Fish Oil for ADHD

September 12th, 2009

Andrew McIntosh, M.D.

Andrew McIntosh, M.D.

For some reason, the discussion of fish oil supplementation conjures up images of a mountebank peddling a potion at an old-style country fair. Indeed, the idea of fish oil supplementation to treat a variety of ailments has been around for many decades. Recently, fish oil has received a great deal of attention in the lay media and professional medical literature for the treatment of behavioral disorders such as ADHD.

After diagnosing a child with ADHD and transitioning to talking about treatments, I often start to feel a bit of tension in the room as parents start to think “I know he’s going to recommend medications and as a family we are not prepared for that”. However, before launching into a discussion of different pharmacotherapies for ADHD, it is important to consider nonmedical management. For example, behavior modification strategies have been adequately studied and proven to be beneficial for many children with ADHD. Three less frequently discussed ADHD treatments which I touch upon during my consultations are essential fatty acid (such as contained in fish oil) supplementation, sleep habits and basic dietary changes.

From scientific studies of essential fatty acids (EFAs) and ADHD we know that (1) individuals who have ADHD may have low levels of EFAs and (2) essential fatty acid supplementation may normalize EFA levels in children with ADHD. The clinical significance of this is somewhat less clear; however, most studies provide evidence of lessening ADHD symptoms. As with most scientific studies, there are concerns with study design and confounding factors but the current body of medical literature generally supports the use of essential fatty acid supplementation in children with ADHD.

The benefit of essential fatty acid supplementation for children with ADHD has been adequately established. However, the next question is “What are the associated risks?”. Fortunately, when used in recommended dosages, there are few potentially serious side effects associated with essential fatty acid supplementation. Reported side effects include: Fishy aftertaste (if the product is made from fish oil), nausea, bloating, or burping. Less common, symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness or trouble breathing may occur. Overall, fish oil supplementation is well tolerated.

There are several commercially available children’s formulations which provide an adequate dosage in a palatable form. The studies evaluating essential fatty acid supplementation for ADHD may serve as a dosing guideline. The three most compelling studies used 500-600mg of Omega-3 fatty acids in a balanced Omega 3, 6, 9 formulation. To keep things simple for my families, I recommend a fish oil-based, balanced product containing Omega 3, 6 and 9 fatty acids with 500-750mg of Omega 3 fatty acids from a high quality manufacturer. Products from Nordic Naturals and other high quality manufacturers are available at local markets (such as Mother’s and some Henry’s markets) and online. If children are not able to swallow the generally large capsules, palatable (“no fishy taste”) children’s formulation liquids and “gummies” are available.

Purchasing guidelines:
Children’s formulation
Fish oil-based product
500-750mg of Omega-3 fatty acids
Balanced Omega 3, 6, 9 product
High quality manufacturer (such as Nordic Naturals)

As evidence in scientific studies continues to build, essential fatty acid supplementation is gaining broader acceptance by mainstream physicians. The current medical literature is generally supportive of the benefit for children with ADHD and the common side effects are relatively mild. For families with children affected by ADHD, essential fatty acid supplementation should be considered an important component of a comprehensive treatment plan.

If you have any questions or would like information about scheduling an appointment with Dr. McIntosh, contact our office at (949) 249-3780 or visit our website for more information.

Staring Spell Seizures

July 1st, 2009

Andrew McIntosh, M.D.

Andrew McIntosh, M.D.

Everyday I’m asked to evaluate children with unusual “spells”. The most common sorts of spells are: staring, fainting, body movements (such as tics, twitches or tremors), unusual eye movements, abnormal sensations, or convulsive episodes. Altogether, these spells are known as “paroxysmal events”. Staring spells are the most common paroxysmal event during childhood. Unfortunately, staring spells can range from a completely benign childhood behavior to much more worrisome epileptic seizures. Although it is relatively uncommon, recurrent staring spells attributed to some sort of benign behavior (such as inattention or “daydreaming”) may actually be seizures such as seen in this -VIDEO-.

