![ACR Appropriateness Criteria for Child
with Headache
Primary Headache
• No imaging is indicated for typical
migraine.
• In ophthalmologic migraine with focal
neurologic symptoms of unilateral
ptosis or complete third‐nerve palsy,
MRI is recommended.
• MRI is also recommended for patients
with miscellaneous findings such as
vertigo, basilar artery migraine
syndrome, persistent confusion
migraine syndrome, progressive chronic
headache, or hemiplegic migraine.
• MRI should be performed for patients
with seizures and postictal headaches.
Secondary Headache
• If neurologic signs or symptoms of increased
intracranial pressure are present, MRI is
recommended. If MRI is not available or
there are problems with sedation, CT should
be performed.
• CT of the head without intravenous contrast
is recommended for sudden severe
headaches (thunderclap headaches).
• If subarachnoid hemorrhage is detected, CT
or conventional angiography should be
performed. MRA is also appropriate but is
generally considered less sensitive in
detecting small aneurysms.
• If intracranial hemorrhage is present, MRI of
the brain should be performed if possible.
Obtaining a concomitant MRA is
recommended.
Hayes LL, Coley BD, Karmazyn B et al. American College of Radiology. ACR Appropriateness Criteria. Headache—child.
Reston (VA): ACR [Internet]. 2012[cited 2015 Jun 25]; 8. Available from: https://acsearch.acr.org/docs/69439/Narrative/](https://image.slidesharecdn.com/dr-151109134702-lva1-app6891/85/La-migraine-16-320.jpg)
![Appropriateness Rating
Category
N Imaged % Important
Abnormalities
Incidental
Abnormalities
Usually not appropriate 72 4 6% 0 1
May be appropriate 13 8 61% 1 1
Usually appropriate 10 8 80% 1 3
Imaging Audit
- 95 patient visits sampled
- Diagnosis: headache in 35, migraine in 53, meningeal infection
in 1, neoplasm with hydrocephalus in 1, metabolic disease in 1
and other non-relevant conditions in 4
- 4 patients imaged did not meet any appropriateness criteria,
but each had prior neurosurgery
Hayes LL, Coley BD, Karmazyn B et al. American College of Radiology. ACR Appropriateness Criteria. Headache—child.
Reston (VA): ACR [Internet]. 2012[cited 2015 Jun 25]; 8. Available from: https://acsearch.acr.org/docs/69439/Narrative/](https://image.slidesharecdn.com/dr-151109134702-lva1-app6891/85/La-migraine-18-320.jpg)
More Related Content
La migraine
- 1. Pediatric Headache and Migraine Current Management and Controversies in the Emergency Department Lawrence Richer MDMSc FRCPC Associate Professor CHU Sainte Justine Oct 29, 2015
- 2. Disclosure • Faculty: Lawrence Richer • Relationships with commercial interests: –Grants/Research Support: CIHR Catalyst Grant, WCHRI – Speakers Bureau/Honoraria: N/A – Consulting Fees: N/A – Other: N/A • All recommendations made without RCT supporting evidence in pediatrics is declared and only offered as a consideration
- 3. Objectives • Consider difference diagnosis of headache in the Pediatric ED • Review basic migraine physiology as it relates to migraine in the ED •Review current evidence for the treatment of migraine in the ED • Consider some controversies, unanswered questions, and ‘best practices’
- 4. Headache in the ED • URTI • Minor head trauma •Primary headaches – 54% of all non‐traumatic neuro in ED • Secondary headaches – Vascular (stroke, RCVS, hemorrhage) – Intracranial hypertension (tumour, IIH) – Orthostatic headache (IC hypotension, POTS) – Metabolic disorders
- 5. Thunderclap Headache • Reaches 7 or more in < 1 min • Etiology –Subarachnoid hemorrhage – Other vascular • Reversible cerebral vasoconstriction syndrome (RCVS) – recurrence over days • Cerebral artery dissection • Pituitary apoplexy • Sinovenous thrombosis • Posterior reversible encephalopathy syndrome (PRES) – Other (infectious, vasculitis, high or low ICP
- 6. Phases of migraine ED Charles A. TheEvolution of a Migraine Attack - A Review of Recent Evidence. Headache. 2012 Dec 20. fatigue; euphoria; depression; irritability; food cravings; constipation; neck stiffness; increased yawning; and/or abnormal sensitivity to light, sound, and smell
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- 9. CSD may trigger the trigeminovascular system Ferrari, M.D., Klever, R. R., Terwindt, G. M., & Ayata, C. (2015). Migraine pathophysiology: lessons from mouse models and human genetics. The Lancet. http://doi.org/10.1016/S1474- 4422(14)70220-0
- 10.
