Post-traumatic Headache in Children and Adolescents.

PURPOSE OF REVIEW: Post-traumatic headache is a common disorder in the pediatric age group, seen both by child neurologists and by non-neurologists. The current review of post-traumatic headache in children and adolescents aims to review the pathophysiology, risk factors, clinical features, neuroimaging, and both acute and preventive treatment options. RECENT FINDINGS: Recent literature provides insight into specific risk factors in the pediatric age group for developing post-traumatic headache as well as unique pathophysiologic changes seen in neuroimaging and neurometabolic pathways. It also elucidates common treatment options and novel treatments being currently explored, such as with monoclonal antibodies to CGRP. Finally, current evidence and guidelines recommend the benefit of a gradual return to normal activity based on symptom stability rather than a specific time period. Review of literature on pediatric post-traumatic headache reveals a growing understanding of the factors involved in developing headache after head trauma and the diagnosis/treatment of headache though future research will help further elucidate these areas.

Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society.

OBJECTIVE: To provide updated evidence-based recommendations for migraine prevention using pharmacologic treatment with or without cognitive behavioral therapy in the pediatric population. METHODS: The authors systematically reviewed literature from January 2003 to August 2017 and developed practice recommendations using the American Academy of Neurology 2011 process, as amended. RESULTS: Fifteen class I-III studies on migraine prevention in children in adolescents met inclusion criteria. There is insufficient evidence to determine if children and adolescents receiving divalproex, onabotulinumtoxinA, amitriptyline, nimodipine and flunarizine are more or less likely than those receiving placebo to have a reduction in headache frequency. Children with migraine receiving propranolol are possibly more likely than those receiving placebo to have an at least 50% reduction in headache frequency. Children and adolescents receiving topiramate and cinnarizine are probably more likely than those receiving placebo to have a decrease in headache frequency. Children with migraine receiving amitriptyline plus cognitive behavioral therapy are more likely than those receiving amitriptyline plus headache education to have a reduction in headache frequency. Recommendations The majority of randomized controlled trials studying the efficacy of preventive medications for pediatric migraine fail to demonstrate superiority to placebo. Recommendations for the prevention of migraine in children include counseling on lifestyle and behavioral factors that influence headache frequency, and assessment and management of comorbid disorders associated with headache persistence. Clinicians should engage in shared decision making with patients and caregivers regarding the use of preventive treatments for migraine, including discussion of the limitations in the evidence to support pharmacologic treatments.

Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society.

OBJECTIVE: To provide evidence-based recommendations for the acute symptomatic treatment of children and adolescents with migraine. METHODS: We performed a systematic review of the literature and rated risk of bias of included studies according to the American Academy of Neurology classification of evidence criteria. A multidisciplinary panel developed practice recommendations, integrating findings from the systematic review and following an Institute of Medicine-compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence. RESULTS: There is evidence to support the efficacy of the use of ibuprofen, acetaminophen (in children and adolescents), and triptans (mainly in adolescents) for the relief of migraine pain, although confidence in the evidence varies between agents. There is high confidence that adolescents receiving oral sumatriptan/naproxen and zolmitriptan nasal spray are more likely to be headache free at 2 hours than those receiving placebo. No acute treatments were effective for migraine-related nausea or vomiting; some triptans were effective for migraine-related phonophobia and photophobia. RECOMMENDATIONS: Recommendations for the treatment of acute migraine in children and adolescents focus on the importance of early treatment, choosing the route of administration best suited to the characteristics of the individual migraine attack, and providing counselling on lifestyle factors that can exacerbate migraine, including trigger avoidance and medication overuse.

Acupuncture in Adult and Pediatric Headache: A Narrative Review.

Headaches in children and adolescents remain a very common problem with migraine being the most common headache disorder to present to medical attention. The approach to the treatment of migraine in children has consisted of treatment with acute and preventive medications, combined with lifestyle modification and behavioral interventions, such as cognitive behavioral therapy. With increasing frequency, complementary and alternative medicine (CAM) approaches, including acupuncture, are often recommended in the pediatric population to address significant disability with limited evidence-based treatment options. In this article, the authors conduct a review of acupuncture in pediatric headache, including neurobiological mechanisms, adult headache studies, pediatric headache studies, safety, and use of acupuncture in other conditions in children. This article aims to summarize the currently available evidence with which to recommend acupuncture in children for the adjunctive treatment of headache. Acupuncture appears to be safe and effective for the treatment of migraine in children.

