Chronic and recurrent

headaches in childhood

Headache in Children
Expectations
- the patient / the family want to know

the cause of HA
-

Headache in Children
Diagnostic steps:
-

Careful history
family history
patient,s pre vious history
headache history

reassurence that
the pa tient does not ha ve e.g . a b rain tumor

questions about the social enviroment

- to ge t relief (pain, accompanying s ymptoms)

Clinical examination

BREAKDOW N OF CHRONIC DAILY HEADACHE

150 patients with chronic
headache
chronicdaily
daily
headache
6.7%
Chronic Migraine
Chronic TTH
Other:
Hemicrania continua
New daily persistent
headache

15.3%

78%
70-- 80% progressively chronified headache
70
b y MEDICATION OVERUSE
(Silbers tein SE et al. Neurology . 1996. AH S Ambas s adors Programme)

Migra ine without a ura : the IHS criteria

N 5

A :
B:

4 - 72 h

Children?

C : 1.
2.

Adolescents?

2/4

++ / +++

3.
4.

distinctions?

D: 1.
1 /2
2.

N +

normal

E:

ICHD-II (Ce pha lalgia 2003)

Migra ine :

Migra ine in c hilde n : the IHS criteria

duration: 1 72 h
( > 2 h: requires corroboration by prospective diary studies)

Clin icallyically - defined Diagnosis

T h e geneti cs o f migrai ne proved to compl ex:
- clinically
clinically-- defin ed phenotypes a r e heterogeneous
- mu tatio n o n th e sam e g en e

qu ite d ifferen t phenotypes

Classification and diagnostic criteria

- descriptive
syndromic
symptomsymptom
- based
- aetiological

A O

localization:
commonly bilateral in y oung children
unilaterality in late adolescence
usually frontotemporal
(occipital headache i s ra re, may
attributed t o structural lesio n )

accompanying symptoms :
( primary headache disorders
disorders))
( secondary headaches
headaches))

in y oung children: photophonia and/or phonophobia m ay be

inferred from their behav iour.

ICHD-II (Ce phalalgia 2003)

1.1. Migraine without aura (MO)

1.2. Migr aine with aur a (MA)
1. 2.1 .Typi
.Typi cal aura with migr aine
head ach e
1. 2.2.Typi cal aura with nonnon- migraine
he adach e
1. 2.3.Typi cal aura without headache
1. 2.4.Fami lial hemipl egic migraine
(FHM )
1. 2.5.Sporadi c hemiplegi c migr aine
1. 2.6 .Bas ilarilar- type migraine
1.3. Childhood periodic syndromes
1.4. Retinal migrain e
1.5. Complications of migraine
1. 5.1.Chronic migr aine
1. 5.2.Status m igraino sus
1.5.3.Persistent aura without
infarction
1. 5.4.Migrainous infarction
1. 5.5.Migrain ee- triggered seizur es
1.6. Probabl e migr aine

Long-term outc ome of childhood hea dache

The evolution of primary headache syndromes cannot be
predicted!
-

1.3. Childhood periodic syndromes:

the IHS criteria
commonly precursors of migraine:
1.3.1. Cyclical vomiting
1.3.2. Abdominal migraine
1.3.3. Benign paroxysmal vertigo of
childhood
Paroxysmal torticollis, etc.

Intrinsic brain activ ity triggers trigeminal meningeal afferents in a

migraine model

Hayrunnisa Bolay1, 3, Uwe Reuter1, 3, Andrew K. Dunn2, 3, Zhihong Huang1, David A.

Boas2 & Michael A. Moskowitz1
Nature Medicine February 2002 Volume 8 Number 2 pp 136 - 142

some patients will worsen and becam e chronic

others will be reliev ed
will stay the same for decades

- f or the Future :
- important to classify subtypes to provide
prognostic factors
- evolutionary patterns

Treatment of pediatric migraine

Treatment of pediatric migraine

Individually tailored regimen of

Nonpharmacologic modalities

trigger factors
pharmacologic

Identification & elaboration

( symptomatic therapy)

nonpharmacologic
treatment

learning disabilities (which can be treated)

stress
hormonal aspects
etc.

Migraine
In children ?
Yes!