- 11. Genetics • Familial Hemiplegic Migraine – Type 1 (CACNA1A) –vg P/Q type Ca++ channel – Type 2 (ATP1A2) – Na+/K+ ATPase pump – Type 3 (SCN1A) – vg Na+ channel – Other ‐ SLC1A3, PRRT2, and SLC4A4 • Susceptibility genes (clinic and population based) – Glumatminergic neurotransmission – Synapse development and plasticity – Pain sensing – Metalloproteinases – Vasculature and metabolism
- 12.
- 13. Russo A, TessitoreA, Giordano A, et al. Cephalalgia. 2012 Oct;32(14):1041–8. Executive resting-state network connectivity in migraine without aura. Cognitive symptoms (attention deficit, difficulty finding words, transient amnesia, and reduced ability to navigate in familiar environments)
- 14. Silberstein SD. Emergingtarget-based paradigms to prevent and treat migraine. Clin. Pharmacol. Ther. 2013 Jan;93(1):78–85.
- 15.
- 16. ACR Appropriateness Criteria for Child with Headache Primary Headache • No imaging is indicated for typical migraine. • In ophthalmologic migraine with focal neurologic symptoms of unilateral ptosis or complete third‐nerve palsy, MRI is recommended. •MRI is also recommended for patients with miscellaneous findings such as vertigo, basilar artery migraine syndrome, persistent confusion migraine syndrome, progressive chronic headache, or hemiplegic migraine. • MRI should be performed for patients with seizures and postictal headaches. Secondary Headache • If neurologic signs or symptoms of increased intracranial pressure are present, MRI is recommended. If MRI is not available or there are problems with sedation, CT should be performed. • CT of the head without intravenous contrast is recommended for sudden severe headaches (thunderclap headaches). • If subarachnoid hemorrhage is detected, CT or conventional angiography should be performed. MRA is also appropriate but is generally considered less sensitive in detecting small aneurysms. • If intracranial hemorrhage is present, MRI of the brain should be performed if possible. Obtaining a concomitant MRA is recommended. Hayes LL, Coley BD, Karmazyn B et al. American College of Radiology. ACR Appropriateness Criteria. Headache—child. Reston (VA): ACR [Internet]. 2012[cited 2015 Jun 25]; 8. Available from: https://acsearch.acr.org/docs/69439/Narrative/
- 17.
- 18. Appropriateness Rating Category N Imaged %Important Abnormalities Incidental Abnormalities Usually not appropriate 72 4 6% 0 1 May be appropriate 13 8 61% 1 1 Usually appropriate 10 8 80% 1 3 Imaging Audit - 95 patient visits sampled - Diagnosis: headache in 35, migraine in 53, meningeal infection in 1, neoplasm with hydrocephalus in 1, metabolic disease in 1 and other non-relevant conditions in 4 - 4 patients imaged did not meet any appropriateness criteria, but each had prior neurosurgery Hayes LL, Coley BD, Karmazyn B et al. American College of Radiology. ACR Appropriateness Criteria. Headache—child. Reston (VA): ACR [Internet]. 2012[cited 2015 Jun 25]; 8. Available from: https://acsearch.acr.org/docs/69439/Narrative/
- 19.
- 20. Predictors of Abnormal Imaging • “First”, “Worst”, thunderclap, or progressive – Bilateral headache > secondary cause (Masano, 2014) •*Focal motor findings • *Unsteady gait / ataxia • *Altered level of consciousness • *Signs/symptoms of raised ICP • *Hypertension (and tachycardia) • *Young age Massano D, et al. J Pediatr. 2014;165(2):376‐82.
