using a bridge therapy. If it's more refractory of more refractory headache disorder. Address triggers in a lifestyle regulation when when formulating a preventive plan begin with low risk preventive, ideally those with side effects similar to placebo. Um try to communicate with the family the health team and the school to optimize care. And maybe consider giving a 504 plan and then you can always refer to us um if the headache is problematic or factory or just not improving, um Here's my team. We have Dr Amy Dolphin who directs the headache program, Dr Maggie Wong, who does the transitional program for young adults, and our nurse practitioner natalia. We have two social workers who provide CBT um cognitive behavior therapy for migraine. We have a full nursing nursing staff as well as social workers that help in the organization of multidisciplinary Care. Um and finally, I'll leave this slide up while we take questions.