Most people are aware that there are different types of seizures. The most common type of seizures seen in the media are dramatic, convulsive seizures in which people have sudden loss of consciousness, fall to the ground and convulse for several minutes. Obviously, these are clearly abnormal events for which families seek immediate medical attention. Staring spells, however, are more subtle and difficult to characterize. There are two main kinds of epileptic staring spells – absence seizures and complex partial seizures.

Although absence and complex partial seizures both involve staring and unresponsiveness, there are several key differences which are important to recognize as the diagnostic testing, treatment and prognosis are significantly different between the seizure types. To help differentiate between absence and complex partial seizures it is important to consider the age of onset, duration, associated movements, and after effects.

Absence seizures usually start during preschool/early elementary years and generally resolve by puberty. It is rare for absence epilepsy to persist into adulthood. Complex partial seizures may begin at any age from early infancy through adulthood. Therefore, any staring spell seizures starting during infancy or as an adult are unlikely to be absence seizures.

Another difference is that absence seizures tend to be shorter than complex partial seizures – generally lasting less than 10 seconds and very rarely persisting beyond 30 seconds. Complex partial seizures almost always last longer than 30 seconds (typically one to three minutes).

Body or facial movements during the spells may provide clues to determining the seizure type. The movements during seizures may be of the trunk/shoulder, arms, legs or other automatisms (repetitive unconscious gestures such as lip smacking, chewing, or swallowing). Interestingly, the movements are often an unusual continuance of the pre-ictal activity. For example, if a child is talking or chewing prior to the seizure there may be an unusual chewing-like movement during the seizure. It is much more common to have unusual movements with complex partial seizures.

The after effects (postictal state) are another difference between the two seizure types. After an absence seizure, the child will resume his prior (pre-ictal) activity. Most of the time with an absence seizure there is a “reset” in which there is a brief moment of confusion and then the pre-ictal activity is resumed. There is sometimes an interesting smooth “continuance” of activity where a child will complete a sentence or seamlessly “pick up where he left off” at an activity immediately after the seizure as if nothing had happened. With complex partial seizures there is usually some sort of altered mental status (confusion, difficulty speaking, sleepiness or unusual emotions) lasting anywhere from several seconds to more than a few hours after the seizure.

For an experienced neurologist, clinically characterizing the spells is the most accurate way to make a diagnosis; however, electroencephalography (EEG) may reveal abnormal electrical activity which helps clarify the diagnosis. In absence epilepsy there is often a very characteristic EEG finding which is observed throughout the entire brain (generalized epileptiform discharges). The corresponding EEG findings for complex partial seizures tend to show abnormal electrical activity localized to one area (focal epileptiform discharges).

Once the seizure type is carefully characterized, there are implications regarding further diagnostic testing, treatment and long term prognosis. For example, if there is a very typical description of absence seizures and a supporting EEG, often no further testing is necessary. However, if there is any suggestion of complex partial seizures, the American Academy of Neurology recommends neuroimaging (an MRI being the preferred imaging modality). Treatments are also considerably different between the two seizure types with some medications for complex partial seizures possibly worsening absence seizures.

It is important for parents to realize that not all staring spells are “daydreaming” or defiant/ignoring behavior. With new treatment options available, clinically characterizing staring spells, getting appropriate testing and adequate treatment from an experienced pediatric neurologist can make a tremendous difference in a child’s life.

If you have any questions or would like information about scheduling an appointment with Dr. McIntosh, contact our office at (949) 249-3780 or visit our website for more information.

PANDAS – A Tic Disorder

May 1st, 2009

Andrew McIntosh, M.D.

Andrew McIntosh, M.D.

Tic disorders are a class of conditions seen very commonly by pediatric neurologists. The most important role for the pediatric neurologist in evaluating children with tics is to determine if the movements are idiopathic (cause unknown) or part of a more worrisome systemic condition, evolving intracranial process or new episodic neurological disorder. Fortunately, the overwhelming majority of tics occurring in children are benign and tend to wax and wane over a course of about six months to two years.

