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First Contact for Primary Care - Pediatric Migraine Action Plan

Dr. Cori Cross (Host): Welcome to Peds Cast, a podcast brought to you by Children's of Alabama. I'm pediatrician Dr. Corey Cross.

Dr. Corinn Cross (Host): Today we'll be speaking with nurse practitioner Scott Turner who is the site investigator at University of Alabama at Birmingham. And he is doing an exciting new study in pediatric migraine management.

He's going to discuss with us pediatric migraine action plans and basically he's going to tell us about this five year study they're doing with about 400 patients. And they're spearheading, basically determining the gold standard for pediatric migraine management. So it's really exciting stuff and thank you Dr. Turner for being here with us. let's start with discussing what a big issue this is for kids and teens. somewhere between in, I'm a pediatrician, so somewhere between 10 and 20% have frequent severe headaches. Is that right?

Scott Turner, DNP: Yeah, that's correct. And it goes all the way down to toddlers. About 3% of toddlers can have migraine. We don't always recognize it in little kids because it often looks like a stomach ache, or cyclic vomiting type picture. But by the time they get into school age years, about 10% of kids will have headaches, and migraines specifically.

And getting into the high school years, about 15 to 25% of youth in high school will have migraine.

Host: And is that something that is not just a one-off, but they have that consistently?

Scott Turner, DNP: Yeah, that's correct. In order to meet the diagnostic criteria for migraine, you have to have had five or more attacks that are somewhat stereotyped, and you have to have had five of them in order to meet the diagnostic criteria for migraine.

Host: I know everybody likes to bring up COVID and try to tie it back to things, but in this case I think it might be relevant. And I was just curious, after online learning and the increased stress that kids were under for such a prolonged period of time, I know that I am seeing increase in stress diagnoses, are you noticing an uptick in headaches and migraines in kids since prior to 2019 and now comparing them afterwards?

Scott Turner, DNP: Yeah, so I think, there are a couple of things at play. Number one COVID was certainly associated with headaches as a primary feature for a lot of folks, both children and adults who wound up contracting the virus. The problem is that many of those kids that had migraine to begin with had an uptick in their migraine frequency following the infection.

We also found a phenomenon, and this has been seen throughout the country, where children that contracted COVID may wind up with chronic migraines or maybe even a new daily persistent headache that won't go away for several months following a COVID infection.

Host: And then was it always linked to actually having a COVID infection or did you see an uptick in headaches and migraines in kids who just had to do online learning or had just increased stress?

Scott Turner, DNP: Yeah, I think both of those were also factors. I, think we have seen an uptick in the number of patients and the number of referrals we've been receiving for managing recurring headaches in children and adolescents. Part of that's due to a retirement or moving away of several different neurologists in the state.

We have lost folks in Montgomery. We have lost neurology in Tuscaloosa. And the group up in Huntsville has stopped seeing children for headaches. So we have become primarily, the folks that see children with headaches here in central Alabama, for sure.

Host: So you guys are really busy.

Scott Turner, DNP: Uh, yeah, we are.

Host: So I know I read a little bit about the study that you guys are doing but maybe you could tell us a little bit more. I mean, I read that it's 400 kids across the country. It seems huge. It seems really exciting.

Scott Turner, DNP: Yeah. So, we are one of 16 sites across the country for a PCORI funded research study, comparing the effectiveness of CBT or cognitive behavioral therapy, either given alone or in combination with amitriptyline.

Host: And amitriptyline is Elavil. And so, the question I have for you is when you're looking at these things, on the one hand you have medication and on the other you have cognitive behavioral therapy alone or in conjunction with medication.

Can you tell us a little bit about what the side effects are of amitriptyline and why one would want to err towards the side of less medication if possible?

Scott Turner, DNP: Yeah. So, the interesting thing about side effects is they can either be helpful or harmful depending on your perspective. So for a good example, amitriptyline, if somebody's having a very difficult time sleeping at night, the side effect of sleepiness and giving it to them at bedtime; may actually help them sleep a lot better at night.

