Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Staying Ahead of Headaches

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Staying Ahead of Headaches · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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  Music.
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  For the busy pediatric practitioner, click on the link in this podcast for free
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  credit that may include CME, MOC, or ethics credit, depending on our topic or podcast.
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  Today, we're talking about something our pediatrician listeners see often, headaches.
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  And as you all know, it can be a headache to try and diagnose what is behind the headache.
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  I'm thrilled today because joining me here in the podcast studio is a new member
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  of our pediatric neurology team, Dr. Azra Akbar.
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  Dr. Akbar, so you come to us from the University of Illinois. Yes, I do.
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  I graduated from fellowship in 2015, my headache fellowship in 2015 and epilepsy fellowship in 2014.
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  And that's when I joined the University of Illinois College of Medicine in Peoria.
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  And why did you want to get a fellowship in headaches?
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  I was a migraineur myself as a child, as a child.
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  So I remember my first migraine, maybe five or six years old.
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  You know, car sickness, motion sickness, throwing up in the car.
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  So it was pretty miserable.
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  Also, a lot of people don't, in those days, maybe didn't believe that kids have
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  migraines, you know, or headaches for that matter.
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  So it's a rough diagnosis for little
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  ones children who can't explain it yes and
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  it's it can be hard as we all know for children to to
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  explain exactly where the pain is coming from or
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  what's wrong they just know something's wrong absolutely sometimes it can just
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  be an aura and the kid can explain that or it could just be abdominal migraines
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  or it could be just nausea or motion sickness which is a precursor it's a childhood
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  equivalent of migraines so yeah so and i'm I'm so sorry you went through that.
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  And so starting at age five, you would get these migraines.
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  Along the way, was it just you realized it's something I just have to suffer
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  through, but I want to make a difference and change this at some point?
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  Absolutely. As I was growing older, I didn't understand what it was.
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  I don't think a five-year-old would understand. It's very hard for them to explain the quality or,
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  you know, what's going on what triggered it identifying
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  triggers that's very hard you know so yeah
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  as i got older absolutely through high school and then
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  to medical school i realized it's it's migraineurs are
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  an underserved population even the medications
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  that are not up till recently all of those medications like beta blockers that
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  came out they didn't they weren't really for headaches they came out for something
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  else like blood pressure right or topamax which is actually for seizures but
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  then And FDA approved it for children for migraines, and it works.
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  But the point, or even Botox for that matter, you see.
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  So Botox didn't actually come out for migraines, but then it was FDA approved
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  after experience from patients who received it for another reason.
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  So, yeah. So it's an underserved, rather underserved population, I think.
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  And more information is coming out about treating headaches and you've been part of that as well.
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  So you recently helped publish a paper in the Journal of Pediatric Neurology
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  about treating children with Botox for headaches. Tell us about that.
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  Absolutely. Yeah. So we had a group of, I want to say, about 20 to 30 children
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  that I'd managed over the past five years, along with collaboration with a pediatric
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  nurse practitioner and a group of other physicians.
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  So yeah, we just wrote about our experience, like really a retrospective chart review.
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  We gave them Botox and there's a remarkable improvement and limited side effects.
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  But the problem is that it's not approved by insurance. For adults,
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  it's easier to get it approved.
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  You know, so a 15-year-old who's 70 kilos versus an 18-year-old who's 70 kilos. those.
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  So it's kind of, I don't see why we can't give it to kids who are refractory
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  to medication otherwise.
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  Because taking a daily pill, right? We have kids who are taking these daily
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  pills, sometimes two, three pills, and they're still missing school.
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  And it can be pretty rough.
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  Yeah. And because of the side effects of the pill and the headache or both?
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  I think both. The headache in itself, I'm not sure.
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  I mean, sometimes migraines can literally really take you out for the day.
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  Right. I know that all too well. Right?
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  Especially even just the aura. Yes.
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  And then you can take the medicine, which may help, but how do you make sure
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  that you're right back to baseline, like you're back to normal?
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  If you're going to sleep off your day, then that takes your day out.
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  Yes, absolutely. Yeah. So in your practice, you see patients at the University
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  of Texas Health Science Center's clinic.
