Headaches: Adjunct Therapies for Pediatric and Adult Patients

Podcast Transcript

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD:

Although headache disorders are recognized as one of the leading causes of disability worldwide, they remain underdiagnosed and undertreated. As a result, many individuals who experience chronic headache continue to grapple with physical pain, reduced quality of life and productivity, and increased financial burdens. In today's episode of Neuro Pathways, we are discussing adjunct therapies for the treatment of headaches. I'm your host, Glen Stevens, neurologist/neuro oncologist in Cleveland Clinic's Neurological Institute. I'm very pleased to have Dr. Desimir Mijatovic. Join me for today's conversation. Dr. Mijatovic is a pediatric and adult pain medicine specialist in Cleveland Clinic, Neurological Institute Center for Comprehensive Pain Recovery. Des, welcome to Neuro Pathways.

Desimir Mijatovic, MD:

Thank you, Glen. I'm happy to be here.

Glen Stevens, DO, PhD:

So to help our audience understand who you are and what you do, tell me a little bit about yourself, what your background is, your training, and how you got into what you're doing.

Desimir Mijatovic, MD:

Thank you. Yeah, so I actually grew up here in the Cleveland area, Broadview Heights. Did most of my training around here. Went to med school at NEOMED and then did my residency here in psychiatry actually at Cleveland Clinic. Then I did a child psychiatry fellowship at Akron Children's and then a pain medicine fellowship at Cincinnati Children's. After all that, I kind of figured out my second year of residency that I wanted to do pediatric pain as well as adult pain. And so I kind of set on this path and then found my way back to Cleveland Clinic, thankfully. And so I just started here a couple months ago as an attending and I'm working in our Center for Comprehensive Pain Recovery, doing adult pain as well as working with our peds neurology to develop an outpatient pediatric pain clinic. And so that's kind of my main goal working here.

Glen Stevens, DO, PhD:

So what percentage of your practice is peds? What percent is adults?

Desimir Mijatovic, MD:

So right now it's 60% adult and 40% pediatric.

Glen Stevens, DO, PhD:

Well, I'm sure that all the pediatricians out there and the adult folks out there are really thankful for the role that you're going. I know you're not primarily a headache related person, but let's just talk a little bit about headache disorders and we'll sort of get into where you fit into that. But tell me where your role is in the headache management.

Desimir Mijatovic, MD:

So as a pain specialist, we treat pain all over the body and so the head, especially in pediatrics, is a very common place for patients to have pain. So in the pediatric side, I'm one of the headache providers, so I'm seeing headaches pretty much every day that I have a pediatric clinic.

Glen Stevens, DO, PhD:

So you'll see primary newly diagnosed headache. You're not always, hey, this is a complicated problem, you'll be first up as well.

Desimir Mijatovic, MD:

Yeah, yeah, yeah. I definitely do see those complicated ones from all over the country that come to see us. And so I definitely have a role in those too, but also a new onset or newly diagnosed headaches.

Glen Stevens, DO, PhD:

And talk about presentation in children versus adults for presentation of headaches.

Desimir Mijatovic, MD:

So there is a difference. In terms of just regular presentation, bilateral headaches or more common in pediatrics, there's a lot more vagaties. And when we look at pediatric headaches, some of that just has to do with the fact that kids have a harder time explaining things, explaining their headaches, or remembering kind of the pattern and things like that. We don't separate tension headaches from migraine headaches from all of these different types as much in pediatrics because there's so much more overlap and the treatment is pretty much the same.

What we see is that obviously when we talk about disability from headaches, for kids, it's going to be more school related. They're missing school, they're having trouble with schoolwork, things like that, or sports. Whereas on the adult side, it's much more work related disability. For both, families get affected, obviously. In terms of lifestyle recommendations that we give for them, it's pretty much the same stuff. We talk about sleep and hydration and basically consistency, keeping consistent on a day-to-day basis. Psychology, so when we talk about headache, psychology seems to work better in pediatrics, whereas medication seems to work better in the adult population. We're also a little bit more limited in terms of the FDA approved treatments for headache in kids as well as what research is out there. There's a lot more robust research, a lot more treatments available for adults. A lot of times we're arguing with the insurance companies for the pediatric treatments.

