2011.03.21. neurológiai betegségek a gyermekkorban

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



2



3

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


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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(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


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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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)


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

2011.03.21. neurológiai betegségek a gyermekkorban

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