Chronic daily headaches in children

Molecular targets of caffeine in the central nervous system

Caffeine is an alkaloid obtained from plants and is one of the most consumptive drug in the form of chocolate, coffee and beverages. The potential impact of caffeine within CNS can be easily understood by mechanism of action-antagonism of adenosine receptor, calcium influx, inhibits phosphodiesterases. Adenosine a neuromodulator for adenosine receptors, which are abundantly expressed within the central nervous system. Caffeine antagonized the adenosine receptor, hence stimulate expression of dopamine. It plays pivotal role in many metabolic pathways within the brain and nervous system, it reduced the amyloid-β-peptide (Aβ) accumulation, downregulation of tau protein phosphorylation, stimulate cholinergic neurons and inhibits the acetylcholinestrase (AChE). It also possess antioxidant and antiapoptotic activity. Caffeine act as nutraceutical product, improves mental health. It contains antioxidants, vitamins, minerals and dietary supplements, by reducing the risk factor of several neurodegenerations including Alzheimer's disease, migraine, gallstone, cancer, Huntington's disease and sclerosis. This act as a stimulant and have capability to increase the effectiveness of certain pain killer. Beside positive affects, over-consumption of caffeine leads to negative impact: change in sleep pattern, hallucinations, high blood pressure, mineral loss and even heartburn. This chapter highlights pros and cons of caffeine consumption.

Sudden Caffeine Withdrawal Triggers Migraine-A Randomized Controlled Trial

Objective: Assessing the effects of caffeine withdrawal on migraine.

Background: The effects of caffeine withdrawal on migraineurs are at large unknown.

Methods: This was a randomized, double-blind, crossover study (NCT03022838), designed to enroll 80 adults with episodic migraine and a daily consumption of 300–800 mg caffeine. Participants substituted their estimated dietary caffeine with either placebo capsules or capsulated caffeine tablets for 5 weeks before switching the comparators for 5 more weeks.

Results: The study was terminated due to low recruitment. Ten subjects with a mean age of 46.3 ± 9.9 years, BMI of 24.9 ± 3.7, and a mean blood pressure of 134/83 ± 17/12 mmHg were enrolled. The average consumption of caffeine per day was 539 ± 196.3 mg. The average monthly headache days and migraine attack frequency at baseline was 11.5 ± 4.9 and 5.2 ± 1.2, respectively. At baseline Pittsburgh Sleep Quality Index was 5.8 ± 2.5 and HIT-6 was 62.8 ± 3.9. There were no differences in these or in parameters from actigraphy during the caffeine period compared with the placebo period. One subject withdrew just after entering the study. In the remaining nine, withdrawal triggered severe migraine attacks in seven, causing one more drop-out, and a typical caffeine withdrawal syndrome in two. Caffeine continuation did not trigger migraines, but one attack occurred in the wake of caffeine reintroduction.

Conclusions: The study failed to answer how caffeine withdrawal affects migraineurs over time, but showed that abrupt withdrawal of caffeine is a potent trigger for migraine attacks.

The Efficacy of Botulinum Toxin in Pediatric Chronic Migraine: A Literature Review

AIMS

To conduct a review of the literature on the use of botulinum toxin for the treatment of pediatric chronic migraine.

METHODS

A review of the literature was performed using EMBASE, PubMed, and Cochrane/Ovid. Using our inclusion and exclusion criteria, we targeted any study, published before April 2020, evaluating the efficacy of botulinum toxin in migraineurs younger than 18 years.

RESULTS

Seven studies were included: 2 retrospective analyses, 3 case series, a case report, and a randomized control trial. Studies included 1 to 125 patients, with the number of botulinum toxin treatments ranging from 1 to 11 treatments. The results of the randomized controlled trial showed nonsuperiority between placebo and botulinum toxin. Results of the other studies were generally favorable but were difficult to compare because of lack of standardization of botulinum toxin dosing, injection paradigm, frequency and duration of treatment, usage of accompanying prophylaxis, and variation in outcome measures across studies. There was low-quality evidence that botulinum toxin improved headache frequency and intensity, though some studies demonstrated efficacy in treatment with botulinum toxin.

