Conan Gasque (Host): Welcome to Inside Pediatrics, a podcast brought to you by Children's Hospital of Alabama in Birmingham. I'm Conan Gasque. Thanks so much for joining us today. Headaches are our topic. It's a very familiar topic for many people as so many people around the world deal with headaches on a regular basis. And we're talking to Dr. Scott Turner, a nurse practitioner in the Children's of Alabama Headache Clinic, and also an Assistant Professor of Pediatrics at the University of Alabama at Birmingham. Dr. Turner, thanks so much for your time today.

Dr. Scott Turner: Well, thanks for inviting me. I really appreciate that.

Host: So again, headaches, very prevalent, a topic that I think everybody knows a little bit about, but we want to take a much more in-depth look today and we're taking a look specifically at children and teens and the way that they're affected by headaches. How common, how prevalent are headaches among these populations?

Dr. Scott Turner: Absolutely. And headaches are actually quite common in children and adolescents, somewhere between 50% and 75% of children and adolescents report having headache at some point during their childhood or adolescence. We know that 9% of children or adolescents have migraine and probably twice that much, 17% to 18% have tension type headache.

Host: And migraine tension headaches, are those the two most common, or are there others as well?

Dr. Scott Turner: Absolutely. Those are definitely the two most common that we see in childhood. There are other types of headache disorders, including trigeminal, autonomic cephalalgias, like cluster headache and there's a number of those types of headaches. And then, there's secondary headaches, which we're always trying to screen for and rule out to make sure that there's nothing more concerning going on when we evaluate children in our clinic.

Host: Whatever type of headache it is that a child or teen might be dealing with, we certainly know it can have a significant impact. How do you sum up the challenges that headaches can create for kids that have them on a regular basis?

Dr. Scott Turner: Yeah. So, I think, the main thing to consider is that, number one, migraine, which is the most common diagnosis that we see in our clinic is actually a childhood onset disorder. It begins in childhood. It continues to increase in prevalence during adolescence, and it actually persists for many people well into adulthood. It's actually the second most disabling condition in the world across all age groups, including children. And it's the first most disabling condition for women between the ages of 15 and 49.

 And so, we know that youth with migraine miss more school. They have more difficulties at school, and they report a lower quality of life than many youth with even juvenile rheumatoid arthritis and cancer do. And because of this, it's important to diagnose, recognize, and diagnose it early and start treatment.

Host: Certainly significant to address this topic for the kids who are dealing with this, and I know that's why the Children's of Alabama Headache Clinic is around. Can you tell me a little bit about the clinic, how long it's been around and what the thought was behind starting it?

Dr. Scott Turner: So, actually, the headache clinic has actually been around for several decades. What happened over the last five years is we've really tried to formalize the headache clinic and to begin to collect data that's really consistent with what other headache centers around the country are collecting. We also have been doing evidence-based practice for a long time, but now we're incorporating some important non-medical interventions into our program.

For example, here at Children's of Alabama, we're a Nerivio Center of Excellence, which means that we're one of several sites around the country that specialize in prescribing and managing the Nerivio device, which is a remote electrical neurostimulation device that helps to turn down the pain signals at the level of your brain stem. We also engage in other activities such as research studies and quite a bit of education for the next generation of physicians and nurses and physician assistants.

Host: A lot of different ways that you all can help these patients through treatment and pain management, multidisciplinary approach in this clinic.

Dr. Scott Turner: Absolutely. One of the things I think we're most proud of is our alliance and our work with the Ireland Center. We work with the pain psychology group here at Children's now to offer a weekly session on learning more about chronic pain, how it works in your body, and how you can use your brain and your responses to pain to really dial down the pain signals in your body.

Most people don't realize that pain is actually something that if you use and train your thoughts and you train your physiological responses to stress, you can actually reduce the pain signals in your body and that actually provides a great deal of pain relief.

