September 15, 2019
Innovations in Pediatric Headache Treatments | FAQ’s with Dr. Christopher Oakley

Innovations in Pediatric Headache Treatments | FAQ’s with Dr. Christopher Oakley


(calm music)>>Headaches are the
number one reason that kids have a neurological problem
and this is the number one reason they go to the
pediatrician, they go to the ER, urgent care, and the number
one reason they get referred to child neurology of pediatric
neurology is headache. And so headaches are
something we see in kids of literally all ages. Infants and toddlers can
get what we call precursors to migraines and these
are vomiting syndromes or recurrent dizzy spells,
things along those lines. They don’t get the typical
headache with the pain. But once kids get into school age, the most common headaches that we see are the most common
headaches we see in adults and that’s tension type
headaches which is what we call the stress headache,
the everyday headache that people complain
about or mention or have, really that typically falls
into a tension type headache which is really a nondescript,
mild to moderate headache that’s just sort of there
and people recognize. And then there’s the
more concerning headache that kids get and
especially the adolescents, and that’s migraines and so
that’s the most disabling, most troublesome headache
that pediatric patients, kids of all ages get and
that’s most of what we see in our practice and in our headache center and those are some of the more
moderate to severe headaches with the other symptoms
like nausea, vomiting, sensitivity to light and sound. The only other one I would maybe mention as far as a common
headache type that we see in pediatrics, we get a lot
of post-traumatic headaches. So a lot of kids that have head injuries, concussions will often
get headaches afterwards and that often overlaps
with tension and migraine but it is slightly different
and we do address that and treat that a little bit different. But those are the most common headaches that we see in kids of all ages. (upbeat music) The biggest question
that I get from parents and from other providers
is when do we worry about these headaches,
headaches is something we see all the time, it’s the number
one reason that they’re showing up in pediatricians
or primary care offices, to the ER, to urgent care,
and when do you worry? When should you do a workup on that child, ultimately is what you’re
getting at and we look for really two things, it’s
history and it’s their exam. And in the history you look for red flags. So these are things such
as overnight headaches or early morning awakening with headaches, overnight vomiting,
early morning vomiting, signs of increased intercranial pressure. You also are looking at things
such as an abrupt onset, the worst headache of my life,
which that’s a tricky one, ’cause every time a child
comes in with a bad headache it’s the worse headache of their life, so you have to use a little
bit of clinical judgment of is this really this bad
or not and you can tell. Other red flags include
other neurological symptoms that might have popped up,
whether be an abrupt change in their mental status and
their grades in school, their behavior, their emotional status or things such as seizures
or movement disorders. These are some of the red
flags that we think about. Other things include their physical exam. So specifically on the
neurological exam you look for a fundoscopic exam looking for signs of intercranial pressure and
sort of optic nerve swelling or papilledema, you
look at their reflexes, is there any asymmetry,
you look for subtle signs of weakness, so is their
pronator drift a little bit off or is there subtle
asymmetry in their strength, in their arms or legs, you
look at their coordination and then you look at their
gate to really make sure you’re not missing
anything and if those areas all look normal, then odds
are there’s nothing much to worry about especially
if they’ve had headaches for at least six months or longer it’s exceedingly unusual at that point that there’d be anything to worry. (upbeat music) So once we’ve gone through
and we’ve figured out kinda what kinda headache your child has and whether or not there’s any
worry or things that you need to think about a workup or
investigation to make sure you’re not missing anything,
the next question that gets asked is well how do
we treat, what do we do to help our kids get
better and feel better so they’re not having the headaches? And I look at this as a
comprehensive approach where it’s sorta like building
a house and I use this analogy in my own clinic
with my own patients ’cause any kid whether they’re
a toddler with building blocks or legos or whether
they’re a graduate student in engineering or architecture understands when you build a house you
have to start at the bottom or the foundation, you work
your way up with the supporting sort of treatments or supporting structure and then you put the roof on to end with. We treating headache as the
same way, you start at the foundation and the simple
thing is working on lifestyle. It’s things we take for granted. It’s are you getting your
age appropriate sleep? And again that’s 10 to 12
hours for elementary school, nine to 10 hours for middle
schoolers, eight to nine hours for high schoolers, and eight hours for college and graduate students. Most of the kids aren’t getting that because they’re too busy,
their lives are too hectic but that’s the recommendation. Are they hydrating? They drinking enough fluids? And I ask how much do
they pee during the day. It’s a weird question, people
don’t keep track of it, but if you’re peeing
every two or three hours you know you’re hydrating,
