Children and Migraine – Webinar

0:00 [Music]
0:04 thank you for joining us tonight we’re
0:06 really excited to finally host our
0:09 children and teens with migraine uh
0:13 webinar this was originally scheduled
0:16 for earlier in the fall unfortunately we
0:18 had to delay it so it’s with great
0:20 excitement that’s finally happening
0:22 tonight our keynote speaker proud to say
0:26 is Dr Marissa
0:28 legman
0:31 and before we begin we just want um to
0:33 say that we are proudly supported by the
0:36 following sponsors with out their
0:38 support and contributions uh events such
0:41 as these would not be possible for
0:46 us and today uh the agenda is I will do
0:50 a quick Migra Canada introduction
0:54 followed by an introduction of Dr
0:55 Marissa lagman Dr lagman will then take
0:59 over with her Pres presentation and the
1:01 end portion of this evening will be
1:03 questions and
1:05 answers so migrant Canada who we are we
1:09 are a federally registered charity
1:11 supporting all Canadians living with
1:13 migraine and headache disorders our
1:15 mission is to improve the lives of
1:17 Canadians with migraine and other
1:18 headache disorders through advocacy
1:20 awareness education research and support
1:23 our five pillars uh we do want to make
1:27 note that developing resources for
1:28 Children and Families is very important
1:31 to us um so with that in mind when we do
1:34 email the link to this webinar recording
1:37 we will be including a short
1:38 questionnaire that we ask you to
1:40 complete and this is to help us better
1:43 understand your needs which resources
1:46 you are looking for to best support your
1:48 child or children who have migraine um
1:51 you can also check out the Pediatrics
1:53 page on the migraine Canada website for
1:55 other resources that we have
1:58 finalized and this is December this is
2:01 our last webinar of 2023 but please stay
2:04 tuned in the coming weeks we will be
2:07 releasing our webinar schedule for the
2:09 first quarter of
2:13 2024 before we begin we always present
2:16 our
2:17 disclaimer um this webinar provides
2:19 information and not medical advice uh
2:22 note that the information presented and
2:24 discussed might not apply to your own
2:26 medical situation or that of your
2:28 child’s and we ask that you always
2:30 discuss Medical Treatments with your
2:32 healthc care provider who knows your
2:34 medical history or your child’s medical
2:37 history Dr Marissa lagman is a fellow of
2:41 the American Headache Society and ucns
2:43 Diplomat in headache medicine she is the
2:46 director of the headache program at the
2:48 hospital for sick children an associate
2:51 professor in Pediatrics neurology the
2:53 director of the comprehensive pediatric
2:56 Headache Center and young adult headache
2:58 transition Clinic as well as the
3:00 Director of the education program of
3:02 pediatric neurology at the Children’s
3:04 Hospital in the London Health Ser
3:06 Sciences Center at Western University at
3:09 the University of Toronto Dr legman
3:11 conducts research projects and is the
3:13 co-chair of the transition of care
3:15 Committee in the Department of
3:17 Neurology Dr langman’s areas of Interest
3:20 include the Pediatric cgrp trials
3:24 migraine variants peripheral nerve
3:26 blocks migraine in women menstrual
3:29 migraine management of pediatric
3:31 post-traumatic headache intractable
3:33 pediatric migraine acute treatment of
3:36 migraine in children and adults
3:38 pediatric migraine variants and
3:43 others and with that I’m going to stop
3:45 sharing my screen so Dr legman can take
3:49 over with her
3:54 presentation thank you so much for the
3:56 nice introduction and I know I’m close
3:59 the 2023 webinar series I hope it’s not
4:03 too late I hope I will close it with a
4:06 bang um please feel free to um post your
4:10 questions I’ll try my best to answer
4:12 them as much as we can um and uh please
4:16 feel free to post your questions anytime
4:19 um uh of this
4:22 uh uh um discussion so I wanted to be
4:26 more of an open discussion the problem
4:29 is I might not be able to cover
4:31 everything I want um or that was posted
4:34 to me so um this Arma I’ll start with my
4:38 disclosure um this are probably some of
4:41 this might be relevant but I will only
4:43 present the published data on Tut of
4:46 migraine however since there’s very
4:49 limited evidence in pediatric migraine
4:52 treatment I’m I will actually mention
4:54 some of the off label treatments that I
4:57 use in my
4:58 practice
5:00 these are the tons of questions which
5:02 came from the migrant Canada members uh
5:05 where I base my um my presentation for
5:08 this
5:09 evening so um just to start with this is
5:12 our outline for our discussion this
5:14 evening so I um at the end of this um
5:18 talk I was hoping that you recognize the
5:21 scope and burden of headache and
5:22 migraine in children and your um
5:24 adolescent um kids um discuss the
5:28 potential causes common triggers
5:30 diagnosis and other symptoms of migraine
5:33 in the our young population describe the
5:36 role of education and implementing
5:38 nonpharmacological therapies and
5:40 headache Management in these young
5:42 patients and I’ll also give you an
5:44 update on the evidence-based strategies
5:47 for acute and prevention Therapies in
5:50 pediatric migraine as well so why do we
5:53 need to even worry about migraine and
5:57 headache in general in in children in
5:59 young population so the World Health
6:03 Organization had this Global burden of
6:05 disease study which was published in
6:08 2019 and they noted that headache
6:13 specifically migraine is the
6:16 second most disabling condition
6:19 worldwide in among
6:22 adolescents 60% of these young patients
6:25 experience significant headache and up
