Nondrug Treatment for Chronic Tension Headache in Teens

Medscape Medical News > Conference News

Fran Lowry

Oct 01, 2013

ORLANDO, Florida — Chronic tension-type headache (CTTH), which may affect up to 20% of teens, can be successfully treated without pharmacologic agents, a new study shows.

A retrospective review of 83 adolescents diagnosed with CTTH found that osteopathic manipulation and instruction in daily mindfulness and the traditional Chinese practice of qi gong was more effective than pharmacologic therapy in relieving their headaches.

"There is nothing in the literature for these kids, who often end up on chronic opioids," lead author Peter Przekop, DO, PhD, from the Betty Ford Center, Rancho Mirage, and Loma Linda University School of Medicine, Loma Linda, California, told Medscape Medical News.

The results were presented here at the American Academy of Pain Management (AAPM) 24th Annual Clinical Meeting.

"I wanted to figure out some way to help them because I see about 60 to 80 teens with this condition a year, and they are miserable. They are not doing well in school, they are not doing well in life. I don't want them on medications, which is always a problem in kids because the brain is changing and developing until 22 to 24 years in females and age 26 in males. Centrally acting medications can affect this development," Dr. Przekop said.

To compare the efficacy of pharmacologic vs nonpharmacologic treatment in teens with CTTH, Dr. Przekop and his team reviewed the charts of 83 adolescents (67 girls and 16 boys) who presented to their outpatient clinic for headache management between 2009 and 2013. Their average age was 15.7 years (range, 13 to 18 years).

"Qi gong is a traditional Chinese practice that aligns breathing, slow, repeated movements and awareness to promote healing," Dr. Przekop explained. "The instruction on how to do mindfulness involves telling the patients to close their eyes, get in touch with what they were feeling inside, breathe, and stop the story going on in their head, to stop the story."There were 2 treatment groups. Group 1 (n = 44 patients) received amitriptyline or gabapentin as daily preventive medication. Group 2 (n = 39 patients) received bimonthly osteopathic manipulation and instruction in daily mindfulness and internal qi gong.

The teens in the experimental group were taught an internal qi gong routine that consisted of 6 simple moves that they practiced each day.

Both groups were assessed at study entry, 3 months, and 6 months to see whether the number and intensity of their headaches changed and whether the intervention affected their general health and quality of life.

Both groups improved, but the improvement was much more dramatic in the group that did qi gong and practiced mindfulness, Dr. Przekop said.

The nonpharmacologic intervention produced better results in headache frequency, headache pain intensity, general health, social activity, and number of tender points in the trapezius, cervical spine, and superior occipital notch than did pharmacologic treatment (P = .001 for all 5 measures).

Over the 6-month period, headache frequency decreased from 23.9 to 16.4 in the pharmacologic treatment group and from 22.3 to 4.9 in the nonpharmacologic group.

"Their perception of their general health improved, and most of these kids actually did quite well," Dr. Przekop said.

"If you meet these kids, they're not doing well in school, they don't have friends, they're staying home, they don't feel good about themselves. That's the thing I wanted to change, and that actually improved," he pointed out. "I think they were able to cope with their overall pain and overall stress and change the way they perceived the world and how they perceived themselves.

"Most pain has a cognitive component, which is how you perceive the world, how you perceive yourself, how you perceive life, and it has an emotional component where these children can't handle negative emotions. That's the thing that really changes with this treatment," he said.

One potential problem is that insurance often will not pay for nonpharmacologic treatment, Dr. Przekop noted.

"These groups were divided pretty much by what insurance would pay. All insurance plans will pay for amitriptyline and gabapentin; few insurances will pay for the other. Some of the kids actually heard that the kids on the non-pharmacologic treatment were improving, and the parents then came and paid cash. It's sad, but that's the state of affairs that we're in now."

Teens Want Control of Their Lives

"Also, the parents are very concerned about beginning their children on these medications, especially over the long run, so this is a great opportunity to begin to say that these non pharmacological things actually do work as good, if not better than medications," he said."I've never seen anything quite like this before, and I think it makes some sense, because when pediatric patients come in they are looking for ways to maintain control of their lives without the use of medications, and if you create the opportunity, many of them will grab on to it," Dr. Hevern, who is also a practitioner at Elliot Pain Management Center in Manchester, New Hampshire, said.

Dr. Przekop and Dr. Hevern have disclosed no relevant financial relationships.

American Academy of Pain Management (AAPM) 24th Annual Clinical Meeting. Abstract #25. Presented September 27, 2013

Weight Loss Advice: It Doesn't Have to Be So Hard

Medscape Diabetes & Endocrinology

An Expert Interview With David L. Katz, MD

David L. Katz, MD, MPH, Laurie Scudder, DNP, NP

Sep 27, 2013

Obesity: How Big Is the Problem?

