Headache - Children`s Hospital Colorado

Headache
Patientage8-17yearsold
CLINICALASSESSMENT
History
•
Goalofhistoryistohelpdistinguishprimaryheadachedisorder
•
Payparticularattentiontothepresenceofuntreatedseasonalallergiesandsnoring
•
UtilizetheHeadacheIntakeQuestionnaireforfamiliestofilloutpriortoappointmentorbyyourselfduring
historytaking.
PhysicalExamination
1. Vitalsigns,includingbloodpressureandtemperature
2. Palpationoftheheadandneck
3. Headcircumference
4. Skinassessmentforneurocutaneoussyndrome,particularlyneurofibromatosisandtuberoussclerosis
5. Detailedneurologicalexamination
LABORATORYSTUDIES|IMAGING
•
•
Computedtomography(CT)scanning
Magneticresonanceimaging(MRI)
CLINICALMANAGEMENT
Behavioralmodification
•
Fluids:Drinkenoughfluid(6to8glassesperday)andavoidcaffeine.
•
Sleep:8to10hoursofsleepeachnightandgotobedatthesametimeeachnightandawakenatthesame
timeeachdaykeeparegularsleepschedule.
•
Nutrition:Consumebalancedmealsatregularhoursanddonotskipmeals.Triggersaredifferentforeach
individual.Possiblefoodtriggersincludeagedcheese,artificialsweeteners,caffeine,chocolate,citrusfruits,
curedmeats(packagedlunchmeats,sausage,pepperoni),MSG,nuts,onions,andsaltyfoods.
•
Exercise/stretching:Atleast45minutesofaerobicactivityand5to10minutesofstretchingeveryday.
•
Stress:Stressisthenumberonetriggerforchildren.Considerstressmanagement,counseling,orrelaxation
techniques.
•
Electronicsoveruse:Limituseofelectronicstolessthan2hoursperdayandnone2hourspriortobedtime.
FOLLOW-UP
•
•
•
•
•
PatientStabilizationinEmergencyDepartmentorUrgentCare
Newonsetheadaches:follow-upin2to4weeks
Childrenwithhighfrequencyheadaches(greaterthan(>)8headachespermonth)andnewchangesto
treatmentplan:follow-upin4to6weeks
Childrenwithlowfrequencyheadaches(lessthan(<)8headachespermonth)andnewchangestotreatment
plan:follow-upin8to12weeks
Childrenwithnochangesandstable:follow–upin10to12weeks,upto1year
ALGORITHM.HeadacheActionPlan
Page1of19
TARGETPOPULATION
Intendedfor:
• Patientsage8to17yearsold
• Primaryheadache(i.e.tensionormigraine)
NotIntendedfor:
•
Patientwithsecondaryheadaches
KEYTREATMENTPRINCIPLES
Indicated:
• Oralfluids
• NSAIDs
• Non-pharmacologicoptions
Notindicated:
• MRI
• CTscan
• Opioids(neverindicated)
TABLEOFCONTENTS
GeneralInformation
Criteria
ClinicalAssessment
LaboratoryandRadiologyStudies
ClinicalManagement
Algorithm
ProviderTools
Parent/CaregiverEducation
Follow-up
FAQ
References
ClinicalImprovementTeam
GeneralInformation
•
•
•
•
Approximately11%ofchildrenand23%ofadolescentsexperiencerecurrentheadaches1
Therearedifferenttheoriesaboutthecauseofheadaches
About60%ofchildrenhaveapositivefamilyhistory,suggestinggeneticfactorsarepartlyresponsible
Otherpossiblereasonsformigraineincludebloodvesselsensitivity,brainandnervoussystemchanges,and
serotoninsystemabnormalities.Medicinesusedtotreatheadachedisordersoftenworkonthesepathways
Criteria(InternationalHeadacheClassificationofHeadacheDisorders-III20133,4)
Migraine:
•
AtleastfiveattacksfulfillingcriteriaA-C
A. Headacheattackslasting2to72hours(untreatedorunsuccessfullytreated)
B. Headacheattackhasatleasttwoofthefollowingcharacteristics:
§ Unilateralorbilaterallocation
§ Pulsating/throbbingquality
Page2of19
§ Moderateorseverepainintensity
§ Aggravationbyorcausingavoidanceofroutinephysicalactivity(e.g.,walkingorclimbingstairs)
C. Duringheadacheatleastoneofthefollowing:
§ Nauseaorvomiting
§ PhotophobiaANDphonophobia(canbereferredfrombehavior)
D. Notattributedtoanotherdisorder
•
Warnings,calledauras,maystartbeforetheheadache.Theseaurascanincludeblurryvision,flashinglights,
coloredspots,strangetastes,unilateralnumbness,orweirdsensationsandusuallyoccur5to60minutes
beforetheonsetoftheheadache.
Tension-typeheadache(TTH):
AtleasttenattacksfulfillingcriteriaA-C
A. Headacheattackslasting30minutesto72hours(untreatedorunsuccessfullytreated)
B. Headacheattackhasatleasttwoofthefollowingcharacteristics:
§ Bilaterallocation
§ Band/pressurequality
§ Mildtomoderatepainintensity
§ Notaggravationbyroutinephysicalactivity(e.g.,walkingorclimbingstairs)
C. Duringheadache:
§ Nonauseaorvomiting
§ Canhavephotophobiaorphonophobiabutnotboth
D. Notattributedtoanotherdisorder
Chronic:
•
•
Bothmigrainesandtension-typeheadachescanbecomechronic,meaningtheyoccuratleast15daysper
monthforgreaterthan3months
Chronicheadachescanresultfromtakingacutemedicationmorethan3timesperweektotreatheadache
attacks(e.g.,acetaminophen,ibuprofen,caffeine,opioids,andcombinationanalgesics).Theseheadachesare
calledmedicationoveruseheadaches.Themosteffectivewaytomaketheseheadachesbetteristostop
takingpainmedicinesaltogetherfor2to3weeks.Afterthattime,useofpainrelieversshouldbelimitedto
nomorethan2to3timesperweek.