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  It's at Wurzbach and Fredericksburg here in San Antonio, and then also at University Hospital.
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  Are you doing that yet, where you're treating patients with Botox?
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  You know, I haven't yet. I started February 26th was my first day.
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  But my other colleagues, Dr. Gross and I know Dr. Fox, they are.
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  Dr. Fox also gives Botox for spasticity, but Dr. Gross gives it for headaches too.
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  So yeah. And so the challenge there can be, there's certain areas on our faces
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  where it can hurt, but there's others where it doesn't.
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  And then the number of shots can be a bit intimidating. Exactly.
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  The number of shots is intimidating when you tell somebody, oh,
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  it's 31 injection sites.
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  But if you look at the protocol, they follow the pain protocol, follow the pain.
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  So I do that, whichever, because, you know, 45 units are left over from when
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  you order it anyways, right?
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  Because it's 155 international units in 31 FDA approved sites.
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  But I use the follow the pain protocol, which is if they have more pain on this
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  side or if they, why waste it? So we just inject it.
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  But you're right. So it's painful.
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  And I did my own because I do acupuncture for myself too.
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  So yeah. So the more muscular, for example, here in this trapezius muscle, it's not that painful.
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  And I've tried it myself, you know, so I can actually tell the patients how it feels.
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  I think here in the temporal area, it's not that painful. Also,
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  it's a very small needle gauge.
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  But this area, the forehead is, because there's, you know, it's a little bit
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  more tighter. So this area hurts.
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  So you can avoid the forehead for kids sometimes or just say,
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  sometimes, this is going to help your headache. It'll be just short. True, true, true.
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  So I just let the patient, so I just let the patient kind of a little bit dictate
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  it too because I don't want to make them miserable especially I always start
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  over here you know the shoulder muscle because it's least painful.
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  Yeah. So, yeah, so that can be. And then, of course, we have newer options available,
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  which are once a month injections, the CGRPs, which are great,
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  but again, not FDA approved for children. So it's FDA approved for 18 and above.
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  But that's the whole point. You know, you try it for your 16 year old or even your 17 year old.
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  But insurance likely won't cover it. That's right.
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  Insurance for Botox specifically wants to show that you have failed a trial
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  of adequately dosed more than two classes of FDA-approved medications for a
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  period of three months and you still have headaches lasting more than 15 days,
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  which is almost always the case, honestly.
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  Especially there's a headache syndrome called medication overuse
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  headaches right and medication overuse
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  headaches are very hard to treat because they're so used
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  to using the higher doses of Tylenol and now it's not Tylenol actually it's
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  more than Tylenol and it's Excedrin and it's the Striptan those are very they're
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  more harder to treat you know so just giving them one daily bill of antidepressant
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  or seizure medicine usually doesn't work.
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  Sometimes you have to do a resetting with IV.
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  I mean, there are studies on this. IVDHE, medication cocktail,
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  migraine cocktail for medication overuse headaches. They're hard to treat.
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  Would you say Botox is highly effective though?
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  In my experience, yes. And from whatever I've studied, of course, it's not perfect.
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  There are are certain side effects. We have another study that hopefully we
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  will be able to publish also retrospective chart review from my old,
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  from my job at University of Illinois College of Medicine in Burya,
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  in which we actually studied it on our 15 to 17 year old, in which we gave them CGRP injections.
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  Yeah. And I think that was a good response to similar to Botox.
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  And you did, so do you, do you do acupuncture on yourself? Yes.
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  Why is that hard to do? No, I wish I had my needle today.
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  It's a really tiny needle. It's like a hair-thin needle. So I'm new in San Antonio.
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  I'm still trying to figure out my way around.
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  You know, finding a PCP or an acupuncturist, so all that.
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  But yeah, I see the points. And that's not professional.
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  I can't do it professionally on other people, but I can do it for myself,
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  kind of, you know, in locations like that.
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  And it helps loosen up the muscle, kind of like dry needling.
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  If you've had a severe back spasm or something like that, going and getting
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  your massage and dry needling can help loosen up the muscle.