6:28 to 9% of them will have migraine and
6:31 migraine is the second most common
6:34 chronic recurrent meaning repeated
6:37 episodes of headache in
6:39 children and there are some studies as
6:41 well which showed that the quality of
6:43 life of these young patients with
6:45 migraine is similar to those with
6:48 rheumatoid arthritis or
6:51 cancer and you can imagine why because
6:54 there’s so many patients who have these
6:57 headache disorders specifically my and
6:59 the problem is they’re usually
7:02 underrecognized and
7:06 undertreated we know this like I’m sure
7:08 you’ve heard about this and it’s also in
7:10 the migraine Canada website that one
7:13 billion um people um have migraine
7:17 worldwide and specifically one in 11
7:20 children will also have
7:22 migraine and in Canada there’s around
7:25 2.5 3.6 million Canadians who have
7:28 migrant as well what’s the impact of
7:32 migraine in school performance I think
7:34 this is one of the most important more
7:36 more important questions that came up um
7:38 from the Migra Canada members which I
7:41 like so I would answer this specifically
7:44 children with migrain have often missed
7:47 school days um some of them lost School
7:50 uh two school days in a month not
7:52 perform Mutual activities two up to four
7:55 days and then they also led to poor
7:59 school performance because of their
8:02 frequent migraine attacks specifically
8:03 for patients with chronic migraine
8:05 wherein they’re having 15 or more heic
8:07 days in a month this is also because of
8:10 their long graduation of their migraine
8:12 attacks the reason for that is sometimes
8:15 they’re not given enough treatment or
8:17 appropriate treatment to actually knock
8:20 out or um their headache attacks they
8:23 have more intense and severe attacks why
8:25 because they’re often associated with
8:27 nause and vomiting and and they’re
8:30 coming from poorer home poorer home as
8:32 well that’s one of the reasons why the
8:35 what study actually pointed that one
8:37 out it also led to uh below average
8:41 scool performance because when you’re
8:43 when they’re having their migraine
8:44 attacks they have difficulty in
8:46 concentrating and they have um slowness
8:49 in thinking right that’s more sless in
8:52 prop um I’m sure you had my your
8:53 migraine attacks as well I do have
8:55 migraine as well when I do have my
8:57 migraine attack it’s slow to process
8:59 things right the feeling of sadness is
9:01 very important in about more than 50% of
9:04 patients and some of them struggle to
9:06 cope with a headache so because they’re
9:08 very young they don’t know yet how to
9:09 cope with pain right and not telling
9:13 that because I do also see patients who
9:16 are adults and they’re having a hard
9:17 time actually coping with pain more so
9:19 with young patients and they do not want
9:22 others noticing their headache and I’m
9:24 sure that’s something that you actually
9:27 experienced when you were younger when
9:28 you have your headaches because they
9:30 think that it’s not cool to have a
9:33 headache and it’s not just from uh the
9:37 burden is not just on the patient it’s
9:39 also from parents like you who are
9:41 having children with migraine you’re
9:43 often miss work of course because you
9:45 have to stay with them right and about
9:48 6% prohibited um by parents to engage in
9:51 on school activity as
9:54 well how common is it as I mentioned
9:57 about 10 to 11% of children will have
10:00 migraine and um and the age of onset
10:04 usually ranges um in different um age
10:08 group um number one it is different in
10:11 in young um um male patients and also
10:14 it’s different in uh uh female patients
10:18 so um I can tell you that in males it’s
10:22 younger in onset um usually in females
10:25 it’s near whenever they have the they
10:27 start their period
10:30 so the main age of onset in boys is
10:32 about seven years and in girls is about
10:34 11 years which is coincident to one to
10:37 two years or one to two years before or
10:40 after they they they start having their
10:42 period so in the younger less than 12
10:45 years of age as you can see here usually
10:49 there are more boys during that age and
10:51 when they reach the puberty more than 12
10:55 years of age that’s when females
10:57 actually predominates
11:03 there was one actually who um one who
11:06 actually ask what causes migraine and
11:09 I’m I’m sorry about this slide because
11:11 it’s a very heavy slide because this is
11:13 the best way I can tell you um what
11:16 causes migraine I think the easiest
11:18 answer to this is we don’t know yet 100%
11:22 what’s causing migraine but we do have a
11:24 lot of studies now which came out for
11:27 the past five to 10 years that we know
11:30 um there are other biomarkers that we’ve
11:32 identified that we trying to actually
11:34 Target their um the migraine treatment
11:37 so we know that it’s actually inherited
11:41 so approximately there are 38 Gene
11:44 polymorphisms which were identified but
11:47 I think there’s
11:48 more and then it could be environment of
11:51 course you you know that there if there
11:53 is some changes in the biometric
11:55 pressure or there’s some stress that
11:58 would trigger a Migra attack there are
12:00 some patients who are very sensitive in
12:02 terms of like MSG for example or they
12:05 have um uh like colored dyes flavor dyes
12:10 or like patients with nitrites for
12:12 example can um trigger their migraine
12:15 attacks it could be a neuroendocrine
12:17 endocrine abnormalities and hormones is
12:19 a big issue as well and there’s some
12:22 drugs which are exacerbating um migraine
12:25 attacks as well so because of this multi
12:29 Le factors then there is this a series
12:33 of events which actually been found on a