CONCLUSION

This review is the first of its kind, updating the literature on the efficacy of botulinum toxin in pediatric patients. Given evidence of its utility in treating pediatric migraines, off-label use should be considered in certain cases. Further study is warranted to better characterize injection paradigms and patient selection because of the limited and inconsistent data available.

Caffeine and Primary (Migraine) Headaches-Friend or Foe?

Background: The actions of caffeine as an antagonist of adenosine receptors have been extensively studied, and there is no doubt that both daily and sporadic dietary consumption of caffeine has substantial biological effects on the nervous system. Caffeine influences headaches, the migraine syndrome in particular, but how is unclear. Materials and Methods: This is a narrative review based on selected articles from an extensive literature search. The aim of this study is to elucidate and discuss how caffeine may affect the migraine syndrome and discuss the potential pathophysiological pathways involved. Results: Whether caffeine has any significant analgesic and/or prophylactic effect in migraine remains elusive. Neither is it clear whether caffeine withdrawal is an important trigger for migraine. However, withdrawal after chronic exposure of caffeine may cause migraine-like headache and a syndrome similar to that experienced in the prodromal phase of migraine. Sensory hypersensitivity however, does not seem to be a part of the caffeine withdrawal syndrome. Whether it is among migraineurs is unknown. From a modern viewpoint, the traditional vascular explanation of the withdrawal headache is too simplistic and partly not conceivable. Peripheral mechanisms can hardly explain prodromal symptoms and non-headache withdrawal symptoms. Several lines of evidence point at the hypothalamus as a locus where pivotal actions take place. Conclusion: In general, chronic consumption of caffeine seems to increase the burden of migraine, but a protective effect as an acute treatment or in severely affected patients cannot be excluded. Future clinical trials should explore the relationship between caffeine withdrawal and migraine, and investigate the effects of long-term elimination.

Chronic Daily Headache in Children and Adolescents: A Clinic Based Study from India

Chronic Daily Headache (CDH) is uncommon in Indian children compared to their adult counterpart. This is a retrospective study looking at the headache phenomenology of CDH in Indian children and adolescents. The validity of the case definitions of subtypes of chronic primary headaches mentioned in the HIS 2004 classification have been evaluated. 22 children (age range 8-15 years; M : F-16 : 6) diagnosed as having primary CDH using a modified definition seen between 2002 and 2003 have been studied. CDH has been defined as daily or near daily headaches > 15d/month for > 6 weeks. The rationale for this modified definition has been discussed. Majority of children (15/22) had a more or loss specified time of onset of regular headache spells resembling New Daily Persistent Headache (NDPH) but did not fulfil totally the diagnostic criteria of NDPH as laid down by IHS 2004. In all cases headache phenomenology included a significant vascular component. Headache phenomenology closely resembled Chronic Tension Type Headache (CTTH) in 4 patients and Chronic Migraine in 3 patients. However, in no patient in these groups, a history of evolution from the episodic forms of the diseases could be elicited. Heightened level of anxiety mostly related to academic stress and achievement was noted in the majority (19/22). Only a minority of patients (3/22) had anxiety and depression related to interpersonal relationships in the family. Medication overuse was not implicated in any patient. CDH in children in India is very much different from CDH in adults with the vast majority of patients exhibiting overlapping features of migraine and tension-type headache. There is need for a modified diagnostic criteria and terminology for chronic primary headaches in children.

Quantitative neuromagnetic signatures of aberrant cortical excitability in pediatric chronic migraine

Background

Reports have suggested that abnormal cortical excitability may be associated with acute migraines. The present study quantitatively assesses the degree of cortical excitability in chronic migraine as compared to acute migraine and healthy controls within the pediatric population.

