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8/10/2019 2011.03.21. Neurológiai Betegségek a Gyermekkorban
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Chronic and recurrentheadaches in childhood
Headache i n Children
Expectations- the patient / the family want to know
„the cause of HA ”
- reassurencereassurence that
the patient does no t have e.g . a brain tumor
- to ge t relief relief (pain , accompanying s ymptoms )
Headache i n Children
Diagnostic steps :-- CarefulCareful historyhistory
family historypatient ,s previous historyheadache historyquestions about the social enviroment
- ClinicalClinical examinationexamination
6.7%
Other:• Hemicrania c ontinua• New daily persistent
headache
BREAKDOWN OF CHRONIC DAILY HEADACHEBREAKDOWN OF CHRONIC DAILY HEADACHE
150 patients with chronic daily headache
(Silberstein SE et al. Neurology . 1996. AH S Ambassadors Programme )
15.3%Chronic TTHChronic Migraine
78%
chronic daily headache
7070 --80%80% ®®®® ®®®® progressivelyprogressively chronifiedchronified headacheheadacheb yb y MEDICATION OVERUSEMEDICATION OVERUSE
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8/10/2019 2011.03.21. Neurológiai Betegségek a Gyermekkorban
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44 -- 72 h72 h
++ / +++
ÕÕÕÕ NNNN + AAAA ÕÕÕÕ OOOO
E :E : normal
AA :: NN ³³³³ ³³³³ 55
CC :: 1 .1 .
2 .2 .
3 .3 .
4 .4 .
2/ 42/ 4
D :D : 1 .1 .
2 .2 .1/21/2
B :B :
MigraineMigraine withoutwithout auraaura : the: the IHSIHS criteriacriteria
• Children ?
• Adolescents ?
• distinctions ?
ICHD -II (Cephalalgia 2003)
MigraineMigraine ::
ClinicallyClinically-- defineddefined DiagnosisDiagnosis
T h eT h e geneticsgenetics o fo f migrainemigraine proved pr oved t ot o complex complex ::
-- clinically clinically -- define d defined phenotypes ph en o typ es a r ea r e he terogeneousheterogeneous
-- mutationmutation o no n t h et h e s a m es a m e g e n eg e n e q u i t eq u i t e different different phenotypes ph en o typ es
ClassificationClassification an dan d diagnosticdiagnostic criteriacriteria
-- descriptivedescriptivesyndromicsyndromicsymptomsymptom-- basedbased (( primaryprimary headacheheadache disordersdisorders ))
-- aetiologicalaetiological (( secondarysecondary headachesheadaches))
MigraineMigraine inin childenchilden : the: the IHSIHS criteriacriteria
duration: 1 – 72 h(>2 h: requires corroboration by prospective diary studies )
localization :commonly bilateral in y oung children
unilaterality in late adolescenceusually frontotemporal
( occipital headache i s r a r e , ma y attributed t o structural le sio n )
accompanying s ymptoms :in y oung children: photophonia and/ o r phonophobia may b e
inferred from their behav iour .