Medscape: Could you review the epidemiology of obesity, particularly in children, and the impact on type 2 diabetes mellitus (T2DM) over the past 5-10 years? Is the epidemic beginning to abate?

David L. Katz, MD, MPH: For a long time, we have been talking about obesity as epidemic in both adults and children. By definition, that term refers to a condition affecting the population at an unprecedented level, so it doesn't necessarily tell us how many people are affected. It just says it is rising beyond all precedent. Actually, rates in adults have stabilized, and so I think the right way to characterize the prevalence of obesity now is hyperendemic.

It seems to be fixed at a very high level, and there are various sources of information that confirm that, including the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System (BRFSS) at the Centers for Disease Control and Prevention (CDC). These various sources of epidemiologic information and population-level surveys suggest that at least two thirds of the adult population is either overweight or obese nationally. Some surveys have suggested it is as high as 80%.

In the case of children, the figure is lower but actually far more worrisome, because the rates of childhood obesity are unprecedented in history. We really don't know what happens when 30% or more kids are overweight or obese over the course of the lifespan. Consider that the adults who are now dealing with hyperendemic obesity were not subject to hyperendemic or epidemic obesity as children. We can anticipate, then, that with a much higher rate of childhood obesity, these kids, when they grow up, will be experiencing an even higher rate of adult obesity.

In terms of the link to diabetes, we have really seen an epidemic of T2DM, and there the term "epidemic" remains appropriate because the rate of T2DM continues to rise. The CDC has projected that should current trends persist, by or about the middle of this century as many as 1 in 3 Americans could be diabetic. Almost all of that will be T2DM. Since that projection was made, on the basis of computer modeling, we are right on course -- a dire course.

The advent of T2CM in children really is a signature event that characterizes the full toll of epidemic obesity. Those of us who trained in medicine less than 100 years ago learned about 2 kinds of diabetes: juvenile onset, now called type 1, and adult onset, now called type 2. Part of the reason it is now called type 2 is because kids get it now, too. That really never should have happened. The advent of T2DM as a condition in children is a direct by-product of epidemic childhood obesity.

Some good news: We have seen some signs of site-specific stabilization in rates of childhood obesity,and even some slight dips in some regions where a lot of work is being done. We have seen stabilization in the overall rate of adult obesity as well. But one other thing to throw in the mix here is that rates of severe obesity in both adults and children continue to rise briskly.

So as we take stock of the obesity epidemic now, it may no longer serve us adequately to keep asking how many people are overweight or obese, because that number may become relatively stable. What we may now need to start asking is how overweight those people are, because the severity of obesity is worsening.

Medscape: Can you briefly review the recent data on obesity rates from the CDC?

Dr. Katz: The CDC is tracking state-by-state prevalence of obesity on an annual basis, and they issue annual color-coded maps depicting obesity prevalence. Many of us in this field have been following the obesity trends for many years, which are based on self-reported data (Figure).

Medscape: Many experts are suggesting that children born after 2000, new millennium kids, are going to be the first generation in history to have a shorter lifespan than their parents. Is it too simplistic to point at obesity as the sole factor in that? Can you discuss that prediction and what led to that conclusion on the part of many experts?

Dr. Katz: Well, in some ways it is too simplistic to even say with any confidence that this is going to happen, although the analysis that set that discussion in motion was certainly robust. There was a study published in the New England Journal of Medicine in 2005 by Jay Olshansky and colleagues.^[2]Inputting current data on obesity and its effect on longevity, these authors used computer modeling to forecast that life expectancy would level off and potentially decline in the first half of this century.

We have epidemic childhood obesity. We are seeing the advent of what formerly were adult-onset conditions. In addition to T2DM, there has been a proliferation of ever more cardiovascular risk factors in childhood. All of this would conspire not only against life in years, but years of life lived in vital good condition. To some degree, it makes sense to look at the toll of all of this -- ever more risk for ever more chronic disease at ever younger ages -- and conclude that this means a shorter life expectancy.

The problem with that projection from the start was the fact that one of the things we do best in modern medicine is stave off death. We do a very poor job of preserving true vitality. If you look at the epidemiology of the United States, and increasingly much of the world, as was addressed by The Lancet in their Global Burden of Disease Report 2010,^[3] the global burden of chronic disease is huge and rising. We tend to do a fairly poor job of maintaining health, and the epidemiology reflects that we have a lot of chronic disease.

However, we are able to keep people with chronic disease alive. That is where the cutting edge of biomedical advance really comes into play. We have powerful drugs and powerful procedures, and of course, that will only be more so in all probability 10, 20, or 30 years from now, when we might start to see the shortened life expectancy of kids growing up today. We don't know that that will come to pass, but it is still a terrible state of affairs if life expectancy per se is not declining, but health expectancy -- years of life lived in vital good condition -- is on the decline. So I think Dr. Olshansky and the authors involved in that 2005 report would look at what we have learned over the 8 years since then and might not be as sure of that conclusion.