ClinicalAssessment
History
• Thegoalofthehistoryistohelpdistinguishprimaryheadachedisorder(migraineortension-type)from
secondaryheadachedisorder(increasedICP,tumor,etc.)
• Payparticularattentiontothepresenceofuntreatedseasonalallergiesandsnoring(considerevaluatingand
treatingpriortoinitiatingpreventativemigrainemedication).
• UtilizetheHeadacheIntakeQuestionnaireforfamiliestofilloutpriortoappointmentorbyyourselfduring
historytaking.
PhysicalExamination
•
•
•
•
Vitalsigns,includingbloodpressureandtemperature
Palpationoftheheadandnecktoassessforsinustenderness,thyroidmegaly,ornuchalrigidity
Headcircumference(eveninolderchildren)
Skinassessmentforneurocutaneoussyndrome,particularlyneurofibromatosisadtuberoussclerosis
Page3of19
•
Detailedneurologicalexaminationwithparticularattentiontofundoscopicexamination,eyemovements,
headtilt,finger-nose-fingertestingfordysmetria,andtandem(heal-toe)gaitforataxia.
NOTE:Morethan98%ofchildrenwithbraintumorshaveobjectiveneurologicalfindings
Table 1: Red Flags
Focal neurologic deficit
Young age (less than 8 years old)
Posteriorly-located headache
New onset or worsening headache
Postural headache
Nighttime awakening headache and or vomiting
Early morning headache and or vomiting
Neurocutaneous stigmata
Laboratory|RadiologyStudies
Diagnostictestsareonlyindicatediftheywillchangeoutcome
Ingeneral,mostchildrenwithrecurrentheadachesrequirenodiagnostictestingforclinicalassessment.Utilize
redflagstoguidediagnostictesting.ThemorecommonredflagsarelistedbelowinTable1.
Neuroimaging
Computedtomography(CT)scanningusuallynotindicatedinachildwithrecurrentheadaches7.
Considerwhenthefollowingarepresent:
§ Acute“worstheadacheoflife”(WHOL)
§ Thunderclapheadache
§ Newfocalneurologicaldeficitiscurrentlypresentonexaminationwithacuteheadache
§ Intractablevomiting
§ Papilledema
§ Fever
Magneticresonanceimaging(MRI)
Ifoneofmoreredflags(listedinTable1)arepresentandthereisconcernforatumororotherstructural
abnormalitythenconsiderobtaininganMRIwithoutcontrast.
§ Asingleoccurrenceofnighttimeawakeningofheadacheinachildwithrecurrentheadachesisnot
alarming;incontrastachildwithamajorityofheadachesoccurringonlyatnighttimewouldbe
worrisome.
§ Severalredflagsmaybemorepredictiveofunderlyingneurologicaletiologysuchasyoungerage,focal
neurologicaldeficit,andposteriorly-locatedheadache.
LumbarPuncture
•
•
•
Mandatoryinfebrilepatientswithnuchalrigidityandnoalterationinconsciousness,signsofincreased
intracranialpressure,orlateralizingfeatures
Indicatedwithmeasurementofopeningpressureincaseofsuspectedsubarachnoidhemorrhage(WHOLand
Thunderclapheadache),acuteorchronicmeningitis,pseudotumorcerebri,orneuroborreliosis
Ifthepatient’smentalstatusisaltered,papilledemaispresent,orfocalfindingsareevident,cranialimagingis
warrantedbeforelumbarpuncture
Page4of19
Electroencephalogram(EEG)
•
•
Oflimiteduseintheroutineevaluationofheadacheinchildren8,9
Maybewarrantedifheadacheisfleetingandisassociatedwithalterationofconsciousnessorabnormal
movement,wherethedifferentialdiagnosiswillincludecomplexpartialseizuredisorders
ClinicalManagement
Behavioralmodification
Allchildrenneedtobecounseledonbehaviormodificationas“headachehygiene”—maintaininghealthyhabitsto
preventheadaches.ThesearefoundinCaregiverEducationbutaresummarizedbelow:
1. Fluids:Drinkenoughfluid(6to8glassesperday)andavoidcaffeine.
2. Sleep:8to10hoursofsleepeachnightandgotobedatthesametimeeachnightandawakenatthesame
timeeachdaykeeparegularsleepschedule.
3. Nutrition:Consumebalancedmealsatregularhoursanddonotskipmeals.Triggersaredifferentforeach
individual.Possiblefoodtriggersincludeagedcheese,artificialsweeteners,caffeine,chocolate,citrusfruits,
curedmeats(packagedlunchmeats,sausage,pepperoni),MSG,nuts,onions,andsaltyfoods.
4. Exercise/stretching:Atleast45minutesofaerobicactivityand5to10minutesofstretchingeveryday.
5. Stress:Stressisthenumberonetriggerforchildren.Considerstressmanagement,counseling,orrelaxation
techniques.
6. Electronicsoveruse:Limituseofelectronicstolessthan2hoursperdayandnone2hourspriortobedtime.
Abortive/Acute(SeeTable2.AcuteOutpatientMedications)
GeneralRecommendations
1.
•
•
•
2.
3.
4.
5.
Createatreatmentplanforhome/schoolacutemanagement
Alwaysincludeacomponentofnon-pharmacologicoptions(seebelow)
Alwayshavefluidreplacementaspartoffirstlinetreatment
Alwayshaveafirstlinemedicationtotakeatonsetandasecondlinetotake2hourslaterforpersistent
heachache
§ Firstlinetherapyshouldnotcontainasedatingmedicationandchildcanreturnbacktoschoolwork
§ Secondlinetherapymaycontainasedatingmedicationandchildshouldrestandavoidactivitywhen
possible
Thekeyistotreatwithanadequatedoseatonsetofauraorheadache
Ifusingatriptan:itismosteffectivetotakeatonsetofheadache
Startwithmonotherapyandprogresstocombinationsasneeded
Abortivetreatmentshouldbelimitedtoonly2to3timesperweek.Payparticularattentiontoprescribing
NSAIDSforextendedperiods,asthiswillincreasemedicationoveruseheadache(i.e.reboundheadache)2
Non-pharmacologicoptions
•
•
•
•
•
•
•
•
USEHEADACHEACTIONPLANALGORITHM
Fluidreplacement:Sportsdrinkwithoutcaffeine(suchasPowerade®,Gatorade®,etc.),coconutwater,or
plainwater
Rest
Darkenroom
Notelevision,cellphone,etc.
