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THE CONSERVATORY OF MEDICAL ARTS AND SCIENCES
THE SEARCHLIGHT MESSENGER
THE SEARCHLIGHT MESSENGER
CORONA VIRUS UPDATES
|Posted on January 8, 2021 at 7:09 PM||comments ()|
LEUKEMIA, THE PARADIGM MIRACLE
|Posted on May 20, 2017 at 7:25 PM||comments ()|
MIGRAINES IN CHILDREN
|Posted on May 20, 2017 at 7:23 PM||comments ()|
Many of you have read my article on migraines entitled
Is My Headache a Migraine. Recently I have been approached with questions from my college campus students regarding their children and the brittle headaches their kids endure. Two students in particular stated that their child’s doctor had diagnosed them as having migraines, prescribed the medicine, periactin as needed, but did not explain to them what migraines in children are really all about.
This is a little disturbing to me, as I feel the more educated my patients are, the better they are able to manage their headaches and lead normal healthy lives. This falls on the treating doctor, and unfortunately, it seems this new era of doctors is in such a hurry, it has forgotten how to teach. Osler would role in his grave!
This part of treatment is obviously more important than the "periactin". And both should be part of an overall plan. "Written down and easy to follow", by both the parents and the little one.
So, I thought this would be a good time to again discuss this very debilitating disorder. No one ever wants to see a child suffer through these. I recommend reviewing the above article in addition to this one.
When you think about someone having a headache, you probably think of an adult. But many kids have headaches too, and for many of the very same reasons that adults have them.
Children and teens can experience muscle tension or migraine headaches. Among school age children ages 5 to 17 in the United States, 20% are prone to headaches. Approximately 15% of these kids experience muscle tension headaches and 5% are dealing with migraines.
Chronic or frequent headaches can be tough to handle, and are even harder to understand when you are young, especially if you do not know anyone else who has them.
By the time they reach high school, most young people have experienced some type of headache. Fortunately, less than 5% of headaches are the result of serious disease, such as a tumor, abscess, infectious disease, or head trauma.
Most headaches are muscle tension type, the result of good and bad stress, sleep issues, or in a few instances, environmental or food triggers. About 5% of recurrent headaches will be diagnosed as migraine.
Episodic headaches are those that occur a few times a month at most. Chronic headaches occur with much more frequency, even several times in a week. If a child who has only had an occasional headache (once or twice a month) starts experiencing them more frequently (two, or three times a week), then these should be considered chronic and medical attention should be sought as soon as possible.
One of the most frustrating aspects of chronic headaches is the stress factor. Avoiding a known trigger is usually easier than avoiding stress. Young people want to do well on tests and in school, and they want to attend important events, but anticipating a math quiz or musical recital, or eagerly looking forward to a party or being in the school play, can result in anxiety or excitement. And, for some kids, this leads to a headache.
Up to 4% of children have their first headache before they reach elementary school, and they may not yet know how to describe the pain. If a young child has been crying or not eating, or has been restless or irritable, consult with your doctor about finding the source of discomfort or pain. Remember, the child has no idea what is happening and this can be very frightening.
The more knowledge (and easy to understand guide lines) school health officials, as well as parents have about children and chronic migraines, such as common triggers, symptoms, prevention, and treatments, the easier it will be to identify the child who is suffering through these headaches.
The best evidence based approach to treatment, interestingly, is the more holistic approach to little patients. It entails two things: 'chronic therapy', which addresses decreasing the frequency and intensity of the headaches, and 'acute therapy', which gives the patient and parents weapons to stave off an evolving attack.
As I have discussed in other articles, in adults, a migraine's throbbing head pain usually occurs on one side of the head, but in children it can affect both sides. The migraine is often accompanied by nausea, vomiting, dizziness, blurred vision, sensitivity to light and sound, and changes in temperament and personality. A headache's duration varies from individual to individual. But, generally, unlike adult migraine, which can continue up to four days, a child's migraine might be as short as one hour or may last for a day or so. Children also improve more rapidly to sleep. So, the best treatment for children is a nap in a quiet, and dark room.
About 15% of kids experience a migraine headache with an Aura. A typical aura is seeing colored or flashing lights, blind spots, or wavy lines or feeling a tingling in the face or an arm or leg. An aura alerts a migraine sufferer to the onset of a headache, warning the child several minutes before the pain starts. A small percentage of migraine sufferers also encounter temporary motor weakness, as they may lose their sense of coordination, stumble, or have trouble expressing themselves.
Young children with migraine may not have head pain at all but rather experience recurrent stomach problems or dizziness. These types of migraine are called migraine variants (Migraine Variants will be addressed in a future article). Children who have migraine also are more prone to motion sickness.
What causes a migraine? This is treated at length in my original article.
