Please take good care of yourselves and practice these guidelines. More information will be posted here as it comes in.

Many of you have read my article on migraines entitled

Is My Headache a Migraine. Recently I have been approached with questions from my college campus students regarding their children and the brittle headaches their kids endure. Two students in particular stated that their child’s doctor had diagnosed them as having migraines, prescribed the medicine, periactin as needed, but did not explain to them what migraines in children are really all about.

This is a little disturbing to me, as I feel the more educated my patients are, the better they are able to manage their headaches and lead normal healthy lives. This falls on the treating doctor, and unfortunately, it seems this new era of doctors is in such a hurry, it has forgotten how to teach. Osler would role in his grave!

This part of treatment is obviously more important than the "periactin". And both should be part of an overall plan. "Written down and easy to follow", by both the parents and the little one.

So, I thought this would be a good time to again discuss this very debilitating disorder. No one ever wants to see a child suffer through these. I recommend reviewing the above article in addition to this one.

Children and teens can experience muscle tension or migraine headaches. Among school age children ages 5 to 17 in the United States, 20% are prone to headaches. Approximately 15% of these kids experience muscle tension headaches and 5% are dealing with migraines.

Chronic or frequent headaches can be tough to handle, and are even harder to understand when you are young, especially if you do not know anyone else who has them.

By the time they reach high school, most young people have experienced some type of headache. Fortunately, less than 5% of headaches are the result of serious disease, such as a tumor, abscess, infectious disease, or head trauma.

Most headaches are muscle tension type, the result of good and bad stress, sleep issues, or in a few instances, environmental or food triggers. About 5% of recurrent headaches will be diagnosed as migraine.

Episodic headaches are those that occur a few times a month at most. Chronic headaches occur with much more frequency, even several times in a week. If a child who has only had an occasional headache (once or twice a month) starts experiencing them more frequently (two, or three times a week), then these should be considered chronic and medical attention should be sought as soon as possible.

One of the most frustrating aspects of chronic headaches is the stress factor. Avoiding a known trigger is usually easier than avoiding stress. Young people want to do well on tests and in school, and they want to attend important events, but anticipating a math quiz or musical recital, or eagerly looking forward to a party or being in the school play, can result in anxiety or excitement. And, for some kids, this leads to a headache.

Up to 4% of children have their first headache before they reach elementary school, and they may not yet know how to describe the pain. If a young child has been crying or not eating, or has been restless or irritable, consult with your doctor about finding the source of discomfort or pain. Remember, the child has no idea what is happening and this can be very frightening.

The more knowledge (and easy to understand guide lines) school health officials, as well as parents have about children and chronic migraines, such as common triggers, symptoms, prevention, and treatments, the easier it will be to identify the child who is suffering through these headaches.

The best evidence based approach to treatment, interestingly, is the more holistic approach to little patients. It entails two things: 'chronic therapy', which addresses decreasing the frequency and intensity of the headaches, and 'acute therapy', which gives the patient and parents weapons to stave off an evolving attack.

As I have discussed in other articles, in adults, a migraine's throbbing head pain usually occurs on one side of the head, but in children it can affect both sides. The migraine is often accompanied by nausea, vomiting, dizziness, blurred vision, sensitivity to light and sound, and changes in temperament and personality. A headache's duration varies from individual to individual. But, generally, unlike adult migraine, which can continue up to four days, a child's migraine might be as short as one hour or may last for a day or so. Children also improve more rapidly to sleep. So, the best treatment for children is a nap in a quiet, and dark room.

About 15% of kids experience a migraine headache with an Aura. A typical aura is seeing colored or flashing lights, blind spots, or wavy lines or feeling a tingling in the face or an arm or leg. An aura alerts a migraine sufferer to the onset of a headache, warning the child several minutes before the pain starts. A small percentage of migraine sufferers also encounter temporary motor weakness, as they may lose their sense of coordination, stumble, or have trouble expressing themselves.

Young children with migraine may not have head pain at all but rather experience recurrent stomach problems or dizziness. These types of migraine are called migraine variants (Migraine Variants will be addressed in a future article). Children who have migraine also are more prone to motion sickness.

What causes a migraine? This is treated at length in my original article.

For most kids, migraine is inherited from a parent. Migraine occurs because of alterations in a person’s genetic makeup.  An individual migraine attack is often triggered by a particular environmental or emotional event. In some cases, triggers can be identified. Among the most commonly recognized ones are stress (good or bad), a change in routine, a change in sleep pattern, bright lights or loud noises, or certain foods and beverages. Let’s look at these for moment.