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection (PANDAS) is a somewhat controversial diagnosis within the specialty of pediatric neurology. Although some neurologists would argue that the diagnosis does not exist, there is a growing body of medical literature with diagnostic criteria, suggested diagnostic testing and evidence-based treatment recommendations. Recently, the National Institutes of Mental Health (NIMH) published a list of frequently asked questions. I’ve selected some of the more common questions raised by families in my office and have included them below.

General Information
PANDAS, is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. The term is used to describe a subset of children who have Obsessive Compulsive Disorder (OCD) and/or tic disorders such as Tourette’s Syndrome, and in whom symptoms worsen following Strep infections such as “Strep throat” and Scarlet Fever.

The children usually have dramatic, “overnight” onset of symptoms, including motor or vocal tics, obsessions, and/or compulsions. In addition to these symptoms, children may also become moody, irritable or show concerns about separating from parents or loved ones. This abrupt onset is generally preceded by a Strep throat infection.

What is the mechanism behind this phenomenon? At present, it is unknown but researchers at the NIMH are pursuing a theory that the mechanism is similar to that of Rheumatic Fever, an autoimmune disorder triggered by Strep throat infections. In every bacterial infection, the body produces antibodies against the invading bacteria, and the antibodies help eliminate the bacteria from the body. However in Rheumatic Fever, the antibodies mistakenly recognize and “attack” the heart valves, joints, and/or certain parts of the brain. This phenomenon is called “molecular mimicry”, which means that proteins on the cell wall of the Strep bacteria are similar in some way to the proteins of the heart valve, joints, or brain. Because the antibodies set off an immune reaction which damages those tissues, the child with Rheumatic Fever can get heart disease (especially mitral valve regurgitation), arthritis, and/or abnormal movements known as Sydenham’s Chorea or St. Vitus Dance.

In PANDAS, it is believed that something very similar to Sydenham’s Chorea occurs. One part of the brain that is affected in PANDAS is the Basal Ganglia, which is believed to be responsible for movement and behavior. Thus, the antibodies interact with the brain to cause tics and/or OCD, instead of Sydenham Chorea.

Is there a test for PANDAS?
No. The diagnosis of PANDAS is a clinical diagnosis, which means that there are no lab tests that can diagnose PANDAS. Instead clinicians use 5 diagnostic criteria for the diagnosis of PANDAS (see below). At the present time the clinical features of the illness are the only means of determining whether or not a child might have PANDAS.

What are the diagnostic criteria for PANDAS?
Presence of Obsessive-compulsive disorder and/or a tic disorder
Pediatric onset of symptoms (age 3 years to puberty)
Episodic course of symptom severity
Association with group A Beta-hemolytic streptococcal infection (a positive throat culture for Strep or history of Scarlet Fever.)
Association with neurological abnormalities (motoric hyperactivity, or adventitious movements, such as choreiform movements)

What is an episodic course of symptoms?
Children with PANDAS seem to have dramatic ups and downs in their OCD and/or tic severity. Tics or OCD which are almost always present at a relatively consistent level do not represent an episodic course. Many kids with OCD or tics have good days and bad days, or even good weeks and bad weeks. However, patients with PANDAS have a very sudden onset or worsening of their symptoms, followed by a slow, gradual improvement. If they get another Strep infection, their symptoms suddenly worsen again. The increased symptom severity usually persists for at least several weeks, but may last for several months or longer. The tics or OCD then seem to gradually fade away, and the children often enjoy a few weeks or several months without problems. When they have another Strep throat infection the tics or OCD return just as suddenly and dramatically as they did previously.

Are there any other symptoms associated with PANDAS episodes?
Yes. Children with PANDAS often experience one or more of the following symptoms in conjunction with their OCD and/or tics:
ADHD symptoms (hyperactivity, inattention, fidgety)
Separation anxiety (Child is “clingy” and has difficulty separating from his/her caregivers. For example, the child may not want to be in a different room in the house from his/her parents.)
Mood changes (irritability, sadness, emotional lability)
Sleep disturbance
Night- time bed wetting and/or day- time urinary frequency
Fine/gross motor changes (e.g. changes in handwriting)
Joint pains

My child has had Strep throat before, and he has tics and/or OCD. Does that mean he has PANDAS?
No. Many children have OCD and/or tics, and almost all school aged children get Strep throat at some point in their lives. In fact, the average grade-school student will have 2 – 3 Strep throat infections each year. PANDAS is considered when there is a very close relationship between the abrupt onset or worsening or OCD and/or tics, and a preceding Strep infection. If Strep is found in conjunction with two or three episodes of OCD/tics, then it may be that the child has PANDAS.

