Study: Migraines in children are under-treated

A study indicates that migraines in children are under-treated and usually do not received evidence-based treatment.

While evidence-based guidelines are fine-tuning a safe, effective approach to acute migraine care, it appears many younger patients are not receiving the care they need for their migraine attacks.

Nearly half of pediatric patients did not receive any treatment for their migraines, and a vast majority of children did not receive evidence-based prescriptions or recommendations, according to the results of a multi-state retrospective study.

The trend appears especially apparent in urban health care centers and emergency department (ED) facilities, where patients seem less likely to receive proper evidence-based treatments or receive any treatment at all.

“This is not just a pediatric problem, we actually know from a number studies over the last 20 years that headache is an underdiagnosed condition,” Robert A. Nicholson, PhD, LCP, FAHS, from the Mercy Clinic Headache Center & Mercy Health Research in St. Louis, Missouri, told Practical Pain Management.

When a patient presents with migraine, evidence-based guidelines typically recommend some form of abortive treatment, such as triptans or nonsteroidal anti-inflammatory drugs (NSAID). However, many patients do not receive any of these treatments, and this appears to be the case for younger patients as well.

“This study does point out that, for adults and children, migraine and headache tends to be undertreated. The fact that many patients, young and older, are sent home with no specific migraine treatment is discouraging, but not surprising,” said Lawrence Robbins, MD,  a headache specialist practicing in Riverbrooks, Illinois.

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Increase in concussions seen in Ontario's children

A study showed that concussions in Ontario's children significantly increased between 2003 and 2010.

The number of children and youth treated for concussions in both emergency departments and physician's offices in Ontario increased significantly between 2003 and 2010, with falls, hockey and skating injuries identified as the leading causes of pediatric concussion, according to a new joint study out of York University and the Institute for Clinical Evaluative Sciences (ICES).

The study," A population-based study of pediatric emergency department and office visits for concussions from 2003 to 2010," published in the journal Paediatrics & Child Health, analyzed all visits related to a concussion by school-aged youth (three to 18 years) in Ontario from 2003 to 2010.

"This study is the first to examine pediatric concussions evaluated in both emergency departments and physicians' offices," says York University Professor Alison Macpherson, the study's lead author. "By examining all of the pediatric concussions evaluated in multiple facilities, we were able to minimize the issue of under-reporting and obtain a more accurate number of concussions treated in Ontario."

Between 2003 and 2010, researchers found a total of 88,688 pediatric concussions were treated in either an emergency department or a physician's office, and there was a significant trend in both locations. The total rate of concussions per 100,000 increased from 466.7 to 754.3 (for boys), and from 208.6 to 440.7 (for girls) during the study period. The numbers also showed that over time more children were being evaluated in physician's offices than emergency departments.

When the sources of concussion were broadly examined, falls were found to be the most common cause of concussion in an emergency department, representing 34 per cent of all emergency department visits, followed closely by exposure to force (25.5 per cent) and motor vehicle collisions (12.3 per cent). When specific causes were examined in more detail, hockey and skating -- common sports in North America -- were the most common causes of concussions that were treated in an emergency department.

"Our findings reinforced that falls in general are the most common cause of pediatric concussions, and that evidence-based prevention initiatives to help reduce the incidence of concussion are warranted -- particularly in sports and recreation programs," says senior scientist and chief science officer at ICES, Dr. Astrid Guttmann, the study's senior author. "Sports-related concussions can be minimized by taking preventive action, such as reducing body checking in hockey or wearing a helmet while cycling."

Macpherson says that future studies can attempt to differentiate between the true incidence of concussions and an increase in those seeking a health evaluation due to increased awareness of concussion and subsequent health consequences.

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When to go to the hospital for a migraine

This article explains when it is appropriate to go to the hospital for a migraine headache.

Headache is one of the most common reasons for an emergency room visit. Some people go due chronic headache or Migraine problems that do not go away with treatment, and in other cases, headache is a symptom of another medical problem.

The best reason for an ER visit is for unusual symptoms that are new to you. You may seek attention to make sure there is no chance of another problem such as aneurysm or meningitis. A severe headache that starts very suddenly (within a second or two) can mean another disorder such as stroke. New symptoms such as a fever, weakness, vision loss or double vision, or confusion are some of most concerning symptoms. If you have a new symptom and serious, life-threatening medical problems such as liver, heart or kidney disease, are pregnant, or have a disorder which affects your immune system such as HIV infection, an ER visit may be more essential.

For many patients, an ER visit for headache or Migraine happens after a long period of severe headache lasting days or weeks. After long time of experiencing severe headache, you may reach the "last straw" and no longer be able to deal with the problem. ER doctors are not specialists in headache and Migraine, and their goals are to make sure there is no serious life-threatening problem and help reduce suffering. Different ER doctors have different ways to treat acute headache and Migraine: there is no universal protocol for emergency treatment of headache disorders.

When going to the ER, be sure to mention:

• your symptoms, including any that are new or unusual for you;
• any medications you have taken, especially in the last few days; and
• if you have had good results from a particular medication regimen, that can be helpful to the ER.

Often ER doctors will want to order tests such as a CT scan of the head or spinal tap to make sure there is no bleeding in the brain, large stroke or meningitis. If you are having your typical severe headache or Migraine, and no new symptoms, the chance these tests will be helpful are extremely low and you have the right to refuse them. (See 5 Things Migraine and Headache Patients and Doctors Should Question.)

The majority of persons coming to an ER for severe headache or Migraine do not get lasting results from the medications given in the ER, so having a good long-term plan and relationship with an outpatient doctor who treats your headache disorder is very important. If you have even occasional long-lasting headaches or Migraines, a good preventive plan is very important, and you should have at least one rescue medication to prevent future ER visits.

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Pediatric emergency department visits due to headaches depend on the month

A study that looked at monthly changes in emergency department visits for children caused by headaches shows that children are more likely to go to the emergency department after they return to school from winter or summer breaks. The authors believe this is due to a change in daily lifestyle.

The objective of this article is to determine the monthly variation of emergency department (ED) visits for pediatric headache. The authors hypothesized youth have increased headache–related ED visits in the months associated with school attendance. In adolescents they found higher ED utilization in January and September, the same months associated with school return from vacation for a majority of children nationally. No significant reduction in the summer suggests that school itself is not the issue, but rather changes in daily lifestyle and transitions.

Methods

• Using a United States representative sample of ED visits in the National Hospital Ambulatory Medical Care Survey from 1997 to 2009, the authors estimated number of visits associated with ICD-9 codes related to headache, migraine, status migrainosus, or tension-type headache in 5- to 18-year-olds.
• Age-stratified multivariate models are presented for month of visit (July as reference).

Results

• There was a national estimate of 250,000 ED visits annually related to headache (2.1% of total visits) in 5- to 18-year-olds.
• In 5- to 11-year-olds, the adjusted rate of headache-related visits was lower in April (OR 0.42, 95% CI 0.20, 0.88).
• In 12- to 18-year-olds, there were higher rates in January (OR 1.92, 95% CI 1.16, 3.14) and September (OR 1.64, 95% CI 1.06, 2.55).

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