MIGRAINE/ANIMAL BITES
| MIGRAINES: EVALUATION AND TREATMENT —Eric H. Kossoff, MD, Assistant Professor of Pediatrics and
Neurology, Johns Hopkins University, School of Medicine, Baltimore, MD
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| Migraines in children: ≈50% of children have headaches and ≈3% have migraines by 7 yr of age; migraine incidence
increases to ≈10% by 15 yr of age; common misdiagnoses—sinusitis; myopia; stress; gastritis; incidental
findings (eg, arachnoid cyst, Chiari malformation) on magnetic resonance imaging (MRI); neurally mediated hypotension;
adverse effect of medication (eg, methylphenidate [Ritalin]); prevalence—highest in women 40 to 50
yr of age; before puberty, migraines more common in boys; after puberty, more common in girls
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| Diagnosis: diagnostic criteria less restrictive in children, compared to adults; characteristics (child must have ≥2)—
history of ≥5 headaches, each lasting 1 to 72 hr; headache may occur unilaterally or bilaterally (more common in
younger children); pulsating quality (but children may describe this differently); moderate-to-severe intensity; exacerbation
with routine exertion; associated symptoms (child must have ≥1)—photophobia or phonophobia; nausea
or vomiting; progression—children may feel sleepy or vaguely ill during prodrome (best time to treat); after
migraine peaks, children often fall asleep, then awaken feeling better; migraine likely diagnosis in children with
consistent history; related history—autonomic complaints (eg, motion sickness); family history of migraines; high
degree of function and academic performance; multiple visits to school nurse; frequent vomiting (autonomic hypersensitivity)
as toddler; aura—≈20% of children have migraines with aura; images may appear distorted or fractured,
often angular or jagged; colors common; black and white, rounded images suggestive of epilepsy; having
children draw these images helpful for diagnosis
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| Types of headache: acute; acute recurrent (includes migraines); chronic progressive (never subsides completely;
continues to worsen; occurs with intracranial masses and progressive hydrocephalus); chronic nonprogressive
(moderate pain, eg, 5 out of 10 on pain scale; if examination and MRI normal, consider chronic daily headache)
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| Practice guidelines: guidelines pertain to children with normal examinations (ie, no papilledema; no signs of focal
weakness); electroencephalogram and laboratory tests not useful; lumbar puncture useful only for children with
questionable disc margins, those who use minocycline to treat acne (may raise intracranial pressure), and those with
history of Lyme disease; cardiology consult useful for children who experience syncope, flushing, or tachycardia
with headaches; MRI does not affect management, so not recommended when routine examination normal
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| Acute management: first-line therapy—nonsteroidal anti-inflammatory drugs (NSAIDs) generally safe and effective;
options include naproxen (eg, Aleve 250-500 mg), ibuprofen (eg, Advil 10 mg/kg), and triptans; nonpharmacologic
options—rest in dark, quiet room; avoid emergency department ([ED]; loud, bright environment noxious
to migraineur); ED options—intravenous (IV) prochlorperazine (Compazine) or metoclopramide (Reglan) which
have some dopaminergic properties; ketorolac (Toradol) oral or intramuscular; IV fluids (can administer while
waiting for oral medications to take effect)
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 | Triptans: serotonin agonists (molecular structure similar to serotonin), affect 1B/1D receptor; mechanism of action—
cause vasoconstriction; affect trigeminal nerve and brainstem (responsible for fast onset of action); selection—7
triptans available; differences include formulations and half-lives (5 short-acting; 2 long-acting); long-acting
(frovatriptan [Frova] and naratriptan [Amerge]) good for managing menstrual migraines; formulations include
injections, dissolvable tablets, nasal sprays, and regular tablets; use in children—beneficial and frequently used,
but not approved by Food and Drug Administration (FDA); speaker prescribes for children ≥5 yr of age (half
doses for children <10 yr of age); nasal spray (zolmitriptan) good for younger children (child leans forward to
spray into nose; nausea may occur if medication swallowed); selecting medication—all first-line medications
appear effective; even though FDA has not approved zolmitriptan for use in children, practice parameters suggest
its use; photocopy of practice parameters typically sufficient for insurance approval; use of samples may
help identify best medications for individual patients
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| Medication overuse headache: overuse of medication epidemic; inappropriate use of anticonvulsants and analgesics
(including ibuprofen, naproxen, and caffeine) may cause rebound headaches; periodic migraine may become
chronic daily headache
