Management of Pediatric Migraine Headache in the Emergency Room and Infusion Center

Migraine is a common disorder that starts at an early age and takes a variable pattern from intermittent to chronic headache with several exacerbations throughout a lifetime. Children and adolescents are significantly affected. If an acute headache is not aborted by outpatient migraine therapy, it often causes severe disability, preventing the child from attending school and social events. Treating the acute severe headache aggressively helps prevent prolonged disability as well as possible chronification. Multiple medications are available, mostly for the outpatient management of an attack and include the use of over‐the‐counter anti‐inflammatory medications as well as prescribed medications in the triptan group. These therapies do sometime fail and the exacerbation can last from days to weeks. If the headache lasts 72 hours or longer it will fall in the category of status migrainosus. Status migrainosus is described as a severe disabling headache lasting 72 hours or more by the ICHD3 criteria. Disability is a major issue in children and adolescents and aggressive acute measures are to be taken to control it as soon as possible. Early aggressive intravenous therapy can be very effective in breaking the attack and allowing the child to be quickly back to normal functioning. This article reviews what is available for the treatment of pediatric primary headaches in the emergency room.     

Comprehensive Inpatient Treatment of Refractory Chronic Daily Headache

Objective.— (1) To assess outcome at discharge for a consecutive series of admissions to a comprehensive, multidisciplinary inpatient headache unit; (2) To identify outcome predictors. Background.— An evidence‐based assessment (2004) concluded that many refractory headache patients appear to benefit from inpatient treatment, underscoring the need for more research, including outcome predictors. Methods.— The authors completed a retrospective chart review of 283 consecutive admissions over 6 months. The inpatient program (mean length of stay = 13.0 days) included intravenous and oral medication protocols, drug withdrawal when indicated, cognitive‐behavior therapy, and other services when needed, including anesthesiological intervention. Patient‐reported pain levels and consensus of medical staff determined outcome status. Results.— The 267 completers (94%) included 212 women and 55 men (mean age = 40.3 years, range = 13‐74) from 43 states and Canada. The modal diagnosis was intractable, chronic daily headache (85%), predominantly migraine. Most (59%) had medication overuse headache (MOH), involving opioids (48%), triptans (16%), or butalbital‐containing analgesics (10%). Psychiatric diagnoses included stress‐related headache (82%), mood disorders (70%), anxiety disorders (49%), and personality disorders (PD, 26%). More patients with a PD (62%) had opioid‐related MOH than those with no PD (38%), P < .005. Of the completers, 78% had moderate to significant pain reduction, with comparable improvement in mood, function, and behavior. Clinical factors predicting moderate‐significant headache improvement were limited to MOH (84% vs 69%, P < .007) and presence of a PD (68% vs 81%, P < .03). Conclusions.— Most patients (78%) improved following aggressive, comprehensive inpatient treatment. Maintenance of improvement is likely to depend on multiple post‐discharge factors, including continuity of care, compliance, and home or work environment.     

Abortive Migraine Therapy in the Office with Dexamethasone and Prochlorperazine

SYNOPSIS
Corticosteroids are commonly used in the abortive therapy of status migrainosus. However, this practice is based more on clinical experience than on published data. At my office, over a period of two years, 108 patients (156 migraine episodes) were treated with intravenous dexamethasone. Most of these patients had prolonged migraines that had resisted other forms of abortive therapy. The first 22 patients (32 migraine episodes) were given 10 mg of dexamethasone over 5 minutes, the next 39 patients (55 migraine episodes) were given 20 mg over 10 minutes, and the last 47 patients (69 migraine episodes) were given 3.5 mg of prochlorperazine over 5 minutes followed by 20 mg of dexamethasone over 10 minutes. Adverse effects were minor and patients with episodic migraines responded more favorably than those with intractable migraines. In the episodic migraine groups, response rates ranged from 80–89%, relapse rates from 29–35%, and remission rates from 57–83%. After the intravenous injections, repetitive oral abortive therapy was often required to treat relapses and secure remission. Adding 3.5 mg of pro-chlorperazine to 20 mg of intravenous dexamethasone significantly shortened the response time.     

Pediatric headache: a clinical review

In this review we describe the epidemiology, classification, and approach to the diagnosis and treatment of episodic and chronic migraine in children. We review both traditional and alternative medications, and offer a glimpse into the future of pediatric headache.     

Ictal Epileptic Headache Mimicking Status Migrainosus: EEG and DWI‐MRI Findings

(Headache 2010;??:??‐??) We report a case of a patient with status migrainosus unresponsive to analgesic therapy in whom electroencephalographic recording revealed an epileptic origin. Intravenous administration of lorazepam induced the prompt resolution of the symptoms.     