12:36 lot of Imaging studies there is this
12:39 hypothalamic activation this is exactly
12:42 where that is what’s the hypothalamus is
12:45 the part of our brain which is
12:47 responsible
12:48 for sleeping uh um our memory as well is
12:53 there and behavior is there so sometimes
12:56 when you have um you can be sluggish or
12:59 can be get fatigued when you have a
13:02 lesion there in that part of our brain
13:05 and then it can actually uh cause
13:08 alteration in the thalamus which is this
13:11 area of our brain which is actually one
13:14 with the um parts of our brain which
13:16 actually is uh a
13:19 um which is responsible for pain um uh
13:23 transmission and there are some studies
13:25 as well which showed that our patient
13:28 migraine brains can have abnormal brain
13:30 connectivity and then that is followed
13:33 by the brain stem activation the brain
13:35 stem activation is this part of our
13:37 brain and that’s the center of nause and
13:40 vomiting and that’s the reason why
13:42 patients with no um with migraine will
13:45 have nause and vomiting as part of their
13:47 symptoms and more and more evidence now
13:51 that it could be a Dison the disorder of
13:53 sensory processing the way that we
13:55 actually process um pain the the way
13:59 that we process changes in pressure for
14:01 example that’s actually more of one of
14:04 the reasons why migraine could have good
14:07 sense actually when there’s a change in
14:09 pressure outside or when there’s a
14:11 change in temperature outside and the
14:13 cortical spreading depression is the
14:16 mechanism why um how on migraine Aura
14:19 like a visual aura or numbness in
14:22 tingling associated with migraine or
14:24 speech problems associated with migraine
14:27 and then after that there is going to be
14:29 a release of the cgrp and all the
14:32 biomarkers like peap these are the
14:35 neuroinflammatory peptides which are
14:37 found to be the Target now for migraine
14:40 and because of this there’s a
14:42 combination of migraine genes hormonal
14:44 metabolic State and then drugs then this
14:47 explains why a patient even in the same
14:50 family they have different ways on how
14:53 their migraine actually comes out or um
14:56 or they have different symptoms with
14:58 their migraine attacks is migraine her
15:02 hereditary as I mentioned genetic is one
15:04 of the most common causes and these are
15:07 different genes I I don’t think you need
15:09 to uh more of memorize them but because
15:12 there’s no single Gene yet that is been
15:15 found to con be connected even in same
15:17 family they have different uh gene
15:20 mutation that was found in in in each
15:22 family so they can’t really say they
15:25 they there’s nothing yet that confirm
15:27 this this is exact the gene mutation
15:29 responsible for the
15:31 migraine 34 to 64 4% of them are
15:35 estimated to be bilateral sorry about
15:38 that um I usually turn off my phone but
15:42 since I’m on call tonight I apologize
15:44 that I have to turn it on for among
15:47 those patients with migraine without
15:49 without Aura um a first degree
15:52 relatively which is two times likely to
15:54 have a migraine without Aura and there’s
15:57 1.4 times likely to have migraine with
15:59 aura and for those first degree relative
16:02 of a patient with migraine with aura
16:05 there are four times likely to have
16:07 migraine with aura and there’s no
16:09 increased risk of migraine without Aura
16:11 so this is why one of the reasons why
16:14 ask my the parents of my family if what
16:17 kind of migraine do they have they have
16:20 Aura if I see them a patient who very
16:22 young I potentially tell them that watch
16:25 out for the other symptoms associated
16:28 with the migraine of your child because
16:29 they may develop some auras in the
16:33 future we need you always actually um
16:36 some of the doctors will always tell you
16:38 especially headache neurologists that to
16:40 do a headache diary that’s very
16:42 important and we almost always tell them
16:45 that we try as much as we can to
16:47 identify what triggers their headaches
16:49 is because it’s one of the best
16:52 strategies to avoid triggers and reduce
16:54 their migraine frequency this is a very
16:57 old study done in
16:59 2012 among children um it’s only 102 but
17:04 they noted that stress lack of sleep
17:07 warm climate and video games actually so
17:10 because of the screen the blue light
17:11 from screens which actually trigger
17:13 migraine attack that’s actually one of
17:16 the most common causes or triggers for
17:19 migraine and we actually I we need you
17:23 to prepare before your um your
17:27 appointment with your doctor especially
17:29 headache neurologist or other
17:30 neurologist or your pediatrician because
17:33 we have um it’s so hard to actually get
17:35 a history from children so we rely a lot
17:38 on the parents and we actually ask um
17:43 the child even if they’re younger I
17:45 asked questions so that’s the reason why
17:47 I need to see the patient with you um
17:50 because I asked them to draw while we’re
17:51 talking about the other parts of the
17:53 history I asked them to draw because
17:55 Studies have shown that if you ask them
17:57 to draw this the best way that they can
18:00 actually describe how they’re feeling in
18:03 terms of if it’s a pounding headache or
18:06 it’s a pressure headache and sometimes
18:08 um we also ask them about sensitivity to
18:11 light or sound right and we can’t expect
18:14 a young child to say that I’m sensitive
18:16 to light or sound so I we ask you how
18:19 your child is behaving when they’re
18:21 having a migraine attack do they cover
18:23 their eyes do they cover their ears so
18:26 that is inferred in their behavior that