Methods

We investigated 27 children suffering from chronic migraine, 27 children suffering from acute migraine, and 27 healthy controls using a magnetoencephalography (MEG) system, recording at a sampling rate of 6000 Hz. All groups were age-matched and gender-matched. Neuromagnetic brain activation was elicited by a finger-tapping motor task. The spatiotemporal and spectral signatures of MEG data within a 5–2884 Hz range were analyzed using Morlet wavelet transform and beamformer analyses.

Results

Compared with controls, the chronic migraine group showed (1) significantly prolonged latencies of movement-elicited magnetic fields (MEFs) between 5 and 100 Hz; (2) increased spectral power between 100 and 200 Hz, and between 2200 and 2800 Hz; and (3) a higher likelihood of neuromagnetic activation in the ipsilateral sensorimotor cortices, supplementary motor area, and occipital regions. Compared with acute migraine group, chronic migraine patients showed (1) significantly higher odds of having strong MEFs after 150 ms; and (2) significantly higher odds of having neuromagnetic activation from the deep brain areas.

Conclusions

Results demonstrated that chronic migraine subjects were not only different from the healthy controls, but also different from acute migraine subjects. The chronification of migraines may be associated with elevated cortical excitability, delayed and spread neural response, as well as aberrant activation from deep brain areas.

Treatment of medication overuse headache--guideline of the EFNS headache panel

BACKGROUND

  Medication overuse headache is a common condition with a population-based prevalence of more than 1-2%. Treatment is based on education, withdrawal treatment (detoxification), and prophylactic treatment. It also includes management of withdrawal headache.

AIMS

  This guideline aims to give treatment recommendations for this headache.

MATERIALS AND METHODS

  Evaluation of the scientific literature.

RESULTS

  Abrupt withdrawal or tapering down of overused medication is recommended, the type of withdrawal therapy is probably not relevant for the outcome of the patient. However, inpatient withdrawal therapy is recommended for patients overusing opioids, benzodiazepine, or barbiturates. It is further recommended to start individualized prophylactic drug treatment at the first day of withdrawal therapy or even before. The only drug with moderate evidence for the prophylactic treatment in patients with chronic migraine and medication overuse is topiramate up to 200mg. Corticosteroids (at least 60mg prednisone or prednisolone) and amitriptyline (up to 50mg) are possibly effective in the treatment of withdrawal symptoms. Patients after withdrawal therapy should be followed up regularly to prevent relapse of medication overuse.

DISCUSSION AND CONCLUSION

  Medication overuse headache can be treated according to evidence-based recommendations.

Chronic migraine plus medication overuse headache: two entities or not?

Chronic migraine (CM) represents migraine natural evolution from its episodic form. It is realized through a chronicization phase that may require months or years and varies from patient to patient. The transition to more frequent attacks pattern is influenced by lifestyle, life events, comorbid conditions and personal genetic terrain, and it often leads to acute drugs overuse. Medication overuse headache (MOH) may complicate every type of headache and all the drugs employed for headache treatment can cause MOH. The first step in the management of CM complicated by medication overuse must be the withdrawal of the overused drugs and a detoxification treatment. The goal is not only to detoxify the patient and stop the chronic headache but also to improve responsiveness to acute or prophylactic drugs. Different methods have been suggested: gradual or abrupt withdrawal; home treatment, hospitalization, or a day-hospital setting; re-prophylaxes performed immediately or at the end of the wash-out period. Up to now, only topiramate and local injection of onabotulinumtoxinA have shown efficacy as therapeutic agents for re-prophylaxis after detoxification in patients with CM with and without medication overuse. Although the two treatments showed similar efficacy, onabotulinumtoxinA is associated with a better adverse events profile. Recently, the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) clinical program proved that patients with CM, even those with MOH, are the ones most likely to benefit from onabotulinumtoxinA treatment. Furthermore, it provided an injection paradigm that can be used as a guide for a correct administration of onabotulinumtoxinA.