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| Second-line acute therapies: many combination agents (eg, butalbital/acetaminophen/caffeine [Fioricet], aspirin/
butalbital/caffeine [Fiorinal], isometheptene mucate/dichloralphenazone/acetaminophen [Midrin]) have sedative
effects, helpful if headaches cause insomnia; dihydroergotamine (DHE) nasal spray (Migranal; may cause nausea);
ergotamine plus caffeine (Cafergot)
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| Third-line acute therapies: valproic acid (eg, IV Depacon; if effective, use Depakote for outpatient therapy); acetaminophen
(Tylenol) with codeine (but avoid narcotics if possible); corticosteroids; IV DHE
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| Prophylactic therapy: when to initiate—headaches occur at least once weekly or ≥4 times each month; quality of
life impaired; patient does not respond to acute therapy or lifestyle modifications; child has complicated migraines
(eg, hemiplegic, confusional, basilar); child requests preventive therapy; when to discontinue—typically after 9 to
12 mo
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| Nonpharmacologic approaches: speaker begins by counseling patient at first visit; reassurance helps 30% of patients
(similar to placebo effect); lifestyle interventions—exercise; get sufficient sleep (8-10 hr); avoid skipping
meals; avoid food triggers, if they occur (but speaker avoids elimination diets)
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| Pharmacologic approaches: begin with low dose, given once daily at night
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| Antihistamines: cyproheptadine (Periactin), used mostly for younger children; some serotonergic benefits; adverse effects
include increased appetite (weight gain) and sedation; good option for children with coexisting allergies
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| Antihypertensive agents: modest effects in children; option for patients with no comorbidities; propranolol contraindicated
for patients with asthma; verapamil (calcium channel blocker) useful for patients with hemiplegic
migraines
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| Antidepressants: tricyclic antidepressants—amitriptyline (eg, Elavil) begun at 10 mg, then advanced every 2
wk, if necessary (to 25 mg then 50 mg); nortriptyline less effective; adverse effects include sedation, dry
mouth, and constipation; selective serotonin reuptake inhibitors (SSRIs)—fluoxetine (Prozac), sertraline
(Zoloft) not as effective as amitriptyline
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| Anticonvulsants: most popular class of preventive agents in children; valproic acid (Depakote)—begun at 125
mg (10 mg/kg in younger children); helpful in patients with epilepsy, low body weight, or mood swings (including
bipolar disorder); associated with weight gain, alopecia, polycystic ovarian change, and teratogenicity
(10%; avoid in teenage girls); available in extended-release and delayed-release formulations; gabapentin
(Neurontin)—no drug interactions (good for patients on other medications); topiramate (Topamax)—most popular
prophylactic therapy, given in low doses (15-25 mg in younger children; 30-50 mg in older children) at
bedtime; indications include patients with pseudotumor cerebri; carbonic anhydrase inhibitor may have weak
diuretic effect (good option for patients with shunts); adverse effects include weight loss, cognitive effects, and
kidney stones (at higher doses); zonisamide (Zonegran)—similar effects, indications, and mechanism of action
as Topamax
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| Alternative approaches: good studies in adults; less data in children; therapies include stress reduction, massage,
biofeedback, counseling, and acupuncture
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| Referral to neurologist: worrisome findings on neurologic examination or MRI; parental request; presence of
complicated migraines; failure of preventive therapy
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| ANIMAL BITES: MANAGEMENT AND PREVENTION —S. Michael Marcy, MD, Clinical Professor of Pediatrics,
University of Southern California and University of California, Los Angeles, Schools of Medicine
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| Incidence: second most common injury treated in ED; incidence peaks in children 5 to 9 yr of age (1.5 times more
common in boys); most bites occur during warm weather, when children and animals interact outdoors; animals—
dog bites most common (\>90%); cat bites represent <10% of cases; others include rodents, rabbits, livestock, and
exotic animals; factors influencing biting behavior—male dogs bite more than female dogs; reproductively intact
animals bite more than neutered animals; chained animals bite more than unchained animals; other factors include
heredity, training, quality of ownership, early experiences, and victim’s behavior; note—most victims know dogs
that bit them (eg, neighbor’s pet, family pet); stray or unknown animals constitute small part of problem; dog
breeds—pit bulls responsible for most bites and most fatalities due to dog bites (capable of exerting 3500 lb/in2 of
pressure); Rottweilers, second most common; attacks on children in swings—3 reports of fatal attacks against infants
