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>> 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.
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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.
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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.
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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.
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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.
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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.
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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.
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(giggling)