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- 24. Approach to abortive therapy • Start with ibuprofen – Ensure right dose, right time –Add metoclopramide 5‐10 mg PO • Consider other NSAID • Consider a triptan – Almotriptan – Sumatriptan + Naproxen sodium – Rizatriptan • Consider infusion
- 25. Drug Tmax (mins) Potency Dose Ibuprofen45 ++ 10 mg/kg (max 800 mg) Acetaminophen 45-60 ++ 15 mg/kg (max 1000 mg) Naproxen sodium 60 ++ > 12 years: 220 mg or 275 mg (generic); not controlled release Diclofenac potassium (Cambia)* 15-30 +++ > 12 years: 50 mg oral solution (safety and effectiveness not established in pediatrics) Oral analgesics for migraine *Not approved for pediatric patients
- 26. Triptans Drug Approval Dose AlmotriptanY (Can1) 6.25 mg or 12.5 mg PO Sumatriptan/naproxe n Y (US1) 10 mg/60 mg PO Rizatriptan Y (US2) 5 mg PO (<40 kg) 10 mg PO (>40 kg) Sumatriptan Y (US) 25-100 mg PO 5 or 20 mg NS 3 or 6 mg SC Zolmitriptan Y (US) 2.5 or 5 mg PO/NS Eletriptan N 20 or 40 mg PO Naratiptan N 1-2.5 mg PO 112‐17 years 26‐17 years
- 27. Novel therapies • Calcitonin gene‐related peptide (CGRP) receptor antagonist – Better than placebo –Development terminated • Serotonin 5‐HT1F receptor agonist (Lasmiditan, COL‐144) – Better than placebo • Combined serotonin (5‐HT 1B/1D) receptor agonist and neuronal nitric oxide synthase (nNOS) inhibitor – Negative phase 2 • Transient receptor potential vanilloid (TRPV1) receptor modulators – Negative phase 2
- 28. Novel therapies • Glutamatergic targets – Ketamine –In development ‐ Tezampanel (LY293558), BGG492, LY466195, ADX10059 • Propofol
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- 30. Trigeminal Sensitization Early treatment (when painis mild) most effective Non-selective COX A/B inhibitor may still be effective
- 31. Practice variation in Canada • Dopamine antagonists (39.5%) • metoclopramide > prochlorperazine •Fluid bolus (24.3%) • Parenteral NSAIDS (9.8%) • Significant variation between sites with all treatments Richer LP, et al. Pediatrics. 2010;126(1):e150‐5.
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- 33. • n=62 • Allreceived 10 ml/kg NS bolus over 30 mins • Discharged with naproxen sodium for 24 hours Brousseau DC, Duffy SJ, Anderson AC, Linakis JG. Treatment of pediatric migraine headaches: a randomized, double-blind trial of prochlorperazine versus ketorolac. Ann Emerg Med. 2004 Feb 1;43(2):256–62. Prochlorperazine vs. Ketorolac
- 34. Agency for HealthResearch and Quality. Acute Migraine Treatment in Emergency Settings. 2012; Comparative Effective Review Number 84. Adult data only
- 35. Phenothiazine vs. metoclopramide Kelly A-M, WalcynskiT, Gunn B. The relative efficacy of phenothiazines for the treatment of acute migraine: a meta-analysis. Headache. 2009 Oct 1;49(9):1324–32. Approximately 15 mm mean difference on VAS in favor of phenothiazines
- 36. Diphenhydramin e Akathisia Rating Scale Objective: 2‐minute seated observation •Inability to remain seated (is the patient shifting)? • Any semipurposeful or purposeless leg or foot movements? Subjective: Three questions • Do you feel restless within, or the urge to move, especially in the legs? • Are you unable to keep your legs still? • Are you unable to remain still, standing or sitting? Prochlorperazine‐induced akathisia = Change in objective scale ≥1 point + change in subjective scale ≥2 points (from preprochlorperazine to postprochlor‐ perazine assessment). Vinson DR, Drotts DL. Diphenhydramine for the prevention of akathisia induced by prochlorperazine: a randomized, controlled trial. Ann Emerg Med. 2001 Feb 1;37(2):125– 31.
- 37. ED visits in pediatric health centers • 35 pediatric EDs (2009–2012) ‐ 32 124 children with migraine –5.5% had a return ED visit within 3 days • Meds ‐ nonopioid analgesics (66%); dopamine antagonists (50%) – metoclopramide or prochlorperazine; diphenhydramine (33%); ondansetron (21%); Triptans and opiate medications (3% each) • Metoclopramide had a 31% increased odds for an ED revisit within 3 days compared with prochlorperazine – Ondansetron had similar revisit rates to those receiving dopamine antagonists. • Diphenhydramine with dopamine antagonists was associated with 27% increased odds of an ED revisit Bachur RG, et al. Pediatrics. 2015.