From drug-induced headache to medication overuse headache. A short epidemiological review, with a focus on Latin American countries

Medication overuse headache (MOH) is a daily or almost-daily type of headache that results from the chronicization, usually migraine or tension-type headache, as a consequence of the progressive increase of intake of symptomatic drugs. MOH is now the third most frequent type of headache and affects a percentage of 1-1.4% of the general population. The currently available data on the impact of chronic headache associated with analgesic overuse in specialist headache centres confirm, beyond doubt, the existence of a serious health problem. Limited amount of data exists on the burden and impact of MOH in Latin American Countries. In this review, we summarise the reliable information from the literature on the epidemiological impact of MOH.

[Management of chronic daily headache in children and adolescents]

Chronic daily headache (CDH) affects 2 to 4% of adolescent females and 0,8 to 2% of adolescent males. CDH is diagnosed when headaches occur more than 4 hours a day, for greater than or equal to 15 headache days per month, over a period of 3 consecutive months, without an underlying pathology. It is manifested by severe intermittent headaches, that are migraine-like, as well as a chronic baseline headache. Silberstein and Lipton divided patients into four diagnostic categories: transformed migraine, chronic tension-type headache, new daily-persistent headache, and hemicrania continua. The second edition of the International Classification of Headache Disorders did not comprise any CDH category as such, but provided criteria for all four types of CDH: chronic migraine, chronic tension-type headache, new daily-persistent headache, and hemicrania continua. Evaluation of CDH needs to include a complete history and physical examination to identify any possibility of the headache representing secondary headaches. Children and adolescents with CDH frequently have sleep disturbance, pain at other sites, dizziness, medication-overuse headache and a psychiatric comorbidity (anxiety and mood disorders). CDH frequently results in school absence. CDH management plan is dictated by CDH subtype, the presence or absence of medication overuse, functional disability and presence of attacks of full-migraine superimposed. Reassuring, explaining, and educating the patient and family, starting prophylactic therapy and limiting aborting medications are the mainstay of treatment. It includes pharmacologic (acute and prophylactic therapy) and nonpharmacologic measures (biobehavioral management, biofeedback-assisted relaxation therapy, and psychologic or psychiatric intervention). Part of the teaching process must incorporate life-style changes, such as regulation of sleep and eating habits, regular exercise, avoidance of identified triggering factors and stress management. Emphasis must be placed on preventive measures rather than on analgesic or abortive strategies. Stressing the reintegration of the patient into school and family activities and assessing prognosis are other issues to address during the first visit. There are limited data evaluating the outcome of CDH in children and adolescents.

Neurodynamic responses in children with migraine or cervicogenic headache versus a control group. A comparative study

Headache in children with unknown aetiology is an increasing phenomenon in industrial countries, especially during growth spurts. During this growth phase, the Long Sitting Slump (LSS) can be a useful tool for measurement of neurodynamics and management. This study investigated the difference in cervical flexion and sensory responses (intensity and location) during the LSS tests in children (n=123) aged 6-12 years, between a migraine (primary headache group=PG), cervicogenic headache (secondary headache group=SG) and control group (CG). The results indicated that the intensities of the sensory response rate were highest in the PG and SG when compared to CG. The responses in the legs were predominantly found in the PG (81.9%) and responses in the spine in the SG (80%). The sacrum position varied significantly between both headache groups (PG and SG) and the CG (p<0.0001), but there was no significant difference between the CG and the PG (p>0.05). No significant difference in the neck flexion range was measured in LSS, nor in standardized knee flexion between the PG and CG (p>0.05). The cervical flexion ranges differed significantly (p<0.0001) between the SG on the one hand and the PG and CG on the other. The biggest difference in neck flexion during knee extension was between the SG and CG.

