Survey of Child Neurologists on Management of Pediatric Post-traumatic Headache

Patterns of Use and Benefit of Triptans in the Treatment of Acute Headache Worsening in Youth With Post-Traumatic Headache

BACKGROUND

Triptans are used to treat migraine attacks, but little to no evidence supports their use for youth with post-traumatic headache (PTH). This study evaluated patterns of use and benefit of triptans in the treatment of acute headache worsening in youth with PTH.

METHODS

A single-center retrospective cohort study was conducted by reviewing charts for 332 patients aged eight to 17 years seen in a child neurology clinic for PTH within one year of concussion. Treatment responses and side effects were recorded. Demographic and headache characteristics associated with triptan use and treatment response were examined.

RESULTS

Eighty of 332 patients (24.1%) used a triptan. Of those, 34 (42.5%) had acute (less than three months) PTH and 46 (57.5%) had persistent (greater than or equal to three months) PTH. Median time from injury to triptan prescription was 123 days (interquartile range, 50, 242). Older patients, those with headache phenotype consistent with migraine, those who previously used a greater number of treatments for acute headache worsening, and those seen by the headache program were more likely to use triptans (χ2 > 7.00, P < 0.01). Sixty percent reported at least partial headache relief with their first triptan, whereas 25% reported side effects, all of which were minor.

CONCLUSIONS

These findings show triptans are more likely to be used for youth with PTH with phenotype consistent with migraine that are unrelieved by other treatments for acute headache worsening. Triptans may be an effective treatment for acute headache worsening in youth with PTH, although randomized controlled trials are needed.

Headache Characteristics of Pediatric Sport-Related Concussion

BACKGROUND

Headache is among the most common symptoms following concussion, yet headache after concussion (HAC) remains poorly characterized. This study describes headache characteristics over the first four weeks following pediatric sport-related concussion.

METHODS

This is a retrospective case series of 87 athletes (mean: 14.9 years; range: 8.4-18.8 years; 38% female) treated in a specialty sports concussion clinic within 28 days of injury. Primary outcomes of headache consistency, frequency, duration, and associated migrainous symptoms were assessed at immediate (0 to 48 h) and weekly time points over the first 28 days post-injury. Generalized mixed linear models compared headache characteristics across time points. Secondary analyses compared each outcome by as-needed analgesic use.

RESULTS

During the immediate post-injury period, headache was more often constant (p = 0.002) and associated with migrainous symptoms (p < 0.001). By the third week post-injury, episodic headache was more prevalent (p < 0.001). Most patients (54%) transitioned from constant, migrainous headache to episodic, non-migrainous headache. This finding was uninfluenced by as-needed analgesic medication use.

CONCLUSIONS

These findings document the trajectory of HAC. Future studies should assess relationships between initial headache characteristics and recovery.

Factor Structure for the Sport Concussion Assessment Tool Symptom Scale in Adolescents After Concussion

OBJECTIVE

To examine the factor structure of the Sport Concussion Assessment Tool-5 (SCAT5) symptom scale in adolescents on their initial presentation to a concussion clinic within the typical recovery period after concussion (ie, <30 days). We hypothesize that the SCAT5 symptoms represent various clinically meaningful groups. A secondary purpose was to examine the effects of sex on the factor structure of the SCAT5 symptom scale.

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

Tertiary, institutional.

PATIENTS

Nine hundred eighty-one adolescents (45% women) aged between 13 and 18 years.

INDEPENDENT VARIABLES

Adolescents completed the SCAT5 symptom scale.

MAIN OUTCOME MEASURES

The factor structure of SCAT5 examined using a principal axis factor analysis.

RESULTS

A 5-factor structure model explained 61% of the variance in symptoms. These 5 factors are identified as Energy (17%), Mental Health (13%), Migrainous (13%), Cognitive (9%), and Vestibulo-Ocular (9%). A similar 5-factor model emerged for each sex, and the proportion of variance in symptoms explained by the 5-factor model was comparable between the sexes.

CONCLUSIONS

The findings of this report indicate that the SCAT5 symptoms aggregated into 5 delineated factors, and these factors were largely consistent across the sexes. The delineation of symptoms into 5 factors provides preliminary validation for the presence of different concussion phenotypes. Confirmatory factor analysis is warranted to examine the applicability and clinical utility of the use of the 5-factor structure in a clinical setting.