One of the things I first have patients, especially children do regarding brittle migraines, is keep a diary of foods, sleep patterns, and other possible triggers. The best way to do this is to get the whole

family involved, and use a big wall calender with plenty of space for everyone to write down what they observe, as one person may notice something another didn't.

There are many triggers in childhood migraines that should be weeded out. Foods are huge, but other things as mentioned above, like stress level, even positive stressors like more money, new teacher, family gatherings, etc. can be big. Sleep can be a major player. I can't stress enough, the value of regular sleep patterns and at least 9 hours of sleep every day for kids.

Food is probably the biggest player, so you have to read labels closely. Here are the biggest triggers I've seen in practice:

(1), Caffeine in any form, even in medicines. Keep in mind that caffeine is also used to treat headaches, but can be a two edged sword, and, induce “rebound phenomena”. (2), Mint, it's in everything, start tossing it out. (3), Red food dyes. (4), Yellow food dyes. (5), Hard aged cheeses, like Parmesan, and cheddars, remember also, that cheeses are not naturally yellow ( they have yellow dye in them). (6), Pizza. (7), Lunch meats. (8), Hot dogs and sausages. (9), Bacon, use "fresh-side", or "sugar cured".

The above meats have nitrates in them which induce migraines.

(10), chocolate in any form. (11), yogurt. (12), Chinese food (oriental).

(13), The additive, Mono-Sodium Glutamate (MSG) is a monster and must be avoided, it is in everything from snack foods, frozen foods, bullion, and ramen, to canned soups. (14), All citrus products. And watch out for sugar binges. Remember to write down every little detail that appears significant on that calendar, and let your doctor know how it's going.

After a formal diagnosis, a doctor's goal is to help reduce or eliminate the symptoms of a migraine and prevent future attacks.

In regard to treatment, sometimes children, especially young children, do not need any medication to treat a headache. Often there are non-medicinal treatments that can provide primary, or added benefit.

During a migraine attack, a child should be allowed to rest, and even sleep, in a quiet, dark and cool room. Raising the child’s head up on a pillow and providing a cool compress for the eyes or forehead can help them feel more comfortable. When at school, a child should be allowed to go to the nurse’s office and rest. Sometimes a quick nap is all it takes and they can return to the rest of the school day.

Trigger avoidance and a regular schedule are huge preventive measures that can be taken to avoid the frequency of attacks. Relaxation and stress management techniques can be helpful during an attack and to help alleviate stress before it becomes a full blown an attack. Daily physical activity is also very important in headache management and stress reduction. Two methods that have been well documented to help children with migraine include meditation and biofeedback. There is also much research that suggests hyper-hydration with plain water may prevent frequency in migraine attack.

Once a migraine has begun, several types of medication can alleviate the symptoms. Analgesics, such as acetaminophen or ibuprofen, are first-line pain relievers for treatment of headaches in children and adolescents. The Triptans can be helpful in those children who don’t find simple analgesics helpful. There are several different triptans available and two (almotriptan [Axert®] and rizatriptan [Maxalt®]) are FDA-approved for children. In addition, your doctor may also prescribe anti-emetics to stop the nausea and vomiting or a sedative to help a child rest.

Aspirin is not generally recommended for kids, as there is now, well documented evidence linking aspirin to the development of Reye's Syndrome, a rare disorder that children and teenagers can get while they are recovering from childhood infections, such as chicken pox, flu, and other viral infections. Reye's symptoms include nausea, severe vomiting, fever, lethargy, stupor, restlessness, and even delirium.

Children and adolescents who experience migraine attacks more than twice a week and which interfere with school or social activities, may be prescribed a daily medicine to try to prevent headaches. There are no medications that have been specifically designed for migraine so they all come from other categories including anti-seizure, blood pressure and anti-depressant drug classes. Common preventive medicines include beta blockers, tricyclic antidepressants, topiramate, and valproate. Please note: none of these medications are approved for migraine treatment in children. However, research in this area continues with excellent progress and doctors will utilize these medications as "off label" prescriptions.

Frequent headaches, especially those that occur more than once a week, deserve treatment, with both medication and non-medicinal options.  Headaches are not good for the brain and headaches often lead to more headaches. With the right treatment regimen your child can get his or her headaches under control and prevent further progression.

Further questions can be directed below, and look for continued articles on headaches in future posts on The Searchlight Messenger.