Demographics, clinical features, and response to conventional treatments in pediatric Pseudotumor Cerebri syndrome: a single-center experience.

OBJECTIVE: The goal of this study was to better understand pediatric Pseudotumor Cerebri syndrome, and its relationship to age, obesity, and other medical conditions; and to evaluate response to conventional treatments. METHODS: A retrospective chart review was performed on consecutive patients who were diagnosed with PTCS between January 1, 2007, and July 31, 2014. A total of 78 patients were included in this study: 54 female (69.3%) and 24 male (30.7%). Variables including age, sex, body mass index, concomitant medical conditions, secondary causes, associated symptoms, physical exam findings, imaging results, recurrence of symptoms, and treatment modalities were analyzed. Patients were grouped into "pre-kindergarten," "elementary," and "adolescent" based on their age; and weight categories of underweight, normal weight, overweight, moderately, and severely obese. RESULTS: Mean age of symptom onset was 11.92 ± 4.09 years. Elementary and adolescent age patients were more likely to be overweight, moderately obese, and severely obese, while this finding was not found for patients in pre-kindergarten group. Headache (83.3%) and visual disturbances (48.7%) were the most common presenting complaints. Asthma (16.6%) was the most common associated concomitant medical condition. Medical management resulted in resolution in 84% of population, 15% required surgical interventions, and the recurrence rate was found to be 20.5%. There was a statistically significant trend in success with medical management in younger patients (p = 0.04), while medically refractory PTCS was seen in adolescent females. Recurrence of PTCS had a linear trend with increased occurrence in adolescent age group with higher BMI. Asthma was observed to be frequently associated with PTCS in our cohort. Obesity is strongly associated with PTCS, not only in the adolescent group but also in the younger elementary age group. Treatment remains similar to management in the adults with a good response (84%) to medical management and a low relapse rate.

Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society.

OBJECTIVE: To provide updated evidence-based recommendations for migraine prevention using pharmacologic treatment with or without cognitive behavioral therapy in the pediatric population. METHODS: The authors systematically reviewed literature from January 2003 to August 2017 and developed practice recommendations using the American Academy of Neurology 2011 process, as amended. RESULTS: Fifteen Class I-III studies on migraine prevention in children and adolescents met inclusion criteria. There is insufficient evidence to determine if children and adolescents receiving divalproex, onabotulinumtoxinA, amitriptyline, nimodipine, or flunarizine are more or less likely than those receiving placebo to have a reduction in headache frequency. Children with migraine receiving propranolol are possibly more likely than those receiving placebo to have an at least 50% reduction in headache frequency. Children and adolescents receiving topiramate and cinnarizine are probably more likely than those receiving placebo to have a decrease in headache frequency. Children with migraine receiving amitriptyline plus cognitive behavioral therapy are more likely than those receiving amitriptyline plus headache education to have a reduction in headache frequency. RECOMMENDATIONS: The majority of randomized controlled trials studying the efficacy of preventive medications for pediatric migraine fail to demonstrate superiority to placebo. Recommendations for the prevention of migraine in children include counseling on lifestyle and behavioral factors that influence headache frequency and assessment and management of comorbid disorders associated with headache persistence. Clinicians should engage in shared decision-making with patients and caregivers regarding the use of preventive treatments for migraine, including discussion of the limitations in the evidence to support pharmacologic treatments.

Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society.