in swings; dog may feel threatened by swinging motion; facial attacks common
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| Microbiology: bacteria present in animal’s mouth source of infection (ie, not skin flora of victim); wounds—
combination of crush injury and laceration or avulsion; open nature of wounds caused by dog bites results in low
rate of infection (5%); common organisms—Pasteurella (eg, P multocida, P caninum); Staphylococcus (eg, S
epidermis, S aureus); Streptococcus (eg, S viridans; primarily groups C and G); anaerobic bacteria; gram-negative
bacteria (eg, Escherichia coli)
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| Pasteurella: normal oral flora in cats and dogs; organisms responsible for 75% of infected cat bites and 50% of infected
dog bites; short gram-negative coccobacilli
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| Sites of injury: ≈66% of dog bites in children 0 to 4 yr of age occur on head or neck; incidence of head and neck injuries
decreases with age; repair of facial injuries—good idea to take picture of injury before repair (helpful to show
extent of injury, in case patient or parents not pleased with outcome)
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| Fractures: facial—although rare, fracture of zygoma or orbit may occur when large dog bites small child; skull—
for craniocerebral injuries in small children, shave hair and palpate beneath skin to feel for defect; infection may
lead to brain abscess
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| Cat bites: puncture wounds typical; facial injuries less common than with dog bites; infection more common (20-
50%) due to closed wound (puncture)
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| General management of bite wounds: clean and débride wounds; use anesthesia, if necessary; consult specialist
for severe wounds to hands, feet, or face; follow precautions for head wounds (especially for young children); immobilize
and elevate injured area; give prophylactic vaccinations for tetanus and rabies, as needed; begin antimicrobial
prophylaxis, as indicated, and continue for 48 hr
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| Cleansing wounds: irrigation syringe or regular syringe and needle effective, but may scare younger children; umbilical
catheter more child-friendly; 8F umbilical catheter has same pressure as 14-gauge needle; anesthesia—
local or general, as needed
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| Indications for antimicrobial prophylaxis: puncture wounds; bites over tendons, joints, or bone; facial bites;
immunocompromised hosts (splenectomized patients vulnerable to septicemia)
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| Antibiotics: amoxicillin-clavulanate covers most organisms (staphylococci, streptococci, anaerobes, and P multocida
), but not methicillin-resistant Staphylococcus aureus (MRSA); clindamycin plus trimethoprim-sulfamethoxazole
(TMP-SMZ) recommended if MRSA suspected, or if patient allergic to β-lactams
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| Psychologic evaluation: almost one half of children experience posttraumatic stress disorder, especially after severe
injury; psychologic support often necessary
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| Indications for hospitalization or parenteral antibiotic therapy: wound care requires general anesthesia;
extensive infection of wound; infection involves tendon, joint, or bone; evidence of systemic illness (eg, bacteremia,
sepsis); patient not responsive to outpatient therapy; patient has impaired resistance; patient or caregiver unreliable;
parenteral antibiotics—ampicillin-sulbactam; clindamycin plus TMP-SMZ; ceftriaxone plus
metronidazole (Flagyl); vancomycin (to cover MRSA) plus ceftriaxone plus Flagyl
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| Failure of therapy: assess at 48 hr; reasons for failure—undrained abscess of soft tissue or lymph node; infection
of deeper structures (eg, bone, joint); retained foreign body (eg, animal tooth); antibiotic-resistant organism; nonbacterial
infection (eg, blastomycosis, rabies)
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Educational Objectives
| The goal of this activity is to provide the clinician with information about the assessment and treatment of children
with migraines and the management of animal bites. After hearing and assimilating this program, the clinician will be
better able to:
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| 1. Diagnose the child with uncomplicated migraines.
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| 2. Design and implement a management plan to address acute and prophylactic therapy for children with migraines.
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| 3. Discuss nonpharmacologic therapies for preventing and treating migraines in children.
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| 4. List the indications for antimicrobial prophylaxis for children with animal bites and select the appropriate antimicrobial
agents.
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| 5. Educate parents about prevention of animal bites.
