MARCY YONKER, MD FAHS

DIRECTOR, PEDIATRIC HEADACHE PROGRAM

Adolescent Migraine Treatment

PROGRAM

ASSOCIATE PROFESSOR, CHILD HEALTH, U OF A

Goals

� Review epidemiology of adolescent migraine

� Review evidence based treatment

� Discuss approach to adolescents vs adults

Migraine Epidemiology

� AMPP-2007

� Total 1 year prevalence ages 12-17 6.3%

� Female 7.7%

� Male 5.0%

Migraine Epidemiology

� Wober-Bingol 2013-reviewed all epidemiologic studies on migraine published in prior 25 years in children and adolescents

� Migraine prevalence 9.1%

� Lipton et al 2011-12-17� Lipton et al 2011-12-17

� CM without MO-0.79%

� CM with or without MO-1.75%

Migraine Epidemiology

� Closer to home- 30% of teens I see have CM

Case 1

� The patient is a nearly 14 yo recently seen for headache.

� She has a many year history of migraine and has been treated in Mexico with flunarizine and amitriptyline prophylaxis but is currently having amitriptyline prophylaxis but is currently having only 3 migraines/month.

� Headache Sx: holocranial throbbing, photo/phono/nausea, 7/10, lasting 6 hrs.

Case 1

� Imaging?

� Acute RX?

� Preventative RX?

� Healthy Habits!� Healthy Habits!

� Headache Diary!

Acute Treatment

� Principles:

� Trigger avoidance-sleep, stress, H20, “healthy habits” but don’t be judgy

� Give them permission to treat early

� Warn about medication overuse but don’t blame the � Warn about medication overuse but don’t blame the patient if they are reacting to their pain, or fear of pain.

� Warn them about potential side effects of triptans.

� Address nausea and vomiting- ondansetron, nasal formulations, injectables

Acute Treatment

� What’s the evidence?

� Riza- 6 and up

� Suma, Zolmi, Almo-12 and up

� What do I do?

Insurance formulary?� Insurance formulary?

� Can you swallow pills?

� Is it full blown when you wake up?

� What works for your mother?

Case 1

� Imaging-nope

� Acute RX= ondansetron + rizatriptan 10

� Prophylaxis=nope

� Followup 2 months with headache calendar� Followup 2 months with headache calendar

� Psychology consult for anxiety

Cases 2 and 3- 2 consecutive patients Monday am Oct 31st

13 y 10 mo girl13 y 10 mo girl

� 1 year history� 27 days/month� Duration 1 dayBitemp squeezing 8/10

13 y 11 month old girl13 y 11 month old girl

� 3 year history� Daily� Duration 1-2 days

� Bitemp squeezing 8/10� Photo/phono� FHx-migraine mother, MGM� PMHx:obesity,insulinresistance

� ROS:snoring, daytime fatigue with at least 9 hrs sleep/night

� MOH: ibuprofen 3 days/wk� PedMidas:21

� Duration 1-2 days� Holocranial throbbing� N/V/photo/phono� FHx-migraine-mother� PMHx: none� ROS: neg� MOH-excedrin/ibuprofen 4 days/wk

� PedMidas:124

Prophylactic Treatment

� Who?

� What?

� How long?

Prophylactic Treatment

� Who?

� greater than 4/month

� Mod-High disability-PedMidas

� Unresponsive to acute medication

What?

� Before Oct. 28, 2016

� Assess comorbidities

� Amitriptyline vs topiramate

� After Oct. 28, 2016

????� ????

CHAMP!

� Multicenter NINDS sponsored trial

� Amitriptyline vs topiramate vs placebo 8-17

� 2:2:1 randomization

� “real world study”- episodic and chronic, could titrate medicationtitrate medication

� Primary outcome >50% reduction in headache days comparing first 28 days in baseline to last 28 days

� Stopped early for futility-52% ami, 55% topiramate61% placebo achieved primary outcome

� Higher AEs in medication groups

Monday, 10/31

� Healthy habits

� Addressed MOH and Rxed triptan, naproxen

� Recommended PSG

� Riboflavin

� Healthy habits-doing everything right

� Explained results of CHAMP

� Discussed CBT option-� Riboflavin

� Followup in 2 months

� Discussed CBT option-live in Prescott

� Addressed MOH-rxedtriptan, naproxen

� Problems with sleep-Rxed amitriptyline

Some Deep Thoughts

� Despite prevailing opinion, adolescents are people too.

� Their personalities/habits/issues are not the causeof their headache problem but may contribute to the overall picture.overall picture.

� Even most obese teenage girls with insulin resistance, anxiety/depression and 24/7 headache get better pretty easily. But if you don’t believe it, they won’t either.

Some Deep Thoughts from Teens

“it’s so nice to know that you don’t think I’m crazy and that you are doing the best you can to help me”

Tips for dealing with teens

� Talk to the patient first� Acknowledge parental concerns but try to encourage the patient tell you the story

� Commend the patient for toughing it out and empathize with what they are going through.

� Explain the options and involve the teen in the decision � Explain the options and involve the teen in the decision making.

� Give them permission to “complain”� Set the goal for treatment- less than 4 migraines/month with as needed medicine that works within an hour

� See them back in 2 months if you are prescribing prophylaxis

My Schtick

� The idea of coming to see me is to make your life better, not worse, so if something I am doing is making your life worse, complain about it. This is the complaining zone. I know you are used to toughing it out, but I can’t fix it if I don’t know it’s a problem. I out, but I can’t fix it if I don’t know it’s a problem. I won’t be offended if you say, “Dr. Yonker, I hate your stupid medicine!”

Summary

� Migraines are a frequent disabling problem for teens.

� There is evidence based acute treatment.

� More work needs to be done in establishing effective accessible evidence based care for prophylaxis.

� Engage teens to work with you to help to solve their headache problems.