Aromatherapy
Massage
Relaxationtechniques
Warmorcoldpacks
Page5of19
Algorithm.HeadacheActionPlan
Developing a Home/School Use Headache Action Plan
Has child failed
adequate dose of
ibuprofen?
NO
st
1 line: Fluid replacement: 24 to 32 ounces at onset PLUS ibuprofen PLUS
non-pharmacologic options (rest, dark room, warm/ice packs, etc.)
nd
2 line: If symptoms persist after 2 hours, administer diphenhydramine
YES
Has child failed
adequate dose of
naproxyn?
st
1 line: Fluid replacement: 24 to 32 ounces at onset PLUS naproxyn PLUS
non-pharmacologic (rest, dark room, warm/ice packs, etc.)
nd
2 line: If symptoms persist after 2 hours, administer diphenhydramine
NO
YES
Has child failed
adequate dose of
triptan OR is triptan
contraindicated?
NO
st
1 line: Fluid replacement: 24 to 32 ounces at onset PLUS triptan PLUS
non-pharmacologic (rest, dark room, warm/ice packs, etc.)
nd
2 line: If symptoms persist after 2 hours, repeat triptan, add NSAID and/or
diphenhydramine
YES
Has child failed
adequate dose of
triptan and NSAID OR
is triptan
contraindicated?
st
1 line: Fluid replacement: 24 to 32 ounces at onset PLUS NSAID PLUS triptan PLUS
non-pharmacologic (rest, dark room, warm/ice packs, etc.)
nd
2 line: If symptoms persist after 2 hours, repeat triptan and add diphenhydramine
NO
Page6of19
Table2.AcuteOutpatientMedications
Medication
Form
Dosage
Maximumdose
Frequency
Formulations
COST*
Sideeffects
Ibuprofen
(Motrin®/Advil®)
PO
10mg/kg/dose
800mg
Q6to8
hours
OTC
GIbleeding,GI
Ulcers,decreased
plateletfunction
Naproxen
(Aleve®/Naprosyn
®)
Acetaminophen
(oral)
PO
5to7
mg/kg/dose
500mg
Q12hours
PO
Weight16.1to
21.5kg=240mg
Weight21.6to
27kg=320mg
Maximumdaily
dose(oralor
rectal):
Greaterthan12
yrs=3g/24
hours
Lessthan12yrs=
5doses/24hours
or2.6grams/24
hours
Q6hours
Chew:100mg
Tab:200mg
Syrup:100mg/5
ml
Susp:125mg/ml
Tab:220,250,
375,500mg.
MANYOPTIONS
OTC
Hepatictoxicity
Maximumdaily
dose(oralor
rectal):
Greaterthan12
yrs=3g/24
hours
Lessthan12yrs=
5doses/24hours
or2.6grams/24
hours
Q6hours
MANYOPTIONS
OTC
Hepatictoxicity
0.25to1
mg/kg/dose
25mg
Q4to6
hours
Blurredvision,
dystonicreaction
0.1mg/kg/day
10mg
Q6to8
hours
NSAIDS:
Acetaminophen
(rectal)
PR
Weight27.1to
32.5kg=400mg
Weight32.6to
43kg=480mg
Weightgreater
than43kg=500
mg
Weight16.1to
27kg=325mg
Weight27.1to
43kg=487.5mg
Weightgreater
than43kg=650
mg
OTC
Antiemetics
Promethazine
(Phenergan®)
PO/PR
Prochlorperazine PO/PR
(Compazine®)
Rectal:12.5,25,
50mg
Syrup6.25mg/5
ml,25mg/5ml
Tabscored12.5,
25,50mg
Rectal:2.5,5,10
mg
Syrup:5mg/mL
Tablet5,10,25
mg
Page7of19
Table2.AcuteOutpatientMedications(continued)
Medication
Form
Dosage
Maximumdose
Frequency
Formulations
Cost*
Sideeffects
Triptans:Triptansshouldnotbeusedmorethantwotimesperweekwithamaximumofsixtimespermonth.
Donotadministerdihydroergotamine(nasalDHEorIVDHE)within24hoursofthelastdoseoftriptan.
FDAapproved:Rizatriptan≥6yearolds,Almotriptan≥12yearolds.Althoughothertriptansarecommonlyprescribedinthecommunityandmaybe
effective,theyarenotFDAapprovedandsafetyhasnotbeenestablishedinpediatricpatients.Aconsultationwithaneurologistisrecommended
priortoprescribingthesemedications.
<40kg:10mg/24
Canrepeat
$37-49/tab
Rizatriptan
<40kg:5mg
hours
ODT:5,10mg
Nausea,dizziness,
PO
in2hrs
!
Generic$10/tab
(Maxalt®) >40kg:10mg
>40kg:20mg/24
Tab:5,10mg
weakness,flushing
hours
Nausea,
Almotriptan
Canrepeat
PO
6.25to12.5mg 25mg/day
Tab:6.25,12.5mg $33-43/tab
somnolence,
!
(Axert®) in2hrs
dizziness
Lessthan50kg:
25mg:$29.99/tab
25mg
50mg:$21.29/tab
PO**
100mg/24hours
Tab:25,50,100
100mg:
mg
Greaterthan50 PO
$23.19/tab
kg:50mg
Canrepeat
Lessthan50kg:
SUMAtriptan
Nausea,dizziness,
in2hrs
!
5-10mg
Intranasal
40mg/hours
Intranasal:5,
(Imitrex®) weakness,flushing
20mg
Greaterthan50 intranasal
kg:20mg
SC:4mg/0.5mL, SC
0.06to1mg/kg 12mg/hoursSC
6mg/0.5mL
ZOLMitriptan
!10
(Zomig®) PO
Greaterthan50
kg:2.5to5
mg/dose
IN
5mg/dose
Eletriptan
!