Could an adult have PANDAS?
No. By definition, PANDAS is a pediatric disorder. It is possible that adolescents and adults may have immune mediated OCD, but this is not known. The research studies at the NIMH are restricted to children.

My child has PANDAS. Should he have his tonsils removed?
The NIH does not recommend tonsillectomies for children with PANDAS, as there is no evidence that they are helpful. If a tonsillectomy is recommended because of frequent episodes of tonsillitis, it would be useful to discuss the pros and cons of the procedure with your child’s doctor, because of the role that the tonsils play in fighting Strep infections.

What exactly is an anti-streptococcal antibody titer?
The anti-streptococcal antibody titer determines whether there is immunologic evidence of a previous Strep infection. Two different Strep tests are commercially available: the antistrepolysin O (ASO) titer, which rises 3-6 weeks after a Strep infection, and the antistreptococcal DNAase B (AntiDNAse-B) titer, which rises 6-8 weeks after a Strep infection.

What does an elevated anti-streptococcal antibody titer mean? Is this bad for my child?
An elevated anti-Strep titer (such as ASO or AntiDNAse-B) means the child has had a Strep infection sometime within the past few months, and his body created antibodies to fight the Strep bacteria. Some children create lots of antibodies and have very high titers (up to 2,000), while others have more modest elevations. The height of the titer elevation doesn’t matter. Further, elevated titers are not a bad thing. They are measuring a normal, healthy response – the production of antibodies to fight off an infection. The antibodies stay in the body for some time after the infection is gone, but the amount of time that the antibodies persist varies greatly between different individuals. Some children have “positive” antibody titers for many months after a single infection.

When is a Strep titer considered to be abnormal, or “elevated”?
The lab at NIH considers Strep titers between 0-400 to be normal. Other labs set the upper limit at 150 or 200. Since each lab measures titers in different ways, it is important to know the range used by the laboratory where the test was done – just ask where they draw the line between negative or positive titers.

It is important to note that some grade-school aged children have chronically “elevated” titers. These may actually be in the normal range for that child, as there is a lot of individual variability in titer values. Because of this variability, doctors will often draw a titer when the child is sick, or shortly thereafter, and then draw another titer several weeks later to see if the titer is “rising” – if so, this is strong evidence that the illness was due to Strep (Of course, a less expensive way to make this determination is to take a throat culture at the time that the child is ill.)

Should an elevated Strep titer be treated with antibiotics?
No. Elevated titers indicate that a patient has had a past Strep exposure but the titers can not tell you precisely when the Strep infection occurred. Children may have “positive” titers for many months after one infection. Since these elevated titers are merely a marker of a prior infection and not proof of an ongoing infection it is not appropriate to give antibiotics for elevated titers. Antibiotics are recommended only when a child has a positive rapid Strep test or positive Strep throat culture.

What are the treatment options for children with PANDAS?
The treatments for children with PANDAS are the same as if they had other types of OCD or tic disorders. Children with OCD, regardless of whether or not their illness is Strep triggered, benefit from cognitive behavioral therapy and/or anti-obsessional medications. A recent study showed that the combination of an SSRI medication (such as fluoxetine) and cognitive behavioral therapy was the best treatment for OCD, and that medication alone or cognitive behavioral therapy alone were better than no treatment, or use of a placebo (sugar pill). It often takes time for these treatments to work, so the sooner therapy is started, the better it is for the child.

Children with Strep triggered tics should be helped by the same tic medications that doctors use to treat other tic disorders. Your child’s primary physician can help you decide which type of specialist your child may need to see to receive these treatments.

