Multifactorial Headache in
Kids:
Practical Suggestions
A.J. Rush, MD
Mary Free Bed Medical Group
pedsrehabdoc.wordpress.com
[email protected]
bit.ly/multiheadache
Case #1: S
• Concussion ’12, 8yo girl with unusually severe
cervicogenic headaches
• Manual medicine & cyproheptadine
• No psychogenic overlay once pain controlled
• Re-presented ’16, 13yo with classic migraine with aura
• Missing >1 day school/week
• Multiple relatives on both sides +migraine
• Topamax, Periactin, Clonidine & Botox
• Breakthrough 1/week
• Triptan works 75%
• 100% functional, straight As, active in extracurricular activities
Goals
• Discuss how headache pain is neuroanatomically
different from other kinds of pain
• Review different types of headaches, their diagnosis &
treatment
• Explain chronic headache’s place on the spectrum of
Central Sensitivity Syndromes
• Explain pharmacology of botulinum toxin as it pertains
to the treatment of migraines
Real Goals: Give You My Scripts
• “Headaches are different from other kinds of pain
because they’re additive”
• “Short term stress is good… but you’ve been hacked”
• “How to get patients to do what they are told”
• “How to succeed in psychotherapy”
My Definition of Multifactorial Headache
• Chronic Daily Headache (ICDH-2): Chronic Migraine or
Chronic Tension-Type Headache (ICHD-3b)
• ≥15/month, >3 months
• 70-80% also have Medication Overuse Headache
• Most of remainder respond to usual therapies
• Multifactorial Headache
• Multiple headache types or comorbidities, does not
respond to what should be reasonable & appropriate
treatment
ICHD-3 (beta) www.ichd-3.org
Multifactorial Headache: Clinical Features
• Hx & PE indicate
multiple headache
types
• Comorbities
• Mental health
• Unrealistic
expectations:
kid/parents
• Loss of function
Etiology
• Migraine
• Tension
• Sinusitis
• Cervicogenic
• TMJ
• Clenching teeth
• Entrapment neuropathy
• Refractive error
Comorbities
• Depression • Primary dysmenorrhea
• Anxiety • Vulvodynia
• Chronic fatigue syndrome
• Stress/Overscheduled • POTS
• Insomnia/sleep apnea • Irritable bowel syndrome
• Allergic rhinitis • Restless leg syndrome
• Paroxysmal limb movements in
• Central Sensitivity
sleep
Syndromes • Multiple chemical sensitivities
• Fibromyalgia
• Mast cell activation syndrome
• Temporomandibular disorder
Spinal Trigeminal Nucleus
• Deep pressure, pain &
temperature from
ipsilateral V, VII, IX & X
• Caudally contiguous
with posterolateral
(Lissauer’s) tract
• Projects to
contralateral VPM via
anterior Henry Carter, 1918, in Grey’s Anatomy
Spinal Trigeminal Nucleus Pain Map
• Subnucleus caudalis
• Nociception & thermal sense
a n s ! from
i
entire face/head,rupper v i l i neck (except
C
ot fo to subnucleus
dental painNgoes
interpolaris)
• Surgical demonstrations
• Meningeal vessels noxious stimuli
• “Non-physiologic” distribution of
referred pain
r i p t o
Dx: Hx i -S c , s
M i n ou ? O K l t . I
r e y a d u
o l d a f a n 8 )
o w 8 ) o (X / 1
“H
• Tabulate the characteristicsre of(X / 1
each headache n d l e type.
u ’ o h a o r I
y o o u t t i o n
• FamHx, SocHx, PMHx, medications, e d y eetc
r s a o u .
ne o n v e l p y 8 -
• Use diagnostic questionaires h iin c
s person o t h o ( ( 1
of t a n n l y d o
l c
y sensitivity n o n r n t
• Depression, anxiety, sleep, central
si m p c a syndromes
. ( Tu
m o m y o u s t o
r
• Quantify school attendance Your ) of it fo /she fib in,
• This, not a pain score, will be )/ 1 8
marker of f h
outcome
i e m p
X B u t t o j u
• Relationships? Ask kid first,mthen om) parent. n t y o u
I w a
• “What is the worst thing in your e
m life?”
k?”
Pittsburgh Sleep Quality Index (PSQI)
• 0-21, >5 is abnormal
• Time physically in bed, asleep,
awakens
• Weekends vs weekdays
• “Don’t train your brain to stay
awake in bed”
• Hypersomnolence: Red flag for
depression or anxiety
• Catalog reasons for broken sleep
• Daytime somnolence
Child Depression Inventory (CDI2)—Short
Form
Points
0 1 2
1. I am sad once in a I am sad many times. I am sad all the time.
while.