18:28 they some sensitivity to light and sound
18:31 which are the things that we
18:33 commonly um ask or one of the diagnostic
18:36 quity of our migraine especially in
18:38 children all right we also look for
18:41 clues in their history that’s why we ask
18:43 you are there any patient or are then
18:45 family members with migraine there are
18:47 this episodic syndromes associated with
18:49 migraine which I’m going to discuss in a
18:51 bit we almost always screen for
18:53 comorbidities like depression anxiety
18:56 obesity suicidal eation and ADV
18:58 childhood experience which I’m going to
19:00 tackle in a few in a few minutes we do
19:03 ask for the past health history why we I
19:07 always tell this to my uh to my patients
19:09 if I just treat their headaches and I
19:11 don’t treat the other things that could
19:13 potentially affect their headaches the
19:15 headaches will not get any better why
19:17 because we need to treat those and we
19:19 need your family doctor’s help or
19:21 whoever the other health specialists who
19:24 are actually um taking care of you to
19:27 actually collaborate and coordinate in
19:30 terms of your treatment plans right so
19:33 for patients with um and this study has
19:36 been done um in 2018 that they found
19:40 that patients with migraine have um
19:43 psychiatric symptoms like internal
19:45 internalizing symptoms or disorders ADHD
19:48 or attention U deficit hyperactivity
19:51 disorder Tourette syndrome and suicidal
19:53 audiation some of them they have
19:55 neurologic symptoms as well like
19:57 restless legs syndrome and epilepsy and
20:00 other medical issues like obesity asthma
20:03 atopic dermatitis anemia anemia is
20:06 something that I always scream for
20:08 because specifically iron deficiency
20:09 anemia can worsen migraine attacks and
20:12 Sleep Disorders we know that sleep is
20:14 one of the most common triggers for
20:17 migraine how about mental health is that
20:20 common yes as I mentioned a while uh in
20:22 the previous slide that you children
20:24 with migraine have twice the risk of
20:27 having an anxiety or depression
20:29 depression and they have three times the
20:32 odds of having suicidal
20:34 ideation ADV childhood experience are
20:37 traumatic experiences that a child um
20:40 has experienced or an adult has
20:41 experienced for the past 18 years of
20:44 their life it’s a risk factor was known
20:46 to be a risk factor for adolescent
20:48 migraine the more adverse childhood
20:51 experience that you have canor in
20:53 migraine and other’s childhood
20:54 experience doesn’t have to be like
20:56 physical sexual or um any kind of abuse
21:00 it could be more of loss of a family
21:02 member or illness in the family or
21:04 bullying that’s very very rampant right
21:07 now whether it be physical or they could
21:10 be more of social media right so I think
21:13 those are the things that we want um the
21:16 parents to actually know and to monitor
21:18 in their children because this could
21:20 impact their their mental health and
21:22 also their development and can also
21:24 worsen their migraine
21:26 attacks so I thought we actually discuss
21:29 a case of course this is not the real
21:31 name of the patient so um we’ll call the
21:34 patient as Charlie so he’s an 8-year-old
21:36 boy um who had at five years old had
21:40 started having headaches they’re only
21:42 happening one to two time two times a
21:44 month uh sleeps then back to Baseline
21:47 after one to two hours so usually that’s
21:49 usually the common story that you will
21:51 hear from your from your um relatives or
21:54 your children with migraine and then at
21:57 6 years old
21:58 she developed this tummy pain around the
22:00 belly button and and they were more of
22:03 dll and you notice that Charlie was
22:06 turning pale they may complain of some
22:09 um nausea and they’re happening every
22:11 two months for six to eight hours there
22:14 are no headaches and they’re normal in
22:16 between the attacks you brought the
22:18 patient to um the their pediatrician
22:21 they look at everything and nothing came
22:23 out and about in in two in 2022 the
22:28 Charlie’s um headaches increased to once
22:31 a week now they’re lasting longer to up
22:34 to six hours they’re more intense that’s
22:36 why he was missing school one to two
22:38 times a month she also he also is still
22:41 nauseous with the headaches and prefers
22:43 to rest in a dark and quiet room you
22:46 check for red flags like more of fever
22:48 all of those things that are worsome
22:50 symptoms and he did not present with any
22:53 and the triggers included weather
22:55 changes and
22:56 dehydration she was kaky as a baby and
22:59 she also has motion sickness I will tell
23:01 you why those those are important and
23:04 the family history showed that his mom
23:06 and maternal grandmother have migraine
23:09 and you examine um We examined the
23:11 patient and did not see any any uh
23:14 abnormal findings so everything was
23:16 normal so this patient was di I
23:19 diagnosed him with migraine without Aura
23:22 because they’re only having one to two
23:24 times in a month the tummy pain that he
23:26 had was in keeping with abdominal
23:29 migraine which is an early manifestation
23:32 of migraine in a young child when she he
23:35 was six right and remember he was also
23:38 KY and that’s what you call infant colic
23:41 which was also found to be related or
23:44 Associated to migraine in in the new
23:47 guidelines probably it will come out
23:48 next year that will be included as one
23:51 of the episodic syndromes associated
23:54 with migraine so what are this early
23:56 signs of migraine in young girl children
23:59 as I mentioned we have abdominal
24:01 migraine then we have this benign
24:04 parisal torticolis is more of the