Medication-overuse headache: Description, treatment, and relapse prevention

Medication-overuse headache (MOH) has increasingly become a focus within the field of headache. The biologic and physiopathologic origin for MOH likely resides in receptor physiology, but it also is probable that the initiation and sustaining dynamics of this pathologic condition involve several other factors. Not all patients with frequent headache eventually overuse their medications, but when it happens (the percentage is approximately 1%), the diagnosis of MOH is clinically important because patients rarely respond to preventive medications while overusing acute medications. Properly treating medication overuse and preventing relapse require recognition of the different factors that contribute to its development and perpetuation, including some behaviors and psychologic elements that are important in sustaining the overuse of medication. The problem regarding the diagnosis, the classification, and clinical aspects of MOH is reviewed in this article. The different therapeutic approaches, initial outcomes, and long-term durability of treatment also are discussed.

Medication-overuse headache in children: is initial preventive therapy necessary?

Chronic daily headaches can be a difficult problem in children as well as adults. Over half of the cases of chronic daily headaches in adults are thought to be due to medication-overuse headache, and treatment consists of discontinuation of these analgesics. Since many patients are also treated with preventive agents at the time of analgesic withdrawal, it is difficult to determine whether discontinuation alone is the most effective treatment. A retrospective study was performed to evaluate the outcomes of 43 children (ages 6-17 years) with medication-overuse headache 1 month after withdrawal of analgesics: 20 children received daily doses of a preventive medication, and 23 received no preventive medication. Headache reduction was assessed 1 month later. There was no difference in the percentage, with 90% or greater headache reduction at 1 month between children treated by withdrawal of analgesic drugs only and those receiving preventive medications (57% vs 50%, respectively). There was no influence of age, gender, use of triptans as rescue agents, or caffeine use on outcomes. A previous duration of headaches over 2 years was negatively correlated with overall outcome. We advise discontinuation of analgesics in all children with medication-overuse headache, without the necessity for starting daily preventive agents concurrently. Should headaches persist after 1 month, such agents can be added. (J Child Neurol 2006;21:45-48).

Medication-overuse headache

Medication-overuse headache (MOH) can be caused by almost all anti-headache drugs including analgesics, ergots, triptans, and combined preparations The prevalence of chronic daily headache (CDH) appears to be between 2% and 4% in the general population. Current epidemiologic studies suggest that MOH accounts for approximately 50% of these cases. The pathophysiology of MOH remains unclear. The only therapy is withdrawal from the overused substances. Prednisone decreases the duration of headache in the first days of withdrawal therapy. The only strategy to reduce the prevalence of MOH is to prevent the development of MOH in the first place by restriction of anti-headache drugs and constant education of patients.

The Classification of Chronic Daily Headache in Adolescents—A Comparison Between the Second Edition of the International Classification of Headache Disorders and Alternative Diagnostic Criteria

OBJECTIVES

To compare the second edition of the International Classification of Headache Disorders (ICHD-2) and the Silberstein-Lipton (S-L) criteria in the classification of adolescents with chronic daily headache (CDH).

METHODS

We reviewed the clinical records and the headache diaries of 170 adolescents (13 to 17 years) seen between 1998 and 2003 at a headache center. Relevant information was transferred to a standardized form that included operational criteria for the ICHD-2. CDH subtypes were classified according the criteria proposed by S-L into transformed migraine (TM) with (TM+) and without medication overuse (TM-), chronic tension-type headache (CTTH), new daily persistent headache (NDPH), and hemicrania continua (HC).

RESULTS

From the 69 patients with TM- according the S-L criteria, most (71%) could be classified as chronic migraine (CM), while a minority of patients required a combination of diagnosis, mainly migraine and CTTH (14.4%). Of the patients with TM+, just 39.6% met the criteria for probable CM (PCM) with probable medication overuse (PMO). If instead of 15 migraine days per month, we considered 15 or more days of migraine or probable migraine, 84% of the subjects with TM- and 68.7% of those with TM+ could be classified. Of the 27 subjects classified as NDPH without medication overuse according to the S-L system, the majority (51.2%) were also classified as NDPH according the ICHD-2. Interestingly, three (11.1% of the subjects with NDPH without medication overuse) were classified as CM in the ICHD-2 because these patients had an abrupt onset of 15 or more days of migraine per month. All patients with NDPH with medication overuse according to the S-L criteria required a combination of diagnoses in the ICHD-2. All subjects with CTTH received a single diagnosis in both classification systems.