For most kids, migraine is inherited from a parent. Migraine occurs because of alterations in a person’s genetic makeup. An individual migraine attack is often triggered by a particular environmental or emotional event. In some cases, triggers can be identified. Among the most commonly recognized ones are stress (good or bad), a change in routine, a change in sleep pattern, bright lights or loud noises, or certain foods and beverages. Let’s look at these for moment.
One of the things I first have patients, especially children do regarding brittle migraines, is keep a diary of foods, sleep patterns, and other possible triggers. The best way to do this is to get the whole
family involved, and use a big wall calender with plenty of space for everyone to write down what they observe, as one person may notice something another didn't.
There are many triggers in childhood migraines that should be weeded out. Foods are huge, but other things as mentioned above, like stress level, even positive stressors like more money, new teacher, family gatherings, etc. can be big. Sleep can be a major player. I can't stress enough, the value of regular sleep patterns and at least 9 hours of sleep every day for kids.
Food is probably the biggest player, so you have to read labels closely. Here are the biggest triggers I've seen in practice:
(1), Caffeine in any form, even in medicines. Keep in mind that caffeine is also used to treat headaches, but can be a two edged sword, and, induce “rebound phenomena”. (2), Mint, it's in everything, start tossing it out. (3), Red food dyes. (4), Yellow food dyes. (5), Hard aged cheeses, like Parmesan, and cheddars, remember also, that cheeses are not naturally yellow ( they have yellow dye in them). (6), Pizza. (7), Lunch meats. (8), Hot dogs and sausages. (9), Bacon, use "fresh-side", or "sugar cured".
The above meats have nitrates in them which induce migraines.
(13), The additive, Mono-Sodium Glutamate (MSG) is a monster and must be avoided, it is in everything from snack foods, frozen foods, bullion, and ramen, to canned soups. (14), All citrus products. And watch out for sugar binges. Remember to write down every little detail that appears significant on that calendar, and let your doctor know how it's going.
After a formal diagnosis, a doctor's goal is to help reduce or eliminate the symptoms of a migraine and prevent future attacks.
In regard to treatment, sometimes children, especially young children, do not need any medication to treat a headache. Often there are non-medicinal treatments that can provide primary, or added benefit.
During a migraine attack, a child should be allowed to rest, and even sleep, in a quiet, dark and cool room. Raising the child’s head up on a pillow and providing a cool compress for the eyes or forehead can help them feel more comfortable. When at school, a child should be allowed to go to the nurse’s office and rest. Sometimes a quick nap is all it takes and they can return to the rest of the school day.
Trigger avoidance and a regular schedule are huge preventive measures that can be taken to avoid the frequency of attacks. Relaxation and stress management techniques can be helpful during an attack and to help alleviate stress before it becomes a full blown an attack. Daily physical activity is also very important in headache management and stress reduction. Two methods that have been well documented to help children with migraine include meditation and biofeedback. There is also much research that suggests hyper-hydration with plain water may prevent frequency in migraine attack.
Once a migraine has begun, several types of medication can alleviate the symptoms. Analgesics, such as acetaminophen or ibuprofen, are first-line pain relievers for treatment of headaches in children and adolescents. The Triptans can be helpful in those children who don’t find simple analgesics helpful. There are several different triptans available and two (almotriptan [Axert®] and rizatriptan [Maxalt®]) are FDA-approved for children. In addition, your doctor may also prescribe anti-emetics to stop the nausea and vomiting or a sedative to help a child rest.
Aspirin is not generally recommended for kids, as there is now, well documented evidence linking aspirin to the development of Reye's Syndrome, a rare disorder that children and teenagers can get while they are recovering from childhood infections, such as chicken pox, flu, and other viral infections. Reye's symptoms include nausea, severe vomiting, fever, lethargy, stupor, restlessness, and even delirium.
Children and adolescents who experience migraine attacks more than twice a week and which interfere with school or social activities, may be prescribed a daily medicine to try to prevent headaches. There are no medications that have been specifically designed for migraine so they all come from other categories including anti-seizure, blood pressure and anti-depressant drug classes. Common preventive medicines include beta blockers, tricyclic antidepressants, topiramate, and valproate. Please note: none of these medications are approved for migraine treatment in children. However, research in this area continues with excellent progress and doctors will utilize these medications as "off label" prescriptions.
Frequent headaches, especially those that occur more than once a week, deserve treatment, with both medication and non-medicinal options. Headaches are not good for the brain and headaches often lead to more headaches. With the right treatment regimen your child can get his or her headaches under control and prevent further progression.
Further questions can be directed below, and look for continued articles on headaches in future posts on The Searchlight Messenger.