Can penicillin be used to treat PANDAS or prevent future PANDAS symptom exacerbations?
Penicillin and other antibiotics kill streptococcus and other types of bacteria. The antibiotics treat the sore throat or pharyngitis caused by the Strep by getting rid of the bacteria. However, in PANDAS, it appears that antibodies produced by the body in response to the Strep infection are the cause of the problem, not the bacteria themselves. Therefore one could not expect antibiotics such as penicillin to treat the symptoms of PANDAS. Researchers at the NIMH have been investigating the use of antibiotics as a form of prophylaxis or prevention of future problems. At this time, however, there isn’t enough evidence to recommend the long-term use of antibiotics.

What about treating PANDAS with plasma exchange or immunoglobulin (IVIG)?
The results of a controlled trial of plasma exchange (also known as plasmapheresis) and immunoglobulin (IVIG) for the treatment of children in the PANDAS subgroup was published in “The Lancet”, Vol. 354, October 2, 1999. All of the children participating in the study had clear evidence of a Strep infection as the trigger of their OCD and tics, and all were severely ill at the time of treatment. The study showed that plasma exchange and IVIG were both effective for the treatment of severe, Strep triggered OCD and tics, and that there were persistent benefits of the interventions. However, there were a number of side-effects associated with the treatments, including nausea, vomiting, headaches and dizziness. In addition, there is a risk of infection with any invasive procedure, such as these. Thus, the treatments should be reserved for severely ill patients, and administered by a qualified team of health care professionals. The NIH is not currently conducting any trials with immunomodulatory therapies, and so is not able to offer either or the treatments.

Of note, a separate study was conducted to evaluate the effectiveness of plasma exchange in the treatment of chronic OCD (Nicolson et al: An Open Trial of Plasma Exchange in Childhood Onset Obsessive-compulsive Disorder Without Poststreptococcal Exacerbations. “J Am Acad Child Adolesc Psychiatry 2000,” 39[10]: 1313-1315. None of those children benefited, suggesting that plasma exchange or IVIG is not helpful for children who do not have Strep triggered OCD or tics.

If you have any questions or would like information about scheduling an appointment with Dr. McIntosh, contact our office at (949) 249-3780 or visit our website for more information.

Sensory Processing Disorder

April 9th, 2009

Andrew McIntosh, M.D.

Andrew McIntosh, M.D.

What is a sensory processing disorder? Well, that depends on who you ask. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) it doesn’t exist and information in the mainstream medical literature is sparse. In my practice, the issue comes up almost every day. Often, sensory processing disorders are part of another, better defined, condition such as an autism spectrum disorder, ADHD or associated with an intellectual disability. However, I follow many children in my practice who have disabling and potentially treatable sensory processing issues but clearly do not meet diagnostic criteria for other common behavioral/neurological disorders. This month, an expert on sensory processing disorder, Betsy Aasland OTR, has written an excellent article for the blog that helps clear up some common questions.

Betsy Aasland, MS, OTR

Betsy Aasland, MS, OTR

Sensory Processing Disorder
“There is just something not right with my little girl!” says a frantic mom to me on the phone. “Her preschool teacher said she has difficulties with fine motor activities and some problems making friends. I just don’t understand because she really is so smart! The school district assessed her and she didn’t qualify for services and the pediatrician doesn’t seem to be concerned. Our family life is so hard because we never know how she is going to react when we go out anywhere! I have just about given up, but my friend from MOPS said she takes her son to occupational therapy for similar problems . . . Can you help?” “It’ll be okay,” I reply. “You’ve come to the right place. I think we can help. Now, tell me a more about your little girl.”

This conversation has taken place over and over again in my practice. As an occupational therapist specializing in the treatment of Sensory Processing Disorder (SPD), I encounter this scenario with parents and children across all ages, race, and socio-economic status.

Sensory processing (also known as sensory integration) is a term that refers to the way the nervous system receives messages from the senses and turns them into appropriate motor and behavioral responses. It is thought that SPD occurs when an individual cannot put all of the information from their senses together in an efficient manner. Therefore, they can’t produce an appropriate response. For example, a child may demonstrate an over-reaction to unexpected loud noises, or conversely, not seem to notice a fire alarm. SPD doesn’t just affect the sense of hearing, but all of the senses, including vision, taste, smell, touch, as well as our sense of movement (vestibular sense) and our sense of where our body is in space (proprioceptive sense).