And so in that sense, the side effect can be beneficial. Of course, the other problem with amitriptyline is that it is associated with an increased risk of QT prolongation. And so, that certainly needs to be avoided in children that have a history or family history of prolonged QT syndrome. And it have either a positive or a negative effect on the mood. And so the advantage of cognitive behavioral therapy is you take away essentially all of those side effects and there is a good reason to think that it may in and of itself be just as effective as the amitriptyline when given alone.

Host: So one of the good things that maybe came out of COVID and lockdown is that we have a much more robust telemedicine network really across the country. And I would think that cognitive behavioral therapy is really practitioner dependent and that there are some areas of the country where there's no one who actually knows how to do CBT or there's just not enough resources for the number of patients who need it.

So tell us about the specialized training that doctors or practitioners need to undergo to be able to deliver CBT.

Scott Turner, DNP: Well, Dr. Cross right now the CBT for this study is actually going to be delivered by the psychologists, behavioral psychologists at the University of Cincinnati, Cincinnati Children's Hospital. And you bring up a good point, which is that here in Alabama, is one of the areas that we don't really have a good resource around cognitive behavioral therapy when it comes to using it as a modality to treat chronic pain. We definitely have very good psychology resources here at Children's Hospital and other parts of the state as well who are quite familiar with cognitive behavioral therapy in general. But as you know, cognitive behavioral techniques are different depending on the type of condition that you're trying to treat.

For example, cognitive behavioral therapy for insomnia would be different than the treatment for something like chronic pain anxiety.

Host: Absolutely. And I would think that after this five year study is done, if cognitive behavioral therapy is found to be as effective alone as a medication, that we'll have to look at that as a medical society to try to figure out how to train more practitioners to be able to deliver that type of care.

Scott Turner, DNP: Yeah, that's correct. And one of the things that they're doing in Cincinnati right now is looking at whether there are other types of professionals that could deliver cognitive behavioral therapy for pain or headache with just as much efficacy as the pain psychologists that they're currently using.

Host: Right. Cause we don't want to give a pill just because it's easier.

Scott Turner, DNP: Exactly.

Host: So I have a question for you, as a pediatrician. So Imitrex, which is a nasal spray that can be given for migraines; now it's off-label for children. But I was curious as to, you know, in your practice a lot of these medications aren't researched in children, and so if you use them in children, they are off-label. And I was just curious if you could speak to that a little

Dr. Corinn Cross (Host): bit.

Scott Turner, DNP: Well, yeah, absolutely. There are clinical care guidelines or clinical practice guidelines that are put out by the American Headache Society and the American Academy of Neurology, and there's one for acute management of migraine in children and adolescents. And then a second one that discusses the different preventative treatment options that are evidence-based.

Admittedly, the evidence for some of the preventative medications is low. It's level B quality because it has not necessarily been consistently shown to be superior to placebo, for things like amytriptyline and topiramate, as we found out in the Champ Study. But if you're looking at the medications that are being used for acute management of migraine in children and adolescents, I think ibuprofen across the board is, uh, level A evidence for efficacy in terms of treating children and adolescents.

The important thing though is that they need to be able to take it at school, because the window to take an acute medicine is about 30 minutes from onset or certainly before it gets to the severe level. Otherwise, the medications don't seem to work all that well.

Host: Right. And you make a very good point that there is a difference between preventative medication and basically rescue meds. And if we were to put it in like asthma terminology, right? We take something to prevent having the attack and then we take something different if we do have an attack to try to get us out of it quicker.

Scott Turner, DNP: Yeah, that's correct. And ibuprofen usually works well for children if they can take it quick enough and they have to take it at a sufficient dose, as well, because oftentimes the parents will look at the back of the bottle and, you know, maybe give them slightly less than what we would recommend for the treatment of migraine. For the children, yeah, we usually dose it at about 10 milligrams per kilogram. And that winds up being a little bit higher than what it recommends on the back of the bottle.

Dr. Corinn Cross (Host): Yeah, they tend to err on the side of caution, on the back of the bottle. So when a child comes to your clinic and walk us through what happens, how do you develop a child's migraine action plan? You know, are they asked to keep a headache diary? Do you try, NSAIDs or ibuprofen first, or do you ever use caffeine? Walk us through what happens to those patients.