assuming you’re not drinking too much caffeine or other
things that would cause you to go to the bathroom more. Diet is another thing that we think about. And it’s are you eating
breakfast, lunch, and dinner? Are you consistent, are you
keeping a stable metabolism, keeping that energy
level up for the brain? Are you overdoing the caffeine? So too much caffeine can cause headaches and especially migraines and be a problem, so especially for the
adolescents, are they doing too much coffee or energy drinks? That’s an easy thing to work on. Exercise is one of the best treatments and also one of the biggest
causes that modifiable or preventable for pediatric headache. So keeping these kids
active cardiovascularly is important, so we
recommend 20 to 30 minutes at least three to four times a week of hot, sweaty, out of
breath, really doing something and then the final sort
of conserve approach is working on day to
day stress and anxiety. And all of these kids
have stress and anxiety, that’s part of life but
if it’s really adding to their daily routine,
if it’s contributing to the headaches, if it’s a lot on them, then it’s taking the step
back, recognizing that and tryna find a way to treat that. Second part of treatment that falls under sort of the conservative,
non-medicine approach if you will is using complimentary
alternative therapies and there’s a lot of evidence
for this in pediatric headache as well as adult headache. More evidence is in the
adult world, but even in the pediatric population we’ve
seen studies that show that behavioral therapy,
pain therapy, biofeedback, physical therapy, acupuncture,
all these have really good evidence and so we use
these at our discretion if the kids buy in, the kids
have to be interested in these. Making a kid go to see a
therapist if they’re not gonna talk to them and it’s
just gonna be a fight, it’s gonna make things worse not better. So we offer all of these to our patients, just like you can and you find the one that works for the kids. They’re all great,
they’re all good options, none of them are perfect. (upbeat music) When you’re going through the treatment sort of algorithm if you
will or the treatment sort of pathway, again you’re
starting with that foundation, the lifestyle changes,
you’re doing your supportive therapies, your complimentary
alternative therapies, and then if that’s not
getting you where you need or if maybe that’s not
something that interests your patients or your families,
we have daily preventative options and we have acute
treatment options as well that fall under sort of the
medicines and nutraceuticals. So, when you talk about daily prevention, there is maybe 15 to
20 different treatments that are available out there. Some of them have been
tested and studied in kids, most have been studied
in adults and we sort of extrapolate down to the
pediatric population. What I will say is that there was a study, the largest NIH funded
pediatric headache study done maybe a handful of years
ago that looked at comparing the top two, what we thought
were the top two medications for pediatric patients to
placebo and what they found was is that they all work, even
placebo and you could take that on the surface and say well
that means nothing works, well that’s not true, it
means everything works. It means all of these are good options and that the most important
part about thinking about medicines, it’s not
so much what you pick, it’s that you get your
patients to buy into it, that you get them to believe
that this is something that’s gonna help them and that you listen to their story and believe
that they need treatment for their headaches and if
they take that treatment that you provide, no matter what it is, because everything has
been shown to be helpful, odds are you’re gonna get some benefit and if not, we go to the next step. When you really tease it out
we have allergy medicines like cyproheptadine or Periactin, we have blood pressure
medicines, beta-blockers, calcium channel blockers
and ARB, so angio-retensin blockers, we have
antidepressants or anxiety meds that we use, so tricyclic antidepressants or SNRIs, things like you
know venlafaxine or duloxetine and then there’s even a
new treatment category that are CDRP related and
that’s a specific chemical that actually is in part
of the migraine pathway that has finally been targeted with some of these new treatment options. Unfortunately these have not
been studied in pediatric patients so they’re
only approved in adults and right now most of
us are not using those in the pediatric populations,
although it’s gonna start happening over the next months to years in the older adolescents
and then trickle down. You also have nutraceutical
options, so this is where some families don’t want
medicines and that’s fine. We know that several of the
vitamins and supplements can be really helpful to
prevent headaches and this would include magnesium, vitamin B2, or riboflavin, coenzyme Q10 and melatonin. There’s others out there as
well, but those seem to have the best evidence and the
best benefit for our patients and those are the ones
that we typically use. (upbeat music) Even if you have a good
preventative plan in place, with your lifestyle changes,
your complimentary therapies, and even a daily preventative,
whether it be medicine or vitamin supplements,
what happens when that kid gets a really bad
headache or a bad migraine and they’re in the midst of it
and how do we make that stop? And so that’s where we talk
about acute treatment options. Within the acute treatment
options, again there’s a variety of options that we have
including medication, but there’s even some