(Relpax®) PO
Naratriptan
!
(Amerge®) PO
Greaterthan50
kg:20to40
mg/dose
1to2.5
mg/dose
10mg/24hours
Canrepeat
in2hrs
Tab:2.5,5mg
ODT:2.5,5mg
Intranasal:5mg
80mg/24hours
Canrepeat
in2hrs
Tab:20,40mg
5mg/24hours
Canrepeat
in4hrs
5mg/24hours
Canrepeat
in2to4hrs
Frovatriptan
!
(Frova®) PO
2.5mg/dose
$59-73/tab
$36-48/tab
$35-36/tab
$42/tab
Nausea,dizziness,
chestpainand
tightness,
weakness,
paresthesia
Nausea,weakness
dizziness,
paresthesia
Nausea,dizziness,
pain(CNS)
Flushing,dizziness,
fatigue,
xerostoma,
paresthesia
*Costbasedonpriceperpill/tablet(unlessotherwisenoted)purchasedfromlocalpharmaciesinColoradofor
cash-payingcustomersduringsecondquarterof2013
**Sumatriptan(Imitrex®):upto3mg/kg/dayPOhasbeentoleratedinsomeadultstudies
!
NotonCHCOformulary
Page8of19
Table2.AcuteOutpatientMedications(continued)
Medication
Form
Dihydroergota
mine
(Migrainol®)
Intranasal
Maximum
dose
3mg/24hours
0.5mgin
eachnare
Donotexceed
foratotal
4mginone
doseof1mg
week
Dosage
Frequency
Mayrepeatevery
15minutesfora
totalofthreedoses
Formulations
COST*
Intranasal:
4mg/mL
$196-247/mL
Vasoconstriction,flushing,
Nauseadiarrhea:Donot
administernasalDHEorIV
DHEwithin24hoursofa
triptandose.
OTC
Nausea,blurredvision,
xerostoma
Sideeffects
Antihistamine
Diphenhydrami
ne(Benadryl®)
PO
0.5
mg/kg/dose
50mg
Q6hours
*Costbasedonpriceperpill/tablet(unlessotherwisenoted)purchasedfromlocalpharmaciesinColoradoforcash-paying
customersduringsecondquarterof2013
Preventative(SeeTable3.PreventativeMedicationstoConsider)
Generalrecommendation
1. Donotforgetchanginglife-stylebehaviorsandstressmanagementarethesafestpreventatives!
2. Considerstartingpreventativeifchildhas3-4headachesormorepermonthwithsignificantdisability(i.e.
missedschool,missedschoolrelatedactivities,etc)
• Thegoalofpreventativetreatmentistodecreaseheadachefrequencyto<1-+2permonth,withdecreases
disabilityforasustainedperiodoftime(4-6months)5
3. Whenchoosingapreventative
• Considerchild’sage,weigh,andcomorbiditieswhenstartingpreventative
• Considertakingadvantageofside-effectprofileofmedication(e.g.consiertopiramateforanobesechild
becauseitcausesappetitesuppressionandweightloss)
• Iflessthan12yearsofage–considertopiramateorcyproheptadine
• Ifgreaterthan12yearsofage–consideramitriptylineortopiramate
• IFobese–considertopiramate
• Ifallergies–considercyproheptadine
• Ifsleepingdifficulties–consideramitriptyline
4. Titrationtips
• Startlowandgoslow–youwanttooptimizeeffectivenessanddecreasepossiblesideeffectsexperienced.
• RefertoTable3.PreventativeMedicationstoConsiderfortitrationguidelines.
• Duringtitration,youdonotneedtoreach“maintenance”doseifpatienthasimprovement/resolutionof
headache
• Improvementtypicallyisobservedafterweeksorpossiblymonthsoftreatments,ratherthanwithindays6
5. Discontinuationtips
• Allmedsshouldbeweanedbyapproximately25%every2weeks,unlessside-effectsareconsideredadverse
orpatientonlowestdose.
Page9of19
Table3.PreventativeMedicationstoConsider
Medications
Titration
Amitriptyline
StartingDose
IncreaseBy
Maintenance
dose
Maximumdose
Topiramate
StartingDose
IncreaseBy
Maintenance
dose
Maximumdose
Propranolol
Verapamil
***
Cyproheptadi
ne
(Periactin)
StartingDose
IncreaseBy
Maintenance
dose
Pediatric/adolescent
Dosing
10mgPOqhs
10mgq3to4wks
Adult
Dosing
10to25mg
25mg
25to50mgPOqhs
150mg
1mg/kg/dayqhsupto
100mg/day
300mg
12.5mgPOqhs
12.5mgq2weeks
25mgqhs
25mgweekly
25mgPOBID
50mgBID
2mg/kg/daydivbid
(upto200mgdivided
twicedaily)
10mgPOTID
10mgq3weeks
20to40mgPOTID
100mgBID
20mgTID
20mgq3wks
40mgTID
Maximumdose
4mg/kg/dayor40mg
TID
80mgTID
StartingDose
2mg/kg/dayPO
dividedtwicetothree
timesdaily
80mgPO
dividedtwiceto
threetimes
daily
IncreaseBy
4to8mg/kg/daydiv
TID
40mgweekly
Maintenance
dose
240mg/dayPO
240mg/dayPO
Maximumdose
Callneurology
Callneurology
StartingDose
IncreaseBy
Maintenance
dose
2mgPOqhs
2mgq3weeks
4mgBID
4mgq3weeks
4mgPOBID
8mgBID
<8yrs6mgpoBID
>8yrs8mgpoBID
8mgBID
Maximumdose
Formulations
Cost*
10mg:$0.13-0.19/tab
25mg:$0.13-0.27/tab
Tabs:10mg,25mg,
50mg,75mg,100
mg,150mg
Sprinkles:15mg,
25mg
Tabs:25mg,50mg,
100mg,200mg
CapSR:60mg,80
mg,120mg,160
mg,
Sol:4mg/mL,8
mg/mL
Tab:10mg,20mg,
40mg,60mg,80
mg
50mg:$0.13-0.24/tab
75mg:$0.13-0.21/tab
100mg:$0.13-0.21/tab
150mg:$0.13-0.27/tab
25mg:$0.23-0.26/tab
50mg:$0.26-0.29/tab
Side-effects
Constipation,dry
mouth,arrhythmia,
sedation.