Scott Turner, DNP: Yeah, absolutely. So, the first thing we try to do is determine whether the headache is a primary headache disorder or a secondary headache disorder. Primary headaches, as you know, or the reason why you have the headache is because you have a headache disorder. And the most common headache disorder in children is actually migraine, not tension type headache as we've been led to believe.

And so we try to determine if they do fit the criteria for migraine or tension type headache or one of the other primary headache disorders. And we do that largely by ruling out any red flags for increase in or cranial pressure. Or any abnormalities on the exam to suggest that they might have a secondary cause for their headaches.

Fortunately, most of the people that come to see us are definitely diagnosed with a primary headache disorder and giving a child and their parents a diagnosis that you can feel confident in, such that you have migraine; really actually is therapeutic in and of itself; knowing why you have the headache is because you have a condition which makes your brain more reactive to stimuli in the environment that might come along and irritate it.

Knowing that that's something that you were born with and will need to learn how to manage over time, can actually be fairly empowering and reassuring realizing that it's not, brain tumor or other scary pathology.

Host: No, that makes sense. I mean, just knowing what's going on is half the battle. You're not sitting there worried that you have a brain tumor or something else going on. You understand what it is and that there is a way to treat it, and that takes away a lot of the anxiety.

Scott Turner, DNP: Yeah. And from that point, we would go on and try to look at how often the headaches are coming and in what situations. What are the symptoms that accompany the headaches because oftentimes in migraine, even though pain is a primary symptom, it's really the other things that might actually be more disabling or keeping children from being at school.

For example, if they get sick to their stomach and throw up, they wind up getting sent home pretty much immediately. And so, giving them treatment for nausea and vomiting either by using an antiemetic like Zofran with the ibuprofen or by moving to a triptan medication when it's appropriate, would be really quite reasonable in that situation.

Host: That makes sense. So in summary, is there anything else that you'd like to share with our listeners today, or would you want to sum up a take home message?

Scott Turner, DNP: Yeah, absolutely. So number one, uh, migraine is really quite prevalent in the pediatric population. I tend to think of it as being at about the same prevalence as asthma. And so if you think about the children in your practice, if you thought about the number of children that have migraine as being equivalent to the number of children that have asthma; it becomes quite apparent that many of them never get diagnosed or recognized and they tend to kind of suffer in silence. Uh, migraine is the most disabling condition in the world for women, ages 14 to 49. It's the second most disabling condition in the world for all other people. And so the problem with migraine isn't necessarily that it's medically serious.

The problem with migraine is it is incredibly disabling and these kids tend to miss a lot of school. By giving them a good answer as to what's going on, you have a migraine, you have migraine as a condition. And by giving them a action plan to try to be sure that they are doing what they can to prevent migraines and doing what they can to treat them, along with the action plan that they need for school or the permission form that they need for school; you actually fight most of the battle for us. So you may not be able to or may not need to refer folks to see us if we can get them treated, quite nicely, by these means.

Host: That's great. And you know, to your point, knowing how many kids are suffering with migraines out there, really is and of itself something will hopefully make pediatricians and practitioners realize that if we're not seeing them, it's not that they're not coming in, it's that we're missing them and that we need to ask more pointed questions to make sure we find them because it is treatable and we can help these kids so that they're not missing so much school and they're not suffering in silence.

So thank you so much for bringing this to our attention and I'm very excited about the study you're doing. I'm super excited to figure out what would be the best algorithms for a lot of these kids and I really appreciate you sharing your expertise with us today.

Scott Turner, DNP: Thank you, Dr. Cross. I enjoyed it.

Host: For more information or to refer patients to Children's of Alabama, visit children'sal.org. That concludes this episode of Children's of Alabama Peds Cast. If you've found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for other topics that might be of interest to you.

Please remember to subscribe, rate, and review this podcast. Thanks for listening to this episode of Peds Cast. I'm your host, Dr. Corey Cross.