Host: You mentioned the Ireland Center. That of course is the behavioral health team here at Children's of Alabama. And again, just one part of the overall headache clinic, correct?

Dr. Scott Turner: Yeah, absolutely. Other groups we've worked with is the infusion center here at Children's. One of the goals that we had was to try to provide an alternative to the emergency room when children are stuck in a migraine that just goes on for several days and doesn't respond to any of the medicines that they use at home. Rather than having to go to the emergency room where it's really loud and really bright and very crowded, we offer infusions through our infusion center. So, a very planned set algorithm for what we give and what we test for. So, that youth can have a much more targeted approach that way and don't have to sit long periods of time in a waiting room with many other children that are needing that service.

Host: How helpful is it to have so many different people involved in this clinic helping kids with headaches In many ways?

Dr. Scott Turner: Yeah. I think the multidisciplinary approach is probably the most essential thing that we do. And that's because I think people have the idea that, you know, if you have chronic headaches, you know, headaches more days out of the month than you don't, I mean, really you wind up not only having a headache problem, but you have a chronic pain problem.

And what we know about chronic pain is the nervous system sort of changes in a way that it becomes easier and easier to experience pain over time. And what we need to do is sort of retrain the nervous system. So, you know, part of that can be done with medication to kind of dial down the signaling of the nervous system, but so much of it has to do with how you, you know, maintain your posture. So, people like physical therapists or occupational therapists can be really, really helpful in regard to training your body. Again, we use the the behavioral health folks at Ireland Center to kind of help with retraining your brain and your responses to pain.

And that approach along with medication and devices seems to be the most effective approach that we know of just based on data that we have gathered from around the world.

Host: A lot of different ways that you can treat these patients and help them out, I guess, with and without medication, right?

Dr. Scott Turner: Exactly. And it's important to realize that, you know, almost never is it a one-size-fits-all type thing. We have to kind of put all of the pieces together how this particular headache problem is affecting that particular individual. Because, you know, some people live with headaches every day and or they're able to go to school, they're able to function quite well and other people, you know, are horribly disabled by what on paper would seem to be a similar burden of headache frequency and such. And so, what we need to do, and what we do in the headache clinic is to try to help tease out some of those things and really create a customized plan for each person so that they can actually perform and function at their optimal level.

Host: Important to focus on each individual patient and kind of figure out what their needs are.

Dr. Scott Turner: Right, absolutely.

Host: So, about how many patients do you have?

Dr. Scott Turner: So, in our clinic, we see in the headache clinic specifically, we see about 300 new patients per year. We probably see about 3000 patients altogether in other aspects of neurology clinic. With our follow-up population, we see many children, both in-person and by telemedicine for their follow-up visits so that we can continue to optimize and, and fine tune their plan.

Host: I know you've mentioned research a little while ago and some of the data that you all have used to figure out different strategies for treatments. You're involved in some research as well. Can you tell me a little bit about that?

Dr. Scott Turner: So, we do some research locally with our own headache population and make sure that we're performing at the level we need to relative to other parts of the country, meet those benchmarks and standards of care.

But we've also been invited through our collaboration with other places around the country to engage in something called the REACH study. And the REACH study stands for Responding with Evidence and Access to Childhood Headache. It's funded for five years through the PCORI, which is the Patient Centers Outcome Research Institute, so a quasi-governmental funding, but we're one of 16 sites around the country that are recruiting patients for this. We're recruiting patients anywhere from 10 to 18 years old and any type of migraine headache, whether it's episodic migraine or chronic migraine or even migraine with medication overuse. Any one of those groups of people would be potentially eligible for this study.

The study is interesting in that like in most cases you'll have a placebo arm and a active treatment arm. But in our study, everybody gets an active treatment. So, the active treatment that everybody gets is cognitive behavioral therapy that's delivered remotely through telemedicine with our colleagues in Cincinnati. And then, half of the group receives in addition to that a medication that we've used for many, many years called amitriptyline.