The idea of SPD was first introduced to the public in the 1960’s by A. Jean Ayers, PhD. She was an occupational therapist and neuroscientist who compared SPD to a neurological “traffic jam” that prevents certain parts of the brain from receiving the information needed to interpret sensory information correctly. In addition to inappropriate sensory responses, children with SPD may demonstrate poor attention span, difficulty following directions, inability to sit still, poor coordination and balance, difficulty making friends, behavioral outbursts, and low self-esteem.

SPD is many times referred to as a “hidden disability” as it can be very difficult for the untrained eye to detect. Historically, SPD has often been misdiagnosed as ADD/ADHD, Autism, and others. While it is true that SPD can co-exist with many other disorders, it can also stand alone as a debilitating issue. Children who suffer from SPD can be very misunderstood. Teachers may label them as a problem child. The pediatrician may say “he’ll grow out of it.” Parents even think that their child is simply quirky, high-energy, or just clumsy. What sets this child apart from his peers? It may be Sensory Processing Disorder. Fortunately, when treated effectively, the symptoms of SPD can be greatly reduced or even resolve completely!

Although some studies suggest that as many as 1 in 20 children suffer from SPD, information and help for those with this disorder is still very limited. A lack of knowledge and resources, combined with the fact that SPD often looks like other disorders frequently results in misdiagnosis and inappropriate treatment. Even when parents do obtain a diagnosis, it can be difficult to find a qualified professional to provide treatment. On top of that, most insurance companies do not cover the cost of treatment. Fortunately, there are more and more medical professionals in Southern California who are familiar with SPD and provide appropriate referrals and diagnostic coding. This improves the prompt delivery of appropriate care and greatly improves the chances of insurance coverage.

The most common treatment for SPD is occupational therapy (OT). An occupational therapist that treats SPD has generally received additional specialized training. OT with a sensory integrative approach typically takes place in a sensory-rich environment. Such specialized centers provide opportunities for sensory-based motor development in the “gym”, tactile art and fine motor activities, and self-regulation in a quiet room. During OT sessions, therapists guide the child through a series of play activities that are subtly designed to provide the “just right challenge” (constantly challenging a child, but always with a successful end result).

Although the recognition and treatment of SPD is gradually becoming more accepted in mainstream medicine, there are still many children suffering with SPD having received an inaccurate diagnosis and inadequate therapies. Well informed doctors, therapists, psychologists and other healthcare professionals/educators being aware of SPD and community resources can greatly improve the quality of life for affected children.

If you would like more information about SPD or to arrange an appointment at Beach Kids Therapy Center please visit their website or call (949) 498-5100.

Medications for Migraine

January 1st, 2009

Andrew McIntosh, M.D.

Andrew McIntosh, M.D.

As a pediatric neurologist with a busy outpatient practice, children suffering from headaches make up about a third of my office visits. Recurrent headaches can be disabling for children. Headaches are the third most common cause of school absenteeism and often result in limitation of sports and other extracurricular activities. Migraine is the most common primary headache syndrome. A comprehensive program to treat migraines may include lifestyle changes with trigger identification and avoidance, medications, complementary and alternative medicine treatments, and strong family/mental health support.

Generally by the time families end up in my office, some effort at lifestyle changes with headache trigger identification and avoidance strategies have been attempted. When families come to see me, I always spend some time educating them and reinforcing adequate lifestyle changes before launching into a discussion of pharmacotherapy. I put together some valuable resources for families including common headache triggers/food triggers and a headache diary available on our web site at http://www.mcintoshneurology.com.

Medications for the management of migraines can be divided into four classes: symptomatic, abortive, preventative/prophylactic and rescue medications. There are several medications within each class. Tailoring an individualized treatment plan is an essential component of an overall management strategy which should be formulated by a professional comfortable with each class of medications.