GetEKGwhenonstable
doseof25mgor
higher**
Weightloss,kidney
stones,wordfinding
100mg:$0.26-0.34/tab
difficulties,
paresthesias,glaucoma
200mg:$0.26-0.42/tab 10mg:$0.13-0.20/tab
20mg:$0.13-0.20/tab
40mg:$0.13-0.18/tab
60mg:$0.13-0.88/tab
Hypotension,vivid
dreams,depression
80mg:$0.13-0.23/tab
40mg:$0.13-0.36/tab
CapER:120mg,
180mg,240mg,
Tab:40mg,80mg,
120mg
TabER:180mg,240
mg
Sol:2mg/5mL
Tab:4mg
80mg:$0.13-0.19/tab
ER120mg:$0.370.93/tab
ER180mg:$0.451.50/tab
ER240mg:$0.402.03/tab
2mg/5mL:$6-7.99
Hypotension,nausea,
AVblock,weightgain.
GetEKGifon240mgor
over**
Sedation,weightgain
*Costbasedonpriceperpill/tablet(unlessotherwisenoted)purchasedfromlocalpharmaciesinColoradofor
cash-payingcustomersduringsecondquarterof2013
**SeeFAQforEKGsinchildren
***Verapamil:startonregularformationfortitration,andformaintenancecanswitchtoappropriateER
formulation(i.e.80mgTID=240mgERqday)
Page10of19
ProviderTools
HeadacheIntakeQuestionnaire
Thistoolcanbegiventopatientsforthemtocompletewhileinthewaitingorexamrooms.Providersthencan
usethisinformationduringtheirvisit.
HeadachesinChildrenCaregiverEducation
Thishandoutcanbegiventofamiliesandpatientsasheadacheeducation
HeadacheDiary
Forpatientstofillouttokeeptrackoftheirheadaches,anypatterns,andfrequencyofheadaches.Canbegivento
patientsforthemtocompletewhileinthewaitingorexamrooms.
Parent|CaregiverEducation11
1. Instructparent/caregiverandpatientaboutmeasurestohelppreventheadachessuchas:
a. Fluids
b. Sleep
c. Nutrition
d. Exercise/stretching
e. Electronicsoveruse
6. Instructparent/caregiverandpatientaboutkeepingaheadachediary
7. Instructparent/caregiverandpatientaboutmedications,includingoptimalschedulingofrescueand
preventativemedications(ifapplicable),useofOTCmedications,etc.
8. Manageexpectationsoftheparent/caregiverandpatient,includinginformingthemthatchangesareoften
seenafteraperiodoftimesuchasweeksormonths,ratherthandays6
Follow-up
Whentoseeyourpatientbackinyourclinic:
1. Newonsetheadaches:follow-upin2to4weeks
2. Childrenwithhighfrequencyheadaches(>8headachespermonth)andnewchangestotreatmentplan:
follow-upin4to6weeks
3. Childrenwithlowfrequencyheadaches(<8headachespermonth)andnewchangestotreatmentplan:
follow-upin8to12weeks
4. Childrenwithnochangesandstable:follow–upin10to12weeks,upto1year
Whentorefertoneurology:
1. Abnormalneurologicalexam(pleaseconsidercallingneurologyforadviceonurgencyofreferralandobtaining
angettingMRIwithoutcontrast)
2. Atypicalmigrainesnotmeetingcriteria
3. Worseningheadaches
4. Notrespondingtopreventativemedications
Whentorefertobehavioralhealth/mentalhealth:
1. Havelowthresholdasdepressionandanxietyarecomorbidwithheadaches
2. Strongfamilyhistoryofmentalhealthissues
3. Anyonewithfrequentabsencesfromschool(Emphasizeneedforformalstresscoping/paincoping)
Whentorefertoconcussionclinic:
1. Anychildwithneworworseningheadachesafteranyheadinjury,mildorsevere.
Page11of19
Whentorefertophysicaltherapy:
• Considerinanychildwithneckpain(cervicalgia),limitedrangeofmotionofneck,orparacervicaltenderness
FrequentlyAskedQuestions(FAQs)
• Areaspirinoraspirincontainingsubstancesokaytogivechildrenfortheirheadache?
AspirinandaspirincontainingdrugssuchasExcedrinarerelativelysafeinadolescents.Therearelessthan40
casesofReyesreportedperyear,with40%ofcasesinchildrenlessthan5yearsoldandover90%ofcasesin
childrenlessthan15yearsold.Werecommendcautioningtheadolescenttoavoidaspirinduringavaricella-or
flu-likeillnessorwithhighfever.Alladolescentstakingaspirinshouldhavevaricellaandinfluenzavaccinations.
• Whatisabdominalmigraine?Howdoyoutreatit?
Anabdominalmigraineisanidiopathicdisorderseenmainlyinchildrenasrecurrentattacksofmoderateto
severemidlineabdominalpainassociatedwithvasomotorsymptoms,nauseaandvomiting,lasting2to72hours
andwithnormalitybetweenepisodes.Headachedoesnotoccurduringtheseepisodes3,4.
DiagnosticcriteriaincludeatleastfiveattacksfulfillingcriteriaA-C:
A. Painhasatleasttwoofthefollowingthreecharacteristics:
§ Midlinelocation,periumbilical,orpoorlylocalized
§ Dullor“justsore”quality
§ Moderateorsevereintensity
B. Duringattacks,atleasttwoofthefollowing:
§ Anorexia
§ Nausea
§ Vomiting
§ Pallor
C. Attackslast2to72hourswhenuntreatedorunsuccessfullytreated
D. Completefreedomfromsymptomsbetweenattacks
E. Notattributedtoanotherdisorder
Abdominalmigrainecanbetreatedwithperiactinandamitriptyline.Considertestingforceliacdisease.