OBJECTIVE: To provide evidence-based recommendations for the acute symptomatic treatment of children and adolescents with migraine. METHODS: We performed a systematic review of the literature and rated risk of bias of included studies according to the American Academy of Neurology classification of evidence criteria. A multidisciplinary panel developed practice recommendations, integrating findings from the systematic review and following an Institute of Medicine-compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence. RESULTS: There is evidence to support the efficacy of the use of ibuprofen, acetaminophen (in children and adolescents), and triptans (mainly in adolescents) for the relief of migraine pain, although confidence in the evidence varies between agents. There is high confidence that adolescents receiving oral sumatriptan/naproxen and zolmitriptan nasal spray are more likely to be headache-free at 2 hours than those receiving placebo. No acute treatments were effective for migraine-related nausea or vomiting; some triptans were effective for migraine-related phonophobia and photophobia. RECOMMENDATIONS: Recommendations for the treatment of acute migraine in children and adolescents focus on the importance of early treatment, choosing the route of administration best suited to the characteristics of the individual migraine attack, and providing counseling on lifestyle factors that can exacerbate migraine, including trigger avoidance and medication overuse.

The Comorbidity of Migraine and Epilepsy in Children and Adolescents.

Migraine and epilepsy share a number of clinical attributes, including pathophysiology and clinical expression. Both are paroxysmal in nature and thus constitute episodic disorders, yet either may be chronic and/or recurrent. Epileptic seizures and migraine headaches may be mistaken one for the other and may even overlap. In particular, occipital lobe seizures may be misdiagnosed as migraine auras. In this article, we review the relationship between migraine and epilepsy, including the known genetic contributions to both conditions, prodromal, ictal, and postictal headache and shared pathophysiology and treatment options. We describe clinical conditions in which both migraine and epilepsy are prominent features. Lastly, we discuss electronecephaographic abnormalities that have been known to occur in individuals with migraine.

The treatment of pediatric migraine.

The management of pediatric migraine requires a balance of biobehavioral measures coupled with agents for acute treatment and, if needed, daily preventive medicines. A recent American Academy of Neurology practice parameter has critically reviewed the limited data regarding the efficacy and safety of medicines for the acute and preventive therapy of pediatric migraine. The first step is to establish the headache frequency and degree to which the migraines impact upon lifestyle and performance. The next step is to institute nonpharmacologic measures such as regulation of sleep (improved sleep hygiene), moderation of caffeine, regular exercise, and identification of provocative influences (eg, stress, foods, social pressures). A wide variety of therapeutic options exist for patients whose migraine headaches occur with sufficient frequency and severity to produce functional impairment. The most rigorously studied agents for the acute treatment of migraine are ibuprofen, acetaminophen, and sumatriptan nasal spray, all of which have shown safety and efficacy in controlled trials. Daily preventive drug therapies are warranted in about 20% to 30% of young migraine sufferers. The particular drug selected for the individual patient requires an appreciation of comorbidities such as affective or anxiety disorders, co-existent medical conditions such as asthma or diabetes, and acceptability of potential toxicities such as weight gain, sedation, or tremor.

Status of neurology medical school education: results of 2005 and 2012 clerkship director survey.

OBJECTIVE: To survey all US medical school clerkship directors (CDs) in neurology and to compare results from a similar survey in 2005. METHODS: A survey was developed by a work group of the American Academy of Neurology Undergraduate Education Subcommittee, and sent to all neurology CDs listed in the American Academy of Neurology database. Comparisons were made to a similar 2005 survey. RESULTS: Survey response rate was 73%. Neurology was required in 93% of responding schools. Duration of clerkships was 4 weeks in 74% and 3 weeks in 11%. Clerkships were taken in the third year in 56%, third or fourth year in 19%, and fourth year in 12%. Clerkship duration in 2012 was slightly shorter than in 2005 (fewer clerkships of ≥4 weeks, p = 0.125), but more clerkships have moved into the third year (fewer neurology clerkships during the fourth year, p = 0.051). Simulation training in lumbar punctures was available at 44% of schools, but only 2% of students attempted lumbar punctures on patients. CDs averaged 20% protected time, but reported that they needed at least 32%. Secretarial full-time equivalent was 0.50 or less in 71% of clerkships. Eighty-five percent of CDs were "very satisfied" or "somewhat satisfied," but more than half experienced "burnout" and 35% had considered relinquishing their role. CONCLUSION: Trends in neurology undergraduate education since 2005 include shorter clerkships, migration into the third year, and increasing use of technology. CDs are generally satisfied, but report stressors, including inadequate protected time and departmental support.