Repetitive neuromuscular magnetic stimulation in children with headache

INTRODUCTION

Repetitive neuromuscular magnetic stimulation (rNMS) was previously applied in adult patients with episodic migraine, showing beneficial effects on headache characteristics, high safety, and convincing satisfaction. This study aims to assess rNMS as a personalized intervention in pediatric headache.

METHODS

Retrospective chart review including patients with migraine, TTH, mixed type headache, or PTH, who had received at least one test rNMS session targeting the upper trapezius muscles (UTM).

RESULTS

33 patients (13.9 ± 2.5 years; 61% females) were included in the primary analysis, resulting in a total of 182 rNMS sessions. 43 adverse events were documented for 40 of those sessions (22%). Most common side effects were tingling (32.6%), muscle sore (25.5%), shoulder (9.3%) and back pain (9.3%). Secondly, in patients (n = 20) undergoing the intervention, headache frequency (p = 0.017) and minimum and maximum intensities (p = 0.017; p = 0.023) significantly decreased from baseline to 3-month after intervention. 11 patients (44%) were classified as ≥25% responders, with 7 patients (28%) experiencing a ≥75% reduction of headache days. After 73% of interventions, patients reported rNMS helped very well or well. A majority of patients would repeat (88.5%) and recommend rNMS (96.2%) to other patients.

CONCLUSION

rNMS seems to meet the criteria of safety, feasibility, and acceptance among children and adolescents with three age-typical headache disorders. A significant reduction in headache frequency and intensity during a 3 months follow-up was documented. Larger, prospective, randomized, sham-controlled studies are urgently needed to confirm if rNMS may become a new valuable non-invasive, non-pharmacological treatment option for pediatric headache disorders.

Characterization of persistent post-traumatic headache and management strategies in adolescents and young adults following mild traumatic brain injury

Characteristics of persistent post-traumatic headache (PTH) in young individuals are poorly known leading to diagnostic problems and diverse management. We aimed to describe headache phenotypes and self-reported management strategies in young individuals with PTH following mild traumatic brain injury (mTBI). A comprehensive structured questionnaire was used to evaluate headache phenotypes/characteristics and management strategies to relieve headache in 107, 15–30-year-old individuals with PTH. Around 4 months post-injury, migraine-like headache in combination with tension-type like headache (40%) was the most commonly encountered headache phenotype followed by migraine-like headache (36%). Around 50% reported aura-like symptoms before/during the headache attack. Medication-overuse headache was diagnosed in 10%. Stress, sleep disturbances, and bright lights were the most common trigger factors. More than 80% reported that their headache was worsened by work-related activity and alleviated by rest/lying down. Simple analgesics were commonly used (88%) whereas prophylactic drugs were rarely used (5%). Bedrest and physiotherapy were also commonly used as management strategies by 56% and 34% of the participants, respectively. In conclusion, most young individuals with PTH after mTBI presented with combined migraine-like and tension-type-like headache followed by migraine-like headache, only. Preventive headache medication was rarely used, while simple analgesics and bedrest were commonly used for short-term headache relief.

Treatment of Post-traumatic Headaches in Children: A Systematic Review

Post-traumatic headache is a secondary headache disorder beginning within 7 days of head injury. We conducted a systematic review of the evidence for treatment of post-traumatic headache in children. Of 2169 unique articles screened, 12 were included. Most studies pertained to headaches after concussion. The authors of seven studies examined the effect of medications, 4 studied nonpharmacological therapies, and 1 studied the reduction of medication usage. Much of the evidence came from retrospective chart reviews, had low level of evidence, and had fair risk of bias. High-quality randomized controlled treatment trials are needed to guide the clinical management of this condition.

A Review of Implementation Concepts and Strategies Surrounding Traumatic Brain Injury Clinical Care Guidelines

Despite considerable efforts to advance the science surrounding traumatic brain injury (TBI), formal efforts supporting the current and future implementation of scientific findings within clinical practice and healthcare policy are limited. While many and varied guidelines inform the clinical management of TBI across the spectrum, clinicians and healthcare systems are not broadly adopting, implementing, and/or adhering to them. As part of the Brain Trauma Blueprint TBI State of the Science, an expert workgroup was assembled to guide this review article, which describes: (1) possible etiologies of inadequate adoption and implementation; (2) enablers to successful implementation strategies; and (3) strategies to mitigate the barriers to adoption and implementation of future research.

Models for Treating Post-traumatic Headache

PURPOSE OF REVIEW

To discuss the treatment of post-traumatic headache (PTH) and how to choose pharmacotherapy based upon known pathophysiology.