Glen Stevens, DO, PhD:

So I hear that a lot from the pediatric folks that school is a big issue. I'm just kind of curious with the pandemic, obviously, school had changed, there's a lot more virtual visiting and I wonder if that meant that headachey kids were actually participating more in school or were they finding the virtual screen and all that type of stuff, a bigger problem and were participating even less? I would generally think that they could potentially participate more, but maybe not. Tell me.

Desimir Mijatovic, MD:

Yeah, so it really depended on how the schools would do the virtual. So some schools would, they would just give you the work that you had to do for that week and you can kind of get it done on your own time. And so the kids with headaches did really well with that because they could do their schoolwork around the time of their headaches. Other schools would say you had to be logged in for this time these days and all that. So that would still be pretty difficult. I think it was a little bit easier for kids in general. The thing that the pandemic messed up is that we talk about screen time, limiting screen time, but now with the pandemic and everything being virtual, these kids are on screens pretty much the whole day because they have to.

Glen Stevens, DO, PhD:

Just to go back to the difference with the peds and the adults, my recollection, again, I'm an adult guy, but I do remember a little bit of the pediatric areas that you can have a little more basilar type migraine in kids and they can have nausea and some even vomiting as headache, which you don't see so much in adults. Do you see much of that? Right.

Desimir Mijatovic, MD:

Yeah, we definitely do. It's pretty common from the patients that I've been seeing since I came back here as a lot more of the systemic effects, basilar effects, dizziness, nausea, vomiting. Of course, it's a concern and it's something that we end up doing more imaging just to make sure that there isn't anything else going on. But yeah, it seems to be pretty common.

Glen Stevens, DO, PhD:

And I know I think we're going to discuss a little bit more some of the pain medicine management related therapies as opposed to the standard types of therapies. But in general, with pediatric patients, I know in adults they use a lot of magnesium, supplements, those types of things. Does that work in kids or do you help them do that

Desimir Mijatovic, MD:

As well? Yeah, it's definitely something that we try as a preventive, try to make sure we do the B vitamins, Co 10, magnesium, these are all things that we try. You get a feel for the families, for the kids, is that, do they want to take something every day? Do they want to take a supplement? Are they interested in medications? But it's definitely an option. It's definitely something that we do.

Glen Stevens, DO, PhD:

And is there use of Botox in pediatric population or is it this another one of these insurance related issues? I have to be honest with you. I'm not sure what the insert says in terms of how young you can treat for that. But what about Botox with these?

Desimir Mijatovic, MD:

We absolutely use Botox. And so usually once they fail two preventive treatments and they have more than 15 headache days a month, they're in that chronic migraine category. I think Botox is an excellent option and it's something that's been very helpful for kids. The unfortunate thing is that insurance and there's some insurances that won't cover it at all if you're under 18, some of them will. And we do see good results for those kids.

Glen Stevens, DO, PhD:

So why don't you just tell us some of the common adjuvant therapies that you use and indications for their usage in your patient population?

Desimir Mijatovic, MD:

After a certain point, once we start looking at some of these other treatments that are more than just the basic, it's kind of the wild west a little bit where we're using treatments that are approved in adults or studied in adults and kids. We're just trying to do what's best for these people, whether it's the adults or the kids, just to try to get them some relief and get them feeling better. What I would say is we look at devices sometimes, so there's some wearable technologies, examples being like the Cefaly or the Nerivio, which are things, well, Cefaly goes on the forehead, which kids don't like that one as much because it has bright lights and all of this stuff. And then the Nerivio is something that they wear on their arm, so it's something that they can actually have at school.