Dr. Counce

Many in my readership have seen my previous articles on Meningitis, and again, it's that time of year, when every August, I write an article on this important subject. This year my article will be accompanied by a discussion regarding the state of the art in the management of this disease.  

Although there are many organisms that can induce meningitis, a crippling and often fatal disease, from parasites and bacteria, to viruses, and even fungi as was seen in the tainted steroid vials from the New England Compounding Center just this last year, the Meningococcal bacterium is relentless in its attack once it invades. A serious pathogen with weaponry that is both efficient, and nearly impossible to repel.

College students, whether returning to school or just starting this fall, should be warned, and remember that there is a killer loose on campus. Its name is Neisseria Meningitidis, also known as the Meningococcus. Yes, it causes meningitis, but this is just one of the specters of disease this killer brings. It is vicious and unwavering in its ability to take down even the most robust human. It can attack at multiple levels affecting multiple systems, taking in some cases, only hours from initial infection to coma and death. Nothing, it seems is spared. From stroke to cardiogenic shock and renal failure, it can kill before meningitis even gets a chance to set up shop.

Although rare in the United States, it has caused epidemics in the United Kingdom and New Zealand, and is obviously an organism to be reckoned with. In addition to striking small children, it likes to attack robust men and women in their upper teens and early twenties. That's right, college students. And when it strikes, you feel like you have the flu; a few hours later, you are septic; in a few more, you are in septic shock. When the inflammation of the meningeal covering around your brain and spinal cord begins (meningitis), it’s too late, and “you will find yourself alone in green pastures with the sun on your face, because you are in Elysium, and you are already dead!"

Imagine a college athlete at age 20 with everything going for him; a great school, academic success, strength and quickness, a full ride scholarship, popularity, and a life style envied by everyone. Then one October morning, he wakes up chilled, notices a mild fever, and he has a sore throat. He thinks “he’s caught a cold”, takes the usual remedies, and doesn’t tell anyone he’s “under the weather today”, because, “it’s just a cold”, and all he needs is rest. The next morning, he is found dead in his dorm room by his team mates. They notice reddish-black “splotches” all over his body.

Unfortunately, this is the rule and not the exception in a meningococcal attack. Small children are done in by this predator even more quickly. It invades through intimate contact usually, but can be acquired from casual contact as well. The really bad thing with this organism, is its deliberate swiftness. Moreover, the agonizing death of shock and accompanying meningeal “tightening” which is brutally painful, and described by survivors, as the most agonizing torture they have every been through. Many say they would rather die than go through it again.  

Survivors usually lose limbs, go blind, develop renal failure, suffer heart attacks or strokes due to ischemia and dissolved blood vessels. The Meningococcus is a deliberate killer with no apparent goal except to take down its host rapidly. Scientists are always perplexed by infectious diseases like this one, which attack, then kill their host and themselves so quickly in the process.

What’s happening? This organism secretes an endotoxin that attacks macrophages (white cells, whose job is to search and destroy invaders), creating circulating cellular debris, at the same time, eating away the intimal lining of our blood vessels, creating an immune reaction of cytokines. This is why many victims have severe petechiae and bruising almost immediately after infection, and of course, the reason the victim succumbs so swiftly.

We can kill this organism with antibiotics. He has never been one to show resistance to our antibiotic weaponry. The problem is that when the organism breaks down from penicillin or any other antibiotic we use, huge quantities of this endotoxin are released, the condition of the patient is exacerbated exponentially, and we gain nothing. The victims die outright or they are left crippled. There is no real treatment for an acute attack, but there is a vaccine! It is our only true and effective weapon right now, and yes, it works very well. Do yourself and others a favor and get the meningococcal vaccine. Realize that most schools require it now, before you start college.

Keep in mind that this is a stealthy organism. Fifteen to twenty percent of Americans are carriers. That means two out of every ten people you brush by, are harboring this organism without it causing illness to them, but they can infect you. It can be transmitted by sharing a cup or straw. Yes you can catch it from a casual kiss as well as sexual activity. Use your head, and keep your hands clean.

Remember, meningitis in general, can be caused by a host of different organisms and viruses, and although the meningococcus has a scary reputation, it is a smaller player in this regard. For example, the organism we worry about the most, and the number one cause of meningitis in children under two years of age in North America, is Haemophilus Influenza (H. Flu.). Also a well known killer, we can take it down with antibiotics if caught in time. Unfortunately, survivors are usually left deaf. This is why we vaccinate against H. Flu. Also known as the HIB vaccine, it is required by all fifty of the United States. The recent Listeria scare is also a concern. Listeria Monocytogenes, although a well known food poisoner and one of the reasons we pasteurize all of our dairy products in the U.S., it is also known for causing meningitis in little ones, especially infants.