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ICHD - II (Cephalalgia 2003)
•• 1.1. M igraine without aura (MO)1.1. M igraine without aura (MO)•• 1.2. Migraine with aura (MA)1.2. Migraine with aura (MA)•• 1 . 2 . 1 .1 . 2 . 1 .Typical aura with migraineTypical aura with migraine•• head ach ehead ach e•• 1.2.2.Typical aura with non1.2.2.Typical aura with non - - migrainemigraine•• he adach ehe adach e•• 1.2.3.Typical aura without headache1.2.3.Typical aura without heada che•• 1.2.4.Familial hemipleg ic migra ine1.2.4.Familial hemiplegic migraine•• (FHM )(FHM )•• 1.2.5.Sporadic hem iplegic migr aine1.2.5.Sporadic hemiplegic migraine•• 1.2.6.Basilar 1.2.6.Basilar - - type migrainetype migraine•• 1.3. Childhood periodic syndrom es1.3. Childhood periodic syndromes•• 1.4.1.4. Retinal migrain eRetinal migrain e•• 1.5. Complications of migraine1.5. Complications of migraine•• 1.5.1.Chronic migraine1.5.1.Chronic migraine•• 1.5.2.Status1.5.2.Status migrainosusmigrainosus•• 1.5.3.Persistent aura without1.5.3.Persistent aura without•• infarctioninfarction•• 1.5.4.Migrainous infarction1.5.4.Migrainous infarction•• 1.5.5.Migraine1.5.5.Migraine --triggered seizurestriggered seizures•• 1.6.1.6. Probable migraineProbable migraine
1.3. Childhood periodic syndromes :thethe IHSIHS criteriacriteria
commonly precursors of migraine:
1.3.1. Cyclical vomiting1.3.2. Abdo minal migraine1.3.3. Benign paroxysmal vertigo of
childhood
Paroxysmal torticollis, etc.
Long -term outcome of childhood headache
• The evolution of primary headache syndromes cannot b epredicted !
- some patients willworsen and became chronic- others w i ll b ereliev ed- wills tay thesamefor decades
- for the FutureFuture :- important to classify subtypes t o provide
prognostic factors- evolutionary patterns
Int rinsic brain activ ity triggers trigem inal me ningea l afferents in amigraine model
Hayrunnisa Bolay1, 3, Uwe Reuter1, 3, Andrew K. Dunn2, 3, Zhihon g Huang1, David A.Boas2 & Michael A. Moskowitz1
Nature Medicine February 2002 Vol ume 8 Number 2 pp 13 6 - 14 2
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TreatmentTreatment ofof pediatricpediatric migrainemigraine
Individually tailored regimen of
pharmacologic(symptomatic therapy )
nonpharmacologic
treatment
TreatmentTreatment ofof pediatricpediatric migrainemigraine
trigger trigger factorsfactorsIdentification & elaboration
- learning disabilities (whichcan be treated )
- stress- hormonal aspects- etc.
Nonpharmacologic modalities
MigraineIn children ?
Yes !
Treatment for acute episode
Preventivetreatment
Biobehavioraltreatment
Primary therapy Rescue therapy
TreatmentTreatment ofof pediatricpediatric migrainemigraineMostMost effectiveeffective medicationsmedications ::
-- ca nca n bebe givengiven quicklyquickly ata t thethe beginningbeginning of anof an
attackattack
-- havehave a rapida rapid onsetonset ofof actionaction
TreatmentTreatment ofof pediatricpediatric migrainemigraine Analgesic trea tment :
v sv s placebo pl aceb o
- acetaminophen 15 mg/kg
- ibuprofen 10 mg/kg
- nimesulide 2,5 mg/kg
Intermittent oral o r suppository adjustement
D amenD amen e te t a l a l .. Pedia tricsPedia trics , 2005 , 2005 ( ( Rev i ew Rev i ew o f 10of 10tria lstria ls ) )
Analgesic treatment
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TreatmentTreatment ofof pediatricpediatric migrainemigraine
(NSAIDs ) or c ombination of analgesics :
Danger : overuse of OTC analgesics :
>> 15 HA15 HA treatment treatment daysdays / / mo n t hmo n t h
RecommandationsRecommandations:: n o t n o t t ot o u s eu s e analgesicsanalgesics >> 22 --3x / 3x / week week
Hershey Hershey && W inner W inner , 2005 , 2005
Analgesic treatment
TreatmentTreatment ofof pediatricpediatric migrainemigraine
AspirinAspirin containing compounds :
Danger : historical concern of Reye ,s
syndrome in children aged < 15 ys
Hershey Hershey && W inner W inner , 2005 , 2005
Analgesic treatment
TreatmentTreatment ofof pediatricpediatric migrainemigraineNonanalgesicinterventions: vs. placebo
- nasal spray sumatriptan , zolmitriptan- oral sumatriptan- oral rizatriptan- oral dihydergotamine- iv. prochlorperazine & ketorolac
conclusionconclusion:: moderatemoderate evi denc eevi denc e that that :: sumatriptansumatriptan nasal nasal spray spray is moreis more effectiveeffective t h a ntha n placebo ( plac e bo ( moderatemoderate evidenceevidence ) )( ( i ni n reductionreduction o fo fsy mpto mssy mpto ms ,, b ut b ut wi thwith moremore adverseadverse ev entsev ents ) )
n on o clear clear diff erenc esdifferenc es i ni n effect effect betweenbetweeno ra l o r a l sumatriptansumatriptan / / rizatriptanrizatriptan and plac ebo !!!! and plac ebo !!! !