Symptomatic, abortive and rescue medications are used during an acute migraine attack. Symptomatic treatments are basic over-the-counter analgesics such as ibuprofen, naproxen, and acetaminophen (“headache medicines”) which “dull” headache pain. If aggressive symptomatic treatment is used early on in the course of the acute migraine, there may be very good control of the headache. Unfortunately, even with good headache relief, many migraineurs report having continued challenges with the “washed out” period that follows the pain relief (difficulty concentrating, fatigue and poor academic performance). Also, overuse of analgesics may result in rebound and/or chronic daily headache.

After their introduction in the early 1990s, new migraine-abortive triptan medications revolutionized migraine treatment and were considered a “miracle drug” for many migraineurs. Triptan medications such as: sumatriptan (Imitrex, Imigran), rizatriptan (Maxalt), naratriptan (Amerge, Naramig), zolmitriptan (Zomig), and others have demonstrated about 60 to 80% effectiveness in providing complete relief within two hours. Additionally, triptan medications help prevent the “washed out” period that follows pain relief. Triptan medications are usually reserved for situations when lifestyle changes and symptomatic treatments have failed to provide adequate relief. Like symptomatic treatments, triptan medications work best when taken very early on in the course of the migraine. Recently, a combination sumatriptan/naproxen medication was released which emphasizes the point that using a triptan medication should not be delayed until symptomatic treatment has been attempted and failed during an acute migraine. Overall, triptan medications are well-tolerated. Special precautions need to be observed when taken with other classes of medication, especially selective serotonin reuptake inhibitors (SSRI’s).

Some general indications for considering the use of a preventative/prophylactic medication include: two or more prolonged and debilitating headaches per month, use of abortive medications more than twice a week and uncommon migraine conditions/migraine variants. Serendipitously discovered medications from a variety of diverse pharmacological classes are used for migraine prevention. Some examples are: anticonvulsants such as topirimate (Topamax), valproic acid (Depakote) and gabapentin (Neurontin); beta-blockers such as propranolol (Inderal) and timolol; tricyclic antidepressants such as amitriptyline and nortriptyline; and other medications including SSRI medications, lisinopril, and Botox injections. Deciding which preventative medication to use and fine tuning the dosage is where an experienced clinician, often in consultation with a specialist, can have the most impact on improving the quality of life of individuals suffering from recurrent migraines. Generally, the clinical decision-making process involves detailed conversation about medication effectiveness and possible side effects. The presence of comorbid conditions is also an important factor. For example, if I am treating an adolescent with migraines who also has a little bit of a depressed mood, I may consider a trial of amitriptyline (tricyclic antidepressant) rather than propranolol (beta-blocker). Many other factors come into play here including the child’s age, nature of the headaches, and other medications/medical conditions.

Rescue medications are stronger opioid analgesic medications (such as hydrocodone or oxycodone-containing medications and morphine) which should be used very infrequently but can be helpful for severe acute migraines which have failed to respond to symptomatic or abortive treatment. These are the sort of medications which may be prescribed for situations in which the symptoms are so severe that, without immediate relief, a trip to the emergency room would be necessary.

Once a diagnosis of common migraine (migraine without aura) or classic migraine (migraine with aura) has been established, most primary care physicians should be comfortable recommending lifestyle changes with trigger identification/avoidance and starting symptomatic treatment such as ibuprofen, naproxen, and acetaminophen. If this initial course of action fails to adequately control the migraines, a trial of an abortive triptan medication should be initiated. As a general rule, children with recurrent headaches that are not clearly part of a common benign primary headache syndrome (such as migraine, tension or cluster headaches) or that have failed abortive treatment should be referred to a specialist such as a pediatric neurologist. Some of this decision-making depends on the experience and training of the primary care physician and the accessibility to pediatric neurologists in the area.

Fortunately, we live in an era having valuable medication treatment options for migraine. In addition to lifestyle changes with trigger identification/avoidance, complementary and alternative medicine treatments and psychosocial support, medications are an important component of a comprehensive management plan.

If you have any questions or would like information about scheduling an appointment with Dr. McIntosh, contact our office at (949) 249-3780 or visit our website for more information.