Glen Stevens, DO, PhD:

And so I'm not familiar with these devices. What do they do?

Desimir Mijatovic, MD:

So it's an electrical stimulation device that either stimulates the nerves in the forehead or around the arm to kind of help scramble or break the signals that are being propagated from the headache or the migraine. I think they're both, I know Nerivio there's an app that they control it with their phone and so let's say they're at school, they have the arm band on, they're having a bad headache, they can actually just turn it on themselves discretely at school to try to either break the migraine that it's coming and try to get some relief there.

Glen Stevens, DO, PhD:

And these are adult approved as well, or pediatric primarily?

Desimir Mijatovic, MD:

Both. So both adult and pediatric.

Glen Stevens, DO, PhD:

And just to reiterate, typically they have to have failed at least a couple of prior therapies or not necessarily?

Desimir Mijatovic, MD:

For these, not necessarily. No. There's some approved diagnoses for them like migraines, things like that, but they don't have to fail medications to be able to qualify for these.

Glen Stevens, DO, PhD:

Other adjunct therapies that you're using?

Desimir Mijatovic, MD:

So the other things we look at procedures. So being a pain medicine doctor, I do a lot of procedures, injections, things like that. And so whenever I'm seeing a patient, that's something that I always evaluate for. Basically, if there's a nerve in the head or in the skin, I can put a needle in it and put some medicine in it. The most common things being like occipital nerves as well as any of the trigeminal nerves, whether it's the trigeminal ganglia itself or any of the superficial branches of the trigeminal nerve. When also looking at the neck, we can do, if there's arthritis or any kind of cervicogenic headaches, we can do injections in the upper cervical vertebrae, whether it's like a third occipital nerve block or a facet injection in the upper vertebrae. Or even there's some evidence that a stellate ganglion block, which is done in the lower cervical vertebrae, provides sympathetic innervation to the face and the upper limb. And that can be helpful too for some people.

Glen Stevens, DO, PhD:

And what are some of the procedures that you'll do just in adults that you just typically don't do in pediatric patients?

Desimir Mijatovic, MD:

So I haven't really done any trigeminal nerve blocks in the pediatric population, at least not the actual trigeminal ganglion. I'll do superficial, like the supraorbital, supratrochlear nerve blocks there, but I haven't really done very many of them. For me to do that on a child, we'd have to make sure that there's no other thing going on with the trigeminal like compression or something like that. And then we would probably need sedation for that as well. So some of these I do with sedation, some of them the patients can tolerate without sedation.

Glen Stevens, DO, PhD:

And talk to me a little bit about ketamine.

Desimir Mijatovic, MD:

So ketamine, I know you've actually had my colleague, Dr. Pavon Tonka here.

Glen Stevens, DO, PhD:

Yes, we did.

Desimir Mijatovic, MD:

And so I know he talked to you a lot about ketamine and so a lot of times in the adults we will do ketamine for treatment resistant migraine. We see decent results from that, just about as effective as ketamine is for everything else. I know Dr. Tonka talked about it as well, but we do get a lot of referrals from our headache center and to do that, I know we see fair results

Glen Stevens, DO, PhD:

And any approval for individuals under the age of 18 or it's not approved and you don't use it at this point?

Desimir Mijatovic, MD:

So when I was at Akron Children's, I used it a little bit for kids. I'm working on a process here that we can do ketamine infusions in the pediatric population. I see it just as helpful as it is in adults for treatment resistant chronic pain, usually like a nerve related pain, whether it's CRPS or neuralgias or headaches potentially.

Glen Stevens, DO, PhD:

Are you doing radio frequency ablations as well for some of that might have occipital neuralgia that's responded and then you're looking for something that's going to have a longer benefit?