Do yourself a big favor, and get the vaccine before heading back to school this fall, it’s never too late. Get it now! If your doctor doesn't offer it, any county health department will have it. Do the right thing. Make sure all of your vaccines are up to date, including the meningococcal vaccine. And don’t forget to keep your hands clean.

Just this month (August, 2013), the US Food and Drug Administration (FDA) broadened the indication for the quadrivalent meningococcal vaccine (Menveo; Novartis Pharmaceuticals, Inc) to include infants and toddlers aged 2 months and older. The vaccine, which protects against the common N meningitidis serogroups: A, C, Y, and W-135, was already approved for use in adolescents and adults aged 11-55 years and in children aged 2-10 years.

Below, is my discussion regarding Neisseria Meningitidis Meningitis and our latest in the standard of patient care in the specialties of Internal Medicine and Pediatrics here in North America and Great Britain.

Dr. Counce

By Dr. C. M. Counce

Meningococcal meningitis is characterized by acute onset of the following:

Don’t forget the general presentation of catarrhal symptoms alone, prior to the presentation of meningeal irritation as noted above. Lethargy or drowsiness in patients frequently is reported. Stupor or coma is less common. If coma is present, the prognosis is obviously poor.

Patients also may complain of skin rash, which usually points to disease progression, and an indication that the cytokine storm has begun.

Elderly patients are prone to have an altered mental state and a protracted course with fever.

Meningococcal septicemia, which is characterized by rapid circulatory collapse and hemorrhagic rash, is a more severe, but less common, form of meningococcal disease as patients are now presenting sooner to our emergency departments.

In young children, subacute infection can progress over several days. Meningococcal meningitis can manifest as follows:

In children, even when the combination of status epilepticus and fever exists, the classic signs and symptoms of acute bacterial meningitis may not be present.  

Neurologic signs of meningococcal meningitis include nuchal rigidity (eg, Kernig sign, Brudzinski sign), lethargy, delirium, coma, and seizures. Irritability is a common presenting feature in children. However, in a 2008 published cohort study from Netherlands (the Meningitis Cohort Study), conducted in adult patients with meningococcal meningitis, only 70% of the patients had the classic triad of fever, neck stiffness, and change in mental status. If the presence of rash was added, 89% of the patients had 2 of the 4 features. Patients older than 30 years were noted to have petechiae (62%) less frequently than younger patients (81%).

A petechial or purpuric rash usually is found on the trunk, legs, mucous membranes, and conjunctivae. Occasionally, it is on the palms and soles. The rash may progress to purpura fulminans, when it usually is associated with multiorgan failure (ie, Waterhouse-Friderichsen syndrome). The petechial rash may be difficult to recognize in dark-skinned patients.  

Laboratory examination of the cerebrospinal fluid (CSF) usually confirms the presence of meningitis. Typical CSF abnormalities in meningitis include the following:

Other laboratory tests can include the following:

An electroencephalogram (EEG) study is sometimes useful to document irritable electrical patterns that may predispose the patient to seizures.  

To prevent serious neurologic morbidity and death, prompt institution of antibiotic therapy is essential when the diagnosis of bacterial meningitis is suspected. Antimicrobial treatment should be administered as soon as possible after a lumbar puncture is performed.

Initial empiric therapy until the etiology of the meningitis is established should include the following agents:

Deterrence and prevention of meningococcal meningitis can be achieved by either immunoprophylaxis or chemoprophylaxis. Rifampin, quinolones, and ceftriaxone are the antimicrobials that are used to eradicate meningococci from the nasopharynx.

Currently, vaccinations against meningococcus A, C, W, and Y are available. No effective vaccine exists to protect individuals from meningococcal meningitis caused by serogroup B. Interesting, in that serogroup B is the mainstream killer in countries with higher prevalence of this disease (The United Kingdom and New Zealand).

Dr. Counce

 

 

 

 

 

 

 What’s going on? Why are more and more people being diagnosed and treated for this problem? As a physician I have seen many presentations of this extremely painful condition, moreover, just this last year, I had 3 friends who were not patients, people I consider very healthy, who had struggled with this problem.