• Whatisacomplicatedorcomplexmigraine?
Ihaveapatientwiththistypeofheadache,istheresomethingIshoulddodifferent?
Complicatedorcomplexmigraineswerepreviouslyusedtermstodescribeheadachesthatareassociatedwith
unilateralmotorweaknessorstumblinggait/ataxia.ThesearedefinedbytheICHD-IIIas“hemiplegicmigraines”
and“migrainewithbrainstemaura”,respectively.TheseindividualsshouldhaveoneMRIwithMRAofthebrain
andMRAofthenecktoevaluateforstructuralorvascularabnormalityincludingdissection.Theyalsoshouldnot
beprescribedtriptansorergotamines.Stronglyconsideronetimeevaluationbyneurologytoruleoutother
etiologies.
• ShouldIavoidOCPsinmypatientwithmigraineswithaura?
MiddleagewomenwithmigraineswithauraonestrogencontainingOCPshavean8foldincreaseinstrokerisk.
Therefore,womenwithmigraineswithaurashouldbeonnoestrogenorverylowestrogencontainingOCPs.
Smokingincreasesthestrokeriskfurther.AdolescentsshouldbecounseledonrisksofestrogencontainingOCPs
andsmokingandwheneverpossibleplacedonlowornoestrogencontainingcontraceptiveoptions.
• Whatarethecontraindicationsforatriptanandhowyoungcanyougivetriptans?
Contradictionsinclude:
§ Hemiplegicmigrainesandbasilarmigraines
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§
§
§
§
§
§
Uncontrolledhypertension
Ischemicheartdisease
Prinz-Metalangina
Cardiacarrhythmias
Multipleriskfactorsforatheroscleroticvasculardisease
Primaryvasculopathies
Rizatriptan(Maxalt®)isapprovedforchildrenovertheageof6years.Almotriptan(Axert®)isapprovedforusein
childrenovertheageof12years.Sumatriptan(Imitrex®),zolmitriptan(Zomig®),andrizatriptan(Maxalt®)have
supportiveefficacyandsafetydatainadolescents.
• WhenshouldIgetanEKG?
TherearenocurrentguidelinesorevidenceinchildrenandadolescentsforsurveillanceofQTprolongationorAV
blockinindividualsonamitriptylineorverapamilrespectively.InadultstherearesignificantlyincreasedQT
intervalsonhigherdosesofamitriptyline.Therefore,ageneralruleofthumbistogetanEKGwhenchildisona
stabledoseofamitriptylineabove25mgORison1mg/kgofamitriptylineatleastfor14-21days.Verapamilmay
causebradycardiaandAVblock,therefore,EKGcanbedonewhenincreasingverapamilpast240mgdaily.
• Shouldmypatientgetallergytesting?
Thereisnoevidenceforallergytestinginchildrenwithheadache.Thereisgrowingevidencefornon-celiacgluten
insensitivityandacommonsymptomofheadache.Testingforglutensensitivityremainsexperimentalandisnot
offeredcommercially.Lastly,untreatedseasonalallergieswhentreatedwillimprovefrequencyofheadaches
experiencedinaffectedchild.
• Whatistheevidencefornutriceuticals/vitaminsandminerals?(Qualityofevidence:D)
Inchildren,theuseofvitaminsandmineralsforpreventionandtreatmentofheadacheisnotwellunderstood5,6.
CoenzymeQ10,magnesium,andriboflavinarelikelytoberelativelysafe;however,efficacyisnotwell
established.Thesesupplementsarelikelytobemoreefficaciousinchildrenwithdeficientvalues.Butterburis
fromatoxicplantwithteratogenic,carcinogenic,andhepatotoxicpropertiesandshouldbeusedwithcaution.
Feverfewinadultsissafe;however,efficacyinchildrenisunclear.
• ShouldIgettheirvisiontestedorsendthemtoophthalmologyfordilatedeyeexam?
Basicvisiontestinginyourofficeshouldscreenforcommonrefractiveerrors;however,correctionofthese
refractoryerrorsdoesnotsignificantlyreducethenumberofmigrainesortensionheadaches.Ifpatienthasred
flagsforincreasedICPorfundiarenotwellvisualized,patientshouldbereferredforadilatedeyeexam.
Ihaveapatientwithheadachespersistentafteraminorormajorheadtrauma,whoshouldIreferthemto,
Neurologyclinicorconcussionclinic?
Patientsshouldbereferredtoconcussionclinicfirst,720-777-1234,thenifconcussionclinicfeelsthatpatient
wouldbenefitfromneurologicalconsultation,theywillnotifyneurologyclinic.