So, people that want to be involved in this study have to be okay with one approach or the other, that they get randomized after watching their headaches for about a month and recording it on a diary. If they're having more than four headaches a month, they're eligible for the study. And we go from there. Participants actually can be compensated for their time with money from the research site.

Host: So, I guess the question is CBT plus amitriptyline—is that as effective or more effective than just the CBT? Is that right?

Dr. Scott Turner: That's exactly right. So, our guidelines currently suggest that amitriptyline plus CBT is the recommended treatment. There is evidence to suggest that the CBT may be the more active of the two treatments and we're trying to sort out is whether the medication is actually a vital part of this or not.

Host: And I guess, if you discover that it's not necessarily a vital part, then I guess that means that even without medication, these patients can really move forward and have positive results.

Dr. Scott Turner: Absolutely. And so yeah, I think many parents hope is that they would be able to find relief for their children without having to use a medication. And so, one of the things we've really tried to work on over the past five years is to really develop non-medical interventions that can either be used in addition to medication or, you know, as it might suggest with this study independently of the medication, to be able to really dial down the overreactivity of the nervous system that characterizes migraine attacks.

Host: I know you're certainly working hard with your colleagues here and around the country to find the best ways to treat patients who are dealing with headaches. For parents who might have a child who's dealing with severe headaches, maybe they're missing a lot of school, what's the first step they should take? What is your advice to them?

Dr. Scott Turner: Yeah. So, I know many people ask, you know, how many is too many? And so, I think in general, I say, if you're having more than one headache a week or the headaches are causing you to miss any school, you really probably need to address the issue then and there. Generally, the first step is to go see your pediatrician. They can perform a neurological evaluation and make sure you don't have any obvious weakness on one side of your body or trouble with your balance or coordination. People with migraine generally have a normal neurological exam and they certainly function quite normally in between attacks.

But when they get attacks, you know, sometimes they have very difficult time functioning. Sometimes, they have mental clouding. In other words, it's hard to focus and concentrate. They may have, you know, kind of transient or temporary vision loss in one part of their vision. They may even have weakness or sensory changes on one side of their body. It makes it really, really difficult to function and people assume that migraine is all about terrible headaches, but it's actually the migraine disease is migraine because it affects the other aspects of your nervous system and it often causes gastrointestinal symptoms such as nausea and vomiting. And it's that collection of symptoms that often makes it very, very difficult for these kids to attend school.

But one of the things we really want to do is make it possible for them to be able to stay at school and function so they don't wind up with two different problems.

Host: Yeah. Because if you're not in school on a regular basis, you fall behind on your work and then that has a negative impact in that area.

Dr. Scott Turner: Absolutely. And it could have a negative impact on your headaches as well, because we know in adults and children that the more stress you put your brain under and your body under, the more likely it is to overreact and, you know, try to shut down temporarily to reset. And that's what you get with a migraine attack.

Host: We certainly appreciate all the work you're doing. Any other resources that you want to talk about for parents who might have a child dealing with headaches?

Dr. Scott Turner: Absolutely. I think there's some really good online resources that are available. One of them is the Headache Relief Guide. So, you can find that at www.headachereliefguide.com. There's also a really important organization called Migraine at School. And it's migraineatschool.org. And it is a group of parents and really concerned individuals that are continuing to work to make the school environment much more welcoming to youth with headaches, to really work on providing accommodations so that the child can stay at school and doesn't wind up with, you know, a headache and a school problem.

So, I think that those resources can be really, really useful to parents along with their pediatrician, pediatricians that have worries that there is something else going on can often order other tests. And then, you know, certainly, they often will refer folks to see us as well, just to try to optimize any care.

Host: All right. Once again, Dr. Scott Turner with the Children's of Alabama Headache Clinic. Thanks so much for your time and your insight today.

Dr. Scott Turner: Thank you.

Host: Thanks for listening to Inside Pediatrics. For more podcasts like this one, go to childrensal.org or wherever you download podcasts.