24:06 tilting of the head it happens in
24:08 between three to six months and they go
24:10 away in time so they will tilt their
24:13 head for maybe a few hours and then back
24:16 to back to themselves as if nothing can
24:19 happen and then in a week or two weeks
24:21 or a month then they tilt the head again
24:23 either right or left the one thing
24:26 that’s important here is that we need
24:28 you need your to bring your child
24:29 because we need to check for other
24:31 things that worrisome things like
24:34 something happening at the back of the
24:35 head of the child so majority of the
24:37 time if they have normal neurologic
24:40 examination we just monitor them but if
24:42 they continue or they become much longer
24:45 then we do pictures of we do your
24:47 Imaging right and then this uh the next
24:50 one is the cyclic vomiting syndrome so
24:53 this is one of the few wherein they can
24:56 actually start around 9 to 10 years of
24:58 age and they can persist even at 19 um
25:02 at 19 years old or 20 years of age I do
25:06 have young patients with cyclic vomiting
25:08 syndrome as well so they would have no
25:11 headache but sometimes they would have
25:12 vomiting and repeated episodes of
25:14 vomiting sometimes for hours or
25:16 sometimes days and they will have it
25:19 happens every four to five weeks or
25:21 every five months or something like that
25:23 some are infrequent some can be very
25:26 disabling that’s why they needed to see
25:28 me or another headache neurologist that
25:31 that need that’s why we need to start
25:33 some medication to prevent the further
25:35 attacks and then this uh there’s another
25:38 thing called benign parisma vertigo
25:40 wherein they have repeated episodes of
25:43 spinning sensation not themselves but
25:46 more of their the themselves spinning
25:48 right um uh and it could last hours as
25:51 well it could last days again they
25:53 actually happen every three months and
25:55 one in some patients they it happens
25:57 every 10 weeks in some patients but in
26:00 between the attacks they could be normal
26:02 so again there are though this all this
26:06 syndromes they actually are associated
26:08 with migraine and they could be periodic
26:11 meaning and normal they the patient is
26:13 normal between attacks they could have
26:16 either paor or pale they become pale
26:19 they can have some flushing of their
26:21 face as well there’s always a strong
26:23 family St of migraine in their in their
26:25 first degree relative and most majority
26:28 of them clinically evolved meaning they
26:30 actually turn into migraine at a later
26:34 age there are other things like infant
26:37 colic as I mentioned alternating hemap
26:39 of child and vestibular migraine there
26:41 are some some other disorders which are
26:45 under investigation like the motion
26:47 sickness called stimulus headache
26:50 recurrent limp pain is sometimes they
26:51 call it growing pains and there’s some
26:54 periodic Sleep Disorders like sleep
26:56 walking sleep talking night Terrors or
26:58 brism which is um a grinding of the
27:02 teeth during sleep these are not yet
27:04 included but they’re being investigated
27:07 that they can potentially be associated
27:09 with
27:10 migraine what’s the connection of the
27:13 gut symptoms to migraine as I mentioned
27:16 in younger children they have more of
27:19 the nausea and the vomiting symptoms and
27:21 then when they turn on into teens then
27:25 those who actually improve then they
27:26 will have this sensitivity to light and
27:29 sound so there are some theories why um
27:32 the gut is almost always considered in
27:35 um in in my review as more of a small a
27:39 part of the brain because majority of
27:41 the um the uh chemicals that are
27:46 associated with migraine like the
27:48 neurokines vas intestinal peptide and
27:51 substance be are also found in our gut
27:54 and there are some theories why um it
27:57 could be potenti entially um uh um
27:59 associated with migraine so this the
28:02 hypothalamus remember that part of our
28:04 brain which is responsible for Sleep
28:06 Behavior memory and all those things so
28:08 that is a connection on that on on our
28:11 pitutary gland and the adrenal so there
28:13 might be some uh problems with that in
28:16 this patients there are some also um
28:20 problem with this patient that is
28:22 inherited susceptibility so the genetics
28:25 again and then the auton OMC instability
28:28 autonomic means that they have this is
28:31 the one responsible for the heart rate
28:34 um blood pressure as well and that has
28:36 some instability in terms of that and
28:39 then there’s some altered motility of
28:41 the gut wo is the other one and there
28:43 could be some visceral hyper sensitivity
28:46 and dismotility
28:47 you might wonder the other question that
28:50 came up is in patients with headache in
28:53 younger patients with headache when do
28:55 we worry and when do we scan can so we
28:59 always make sure that we take a good
29:01 history that’s the most important one
29:05 and this has been shown in different
29:07 studies that if uh any scans or
29:10 neuroimaging is not indicated if a
29:12 patient comes to us with a recurrent
29:14 headache with a normal neurological
29:17 examination so all the doctors who are
29:19 seeing your children with M with
29:21 headache or or migraine they needed to
29:24 have a complete neurological examination
29:26 because that’s help us um to decide if
29:29 we need to do City scans or MRIs and we
29:33 only consider them based on a lot of
29:36 studies um if they do have abnormal
29:39 neurological examination pilm means
29:42 they’re swelling at the back of the of
29:44 the eyes where in the nerves the optic
29:45 nerves has has um has some swelling