Desimir Mijatovic, MD:

So I actually just came from a patient where I had a conversation about that. Yeah, if the occipital nerve blocks are helpful but the pain keeps coming back, then that would be a time to think about an ablation, which is something where we can actually deactivate the nerve using heat. The great thing about that is that can give longer lasting benefit. Usually six to 12 months at least the nerve does grow back and so we sometimes have to repeat it. What we see is that over time, that nerve, once it grows back multiple times, it's not as sensitive as it is before.

Glen Stevens, DO, PhD:

So the art of medicine is what's really the difficult part of medicine. You have a lot of tools in your belt it sounds like. And of course we didn't go through all the standard therapies because it's a pain medicine where at this point we're more interested in what's potentially the next level that's there, but what's your decision tree? How do you decide what therapy you're going to use next and...

Desimir Mijatovic, MD:

Yeah. Yeah, and you're right, it definitely is an art. It's something that you have to look at the whole picture before you can make some of these decisions. So anytime we think about an obvious neuralgia where the patient has a clear occipital neuralgia with tenderness, shooting, pain, tingling, all these things, that obviously sparks the thought in my head. The other thoughts are they've tried a lot of other treatments, they're interested in something interventional. So patient preference is a big thing. Unfortunately, I see a lot of kids or adults who their medication list is 20 medications long that they've tried and failed before and they have a hard time finding interventions in their area or where they're coming from. And so it's something that's worth a try to give them some benefit. Again, most of these can be done very safely and very easily. A lot of them are done in the office, so it's easy for everybody involved. And so I think it's worth a try for a lot of these people.

Glen Stevens, DO, PhD:

How laborious is the approval process for these?

Desimir Mijatovic, MD:

I'm really lucky. I have a great staff that I work with and so they take care of a lot of that stuff for me. Botox is pretty difficult to get approved, but the other nerve blocks are pretty easy overall.

Glen Stevens, DO, PhD:

I always assumed, and maybe incorrectly, that occipital neuralgia would be more common in older patients and maybe related to a lot of underlying neck related problems. How common is it actually in the pediatric population or adolescent?

Desimir Mijatovic, MD:

So it's fairly common. Sometimes I wonder if it's secondary. So let's say they have a primary headache syndrome, then they get secondary myofascial pain from it with a lot of spasm intense muscles in the neck, and that causes a secondary occipital neuralgia for them. So it's hard. I think in general it's about the same as in the adult population, at least from what I'm seeing clinically.

Glen Stevens, DO, PhD:

And peripheral nerve stimulators, is that what you described earlier with the thing on the supraorbital area or is that a separate process?

Desimir Mijatovic, MD:

Yeah, so those devices like the Nerivio or the Cefaly, those are external nerve stimulators, kind of like a TENS unit, transcutaneous electrical nerve stimulation. The stimulators are actually implanted. So that would be with the help of a surgeon where they would implant the electrodes under the skin across the course of the nerve, whatever nerve we're trying to stimulate. Most commonly those are done in the occipital nerves or sometimes a sphenopalatine ganglion. And then there's an impulse generator that's implanted under the skin that will send a constant stream of electricity to that electrode to stimulate the nerve to basically scramble those pain signals that are being sent.

Glen Stevens, DO, PhD:

So how are you deciding when a patient needs to go to that level or that it's going to be effective?

Desimir Mijatovic, MD:

Yeah, so let's say we have the case with the occipital neuralgia. So let's say you've done some nerve blocks, they get temporary benefit from them. Then we try an ablation and maybe that ablation didn't help as much as we would hope that it helped or it didn't last long as much as we would want it to. So that would be a thought that maybe a stimulator. Stimulators are big deals. It's an electric device that's implanted in their body. And so there's a lot that comes with that decision and they come with their own problems as well. So it's really kind of last line therapy a lot of the time.

Glen Stevens, DO, PhD:

Any new devices coming on the market or ways of trying to treat these headaches that are different than what's currently being used or?

