Annual Meeting Reviews

The Complex World of Headaches

By Maria Matuszczak, MD
Professor of Anesthesiology
Vice Chair and Chief, Division of Pediatric Anesthesia
Department of Anesthesiology
McGovern Medical School
The University of Texas Health Science Center at Houston
Houston, Texas

Dr. Blake Windsor presented the lecture titled 'From a Bump in the Noggin to a Life Altering Event: A Review of Modern Concussion Management for the Pain Physician'. His lecture focused on recognizing and treating concussions as early as possible. This does not only concern sports concussion but all types of concussion like after a motor vehicle accident for example, often missed.

There exists no clear consensus of what a concussion is. Even in mild concussions there is mitochondrial uncoupling, inefficient use of energy causing brain dysfunction. The first step is to recognize the symptoms at presentation. Symptoms are classified in five categories; somatic, vestibular/oculo-motor, cognitive, emotional, and sleep. A post-concussion symptom scale can be used to follow the improvement and recovery over time. The treatment is dependent on severity and category of symptom.

The timeline of concussion recovery can be anywhere from one week to three months, beyond that, symptoms become chronic. Twenty-five percent of patients still have headache after one month and about five percent develop chronic conditions. Risk factors for delayed recovery are; female sex, delayed presentation, ADHD, and previous mental health issues, just to name some. The goal is to avoid the development of chronic symptoms, like headache, sleep disorders and to reintegrate into normal life and attending school as soon as possible. Concussions need to heal by active rest; the longer the wait to get active the longer the symptoms last.

Dr. Stacy Peterson’s lecture, 'Non-Invasive Treatment in Pediatric  Headache – Old and New Therapies', focused on migraine. Children with migraine miss in average eight days of school per year. Is has as much an impact as diabetes or cancer. The definition of pediatric migraine differs from the adult. Without an aura there need to be five migraines lasting one to 72 hours and presenting at least two out of six characteristics. With an aura, two events qualify for the diagnosis of migraine. The diagnosis of chronic migraine requires 15 headaches per month and they can be of different type.

Three to twenty-three percent of children present with migraine headache with a higher percentage in girls after puberty. Knowledge about the timeline of migraine, prodrome, aura, headache, and post-drome and their different symptoms can help parents to recognize their child’s migraine as children often start complaining very late. Pathophysiology is very complex and not fully understood yet.  It involves cortical depolarization, release of CGRP and PACAP, trigemino-cervical pathways, and upper cervical nerves. CGRP levels at baseline and during an attack are significantly higher in a child with migraine. Approved preventive medication for children 12 and older - Topiramate; approved abortive medications are within the triptan group. In addition to medication, multimodal treatment approach includes lifestyle modifications, integrative therapies, cognitive behavioral therapy, vitamins, Botox, and nerve blocks.

Most medications available for adults are insufficiently studied in children, and some show less benefits in children. Anti-CGRP monoclonal antibodies are not approved in children, even though they show a 50% decrease in adult migraine after a month of treatment.  CGRP plays a role in CNS maturation, in recovery after injury, in the utero-placental function, and in many other systems.  This should be considered when prescribing this medication in the younger age or in pregnant adolescents. Expert consensus and recommendations for indications, contraindications and monitoring are available.

Dr. Shalini Shah’s 'Interventional Options for the Treatment of Headaches' discussed peripheral nerve blocks. Several pediatric studies demonstrate the benefit of bilateral occipital nerve blocks with lidocaine on primary chronic headache and post traumatic headache. The technic of occipital and orbital blocks were described.

The 200-year history of the use of Botox was presented. The ophthalmologic use of Botox anecdotally showed a decrease in migraine. Studies then demonstrated efficacy in the frequency of migraine and in the change from baseline. The toxin prevents the binding of the SNARE complex to the synaptic membrane and prevents neurotransmitter  cGRP and substance P) release. Muscle relaxation is not the intended treatment. In children most of the evidence comes from retrospective studies. Dr. Shah’s five-year retrospective study demonstrated safety, efficacy, and tolerability in a longitudinal evaluation. It showed that there is no loss of efficacy or development of tolerance with repeated injections. There is decrease in frequency and intensity but not in duration of migraine. A just published pediatric randomized cross over study with 31 injection points showed similar results. For all these blocks the experience of the performer and the correct indication is crucial for success.

Dr. Emily Law presented 'Comorbidities in Pediatric Headache'. Headache is the third most prevalent illness in the world. Headache impacts every aspect of the child’s life and of their family. The triad of headache, depression and anxiety, and sleep disturbances is generally present. Insomnia is defined as three nights per week for three months and creates a vicious cycle with migraine.

Cognitive-behavioral therapy is the first-line treatment for adults. CBT-intervention may disrupt migraine. A determination needs to be made if internet delivered CBT-I will improve insomnia as compared to sleep education. Secondary outcomes will look at multimodal sleep assessment, headache diary, and quality-of-life self-assessment. Dr. Law describes the Internet CBT-I (Web-ASLEEP) which is under construction. The goal of the program is to minimize time to be awake in bed. The second part of the study will use the WEM-MAP which is about pain coping skills and includes parents’ interventions. The other part of the triad is depression and anxiety. COVID 19 triggered a study to look at well-being for children with headache. 

The study describes the exposure to COVID, impact of the COVID pandemic, economic stress and symptoms on children and family, and impact on pain problems. Two hundred fifty (250) families participated. Nearly half of the families experienced economic stress and those with lower incomes experienced more stress. Youth of these families had elevated symptoms, insomnia, depression, and anxiety, similar to the parents. They also experienced more pain. Implications from this study is to strengthen referral pathways for minority/low SES families.

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