We certainly don't have clear signs of declining life expectancy. It may come to pass, but it may be that medical technology will help us hang on to years of life. What we are clearly losing already is life in years. We are much more confident about that. The basic sentiment in that assertion -- that this is the first generation of kids where we are looking ahead at a shorter life expectancy -- I think is still valid. Whether or not we measure what they are losing in years of life or life in years is what remains to be seen, but clearly there is a lot at stake.

 

Researchers Dissect Link Between Fertility Treatment and Childhood Cancer

Medscape Ob/Gyn 

Peter Kovacs, MD, PhD

DisclosuresOct 02, 2013

Fertility Treatment and Childhood Cancer Risk: A Systematic Meta-analysis

Hargreave M, Jensen A, Toender A, Andersen KK, Kjaer SK
Fertil Steril. 2013;100:150-161

Background

Controlled ovarian stimulation has been available since the 1960s and in vitro fertilization (IVF) since the late 1970s. It is estimated that 4-5 million children have been born following IVF. In developed countries, up to 5% of children born are conceived through IVF.

Since assisted reproductive technology (ART) was introduced, its safety has been questioned and tested. There are immediate risks that are associated with the intervention itself, such as ovarian hyperstimulation; bladder, bowel, and blood vessel injury during retrieval; infections related to the vaginal procedures; and an increased risk for thrombosis.

Numerous studies have evaluated the long-term risks associated with hormone use itself. Most have been reassuring and have found no additional adverse effects with the use of hormones, though infertility itself is a known risk factor for certain gynecologic cancers.

The risk for birth defects following assisted reproduction has also been studied by several groups. While an overall increased risk was seen in ART pregnancies, it is believed that this excess is associated with infertility and the underlying problems rather than the treatment itself.^[2]

Risk for cancer in the offspring conceived through ART is much less studied. In 2005, a meta-analysis found no increased risk for childhood cancer in children conceived via IVF.^[3]

This study is another analysis based on the results of reports published before and after 2005.

Study Summary

Twenty-five studies were included in the analysis. They are all cohort or case-control studies that assessed the association between medically assisted reproduction (stimulation only, insemination, or IVF) and childhood cancer risk. Overall, an increased risk for cancer was seen among those exposed to ART (relative risk [RR], 1.33; 95% confidence interval [CI], 1.08-1.63). When cancer subtypes were evaluated separately, an increased risk was found for hematologic cancers (RR, 1.59; 95% CI, 1.232-1.91) and central nervous system cancers (RR, 1.88; 95% CI, 1.02-3.46). The risk for neuroblastoma, retinoblastoma, and other solid cancers was also higher among those exposed to ART, though the association was based on a small number of cancers.

In their concluding remarks, the authors discussed that while the relative risks show an increased risk, the absolute number of additional cancers is very low. They also mentioned that at this point it is unknown whether the increased risk is associated with infertility or with the technology used to treat it.

Viewpoint

Cancer is the leading cause of death by disease among children under the age of 15 years. Every year, cancer is diagnosed in 1-2 of every 10,000 children. The most common cancers are leukemias, brain tumors, and central nervous system tumors.

While diagnostic and treatment options constantly are improving, cancer is still associated with significant morbidity and mortality. Long-term health may be affected by the treatments even in those who are successfully cured of the disease.

The etiology of childhood cancer is not known, though infectious agents, inherited genetic problems, and exposure to radiation or carcinogens have been all considered. It is also possible that the eggs, sperm, and embryos exposed to in vitro culture conditions are programmed in a way to be at risk for cancer. Epigenetic alterations may activate harmful genes or may suppress genes that are protective. Imprinting defects are believed to play a role in some really rare conditions following ART.^[5]

The possibility that the increased risk is associated with infertility itself, however, cannot be ruled out. In order to answer this, one would need to compare cancer risk in children born to infertile mothers exposed to or not exposed to ART. The authors did point out that only 2 out of 25 studies have taken subfertility into account. Neither of them found an elevated risk for cancer in the children exposed to fertility treatment.

Another study published in 2013 also found an increased relative risk for cancer among children conceived through ART. The 18% relative increase in the risk found by this group would mean 4 additional childhood cancers per 100,000 exposed children.^[8] The absolute risk is low, though, and the couples need to be counseled about both the relative and absolute risks. In addition, it is also important to study how the laboratory procedures may affect the gene expression in the embryos and what steps could be made to avoid these undesired effects. It is already known that the obstetric outcome after ART is not as good as after spontaneous conceptions. It is also known that malformation rates are relatively increased (small absolute increase) following fertility treatment. It is, however, not known to what degree (if at all) the technology is responsible for these findings. The role of infertility as the etiology of these adverse effects needs to be further explored.