•
Page13of19
HeadacheIntakeQuestionnaire
1. Whendidyourheadachesstart?(chooseone)
Lessthan1monthago 1-5monthsago 6-12monthsago Morethan1yearago
2. Howmanydayspermonthdoyouhaveaheadache?#____headachedayspermonth
3. Whereareyourheadachesusuallylocated?
Forehead Temples/Side Top Back Behindeyes Ononeside AllOver
4. Ingeneral,areyourheadaches(chooseone): Worsening Stayingthesame Improving
5. Yourheadachesmostlyorusuallyfeellike:
Pounding/Throbbing/Pulsating Squeezing Stabbing Pressure Dull
6. Onascaleof0-10,onaverage,howsevereareyourheadaches:_______
7. Onaverage,howlongdoyourheadacheslastinHOURS?______hours
8. Yourheadachesareworseinthe morning afternoon evening duringthenight
9. Doyouhaveanyofthefollowingsymptomspriortoyourheadache?
Visionchanges Numbness WeaknessinONEbodypart Other:______________
10. Duringtheheadache,doyouhaveanyofthefollowingsymptoms?
Nausea Brightlightsbotherme Physicalactivitybothersme Vomiting
Loudnoisesbotherme WeaknessinONEbodypart
11. Didyourheadachestartafteraheadinjury? Yes No
12. Didyourheadachestartafteranytypeofinfection? Yes No
13. Areyourheadachesworsewhenyouarelyingdown? Yes No
14. Doyourheadacheswakeyouupinthemiddleofthenight? Yes NoIfyes,howoften?_____
15. Thefollowingthingstriggermyheadaches:
Stress Lackofsleep Physicalexercise Dehydration Skippingmeals
Other:_____
16. Whenyougetaheadache,whatmedicationdoyoutaketohelpstopit?
Medication______________________Dose__________Doesithelp? Yes No
Medication______________________Dose__________Doesithelp? Yes No
Medication______________________Dose__________Doesithelp? Yes No
17. Howmanydaysamonthdoyoutakeamedicationtostopaheadacheafterithasstarted?____days
18. Howmanydaysinthelastmonthdidyoumissschoolbecauseofheadaches?____days
19. Howmanydaysinthelastmonthdidyoumissactivities/sportsbecauseofheadaches?_____days
Page14of19
CAREGIVEREDUCATIONMATERIALS
HeadachesinChildren
Headachesareacommonprobleminchildren.Approximately11%ofchildrenand28%ofadolescentsexperience
recurrentheadaches.
Whatcausesheadaches?
Therearedifferenttheoriesaboutthecauseofheadaches.Oftenseveralfamilymembersareaffected,suggesting
geneticfactorsarepartlyresponsible.Otherpossiblereasonsformigraineinclude:bloodvesselsensitivity,brain
andnervoussystemchanges,andserotoninsystemabnormalities.Medicinesusedtotreatheadachedisorders
oftenworkonthesepathways.
HeadacheTypes:
• MigraineHeadaches
Migraineheadachesarerecurrentheadachesthatoccuratintervalsofdays,weeks,ormonths.Migraines
generallyhavesomeofthefollowingsymptomsandcharacteristics:
§ Theycanlastfor2to72hoursifnottreatedwithrest,sleep,ormedications
§ Theyareoftenlocatedononeorbothsidesoftheheadnearthetemplesoreyes
§ Childrencomplainofathrobbing,pounding,orpulsatingpain
§ Theyareworsewithnormaldailyactivitiesorexertionsuchasclimbingstairs,running,ridingabicycle
§ Nausea,vomiting,stomachpain,difficultieswithbrightlightsorloudsounds,orsensitivitytosmells
commonlyoccurwiththemigraines
§ Warnings,calledauras,maystartbeforetheheadache.Theseaurascanincludeblurryvision,flashing
lights,coloredspots,strangetastes,orweirdsensationsandusuallyoccur5to60minutesbeforethe
onsetoftheheadache.
• Tension-TypeHeadaches
Tension-typeheadachesarerecurrentheadachesthatgenerallyhavesomeofthefollowingsymptomsand
characteristics:
§ Theycanlastfrom30minutestoseveraldays
§ Theyfeellikeabandtighteningaroundthehead
§ Sometimemuscletightnessisnoticed
§ Childrenmaybesensitivetobrightlightorloudsounds
• ChronicHeadaches
§ Bothmigrainesandtension-typeheadachescanbecomechronic,meaningthattheyoccuratleast15days
permonthforgreaterthan3months
§ Chronicheadachescanresultfromtakingsometypesofmedication—forexample,acetaminophen
(Tylenol),ibuprofen(Motrin),caffeine,andsomeprescriptionmedications—almosteveryday.Theseare
calledmedicationoveruseheadaches.Themosteffectivewaytomaketheseheadachesbetteristostop
takingpainmedicinesaltogetherfor2to3weeks.Afterthattime,useofpain-relieversislimitedtono
morethat2to3timesperweek.
HeadacheTreatment:
WhatdoIdoifmychildgetsaheadache?
• Followyourhealthcareprovider’sinstructionsinusingthemedicationandtreatmentplan
• Haveyourchildtaketheirabortive(“asneeded”)medicationassoonastheyfeelpain
• Donotuseabortivemedicationsmorethan2to3dosesperweek.Takingabortivemedicationseveryday
canactuallycauseanincreaseinyourchild’sheadaches.
Page15of19
•
•
Developaheadachetreatmentplanwithyourhealthcareprovidersoyourchildcantakeabortive
medicationatschoolasrecommended
Drinkingmorefluids(especiallysportsdrinks)duringaheadachemaybehelpfulinalleviatingthe
headachequicker
WhatcanIdotopreventmychild'sheadaches?
Themostimportantthingstohelpdecreasethefrequencyandseverityofyourchild’sheadachesinclude:
•
FLUIDS:Makesureyourchilddrinksenoughfluids.Childrenandadolescentsneed4to8glasses(8oz)of
fluidsperday.Caffeineshouldbeavoided.Sportsdrinkswithoutcaffeinemayalsohelpduringaheadacheas
wellasduringexercisebykeepingsugarandsodiumlevelsnormal.
•
SLEEP:Makesureyourchildgetsplentyofregularsleepatnight(butdoesnotoversleep).Fatigueandoverexertionaretwofactorsthatcantriggerheadaches.Mostchildrenandadolescentsneedtoobtain8to10
hoursofsleepeachnightandkeeparegularsleepscheduletohelppreventheadaches.
•
NUTRITION:Besurethatyourchildeatsbalancedmealsatregularhours.Donotallowchildtoskipmeals.
Trytoavoidfoodsthatseemtotriggerheadaches.Rememberthateverychildisdifferent,soyourchild's
triggersmaybedifferentfromanotherchild.Possiblefoodtriggersincludeagedcheese,artificialsweeteners,
caffeine,chocolate,citrusfruits,curedmeats(packagedlunchmeats,sausage,pepperoni),MSG,nuts,onions,
andsaltyfoods.
•
EXERCISE/STRETCHING:Makesureyourchildgetsatleast45minutesofaerobicactivitythatincreasestheir
heartrateand5to10minutesofstretchingeveryday.Thisdoesnotincludethingssuchasweight-lifting.
•
STRESS:Planandscheduleyourchild'sactivitiessensibly.Trytoavoidovercrowdedschedulesorstressfuland
potentiallyupsettingsituations.Considerstressmanagementcounselingorrelaxationtechniquesifstress
seemstobecontributingtoyourchild’sheadaches.