The Hospital Management of Severe Migrainous Headache

In a two year period, 47 patients with migraine were hospitalized for the management of severe headache; 18 had acute migraine (duration less than 72 hours), 17 had status migrainosus (duration by definition more than 72 hours), and 12 had chronic daily headaches qualitatively of a migraine type. Treatment in all comprised cessation of all previous medication, plus one of the following: intravenous DHE, intravenous lidocaine, a combination of lidocaine + DHE, or subcutaneous sumatriptan. Improvement from DHE, lidocaine, or both was slow and often incomplete. Sumatriptan was not used in patients with chronic daily headaches; in the 8 cases of acute migraine or status migrainosus in which it was used, improvement was rapid and complete in seven.     

Parent Responses to Pediatric Headache

Evaluated child and parent report versions of a 16-item parent response to children's recurrent pain episodes scale (PR-PAIN) on a sample of 153 pediatric headache patients. Factor analyses yielded three factors—Solicitous, Affiliative/Distracting, and Negative responses—for each report form. Correlations among factor scores provided evidence for convergent and discriminant validity. Factor scores from the parent and child report scales were differentially related to levels of episode-specific disability and overall behavior problems, supporting the criterion-related validity of both the child and parent measures, The PR-PAIN scale may assist in performing a thorough functional analysis of pediatric headache and other pain-related problems.     

Managing intractable migraine with naratriptan

BACKGROUND: Intractable migraine presents a significant treatment challenge to both patient and physician. Most attacks are treatable or self-limiting, but occasionally they may continue for extended periods regardless of treatment. OBJECTIVE: To determine the efficacy of naratriptan 2.5 mg twice daily for the treatment of intractable migraine. METHODS: We reviewed 24 patients treated with naratriptan twice daily for an intractable migraine attack. Patients were permitted to take prophylactic medication if such treatment had been effective in the past. RESULTS: Nineteen patients (79%) improved. Twelve patients showed excellent response with cessation of pain and associated symptoms, 7 patients partially responded with lessening of pain and cessation of associated symptoms, and 5 patients were nonresponsive. CONCLUSION: Short-term daily administration of naratriptan may be effective in terminating status migrainosus.     

Chronic Daily Headache: Long-Term Prognosis Following Inpatient Treatment With Repetitive IV DHE

We retrospectively studied the long-term (2-year) outcome of 50 consecutive patients admitted to our inpatient headache program because of chronic daily headache (CDH) associated with the overuse of analgesics, ergotamine, or both. They had been detoxified, given repetitive intravenous dihydroergotamine (IV DHE) and prophylactic medications as part of the program, and had become headache-free on this regimen. At the time of admission, 37 of the 50 patients had transformed migraine (TM), 12 had new daily persistent headache (NDPH), and 1 had chronic tension-type headache; 29 of the patients with TM, 7 of those with NDPH, and the single patient with chronic tension-type headache had coexistent migraine. Substances abused, alone or in combination, included: caffeine in 39 patients (av. 441 mg/d), acetaminophen in 32 (av. 2187 mg/d), aspirin in 24 (av. 1807 mg/d), ibuprofen in 9 (av. 1156 mg/d), narcotics in 7 (av. 10.1 mg morphine equivalents/d) and ergotamine in 11 (av. 2.3 mg/d). Twenty patients were using preventive medication at the time of admission. Follow-up evaluations were performed at 3, 6, 12, and 24 months after discharge. Forty-three patients were analyzed at 3 months. Of these, 44% had an excellent or good result and 28% a fair result; 3 were overusing analgesics. At 24 months, 39 patients were analyzed: 59% had a good or excellent result and 28% a fair result; 5 were overusing analgesics, 4 of whom were doing poorly.(ABSTRACT TRUNCATED AT 250 WORDS)     

Butalbital and Pediatric Headache: Stay off the Downward Path

Despite limited evidence from the literature surrounding safety or efficacy, butalbital‐containing medicines (BCMs) have maintained their rank as “go‐to” prescribed migraine and headache relief drugs in the United States, despite bans on these barbiturates in Germany and other European countries. Providers at the Pediatric Headache Program at Boston Children's Hospital recommend that clinicians prescribe triptan‐based medications instead of BCMs, given the known negative side effects of BCMs on the general population, and the uncertain longitudinal trajectory of BCMs on developing brains.     