29:49 decreased level of Consciousness
29:50 weakness or and steady gate they have
29:53 been shown to have uh this patient
29:55 presenting with this have significant
29:58 findings on their MRI or CT scans
30:01 there’s some also predictors of presence
30:03 of a lesion in the brain if the
30:06 headaches are initially presenting less
30:08 than one month absence of a family
30:11 history of migraine abnormal neurologic
30:14 examination gate abnormalities and also
30:17 seizures the parts of the other history
30:20 have been inconsistent findings for the
30:22 past year so we don’t actually rely on
30:25 on them too much we rely more on our
30:28 neurological examination before we do
30:31 any Neuro Imaging whether it be a CT
30:33 scan or
30:34 MRI so now the other thing is that in
30:38 children when do we know if a headache
30:41 is a migraine is basically the same as
30:44 in adults the only difference is that
30:46 it’s shorter in children it’s shorter
30:48 it’s only 2 to 72 hours they the child
30:52 should have at least five attacks and in
30:55 children they in in older you patients
30:59 it’s usually one side right of the head
31:01 that hurts but 80% in children in
31:04 specifically in alel and can be
31:06 bilateral it’s also more more commonly
31:09 found the pain is mostly on the frontal
31:12 area the pounding quality of the
31:13 headache of course in younger younger
31:15 patient you won’t actually get that
31:17 pounding history right so and and that’s
31:20 has been shown in studies that 40 to 60%
31:23 of them can be pounding but usually a
31:26 child with migraine will stop whatever
31:28 they’re doing they stop playing they
31:31 stop um you know watching TV whenever
31:34 they have a headache and they moderate
31:35 severe intensity and as I mentioned
31:38 majority of them will have Noster or
31:40 vomiting but if a patient does not have
31:43 noer or vomiting the patient should have
31:45 S both sensitive should be sensitive to
31:47 both light and sound okay and there are
31:52 different phases of migraine attack and
31:54 these are also seen in younger patients
31:56 so please don’t think that uh they won’t
31:59 present with craving for food for
32:01 example or yawning or um heighten
32:05 perception for like we for example they
32:08 could present with auras as well and
32:10 then their headaches are basically the
32:12 same um and then they could have some
32:15 hangover symptoms as well after after
32:18 their headache
32:20 attack one important thing that I
32:23 usually tell all my uh when I do a
32:26 lecture for everyone whether it be from
32:28 family doctor from pediatrician and also
32:31 for patients is that the role of doctors
32:34 to actually and you as parents of young
32:37 patients with migraine is very important
32:40 because you need to be aware of this
32:42 number one and number two they needed to
32:44 actually have a diagnosis early because
32:48 early diagnosis will mean that there
32:50 will be some appropriate treatment
32:53 started on your children and the other
32:55 thing that actually improved impres the
32:57 prognosis of your children with migraine
33:00 because that has been shown in studies
33:02 consistently that if you start early in
33:05 terms of the treatment then then they
33:07 don’t go to The Chronic migraine
33:11 stage and there’s different goals for
33:13 pediatric treatment one one number one
33:15 goal is to reduce the disability so we
33:17 don’t want them missing school and we
33:19 also need to teach them how to uh
33:22 develop like pain coping strategies
33:25 right and that will also help reduce the
33:28 risk of disease progression from
33:30 episodic to Chronic migraine and because
33:32 of that they will actually have better
33:34 quality of life and we can achieve this
33:37 in few different things four strategies
33:40 so self-management is that’s where you
33:43 actually has a big role on this and then
33:46 as I mentioned treat all the other
33:49 things that are commonly found like if
33:51 you have patients with sleep problems we
33:53 have to treat that one we have to make
33:55 that better if your child has has some
33:57 um mental health issue we need to treat
33:59 that if we need to actually get you to
34:01 go do a cognitive behavior therapy then
34:04 that’s a the thing that’s our first line
34:06 of treatment for them and then the the
34:08 medications are divided into two the
34:10 acute or rescue therapy or the
34:12 prevention
34:14 therapy here um is the table that we
34:17 actually all share to our patients at
34:19 Women’s College Hospital we started this
34:21 when I was a Women’s College Hospital
34:23 and at sick kids I’m still at sick kids
34:25 by the way but I’m not a connected with
34:27 um I’m not doing my practice of Women’s
34:30 College Hospital I’m partly connected
34:31 doing some research there there the
34:33 supplements we almost always start this
34:36 mainly because even if they have low
34:38 evidence for children mainly because
34:41 they have low side effect profile and
34:43 there are some children who definitely
34:44 actually benefit from this screen time
34:46 is something that we actually uh try to
34:50 see if we can stop them or avoid them if
34:52 they can’t stop they’re using it for
34:55 learning then I usually don’t stop them
34:57 from using it I asked them to take
34:59 frequent breaks so one hour of screen
35:01 and five to 10 minute break and then go
35:03 back to it again hydration is very
35:05 important headache diary um Canadian
35:09 migraine tracker which is um supported
35:11 by migraine Canada as well and then
35:14 having physical activity which is not a
35:16 big problem for children because they’re
35:17 definitely very active avoiding what
35:19 triggers them so having the diara is
35:22 actually going to help identify what