Desimir Mijatovic, MD:

I think those stimulators are probably the most recent development that's on the market from what I've seen. A lot of the new medications, like the CGRP medications are also something. Again, not approved in kids unfortunately. And so a lot of times we're arguing with the insurance companies, but I know there's a lot of research that's being done to try to get them approved so that kids can get some benefit from them too.

Glen Stevens, DO, PhD:

So if somebody's out here listening and they go, "Wow, this stuff sounds like it could get a little complex," how do we refer patients to get these types of things looked into, evaluated, try and determine? I guess a simple answer is if you have a patient that you're managing and you can no longer manage their problem, you should refer them to a specialist. But how do they reach out to you?

Desimir Mijatovic, MD:

So anybody can reach out to me. I'm always happy to help out with any patients. If it's an adult patient, it's a referral to the Center for Comprehensive Pain Recovery, and then if it's a pediatric patient, it's just a consult to peds neurology.

Glen Stevens, DO, PhD:

So what's the relationship between that and the headache center?

Desimir Mijatovic, MD:

With the adults, so we're all under the NI, so Neurological Institute, so we share patients very frequently. I just recently talked to the headache center, and so I told them, "Hey, I do these injections, these are ways that I can be helpful for you, so please send me these patients."

Glen Stevens, DO, PhD:

But you don't physically see patients in the headache center?

Desimir Mijatovic, MD:

No, no, no. We currently are seeing patients in the S building on S 70 in the adults.

Glen Stevens, DO, PhD:

So I'm curious how many psychiatrists have gone the direction that you've gone. I would imagine you're a rare bird, right?

Desimir Mijatovic, MD:

Yeah, so I actually looked it up on the ABPN website to see how many psychiatrists or neurologists get boarded in pain management a year. And it's usually about 10, five to 10 every year. But how many of those are psychiatrists? I don't know.

Glen Stevens, DO, PhD:

I would think it's a low number.

Desimir Mijatovic, MD:

I think it's a low number. And then I don't think I've met any psychiatrist that did a child psych fellowship and then a pediatric pain fellowship. So I don't know if there's anybody. I think I might be the only one.

Glen Stevens, DO, PhD:

And I'm sure being a psychiatrist gives you a different orientation than the rest of the group. Do you still do general psychiatric care or are you really entrenched in the pain management group?

Desimir Mijatovic, MD:

So I would say a lot of the times you can't really separate them. I'm not treating schizophrenia or severe mental illness from that sense, but I do treat depression, anxiety. A lot of the medications that we use in psychiatry are the same medications that we use in pain management. And when we talk about adults, typically the studies show about 50% of adults with chronic pain have some kind of psychiatric condition, whether it's depression, anxiety. And then in the pediatric population, it's closer to 80%.

Glen Stevens, DO, PhD:

Well, a lot of comorbidity.

Desimir Mijatovic, MD:

Yeah.

Glen Stevens, DO, PhD:

It seems like maybe everybody should be a psychiatrist that goes into managing that.

Desimir Mijatovic, MD:

It's part of the training to get some psych under your belt when you're doing a pain fellowship, because you're right. I do think it's super important. Also, there's a huge shortage of psychiatrists, so I can't really separate that kind of work, otherwise I would be doing the patients a disservice if I didn't.

Glen Stevens, DO, PhD:

Well, Des, thank you for joining me today. This has been a very insightful conversation. I appreciate your time. It sounds like you're going to stay busy.

Desimir Mijatovic, MD:

Very.

Glen Stevens, DO, PhD:

And the sad part is that there are not enough psychiatrists out there, so they may call on you to do some general psychiatric care as well. Welcome to the Cleveland Clinic. Sounds like you have a niche that will keep you busy.

Desimir Mijatovic, MD:

Absolutely. Thank you so much, Glen. I'm really happy to be here and be able to talk with you.

Conclusion: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's consultqd.clevelandclinic.org/neuro, or follow us on Twitter @CleClinicMD, all one word. And thank you for listening.