RECENT FINDINGS

Preclinical models of traumatic brain injury are finally revealing some of the mechanisms of PTH, including the significant role that inflammatory neuropeptides like calcitonin gene-related peptide (CGRP) play in the initiation and persistence of symptoms. To effectively treat post-traumatic headache (PTH), one needs to understand the pathophysiology behind the initiation and persistence of symptoms. Recent animal models are starting to elucidate these mechanisms, but effective treatment will also likely rely on the identification of patients who are most at risk for persistent PTH. Trials of early, targeted therapy for at-risk patients will be needed to validate these hypotheses. Additionally, high powered clinical trials are lacking in the field of persistent PTH for medications that are known to be effective in primary headache disorders. Effective treatment for persistent PTH also requires understanding how headache interacts with the complex nature of persistent post-concussion symptoms, as this disease often necessitates a multi-disciplinary approach. Regardless, with the knowledge gained by new PTH models cited in this paper, and an increasing availability of novel headache medications, more effective treatment models are on the horizon.

Post-traumatic Headache in Children and Adolescents

PURPOSE OF REVIEW

Post-traumatic headache is a common disorder in the pediatric age group, seen both by child neurologists and by non-neurologists. The current review of post-traumatic headache in children and adolescents aims to review the pathophysiology, risk factors, clinical features, neuroimaging, and both acute and preventive treatment options.

RECENT FINDINGS

Recent literature provides insight into specific risk factors in the pediatric age group for developing post-traumatic headache as well as unique pathophysiologic changes seen in neuroimaging and neurometabolic pathways. It also elucidates common treatment options and novel treatments being currently explored, such as with monoclonal antibodies to CGRP. Finally, current evidence and guidelines recommend the benefit of a gradual return to normal activity based on symptom stability rather than a specific time period. Review of literature on pediatric post-traumatic headache reveals a growing understanding of the factors involved in developing headache after head trauma and the diagnosis/treatment of headache though future research will help further elucidate these areas.

Evaluation of Posttraumatic Headache Phenotype and Recovery Time After Youth Concussion

IMPORTANCE

The Four Corners Youth Consortium was created to fill the gap in our understanding of youth concussion. This study is the first analysis of posttraumatic headache (PTH) phenotype and prognosis in this cohort of concussed youth.

OBJECTIVE

To describe the characteristics of youth with PTH and determine whether the PTH phenotype is associated with outcome.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study examined outcomes from patients in a multi-institutional registry of traumatic brain injury (TBI) clinics from December 2017 to June 2019. Inclusion criteria included being between ages 5 and 18 years at enrollment and presentation within 8 weeks of a mild TBI. Data were analyzed between February 2019 and January 2021.

EXPOSURE

Mild TBI with standard care.

MAIN OUTCOMES AND MEASURES

Time to recovery and headache 3 months after injury; measurement device is the Postconcussion Symptom Inventory (PCSI). PTH with migraine phenotype was defined as moderate-severe headache that is new or significantly worse compared with baseline and associated with nausea and/or photophobia and phonophobia.

RESULTS

A total of 612 patients with 625 concussions were enrolled, of whom 387 patients with 395 concussions consented to participate in this study. One hundred nine concussions were excluded (concussions, rather than patients, were the unit of analysis), leaving 281 participants with 286 concussions (168 [58.7%] girls; 195 [75.6%] White; 238 [83.2%] aged 13-18 years). At the initial visit, 133 concussions (46.5%) were from patients experiencing PTH with a migraine phenotype, 57 (20%) were from patients experiencing PTH with a nonmigraine phenotype, and 96 (34%) were from patients with no PTH. Patients with any PTH after concussion were more likely to have prolonged recovery than those without PTH (median [interquartile range], 89 [48-165] days vs 44 [26-96] days; log-rank P < .001). Patients with PTH and a migraine phenotype took significantly longer to recover than those with nonmigraine phenotype (median [interquartile range], 95 [54-195] days vs 70 [46-119] days; log-rank P = .01). Within each phenotype, there was no significant difference between sexes in recovery or PTH at 3 months.

CONCLUSIONS AND RELEVANCE

PTH with a migraine phenotype is associated with persistent symptoms following concussion compared with nonmigraine PTH or no PTH. Given that female sex is associated with higher rates of migraine and migraine PTH, our finding may be one explanation for findings in prior studies that girls are at higher risk for persistent postconcussion symptoms than boys.