Treatment for
acute episode

Primary therapy

Treatment of pediatric migraine

Most effective medications
medications::
- can be given quickl y a t the beginning of an
a ttack
- ha ve a rapid onset of a ction

Preventive
treatment

Biobehavioral
treatment

Rescue therapy

Treatment of pediatric migraine

Analgesic treatment:
Analgesic
treatme nt
- acetaminophen
- ibuprof en
- nimesulide
Intermittent oral or

vs placeb o
15 mg / kg
10 mg / kg
2,5 mg / kg

suppository adjustement

Damen e t a l.l . Pedia tric s , 2 0 0 5

( Rev iew o f 1 0 tria ls )

Treatment of pediatric migraine

Analgesic treatme nt

Analgesic treatme nt

(NSAIDs) or c om bination of a nalgesics :

Danger:

Treatment of pediatric migraine

overuse of OTC ana lges ics :

> 15 HA treatment days /month

Recommandations:: not to us e analgesics > 2 - 3x /week

Recommandations
/ week

Aspirin containing c ompounds :

Danger:

historical concern of Re ye,s

s yndr ome in c hildre n a ged < 15 ys

inner , 200 5
Hershey & W inner,

inner , 200 5
Hershey & W inner,

Treatment of pediatric migraine

Nona nalgesic interve ntion

Nonanalgesicinterventions:

v s . pl ac e b o

New frontier for symptomatic treatment o f

childhood migraine:

nasal spray sumatriptan, zolmitriptan

oral sumatriptan
oral rizatriptan
oral dihydergotamine
i v. prochlorperazine & ketorolac

conclusion :

Treatment of pediatric migraine

NASAL TRIPTANS

mod erat e evi denc e tha t : sumatriptan n asal sp ray

is more eff ective th an placebo ( mo dera te evide nce)
nce)
( i n red uctio n o f sy mpt o ms , b ut w ith mor e a dverse ev ents)
ents )

n o clear diff erenc es i n eff ect betwe en

e.g. nasa l s umatriptan

fast abs oprtion imme dia tly a fter dos ing

iv.. prochlorperazine is more eff ecti ve tha n ketor olac

iv

Currently n o triptans a re allowed b y th e F DA for th e us e i n

pediatric migraine.

oral sumatriptan / rizatriptan and plac eb o !!! !

Dam en et a l.l. Ped iatric s,
s, 200 5
( Review of 1 0 tria ls
) )

Treatment of pediatric migraine

Treatment of pediatric migraine

Preve ntive Treatme nt Strategy

Oral triptans may not be effective in

children because of:
- gastric stasis, nausea and vomiting

Currently, the FDA:

- has not approv ed any medication f or the prevention of migraine in
children.
- has approv ed 5 medication for adults.

delayed absorption
- attacks tend to be shorter in children than

Indication: - frequency of HA ( > 3 - 4 HA/m )

- significant disability during H A (pedMIDAS
(pedMIDAS))

m ay spontaneously remit <2h

(ma ximum benefit of drugs close to 2 h)

those in adults,

Tricyclic Antidepressants, antiepileptic medications,

antiserotoneric ag en ts,
ts , B - blo ckers,
ckers , Calcium C hannel
B lo ckers,
ckers, N SA ID s,
s , etc...

Overall efficacy of p re venti ve an titi- migraine drugs

Treatment of pediatric migraine

Best therapeutic
therapeutic gain
gain compared to placebo.
(% of resp on ders
ders ,i. e. 50% r ed uctio n in attac k frequ ency )

Valproate

Placebo s have a profound effect in headache

45

Betablockers

Frequent
adverse
effe cts

40

Flunarizine

42

Riboflavin (400mg)

37

Q10 (300mg/d)

33,3

Candesartan

31

Lisinopril

Rare
adverse
effe cts

29

Pizotifen

20

Mg(24mM)

18

Cyclandelate

7,4
0

10

15

20

25

30

35

40

45

50

55

- Responder rate to placebo

a, acute headache events: 20-30%
b, in prevention trials:
30%
- Effects of placebo are long-term (over ~ 6-9 months)
- Subcutaneous placebo is more effective than oral placebo
- Side effects: body w eight
- Similar mode of action as real drug (PET, fMRI studi es)
Diener, 2005