…
5. I am important to I am not sure if I am My family is better off
my family. important to my without me.
family.
…
12 I do not feel alone. I feel alone many I feel alone all the
. times. time.
ACR Fibromyalgia Dx Criteria
• Widespread Pain Index: Last week which of 19 body parts had
pain
• Symptom Severity Scale Score:
• Fatigue
• Waking unrefreshed
• Thinking/remembering/depression/nervousness
• Muscle pain, IBS, asthenia, abdominal pain/cramps, hypesthesia/
paresthesia, dizziness, insomnia, constipation, nausea, chest pain,
blurred vision, fever, diarrhea, dry mouth, pruritus, wheezing, Raynaud’s,
urticaria, tinnitus, emesis, heartburn, oral ulcers, loss/change in taste,
seizures, dry eyes, SOB, anorexia, rash, sun sensitivity, hearing difficulty,
easy bruising, alopecia, frequent urination, dysuria, bladder spasms
Chronic Fatigue Syndrome Dx Criteria
• Severe fatigue ≥6 months
• Interferes with activities/school
• ≥4 of
• Post-exertional malaise
• Unrefreshing sleep
• Significant impairment of short-term memory or concentration
• Muscle pain
• Multijoint pain without effusion/induration/erythema
• New/different headaches
• Tender lymphadenopathy
• Frequent sore throat
• Lyme titer???
Headache PE
• Basic psych exam • Stigmata of allergic rhinitis
• Basic neuro exam • Sinus percussion
• Cervical ROM • Spinomandibular ligament
• Cervical muscle • TMJ
tension/tenderness • Mandibular excursion
• Greater & lesser occipital • Temporalis insertion
nerves
• Conchae beneath mandible
• Temporalis muscle texture
Workup
• MRI?
• No
• Not even if they’ve had a concussion: Even if they had a
subdural it won’t need decompression
• Unless neuro exam abnormal, new onset basilar migraine,
etc
• Unless it’s necessary to create trust
Treatment—Educational Script: “Headaches are
Additive” i o n
p t a t
Te m f r o m
t t h e p u t
• Headaches are different from Fighother r g e n t
sortsin of ipain.
p t v e If my
n v e c i c e m
hand & foot hurt at the same
… c o time a l n o
that’s worse f ro than
“ o d r i s
a signalse
just one or the other, but othose
l y -m two t h pain
a t f t h e will
p
never share real estate in my n t s
nervous n s
system. o On o mthe
ff e re e g i o r s f r
a
other hand, all headaches share e d r
a single t h e
ofinal common
c a l i z e &
l o
pathway… well, one for each side f a
of c my ”
head. So ‘
the 1 4
a d & e s … d r a n
h e
pain is additive & I only have amsingle n i n g pain c h a n
threshold
e a
t he Ram
• So maybe you could handle your _____ if you didn’t also
have _____ & _____. We’ll treat all of them
simultaneously
Treatment—Educational Script: “Stress is
Good…”
D o n R es is t
ot u t
“neu se w he Urg
• Short term ro o r
geisngood:dIts makes e
inflstress
a ic m l i ke
you stronger, faster, see
m
better in“vthe dark… mat it’s likeucoas superpower. But your body
was never sodi foriolong
amade n”: termalstress—you get fat & lose
a c ti la tio
your hair vati n”, “
prot on”, ma s
• Short termepain or “ You yank
in e is good: t ce your hand off the hot
x t r i n t r a l l
stove & your nervous avasystem
satio edoesc llula helpful things like
sending messages to adjustnblood .” r
flow & help the healing
process
• Long term pain is not good for you. We were never meant
to have it so we don’t have natural defenses against it
“… But You’ve Been Hacked”
• The cells which carry pain signals are organized in rows.