CONCLUSIONS

(i) Among adolescents with TM, the majority (58.1%) could be classified as CM, according to the ICHD-2. These results were driven by TM without medication overuse. (ii) If the ICHD-2 criteria for CM are revised to require 15 days of migraine or probable migraine, the proportion of patients with TM- who meet the criteria for CM increases from 71% to 84%; for TM+, the proportion with probable chronic migraine and PMO increases from 30% to 68%. (iii) About half of the patients with NDPH according to the S-L criteria have too many migraine features to meet ICHD-2 criteria for NDPH.

Traitement médicamenteux de l’accès migraineux chez l’enfant

Migraine, according to the criteria of the International Headache Society, occurs in about 5 to 10% of children. Management of acute headache is only one of the parts of the treatment, along with identification of migraine precipitants, adjustments in lifestyle, and when necessary the use of preventive therapy, which can include non pharmacologic (relaxation or biofeedback) or pharmacologic treatment. In the acute migraine attack, a single dose of either ibuprofen 10 mg/kg or paracetamol 15 mg/kg has been shown to be effective, with only a few adverse effects. In severe migraine attacks, dihydroergotamine mesylate administered orally (20 to 40 microg/kg) or intravenously (maximum 1 mg/day) may be helpful, but there have been no large placebo-controlled trials of this treatment. Among the different triptans, it is the sumatriptan nasal spray whose efficacy has been best demonstrated. The most frequent adverse event is transitory unpleasant taste.

Assessment and management of disability in chronic daily headache

The problem of chronic daily headache is ubiquitous and affects up to 5% of the world's population. In most cases, it is associated with the overuse of symptomatic medications in patients with a history of migraine or tension-type headaches, indicating an urgent need for intensive public and professional education. In a minority, it develops de novo from episodic migraine without excessive drug intake. The condition is likely to have a biologic (rather than psychologic) basis. The degree with which it negatively impacts patients and their family is reviewed. Current treatment regimes are described, but it is noted that those currently employed are seldom adequate in the long term, possibly because of the unavailability of nonpharmacologic treatments to most people or because of the low frequency of use of preventative pharmacologic and lifestyle measures.

Medication-overuse headache: a worldwide problem

Medication overuse and subsequent medication-overuse headache (MOH) is a growing problem worldwide. Epidemiological data suggest that up to 4% of the population overuse analgesics and other drugs for the treatment of pain conditions such as migraine and that about 1% of the general population in Europe, North America, and Asia have MOH. Recent clinical studies gave further insights in clinical and pharmacological features, such as critical monthly doses and frequencies. These features seem to vary significantly and depend on the primary headache disorder and the type of drug that is overused. Along with these findings the new international classification of headache disorders has now incorporated additional criteria and new headache entities that will facilitate the diagnosis of MOH. Withdrawal therapy is the only treatment for this disorder and clear restriction of monthly doses is the central requirement for successful prevention.

Medication overuse headache

PURPOSE OF REVIEW

The current literature on medication overuse headache will be reviewed with regard to clinical presentation, pathophysiology, therapy and prognosis in the light of the new headache classification.

RECENT FINDINGS

Medication overuse headache is a widely unrecognized medical condition, which according to recent epidemiological studies has evolved to the third most frequent form of headache after tension-type headache and migraine. The first classification of headache disorders from 1988 defined medication overuse headache (formerly called 'drug-induced headache') on the bases of drugs that were available in the 1980s. For the most important anti-headache drugs, including triptans, new data on specific clinical features and more important mean critical monthly dosages and mean critical monthly intake frequencies are now available. Furthermore, recent prospectively conducted studies have revealed rates and predictors of relapse after successful withdrawal.

SUMMARY

The newly available data on medication overuse headache may provide the basis for future consensus guidelines for the management of this condition.