•
ELECTRONICOVERUSE:Trynottoexceed2hoursperdayofTV,movies,videogames,orcomputeruse.Turn
offallelectronicdevicesatleast1hourbeforebedtimetoallowtimetounwind.
Worrisomesymptomsthatshouldbebroughttoyourdoctor’sattentioninclude:
• Headachesthatawakenyourchildfromsleep
• Earlymorningvomitingwithoutupsetstomach
• Worseningormorefrequentheadaches
• Personalitychanges
• Complaintsthat“thisistheworstheadacheI’veeverhad!”
• Theheadacheisdifferentthanpreviousheadaches
• Headacheswithfeverorastiffneckorheadachesfollowinganinjury
Diaries
Keepadiaryofyourchild'sheadaches.Writedowneverythingthatmightrelatetoyourchild'sheadache(food,
activities,orstressors),howlongitlasted,andthepainratingona0-10scale.Therearedaily,weekly,and
monthlyheadachediariesavailableontheAmericanHeadacheSocietywebsite:www.achenet.org.
Websitesformoreinformationonheadaches
www.achenet.org
www.migraines.org
www.discoveryhealth.com
Page16of19
HeadacheDiary
•
•
Markifyouhadaheadache,howlongitlasted,andhowbaditwasonascaleof0-10
Markwhattreatmentsyoutried(includingsleep,relaxation,medications,etc.)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Didyouhave
headache?
Howlong?
Howbad?
Treatment(s)
tried?
WasitHelpful?
Didyouhave
headache?
Howlong?
Howbad?
Treatments
tried?
WasitHelpful?
Didyouhave
headache?
Howlong?
Howbad?
Treatments
tried?
WasitHelpful?
Didyouhave
headache?
Howlong?
Howbad?
Treatments
tried?
WasitHelpful?
Didyouhave
headache?
Howlong?
Howbad?
Treatments
tried?
WasitHelpful?
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Hours
/10
Yes/No
Hours
/10
Yes/No
Hours
/10
Yes/No
Hours
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Hours
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Page17of19
References
1.
LiptonRB,BigalME,DiamondM,FreitagF,ReedML,StewartWF.Migraineprevalence,diseaseburden,
andtheneedforpreventivetherapy.Neurology2007;68:343-9.
2.
LewisD,AshwalS,HersheyA,HirtzD,YonkerM,SilbersteinS.Practiceparameter:pharmacological
treatmentofmigraineheadacheinchildrenandadolescents:reportoftheAmericanAcademyofNeurology
QualityStandardsSubcommitteeandthePracticeCommitteeoftheChildNeurologySociety.Neurology
2004;63:2215-24.
3.
TheInternationalClassificationofHeadacheDisorders,3rdedition(betaversion).Cephalalgia
2013;33:629-808.
4.
OlesenJ.ICHD-3betaispublished.Useitimmediately.Cephalalgia2013;33:627-8.
5.
HersheyAD,KabboucheMA,PowersSW.Treatmentofpediatricandadolescentmigraine.PediatrAnn
2010;39:416-23.
6.
JacobsH,GladsteinJ.Pediatricheadache:aclinicalreview.Headache2012;52:333-9.
7.
BayramE,TopcuY,KaraogluP,YisU,GuleryuzHC,KurulSH.Incidentalwhitematterlesionsinchildren
presentingwithheadache.Headache2013;53:970-6.
8.
OzgeA,TermineC,AntonaciF,NatriashviliS,GuidettiV,Wober-BingolC.Overviewofdiagnosisand
managementofpaediatricheadache.PartI:diagnosis.JHeadachePain2011;12:13-23.
9.
MartensD,OsterI,PapanagiotouP,GortnerL,MeyerS.RoleofMRIandEEGintheinitialevaluationof
childrenwithheadaches.PediatrInt2012;54:580-1.
10.
LewisDW,WinnerP,HersheyAD,WasiewskiWW.Efficacyofzolmitriptannasalsprayinadolescent
migraine.Pediatrics2007;120:390-6.
11.
CraddockL,RayLD.Pediatricmigraineteachingforfamilies.JSpecPediatrNurs2012;17:98-107.
12.
Classifyingrecommendationsforclinicalpracticeguidelines.Pediatrics2004;114:874-7.
Page18of19
CLINICALIMPROVEMENTTEAMMEMBERS
SitaKedia,MD|Neurology|Sita.Kedia@childrenscolorado.org
JenniferJorgensen,PharmD|Pharmacy|Jennifer.Jorgensen@childrenscolorado.org
StevePerry,MD|PrimaryCarePhysician|sperry7893@msn.com
DenisePickard,RN,MSN|ClinicalCareGuidelineCoordinator|Denise.Pickard@childrenscolorado.org
APPROVEDBY
ClinicalCareGuidelineandMeasuresReviewCommittee–datehere
MedicationSafetyCommittee–datehereornotapplicable
Pharmacy&TherapeuticsCommittee–datehere
MANUAL/DEPARTMENT
ORIGINATIONDATE
LASTDATEOFREVIEWORREVISION
APPROVEDBY
ClinicalCareGuidelines/Quality
October10,2013
October10,2013
REVIEW/REVISIONSCHEDULE
ScheduledforfullreviewonOctober10,2016
Note:clinicalcareguidelinesarerecommendationsdesignedtoassistcliniciansandpatientsmakeappropriate
healthcaredecisionsforspecificclinicalcircumstancesandoptimalpatientoutcomesbasedonthebestavailable
evidenceandtoidentifyandtrackrelevantandmeaningfulmeasuresrelatedtoguidelinedirectedcare.These
guidelinesshouldnotbeconsideredinclusiveofallpropermethodsofcareorexclusiveofothermethodsofcare
reasonablydirectedatobtainingthesameresults.Theultimatejudgmentregardingcareofaparticularpatientmust
bemadebytheclinicianinlightoftheindividualcircumstancespresentedbythepatientandtheneedsandresources
particulartothelocalityorinstitution.
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