The ones for your nose are next to the ones for your
cheek & so on
Just Say No
• When a given nerve cell’s been icarryingd e your headache
D o n ot s a y “w
too frequently for too long it doesn’t n e u know
r o n ” what the
m i c r a n g e
yna it’s apparently important,
signal means, onlydthat i c a l so it
p a n d e d c or t
makes itself more o r “ex
efficient. So your pain gets worse
m a p. ”
Cheek Ear
Nose Cheek
bone
Cheek Ear
Nose Cheek
bone
“… But You’ve Been Hacked, Part 2”
• Some of these cells have connections to up to 3,000 other
cells. But they don’t really talk to them. Those connections are
just there in case you need them someday
• Once that nose-pain cell has been turned on way too high for
too long it starts to talk to its neighbors, share its message
• & they’ll pass that signal along, but the trouble is your cells
farther up in your brain don’t have any way of knowing that
signal’s a lie. You’ve been hacked
• As the pain spreads it tends to lose not just the specific
location but also its character, timing & associated symptoms
Lies
Cheek Ear
Nose Cheek
bone
Lies More Lies
Cheek Ear
Nose Cheek
bone
Treatment: Realistic Expectations
• Target outcome variable is • Gradual increase
functional • School schedule—partial
• Days at school days
• Chores • Light exercise
• Social life • Realistic schedule
• Sports • There’s only so many hours
• Job in the day
• I don’t ask pain scores • Regularize sleep schedule
Script: “How to Get Patients to Do What They’re Told”
Buy This Book, Attend This Course
Ability Motivation
Personal How to do it Change
correctly emotional
perception
Social Buddy Cheerleader or
Someone with
vested interest
Structur Convenienc Rewards/
al e consequences
Treatment: Comorbidities
• Team must be on same page • Multiple medication failures/
• Depression: 70% of chronic reactions = Genetic testing
pain patients • MTHFR
• Difficult to access care • Receptor variants
• Increases firing frequency in • CYP450 variants
dorsal columns • Emphasis on empowering
• Avoid analgesics that cause patient
depression (AEDs) • Insomnia: Short-term meds, then
• ADHD with poorly controlled CBT
mental or physical health = • Fibro: Aerobic reconditioning
Neuropsychological consult • Myofascial pain: Manual therapies
Script: “How to Succeed in Psychotherapy”
• Of course it’s unpleasant
• Competence, trust, “click” & accountability
• Realistic, objective, functional goals
• Cognitive behavioral therapy: “You and your therapist
will think about things you can do differently to be
cured”
• pedsrehabdoc.wordpress.com/2017/06/24/how-to-
succeed-in-psychotherapy/
Treatment: Migraine
• School-age: Cyproheptadine
• Tween+
• Topiramate: teratogen
• Botulinum toxin (next slide)
• TCAs: Nortriptyline
• B-blockers: Propranolol, metoprolol
• AEDs: Valproic acid, gaba-ergics
Treatment: Botox
• “Toxin”
• Commonly takes 3 • Retrograde axonal
treatments transport
• Cleaves SNAP-25, blocks • Mice: 1-3 days to STN
the release of: • Blocks nociceptive sensory
• ACh: Pain-spasm-pain cycle afferents
• Substance P, CGRP, • Theoretical trans-synaptic
glutamate, PACAP: transport
Neurogenic inflammation
Site Dose (units & sites)
Corrugator (A) 10 ➗ 2
Procerus (B) 5➗1
Frontalis (C) 20 ➗ 4
Temporalis (D) 40 ➗ 8
Occipitalis (E) 30 ➗ 6
Upper cervical paraspinals (F) 20 ➗ 4
Trapezius (G) 30 ➗ 6
Total 155 ➗ 31 sites
Case #2: C
• 16yo boy with chronic tension-type headache x13 years, quit
baseball 7-8 years ago
• Hx: Depression>anxiety, failed multiple medications, ADHD, insomnia,
Raynaud’s, fibromyalgia, chronic fatigue syndrome
• PE: Mood down, entire head tender except his sinuses
• MTHFR reduced activity desmethylfolate 1mg QOD
• Neuropsych: Not ADHD, just affective disorder. Stopped Adderall
• 1 month later: Headaches, depression, sleep, fatigue 50%
improved
• Starts pain psychology next month
Case #3: E
• 12yo girl with chronic tension-type headache
• Also cervicogenic headache, fibromyalgia, depression
• Failed PT/OT
• Used up all psychotherapy benefits
• Father getting out of prison soon
• Now with syncopal episodes, catastrophizing
• Rx
• Education: You Don’t Need Either a Seizure or Cardiac Workup
• Psychotherapist persuaded insurance to cover unlimited visits
Closing
• Treat of all headache types simultaneously
• Comorbidities must also be managed
• Questionnaires done with the patient facilitate Hx
• Don’t just tell patients what to do but how to do it
• Having a collection of scripts which I deliver personally
while sketching on the exam table paper works better
for me than handouts
References
• Migraine literature review, botulinum toxin mechanism of
action
• Ramachandran, Roshni & Tony L Yaksh. “Therapeutic Use of
Botulinum Toxin in Migraine: Mechanisms of Action.” British
Journal of Pharmacology 171.18 (2014): 4177–4192.
• Pediatric chronic daily headache management
• Mack KJ. “An approach to children with chronic daily
headache.” Developmental Medicine & Child Neurology 48
(2006): 997-1000.
• Pediatric Pain Master Class, Children’s Hospital of MN