35:24 triggers their migraine attas sleep
35:26 sleep is something that I spend a lot of
35:28 time actually discussing with my
35:30 patients it’s not just a number of hours
35:32 of sleep it’s the regular sleeping and
35:35 waking time that matters a lot as well
35:38 um I think that’s something that you’re
35:40 you need to um actually explain or make
35:43 sure that your children will have those
35:45 regular sleeping time and waking time I
35:48 love oversleeping but if I oversleep for
35:50 more than an hour I’ll have a big
35:52 headache on a Sunday afternoon or Monday
35:54 morning so oversleep for an hour not
35:57 more than that because that will can
35:59 potentially trigger a migraine Attack
36:01 eating please do not skip any meal high
36:04 protein for breakfast is something
36:06 that’s actually we uh advised because
36:08 low blood sugar can trigger migraine and
36:10 the downtime among all the treatments
36:12 for migraine cognitive behavior behavior
36:15 therapy has been found to be useful and
36:18 I can tell you that um that when you
36:21 actually have PE uh children with this
36:23 focus on the function during the
36:26 migraine attack not on the pain okay so
36:29 I think um maybe mainly because majority
36:32 of the medications sometimes would not
36:34 help especially if you actually G gave
36:37 the medicine too late right okay so
36:41 there’s a question about the role of the
36:43 psychological interventions like
36:45 cognitive behavior therapy and this is
36:47 just to show you that there are nine
36:49 trials in children with Mig comparing
36:51 nonm medication intervention uh to
36:54 control um to control uh or another
36:57 nonpharmacologic therapies and it showed
37:00 that short and long-term outcomes are
37:02 better with non-medication therapies and
37:05 that’s the reason why we spend so much
37:07 time on discussing this and we provide a
37:09 lot of apps for uh
37:13 parents it’s important treat early I’m
37:15 sure you’ve heard this from your
37:17 neurologists or from the doctors who
37:20 actually told you to start early in
37:22 terms of treatment I show this picture
37:24 to my young patient even if they’re
37:26 father five or six why because it’s up
37:29 to them for them to tell you the the
37:31 parent to actually that their migraine
37:33 is starting or the headache is starting
37:36 because if you treat it late then there
37:39 is this pain switch in the brain that
37:40 turns on so and Studies have shown that
37:44 if you treat early then there’s more
37:46 success that you will be um the
37:48 treatment um if you treat late the
37:51 problem is in terms of success from that
37:54 treatment it drops from 80% to 50% %
37:57 there is a lower recurrence rate as well
37:59 if you treat early um meaning it doesn’t
38:02 come back right and there will be lower
38:04 adverse event rate meaning there will be
38:07 less nausea n less vomiting because as I
38:10 mentioned this part of our brain is the
38:12 center for nausea and
38:14 vomiting I don’t know if you’re familiar
38:17 with this it’s called tra map this is
38:19 the um traffic light of migraine that I
38:22 actually uh uh discuss with our with our
38:25 patients so it doesn’t include only
38:27 headache but also all the other symptoms
38:30 of migraine whether it be nausea
38:32 vomiting sensitive to light or sign or
38:34 fogginess right so a red migraine means
38:37 they have to stop it’s based on how
38:38 they’re functioning yellow migraine they
38:40 have to slow down and green migraine
38:42 they can go and depending on that there
38:45 are some trip tents which are
38:47 unfortunately not approved here in
38:49 Canada but the only one approv by in
38:51 Canada is the Almo trip tent but for um
38:54 the US guidelines we use and I use it um
38:57 for more than six that we can use the
38:59 Riser trip 10 disintegrating tablet and
39:02 for 12 years old I can use alatri 10
39:05 risan the combination sumpan approx sux
39:09 the sumpan nasal spray and Zan nasal
39:12 spray and anti-inflammatory medications
39:14 like abup profen and aoxin can be used
39:16 and if they have nausea then I I give
39:19 nausea medication as
39:21 well and when they start prevention
39:24 therapy if they have frequent headach
39:26 and they have migraine disability and or
39:29 both like so meaning it’s more mainly
39:32 based on the disability or if they’re
39:34 overusing medications and there’s like
39:37 three medications which were approved uh
39:40 with level B recommendation one is
39:42 propanolol two is toate and the other
39:45 third one is amitryptiline
39:47 how about the vitamin supplements as
39:50 I’ve mentioned there is uh no great
39:53 evidence that they work but on majority
39:56 of the trials that were done is the
39:59 coenzyme Q10 and magnesium has been with
40:02 um been useful uh with low side effect
40:05 profile that’s the reason why majority
40:07 of my patients are on magnesium and
40:09 coenzyme
40:10 Q10 how about the new migraine therapies
40:13 can we use them in children yes because
40:16 we have evidence that the cgrp levels
40:19 are not just elevated in adults but also
40:22 in pediatic migraine
40:23 patients what are this yoa pant uh Rema
40:28 pant apparently was just approved last
40:30 Friday for aute therapy in adults and
40:33 soan is potentially coming this is a
40:36 nasil spray and a tojan can be used as
40:39 prevention all of this including the
40:41 aruma Balan fman and otin all of the
40:45 trials in pediatric migraine trials are
40:48 being done not just here in Canada but
40:51 also in the
40:52 US Z vean I will start a trial in
40:55 Children’s Hospital Hospital uh
40:57 hopefully early next year the aoip pant
41:00 that we will start that soon as well at
41:02 the Children’s Hospital the Arab trial