My Advice to Medical Students
|Posted on March 22, 2016 at 2:54 PM||comments ()|
Managing Headache: Too Many Tests, Not Enough Counseling?
|Posted on April 20, 2015 at 2:25 PM||comments ()|
Headache is one of the most common pain disorders seen in outpatient practice, and the authors of the current study provide a brief overview of the epidemiology and larger consequences of headache. Nearly everyone experiences headache at some point, and the prevalence of recurrent, severe headaches approaches 25%.
The high prevalence of headache is associated with substantial societal costs. There are approximately 12 million clinician office visits for headache per year in the United States, and headaches are estimated to cost the US economy $31 billion per year. The evaluation of headache accounts for some of this financial cost, but it can also have severe medical consequences. One study estimated that 4000 additional cancers were promoted by the 18 million computed tomography (CT) scans of the head performed in the United States in 2007. Another study found that the majority of all CT imaging of the head and brain were inappropriate, based on current recommendations. Most inappropriate CT imaging was ordered for headache.
The inappropriate use of resources in the management of headache has led to recommendations to reduce the use of brain imaging and physician referral, as well as limited use of opioids and barbiturates in the treatment of headache. But are clinicians following these recommendations? The current study by Mafi and colleagues explores this issue.
Study Synopsis and Perspective
Contrary to practice guidelines, clinicians treating patients with headache are increasingly ordering costly imaging tests and referring patients to other physicians, and they are doing less counseling on lifestyle changes, authors of a new review suggest.
The researchers found an almost doubling of the use of CT and magnetic resonance imaging (MRI) in a recent 10-year period.
Although given the nature of the study they could not determine which referrals or imaging studies were not appropriate, the trend toward a doubling of these tests is concerning, said lead study author John N. Mafi, MD, fellow, general internal medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
"We have no reason to suspect that headache is a disease that epidemiologically or pathophysiologically has changed over the past decade, so this, we think, is inappropriate changes in physician practice patterns."
The study was published online January 8 in the Journal of General Internal Medicine.
Researchers used data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) from January 1, 1999, to December 31, 2010. Both surveys obtain nationally representative samples of ambulatory patient visits across the United States.
From these surveys, researchers identified ambulatory visits (excluding emergency department visits) with a chief complaint and/or a primary diagnosis of headache. They also included those with secondary complaints and diagnoses of headache but unrelated primary reasons for the visit (eg, hyperlipidemias).
In the group of patient visits with a chief complaint of headache (80.8%), the surveys provide duration or context of symptoms in 5 categories: new onset (<3 months), acute-on-chronic flare-up, chronic routine, routine/preventive, and preoperative or postoperative visit.
Researchers studied 4 types of measures: use of advanced imaging, including CT and MRI; referrals to other physicians; counseling on diet, nutrition, exercise, mental health, and stress management; and use of medications.
The analysis included 9362 visits related to headache, which represented approximately 144 million visits during the study period. Almost 75% of the patients were women, and their mean age remained the same during the study, at approximately 46 years.
The study showed that advanced imaging, including CT or MRI, increased from 6.7% of visits in 1999-2000 to 13.9% in 2009-2010 (P < .001), as did referrals to other physicians, which rose from 6.9% to 13.2% (P = .005).
Although rare, there are "real concerns" about kidney injury due to use of contrast dye and radiation during imaging tests, commented Dr Mafi.
The study showed that during the same study period, counseling for headache prevention declined from 23.5% to 18.5% (P = .041).
But there were also somewhat encouraging results. For example, use of opioids and barbiturates, which are not recommended for headache, remained the same at approximately 18%.
"That's still quite a high number for a discouraged medication, so there's lots of room for improvement," commented Dr. Mafi.
Also, preventive medication for migraine, such as verapamil, amitriptyline, propranolol, and topiramate, nearly doubled — from 8.5% to 15.9% (P = .001). Abortive therapies, such as triptans and ergot alkaloids, rose from 9.8% to 15.4% (P = .022).
Use of nonsteroidal anti-inflammatory drugs and acetaminophen remained stable at roughly 16%.
The trends remained after adjustment for age, gender, race, geographic region, insurance status, symptom duration, urban location, and whether the physician was identified as the primary care practitioner. As well, there were similar trends between visits related to migraine vs nonmigraine headache, although patients with migraine received triptans/ergot alkaloids and preventive therapies more often, and their use of opioid or barbiturates was higher.
Use of CT/MRI rose more rapidly for those with nonmigraine headache, as did referrals to other physicians.
Acute vs Chronic
As for acute vs chronic headache, again the trends were similar. Use of CT/MRI appeared to rise more rapidly among patients with acute symptoms, although this difference did not achieve significance.
In addition, patients with chronic headache had lower adjusted odds of receiving referrals to other physicians (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.42 - 0.82) or undergoing advanced imaging (OR, 0.47; 95% CI, 0.35 - 0.63) compared with other presentations. However, there were no significant differences across time as trends in referrals and imaging still nearly doubled for both groups.