Biofeedback Therapy for Pediatric Headache: Factors Associated With Response

Objectives.— The goal of this study was to measure the effect of biofeedback therapy on pediatric headache and to identify factors associated with response to biofeedback therapy. Background.— In the United States, 17% of children have frequent or severe headaches. Biofeedback therapy (BFT) appears to be an effective treatment for headaches in adults and is often recommended for children with headaches, but there are few data in the pediatric population. It is also not clear which patients are most likely to benefit from biofeedback therapy. Methods.— We examined the records of patients, aged 8 to 18 years old, who were referred to a pediatric BFT clinic for management of headache between 2004 and 2008. We extracted data regarding patient and headache characteristics, medication use, family history, and measures of depression, anxiety, and somatization. Chronic headache was defined as ≥4 headache days/week. Positive response to biofeedback was defined as a 50% reduction in number of headache days/week or hours/week, or ≥3‐point decrease in severity (0‐10 scale) between first and last visits. We analyzed the responder rate for those with episodic and chronic headaches and performed multivariable analysis to determine what factors were associated with headache response to biofeedback therapy. Results.— We analyzed records from 132 children who attended ≥2 biofeedback sessions. Median headache frequency dropped from 3.5 to 2 headache days/week between the first and last visits. The response rate was 58% overall; 48% for chronic headaches and 73% episodic headaches. In multivariate analysis, ability to raise hand temperature by >3°F at the last visit and use of selective serotonin reuptake inhibitors (SSRIs) were associated with a positive response, and preventive medication use was associated with nonresponse. Anxiety, depression, and somatization were not significantly associated with response to biofeedback therapy. Conclusions.— Biofeedback therapy appears to be an effective treatment for children and adolescents with both episodic and chronic headaches. Further study is warranted to compare biofeedback with other treatments for chronic pediatric headache. Use of SSRIs appears to be associated with a positive response to biofeedback therapy, but the reasons for this relationship are unclear and merit further study.     

Headache and Electroconvulsive Therapy

SYNOPSIS
While headache is a documented side effect of electroconvulsive therapy (ECT), there is little information on this phenomenon. Studies of the mechanisms of ECT as a treatment for depression indicate that alterations in serotonergic neurotransmission appear to be related to its efficacy. While ECT and many of the antidepressant drugs have similar effects on serotonergic transmission, they are notably different in the changes they induce in type 2 receptors for 5-hydroxytryptamine (5-HT). ECT upregulates 5-HT₂, and antidepressants down regulate the receptor's expression. 5-HT₂ receptor sensitization has been associated previously with headache genesis, which may explain why ECT induces headache, and amitriptyline relieves headache.
In our study we surveyed 98 patients retrospectively about their experiences with headache prior to and following ECT. Of the 54 patients who submitted properly completed questionnaires, five reported new onset of headaches following ECT, four reported exacerbation of a previous headache problem, and two reported their headaches improved. The patients experienced changes in the character or location of pain, with a tendency to progress from tension-type to migrainous headache. In all but two cases these developments persisted at least eight months after ECT. We discuss the possible reasons and significance of our findings.     

Pediatric Headaches: What Do the Children Want?

One hundred consecutive children (aged 3 to 17 years), drawn from primary care pediatric clinics, with a greater than 3-month history of headaches completed surveys to determine the type and associated features of their headache and to query their reasons for wanting to see a physician. Additionally, the children were asked to draw pictures of how they felt when they had a headache to assess their nonverbal perceptions. Over 90% of the headaches were migrainous (65% common, 23% classic, 5% basilar). The children wanted three answers from the physician: what was the cause of their headache, what would make it better, and reassurance that they had no life-threatening illness. Furthermore, 33%, of the children's illustrations disclosed depressive features of helplessness, frustration, and anger. Over 20% of the adolescents depicted themselves as dead, dying, or about to be killed by their headache.     

Dysautonomia and Headache in the Pediatric Population

Dysautonomia and headache are 2 common diagnoses within pediatric neurology; in the case of dysautonomia, a lack of consideration may lead to misdiagnosis. Despite being common conditions, there is a lot to learn about each individually as well as collectively. Many of the symptoms between headache and dysautonomia patients overlap making the diagnosis difficult. Migraine patients often exhibit symptoms of dysautonomia, namely postural orthostatic tachycardia syndrome (POTS); yet these symptoms are overlooked or lumped in as a part of their migraine diagnosis. The distinction or coexistence between dysautonomia and headache is identified through a thorough history, a full exam, and an open mind. This is crucial for the treatment and outcomes of these patients. Struggles arise when critical treatment differences are overlooked because dysautonomia is not considered. In this review, we will look at the epidemiology of dysautonomia and headache with focus on POTS and migraine. We will then compare the clinical features of both conditions as well as some hypothesized pathophysiology overlaps. We will conclude by summarizing the diagnostic approach and multitiered treatment options for POTS and migraine.