41:05 for Pediatric patients is ongoing at
41:07 siik kids uh which I’m the principal
41:11 investigator and also at um children’s
41:14 hospital and the ipab trial is actually
41:18 going to start soon at the Children’s
41:20 Hospital okay so all of this and we are
41:24 making sure that um
41:26 this drugs will be tested in younger
41:29 patients so they can be available and
41:32 you don’t have to pay it out of pocket
41:34 because once they approve then your your
41:36 insurance will cover
41:38 them how about the devices unfortunately
41:42 we don’t have all of this we only have
41:46 the noninvasive veal stimulator which is
41:50 the GMA core and also the seph which is
41:54 the electrical trial nerve stimulation
41:57 so there’s not much evidence on on the
42:00 use of seph but there is some evidence
42:03 because this is the cheapest we can have
42:05 we have here in Canada these is the most
42:07 common ones that I use an off label
42:11 treatment the gamma core is approved for
42:14 12 years old and up but the problem and
42:17 there’s some evidence for their use in
42:19 adolescent patients like 12 years old
42:21 and up the problem is they’re so
42:24 expensive for SE it costs around
42:28 $500 and for GMA cor for three Monon
42:31 treatment it’s used um it’s actually
42:33 around $1600 to
42:35 $1,800 right so they’re quite expensive
42:37 and majority of your insurance coverage
42:40 will actually not cover them except for
42:42 some like maybe sunlife will cover
42:45 separately but there’s some few few
42:46 patients who actually will cover th
42:49 those
42:50 devices and what’s your role as parents
42:53 for your child I think all the things
42:55 that I mentioned about the
42:57 self-management strategies like the diet
42:59 the hydration sleep exercise Stress
43:01 Management school advocating for school
43:04 is actually very important right so and
43:07 making sure that they’re Physically
43:08 Active the home life make it as as as as
43:12 normal as possible and then identifying
43:15 the triggers and taking the medication
43:17 early and life balance and actually
43:19 pacing these are very important in terms
43:23 of your role as a parent and guiding
43:25 your children with migraine again focus
43:28 on function not on pain as I mentioned
43:31 your role as um in this um is to in the
43:36 self-management helping them develop
43:38 pain scoping skills or uh and using the
43:40 headache diary and then monitoring the
43:43 symptoms and advocating for your child
43:45 in in school and health care providers
43:47 as well and treat early once they have
43:50 the Treatment available and prescribed
43:52 by your doctor please treat early and
43:55 then teach them when to tell you and if
43:57 you do have um they there are attacks
44:00 which are happening in school then get a
44:03 letter from your doctor and and that
44:05 letter is actually available in migrant
44:06 Canada because the pan group that I’m
44:09 co-leading with Dr or is actually one of
44:11 the things that we are um we did so um
44:15 all you have to do is get that letter
44:16 and ask your family doctor to actually
44:19 um um sign it so you can actually give
44:23 that to school so the teacher or the
44:25 principal can give the medicine to the
44:27 um in school once the headache starts um
44:31 and then prevention therapy and uh to
44:33 improve compliance right so you can help
44:35 make sure that because that prevention
44:37 therapy is not going to be forever right
44:40 once they are better then they can um we
44:43 can actually get rid of it at some point
44:45 so what happens uh with in patients with
44:48 pediatric migraine if the Studies have
44:51 shown that the if the headache starts
44:53 early if the migraine starts early then
44:56 there is a highly likelihood that it
44:58 could develop into chronic migraine but
45:01 they can also get better as well and in
45:04 male patients I tell them they’re very
45:06 lucky because they don’t have the
45:08 hormonal effects or side effects on
45:10 migraine then um on their late teens or
45:13 early 20s majority of their migrant
45:15 attacks are much much lesser they can
45:17 happen once or twice in a year we can
45:20 get rid of all of them but they’re less
45:22 often and in patients with early
45:25 developmental disorders Unfortunately
45:27 they may be associated with Persistence
45:28 of migraine so the heart of migraine
45:31 Management in Children of uh of Al Del
45:34 is usually education shared decision
45:37 making and we actually make sure that we
45:39 indiv individualize the treatment and
45:42 there are four key aspects as I kept on
45:44 telling you that so um acute treatment
45:46 which are the rescue medicines the
45:49 prevention therapy if your child has
45:51 frequent headaches with frequent
45:52 disability or overusing medications then
45:55 they need to be on on prevention therapy
45:57 for a while usually we maintain it for 6
46:00 to 12 months because Studies have shown
46:02 that even if you take away the medicines
46:04 after six months for example then the
46:06 headaches will not worsen
46:08 self-management and education is you’re
46:11 going to be your part we have a big role
46:12 in that please help us with that and of
46:14 course the cability management the
46:17 bottom line is we know we are now in the
46:21 era that we exactly understand what’s
46:24 happening during a migraine attacking
46:26 the brain So based on this understanding
46:28 we’re designing treatment option or
46:30 we’re making them individualized
46:32 treatment the trials in the Pediatric
46:34 mic in pediatric patients are still
46:37 ongoing but we’re hoping someday we
46:40 actually going to be uh successful in
46:42 finding out and making those available
46:45 for your children thank you for your
46:51 [Music]