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Discussed on This Program
Acetaminophen (N -acetyl-P -aminophenol; APAP) [Tylenol, others]
Acetaminophen with codeine [Tylenol with codeine, others]
Almotriptan maleate [Axert]
Amitriptyline HCl [Elavil]
Amoxicillin and potassium clavulanate (co-amoxiclav) [Augmentin, Augmentin ES-600, Augmentin XR]
Ampicillin sodium and sulbactam sodium [Unasyn]
Aspirin, butalbital, and caffeine [Fiorinal, Fiortal]
Butalbital, acetaminophen, and caffeine [Fioricet, others]
Ceftriaxone sodium [Rocephin]
Clindamycin [several trade names]
Cyproheptadine HCl
Dihydroergotamine mesylate [D.H.E. 45, Migranal]
Eletriptan Hbr [Relpax]
Fluoxetine HCl [Prozac, others]
Frovatriptan succinate [Frova]
Gabapentin [Neurontin]
Ibuprofen [Advil, others]
Isometheptene mucate/dichloralphenazone/ acetaminophen [Duradrin, Midrin, Migratine]
Ketorolac tromethamine [Toradol, others]
Methylphenidate [Ritalin, others]
Metoclopramide [Reglan, others]
Metronidazole [Flagyl, others]
Naproxen [Aleve, others]
Naratriptan HCl [Amerge]
Nortriptyline HCl [Aventyl HCl, Aventyl HCl Pulvules, Pamelor]
Prochlorperazine [Compazine, Compro]
Propranolol HCl [Inderal, Inderal LA, InnoPran XL]
Rizatriptan benzoate [Maxalt, Maxalt-MLT]
Sertraline HCl [Zoloft]
Sumatriptan succinate [Imitrex]
Topiramate [Topamax]
Trimethoprim-sulfamethoxazole (co-trimoxazole; TMP-SMZ) [several trade names]
Vancomycin [Vancocin, Vancoled]
Verapamil HCl [several trade names]
Zolmitriptan [Zomig, Zomig-ZMT]
Zonisamide [Zonegran]
Suggested Reading
Abuabara A: A review of facial injuries due to dog bites. Med Oral Patol Oral Cir Bucal 11:E348; Ahonen K, et
al: A randomized trial of rizatriptan in migraine attacks in children. Neurology 67:1135, 2006; Chu AY, et al: Fatal
dog maulings associated with infant swings. J Forensic Sci 51:403, 2006; Damen L, et al: Prophylactic treatment of
migraine in children. Part 1. A systematic review of non-pharmacological trials. Cephalalgia 26:373, 2006; Damen L,
et al: Prophylactic treatment of migraine in children. Part 2. A systematic review of pharmacological trials. Cephalalgia
26:497, 2006; Evers S, et al: Treatment of childhood migraine attacks with oral zolmitriptan and ibuprofen. Neurology
67:497, 2006; Golden AS, et al: Nonepileptic uses of antiepileptic drugs in children and adolescents. Pediatr Neurol
34:421, 2006; Mack KJ: Episodic and chronic migraine in children. Semin Neurol 26:223, 2006; Monastero R, et
al: Prognosis of migraine headaches in adolescents: a 10-year follow-up study. Neurology 67:1353, 2006; Pakalnis A,
Kring D: Zonisamide prophylaxis in refractory pediatric headache. Headache 46:804, 2006; Raieli V, et al: Recurrent
and chronic headaches in children below 6 years of age. J Headache Pain 6:135, 2005; Riva D, et al: Cognitive
and behavioural effects of migraine in childhood and adolescence. Cephalagia 26:596, 2006; Rubin DH, et al: Schalamon
J, et al: Analysis of dog bites in children who are younger than 17 years. Pediatrics 117:e374; Villani NM:
Treating dog and cat bites. Adv Nurse Pract 14:44, 2006; Winner P, Hershey AD: Diagnosing migraine in the pediatric
population. Curr Pain Headache Rep 10:363, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the following has been disclosed: Dr. Marcy is a consultant for GlaxoSmithKline, Merck, Sanofi-Pasteur, Medimmune,
and Abbott.
Dr. Kossoff was recorded in Baltimore, MD, at Pediatrics for the Practitioner Update 2006, held September 28-29,
2006 and presented by Johns Hopkins University, School of Medicine, Division of General Pediatrics and Adolescent
Medicine and Johns Hopkins Children’s Center; Dr. Marcy was recorded in Palo Alto, CA, at Pediatric Otolaryngology
Update 2006, held October 27-28, 2006 and presented by the Department of Otolaryngology-Head and Neck
Surgery, Stanford School of Medicine and the Lucile Packard Children’s Hospital. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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