Numerous factors are driving these trends, including a growing number of assertive and demanding patients, the authors suggest. "They come in and say 'I need an MRI for my headache' as opposed to 'I have a headache'," said Dr Mafi, adding that MRI and CT are more available now than ever before.
As well, physicians have an incentive to make patients happy because they are increasingly being rated on satisfaction surveys, said Dr Mafi.
There are also financial incentives for physicians to do more testing and concerns about legal liability if tests are not ordered.
Time constraints are another contributing factor. "There is simply not enough time during the visit to counsel" patients on making lifestyle modifications to help treat their headache, said Dr Mafi.
Reversing the trends will require a change in approach to reimbursement that relies less on the physical clinician visit and more on new technologies, said Dr Mafi.
"Rather than lengthen the visit or pay doctors more, I think we need to move away from that 20th-century mindset and really think about reimbursing care across a continuum of time," he said. "We need to think about reimbursing high-quality care at any time, whether it's electronic or through a secure email message between the patient and physician, or an electronic visit or telemedicine visit where patients can contribute to their records online and have the doctor provide feedback."
For a comment, Medscape Medical News reached out to Elizabeth Loder, MD, chief, Division of Headache and Pain, Brigham and Women's Hospital, Boston, Massachusetts, and immediate past president, American Headache Society (AHS), who headed the AHS "Choosing Wisely" project that looked at opioid prescribing.
The new study was well done, has "some fascinating findings," and is important in light of the fact that headache treatment and management trends are a neglected medical problem, said Dr Loder.
However, she raised several issues about interpretation. For one thing, she pointed out that the NAMCS and NHAMCS do not provide information that would help determine whether imaging studies were appropriately or inappropriately ordered.
"In clinical practice, we see both underuse and overuse of imaging studies. Patients with complex, refractory chronic headache problems frequently have multiple — usually unnecessary — imaging studies. In contrast, it remains common for us to see in a headache clinic patients with worrisome presentations of headache who have not been imaged."
The data suggest that much of the increase in imaging may be due to an increase in acute as opposed to chronic headache, said Dr Loder. "This is exactly the situation where imaging is most likely to be appropriate."
As well, the results show that imaging is more common in patients with nonmigraine headache rather than migraine headache. "Again, this is a situation where imaging may well be appropriate."
Dr Loder stressed that when the AHS formulated its "Choosing Wisely" recommendations, the committee felt that evidence to discourage imaging was strong only for patients with stable headache who met criteria for migraine.
According to the recommendations, imaging in patients without migraine is not necessarily inappropriate.
"The proportion of scan abnormalities is higher in patients with nonmigraine headaches and we did not feel evidence was sufficient to discourage imaging in those cases."
Dr Loder also noted that the increase in imaging and referrals has occurred alongside an "enormous downward pressure" on the time physicians can devote to patient concerns during an office visit. Physicians have to spend more time on paperwork, electronic medical record "meaningful use" requirements, and other things, she said.
"Ordering tests and making referrals are both relatively quick ways to demonstrate concern for a patient's symptoms and maintain patient satisfaction."
She pointed out that although some guidelines or recommendations encourage physicians to counsel about diet, nutrition, and lifestyle, these are based only on expert opinion. "The evidence that this type of counseling actually improves patient outcomes is thin to nonexistent."
She also noted that the "Choosing Wisely" recommendations were developed on the basis of processes that are less rigorous and detailed than those used to create actual guidelines (eg, those developed by the American College of Physicians in 2000), and the two probably should not be confused.
"'Choosing Wisely' recommendations are intended to identify practices that often — although not always — represent low-value care and that patients and physicians should discuss and question," said Dr Loder. "That is not the same thing as saying they are always inappropriate."
According to these recommendations, situations exist where the use of opioids and barbiturates may be appropriate, although they should not be first-line treatments in most situations, said Dr Loder. Similarly, the recommendations encourage the use of advanced imaging with MRI rather than CT in nonemergent headache for which imaging was thought to be appropriate.
"I think the authors are overstating the case for limiting imaging studies when they say that there is 'broad agreement' on these issues and characterize these things as 'low-value services.' They are not inherently low value — they are low value only in specific contexts."
Dr Loder found it "very interesting" that among those presenting with headache, women were significantly less likely than men to have imaging studies.
Dr Mafi and Dr Loder have disclosed no relevant financial relationships. Dr Loder is acting director of research at the BMJ but noted that although she is paid for that work, her comments do not necessarily reflect the views of the BMJ, the AHS, or Brigham and Women's Hospital.
J Gen Intern Med. Published online January 8, 2015. Abstract
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