Food Allergy Diagnosis and Therapy

Immunotherapy

Where Are We Now?

Aleena Syed, Arunima Kohli1, Kari C Nadeau

Immunotherapy. 2013;5(9):931-944. 

Abstract

Food allergy is a growing worldwide epidemic that adversely effects up to 10% of the population. Causes and risk factors remain unclear and diagnostic methods are imprecise. There is currently no accepted treatment for food allergy. Therefore, there is an imminent need for greater understanding of food allergies, revised diagnostics and development of safe, effective therapies. Oral immunotherapy provides a particularly promising avenue, but is still highly experimental and not ready for clinical use.

Introduction

IgE-mediated food allergy (FA) is a growing problem worldwide. Defined as an immune response to a given food that occurs reproducibly upon exposure, FA affects anywhere from 1 to 10% of the population, with greater prevalence in children (4–6% in the USA vs ~2% in adults). This prevalence has been increasing at a rapid rate, as has been demonstrated by data from the USA, UK, Australia and China. 

Despite this burden, the only currently accepted treatment for FA is complete avoidance of the offending allergen, with epinephrine delivered in the case of accidental ingestions – which occur frequently, even in the most careful patients, and are often undertreated.  As such, FA is a highly stressful condition, generating elevated anxiety in allergic subjects and their families. FA is associated with significantly decreased quality-of-life scores to a degree that is greater than that seen in many other chronic childhood diseases. There is, therefore, an urgent need for an effective therapy for the treatment of FA. Contingent with this is the need for greater understanding of the mechanisms of FA, as well as a need for more precise diagnostics. There is still much that remains unknown, and extensive research in many areas is needed to fully understand this disease and potential treatments. This article aims to address the current state of the field and to speculate on its future.

Acute symptoms include urticaria, flushing, angioedema, abdominal pain, nausea, vomiting, diarrhea, wheezing, coughing and/or bronchospasm, rhinorrhea and hypotension or syncope.

Not all foods are allergenic; in fact, of the over 12,000 food allergens known, only a small number induce allergies. Further questions are raised by spontaneous resolution of FAs. Children usually outgrow allergies to milk, egg, soy and wheat, but not peanut or tree nut allergies.Why this happens, and why only some FAs resolve independently while others remain, is unclear

The environment of the gut is also likely to be crucial. Intestinal permeability is positively associated with increased FA incidence; a study of food-allergic infants demonstrated they had greater intestinal permeability compared with healthy infants, an effect that lasted even after 6 months on an exclusion diet. Likely to be even more important are the microbiota found in the gut. The hygiene hypothesis suggests that changes in the pattern of intestinal colonization during infancy and decreased exposure to infectious agents in childhood are important factors in the development of allergic disease, and may help explain why allergy prevalence is increasing. Antibiotic use and exposure to pets, farms and farm animals have been linked to decreased atopy risk. In addition, differences have been found in gut microbial flora between allergic and nonallergic children, suggesting certain microbes may be more important to sensitization than others.

USPSTF: Blood Pressure Screening Not Useful for Children

Medscape Medical News

Lara C. Pullen, PhD

Oct 07, 2013

The US Preventive Services Task Force (USPSTF) has concluded that "the current evidence is insufficient to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood."

The recommendation stands in contrast to the endorsement from the American Academy of Pediatrics of the National High Blood Pressure Education Program 2004 recommendations that children aged 3 years or older have their blood pressure measured at least once at every "health care episode."

The USPSTF published their recommendation statement online October 7 in both the Annals of Internal Medicine andPediatrics . Task force members reviewed studies published since 2003 and could not find any clear evidence that justified blood pressure screening in the general pediatric population.

The recommendations, which are an update to 2003 recommendations, relate specifically to children and teenagers who do not have an underlying health problem and have no signs or symptoms of high blood pressure and encourage clinicians to consider each patient specifically and make an individual decision for each patient.

As the childhood obesity rate has increased, so has the prevalence of high blood pressure in children and teenagers. The prevalence of hypertension among US children and adolescents ranges from 1% to 5%. The prevalence of hypertension among obese children is 11%.

Some clinicians have proposed that screening for hypertension in children and adolescents may allow for interventions to reduce blood pressure, thereby reducing the risk for cardiovascular events and death in adulthood. However, the task force could not find evidence to substantiate this hypothesis.

"We call on the research community to strengthen the evidence base linking screening and treatment of high blood pressure in children and teens to their long-term cardiovascular health," said USPSTF member Kirsten Bibbins-Domingo, MD, PhD, in a USPSTF news release.

Full conflict-of-interest information is available on the journal's Web sites.

Pediatrics. Published online October 7, 2013. Abstract

Ann Intern Med. Published online October 7, 2013. Full tex
t