non-medicine options, procedure or technology based treatments that are also available. From a medication standpoint, combination tends to work best. We start simple, so it’s an
age and weight based dosing for either ibuprofen or acetaminophen, the younger kids in the studies
both were equally effective and the teenagers and adults,
the nsaids, the ibuprofen category, the naproxen
category tend to work better. So it’s that with hydration,
so with a bottle of water, Gatorade, juice, I don’t care,
something non-caffeinated, just to give them more fluids. If it’s actually a migraine,
then we can add from there, caffeine, which sometimes has helped in small amounts once in awhile. Daily caffeine can make
things worse big picture, but small amounts at
the onset of a migraine can be really helpful and we
can also add antiametics in, especially the antidopaminergic agents such as Compazine or Reglan. Compazine tends to have better
evidence in the pediatric population, Reglan is used more commonly in the adult population, both are good. We can also add in
migraine specific medicines with the triptans, so that’s
a category of medicines that work just for migraine
as well as other headaches like cluster headaches,
although we don’t see too much of that in the pediatric population. And there’s seven or eight
of these that it’s trial and error, you try one
and if it works great and if it doesn’t, you
kinda go down the line until you find one that
does work for your patient. But this is the combination
that could be used acutely when at onset of a migraine. If that doesn’t work,
there are procedure based operations that we have
such as nerve blocks, there’s always infusion
centers, there’s ER protocols and inpatient IV
protocols that can be done for patients if they’re
really stuck in a bad headache and there’s even a new
nerve stimulating device called Cefaly that’s been
around for a few years that can be used as an
acute option as well that we use in our clinic. (upbeat music) We’re sort of in a new
era of pediatric headache and the fact that in the
last handful of years there’s been several new
options that have hit the market and been looked at for both acute and preventative standpoints. Now some of these have been looked at in pediatrics on the
surface, most of these have been studied in adults,
as most sort of big studies go with new treatments, whether
they’re medicines, devices, technologies, they tend
to start with the adults and then from there move into
the pediatric population. From a medication
standpoint, the newest option that the sort of biggest option out there and it’s everywhere on
the news and the reports, it’s the CGRP antibody
treatments and this is a new category of medicine
designed specifically to go after the migraine pathway, to go after actually what’s happening
during a migraine to stop that and to prevent that from happening and these are injectable
options and or an IV option. There are three that are now on the market that have been out for the first time. One was out in May and
then two more have come out this fall in September, October
and these are auto-injectors or injections that have to
be given about once a month that work as an immune
modulating treatment to target either the
antibody the antibody itself, the CGRP molecule peptide itself or the receptor where these bind. Both have good evidence in
adults and we’re just getting in to the pediatric study stages now. So right now they’re not
being used wide spread in pediatrics but with these
new studies that are developing and coming out, this will be
the hope in the near future that we’ll have new treatment options to offer these patients. From a technology side, Cefaly, which is a nerve stimulating device
designed to target the trigeminal nerve in the forehead, you wear it right here,
you put a little patch on, it connects by magnet
and it works as a direct nerve stimulator for that trigeminal nerve which we know is the nerve
involved in many headaches including migraine and so
it’s got both a preventative setting that you wear daily to substitute for a daily preventative
medication or supplement and it’s also got an
acute setting that again, you could substitute
instead of the medications you’re using, you could use this instead. And so we have this to
have our patients try and if they find it
helpful or if they like it or can tolerate it, it’s a great option for those patients that we can do. (upbeat music) I think that the biggest
reason is is that we have a team approach from the
beginning that we have access to every discipline and every
option that could be used for the treatment of headache. In our clinic alone I have
a team with a dedicated nurse practitioner and physician assistant that the three of us do
nothing but headache medicine. We also have a dedicated
behavioral psychologist that is part of our clinics
at various locations. We serve here at the children’s center and then through the outpatient
center here at Hopkins. We also have an office where we all serve patients at Bay View. We do outreach clinics up
at Green Spring Station and then we also have an outreach clinic down in Annapolis, it’s through AAMC, but it’s actually a Hopkins based clinic, it’s just housed at Anne
Arundel Medical Center. And I think that we offer a
multidisciplinary approach that not everywhere can and
we’re fortunate to have that but that’s how you get these kids better is you look at them like a whole person, treat them all around
rather than just giving them a medication or a treatment
because that’s unfortunately all that some places can do
’cause of the limited resources. (upbeat music) (giggling)

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