iv iv .. prochlorperazine is more effective than ketorolac
Da m e nDa m e n e te t a l a l .. Pediatric sPediatric s , 200 5 , 200 5 ( ( Review Review of 1 0of 1 0 t ria l st ria l s ) ) ) )
Nonanalgesic interventionTreatmentTreatment ofof pediatricpediatric migrainemigraine
• New frontier for s ymptomatic treatment ofchildhood migraine :
NASAL TRIPTANSNASAL TRIPTANS
e.g . nasa l nasa l suma tr iptansumatr iptanfas t fas t absoprtionabsoprtion immedia t ly immedia t ly a f te r a f te r dos in g dos in g Currently n o triptans a re allowed b y th e F D Af or t he us ei n
pe di at ric migr ain e.
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TreatmentTreatment ofof pediatricpediatric migrainemigraine
O r a l O r a l triptan striptans may n ot b e effective inchildren because of:
- gastric stasis , nausea and vomiting
delayed absorption- attacks tend to be shorter in children than
those in adults, m ay spontaneously remit <2h(ma ximum benefit of drugs close to 2 h)
TreatmentTreatment ofof pediatricpediatric migrainemigraine
Preventive Treatme nt StrategyCurrently, the FDA:
- hashas n otn ot approv edapprov ed any medication f or the prevention of migraine inchildren.
- has approv ed 5 medication for adults .
Indication: - frequency of HA ( > 3-4 HA/m)-- significantsignificant disabilitydisability duringduring HA (HA ( pedMIDASpedMIDAS ))
Tricyc lic Antidepressants , antiepileptic medications,antiserotoneric antiserotoneric a g e n t sa g e n t s,,
BB -- blockersblockers ,, CalciumCalcium Channel Channel BlockersBlockers ,, NSAIDsNSAIDs, etc.. ., etc.. .
OverallOverall efficacyefficacy of of preventivepreventive antianti --migrainemigraine drugsdrugs
Best tBest t herapeuticherapeutic «« gaingain »» compared to placebo.compared to placebo.(% of(% of ““ respondersresponders ””
,i.e. 50% reduction in attack f requency),i.e. 50% reduction in attack f requency)
1 8
20
29
37
42
40
45
33,3
31
7,4
0 5 1 0 1 5 2 0 2 5 3 0 3 5 4 0 4 5 5 0 5 5
Cyclandelate
Mg(24mM)
Pizotifen
Lisinopril
Candesartan
Q10 (300mg/d)
Riboflavin (400mg)
Flunarizine
Betablockers
Valproate
FrequentFrequentadverseadverseeffectseffects
RareRareadverseadverseeffectseffects
TreatmentTreatment ofof pediatricpediatric migrainemigrainePlaceboPlacebo s have a profound effect in headache
- Responder rate to placebo
a, acute headache events : 20-30%b, in prevention trials: 30%
- Effects of placeb o are long-term (over ~ 6-9 months )
- Subcutaneous placebo is more effective than oral placebo- Side effects : body weight - Similar mode of action as „ real” drug (PET, fMRI studies)
Diener , 2005