Which of the drugs appears to be the most effective preventative drug for children and adolescents with headaches?

By | May 13, 2012

Which of the following appears to be the most effective preventative medication for children and adolescents with migraine headaches?

A. Propranolol (Inderal)

B. Gabapentin (Neurontin)

C. Topiramate (Topamax)

D. Levetiracetam (Keppra)

E. Zonisamide (Zonegran)

The answer is C. Data on preventative medication for children and adolescents with migraine headaches is sparse, as noted by the American Academy of Neurology in 2004. A more recent review published in 2007 identified and evaluated the data regarding medication use for migraine prophylaxis in the pediatric population. Few controlled clinical trials regarding prophylaxis therapy are available, and no medication is approved by the FDA for prophylaxis of migraines in children. Of the drugs with available data, topiramate (Topamax), divalproex sodium (Depakene), flunarizine, amitriptyline (Elavil), and cyproheptadine (Periactin) showed efficacy in decreasing migraine frequency and duration in children, without the large clinical trials necessary to validate their utility. Topiramate, divalproex sodium, and amitriptyline had the most data on their use for prophylaxis of migraines in children. Flunarizine is not available in the United States. (Eiland, Jenkins, & Durham, Ann Pharmacother 2007; Lewis, Ashwal, Hershey, et al., Neurology 2004)

Which of the following is the most important trigger of hemodialysis headache ?

A. Calcitonin gene-related peptide (CGRP)

B. Substance P

C. Nitric oxide (NO)

D. Serotonin (5-HT)

E. Prostaglandins

The answer is C. Although calcitonin gene-related peptide, substance P, serotonin (5-HT), and prostaglandins are some of the multiple endogenous agents that mediate neurogenic inflammation in primary headache, and possibly hemodialysis headache, bradykinin modulation of nitric oxide (NO) synthesis is thought to play an important role in its triggering. Nitric oxide is increased in the plasma of patients with a hemodialysis headache, which may be mechanistically similar to an NO donor headache. (Antonizzi & Corrado, Curr Pain Headache Rep 2007)

Headaches that develop during scuba diving are most commonly due to:

A. Migraine triggered by the dive.

B. Decompression sickness.

C. Carbon monoxide (CO) intoxication.

D. Hypercapnia with PaC02 >50 mm Hg.

E. Beach bar hangover.

The answer is D. Headaches that most commonly occur during or after scuba diving are due to hypercapnia from hypoventilation in the setting of exercise. Focal neurological symptoms, alteration in consciousness, and musculo-skeletal pain indicate decompression sickness. Treatment with 100% oxygen by nasal prongs or face mask acutely and then in a hyperbaric chamber is indicated with decompression sickness. Other headaches associated with diving include sinus barotrauma, arterial gas embolism, carbon monoxide toxicity, hyperbaric-triggered migraine, cervical and temporomandibular joint strain, supraorbital neuralgia, carotid artery dissection, and exertional and cold stimulus headaches. (Cheshire, Curr Pain Headache Rep 2004; ICHD-II, Cephalalgia 2004)