- 38. Other dopamine antagonists • Droperidol – Butyrophenone –Mean difference in VAS ~ 40 mm – Possible risk of QT prolongation • Chlorpromazine – Associated with increased risk of hospitalization in one retrospective study
- 39. Ketorolac • Survey (n=40) – 78% always or sometimes use ketorolac among Alberta pediatric ED physicians –84% of those use it in combination with other medications • Ketorolac + metoclopramide / prochlorperazine – Used in 36% of ED presentations in Canada
- 40. RCT metoclopramide +/‐ ketorolac • n=53 (8 to 17 years) –n=26 ketorolac; n=27 placebo – no significant difference • 1/4 mild akathisa • 2/3 had recurrence of headache Richer et al., not yet published
- 42. Dihydroergotamine – side effects • skin reactions (29 percent) and/or local reactions (22 percent) •sedation (20 percent) • digestive issues (12 percent) • nausea or vomiting (11 percent) • chest symptoms (9 percent)
- 43. Best practice – first line therapy? • Prochlorperazine better than metoclopramide •Consider droperidol if prochlorperazine not available and metoclopramide not sufficiently effective – Probable increased risk of side‐effects • Consider combination therapy – Evidence for DHE + neuroleptic/metoclopramide
- 44. Propofol • Rapid onset – GABAA receptor potentiation –Na+ channel blocker – Endocannabinoid system • Propofol > dexamethasone = SC sumatriptan • Risk of addiction • Ongoing pediatric study (NCT02485418) – IV propofol infusion starting at 20 mcg/kg/min for 20 minutes, then 30 then 40 Moshtaghion H, et al. Pain practice 2014; published online July 12. DOI: 10.1111/papr.12230.
- 45. Ketamine • Analgesic and anesthetic properties – antagonist of NMDA glutamate receptor •Possible treatment of prolonged aura – Blocks cortical spreading depression – Ketamine 25 mg IN vs. Midazolam 2 mg IN – Reduced severity but not duration of aura
- 46. Magnesium • Magnesium sulfate 30 mg/kg IV (max 2000 mg) – Infused over 30 min –1000 mg dose diluted in 50–100 mL of 5% dextrose water or normal saline – Cardiorespiratory monitor
- 47. Dexamethasone Colman I, FriedmanBW, Brown MD, Innes GD, Grafstein E, Roberts TE, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ. 2008 Jun 14;336(7657):1359–61.
- 48. Best practice ‐ recurrence • Dexamethasone may reduce headache recurrence although no data availalbe in children •Consider dexamethasone 0.5 mg/kg IV (max 25 mg) single dose prior to discharge especially if known to experience recurrence – Adult studies support IV delivery, but PO bioavailability is high as well
- 49. When to admit? • Partial response in ED • Repeated visits to ED •Dehydration, intractable vomiting • Co‐morbidities – Psychological – Other medical (e.g. hypertension) • Further investigation
- 50. Dihydroergotamin e Side Effects Chest pain(more common with sumatriptan), nausea (more common with DHE), drowsiness, flushing, neck stiffness, vertigo, weakness, and injection site reactions • 70% response • repeated dosing may be more effective (IN and IV) • 3 and 6 day protocols • nausea is a limiting SE • sumatriptan SC may be superior initially, but DHE more likely to sustained pain free Kabbouche MA, et al. Headache. 2009;49(1):106‐9.
- 51. Best practice ‐ admission • Admission may be associated with better outcomes when treating chronic daily headache –Consult other disciplines (e.g. psychiatry) – Hydration and carbohydrate replacement • Consider – Repeated dosing of DHE with neuroleptic / metoclopramide Marmura MJ and Goldberg SW. Current neurology and neuroscience reports. 2015;15(4):13.
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- 53. ED Treatment of Post‐Traumatic HA • Avoid medication overuse, light activity, hydration • Are there migraine characteristics? –Use migraine therapy per local protocol – Case series of sumatriptan or DHE show benefit • Amitriptyline frequently prescribed symptom reducing treatment Dubrovsky AS, Friedman D, Kocilowicz H. Pediatric post‐traumatic headaches and peripheral nerve blocks of the scalp: a case series and patient satisfaction survey. Headache. 2014;54(5):878–87.
- 54. Dubrovsky AS, Friedman D, Kocilowicz H. Pediatric post‐traumatic headaches and peripheral nerve blocks of the scalp: a case series and patient satisfaction survey. Headache. 2014;54(5):878–87. •Peripheral nerve block – 71 % reporting immediate relief – Decrease mean intensity of 93% – GON + supra‐orbital nerve (SON) in 60% – GON alone in 27% – GON + lesser occipital nerve +/‐ SON in 14%
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