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  Do you hope to incorporate acupuncture or you could suggest an acupuncturist
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  once you've been here longer for patients?
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  I hope so. Yes, a more holistic approach, vitamin supplementation,
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  like magnesium supplementation, riboflavin, coenzyme Q10, massage.
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  I highly recommend that for families and patients. I really do.
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  And prevention, any other techniques, lifestyle that you'd recommend? Absolutely.
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  Absolutely. Lifestyle modification, increased water intake, and most importantly,
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  identifying your triggers.
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  Like some people will tell you, like there's enough evidence on MSG,
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  tyramine-containing foods, you know, processed meats, aged cheese, aged meat.
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  So all of that. And then sleep hygiene.
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  So strong perfume, strong smell, loud noises.
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  So kind of identifying those triggers. And lunch meat can be a big one. Absolutely, yeah.
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  And it's ubiquitous in our kids' lunches and in the lunch rooms and to make a quick lunch.
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  But that really can be causing headaches.
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  Absolutely. Processed foods. Yeah, absolutely.
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  And stress and anxiety are related.
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  You know, you hear the kids usually in the summer, their headaches may get better
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  because they get to sleep in more. They get to relax more.
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  So that's the thing. So lifestyle modification, I totally agree with that.
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  A child who's being bullied could be experiencing headaches?
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  Stress can do so much. You know, there's this book that says the body keeps the score.
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  I've heard of that. Would you recommend reading that? I recommend reading it.
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  I'm listening to it on Audible like the second or the third time. It is so true.
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  You know, a lot of people may not agree with me or they may, I don't know.
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  But I speak as a patient too. You know, I'm not speaking as a physician.
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  I'm speaking as a patient too, because I'm a patient of suffering from migraines.
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  Means stress and anxiety can do lots of things to your body and the body does
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  keep us core we don't know why i'm losing my hair like you know why are we losing
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  our hair why are we the cortisol why are we gaining weight why are we not sleeping
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  right so yeah and it's all the stress,
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  and i'm sure social media is not helping it things totally totally what the
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  kids these days have to go through i think it's more than what we had to go
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  through we didn't have social media right Right.
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  It is stressful. One, yes, one doctor we had on the show recently talking about social media.
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  It's, it's, you see what you're missing, like you're, what you're missing out on really.
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  Absolutely. And that's the opposite of gratitude. Yes. We'll never be grateful
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  like that. And then we'll never be happy.
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  Because the mission in life is not, whatever we do, like you get an education
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  or you go to the gym, the goal is to be happy, right?
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  The degree is just a paper, but there was a goal behind it, to get somewhere in life, to be happy.
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  So and we have coming up on pediatrics now
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  i'm interviewing a doctor who was recently on the front page
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  of the new york times for a book he's read he's for a book he's
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  written and he says so he believes
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  that social media and cell phones are taking away children's taking away childhood
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  now so he has some solutions and and a great perspective so that's coming up
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  in about a month oh that's great what are the i mean i would love to know yes
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  i'll know more More after that interview.
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  Yeah. And for our listeners, know that that's coming up. I know it's such a
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  big topic in pediatrics right now.
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  Back to the headaches are so...
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  Let's go over, what are the warning signs and update on that where it could
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  be that, you know, it's, we know it's rare where it's a brain tumor or something
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  serious, but of course we have to be very careful not to miss that.
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  So what are the top warning signs there? Like a headache that wakes a child up from sleep? Exactly.
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  Exactly. Now, medication overuse headaches, hypnic headaches can do that too.
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  But if you have a child who's waking up from sleep, you know,
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  wakes up in the middle of the night with a headache and has vomiting or projectile vomiting, right?
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  Or usually the thing is focal neurological findings.
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  So focal neurological findings would be, it could be a migraine with aura or
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  a hemiplegic migraine, but that will resolve.
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  A kid who was able to walk before and now they keep waking up and they fall.
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  They get as ataxic, as you would say, or they cannot walk in a straight line, right?
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  Or they have neck stiffness, they have difficulty moving their neck,
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  or they have a fever or they can't see out of this eye or this hand is constantly weak.
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  Those are all warning signs. And absolutely, that needs imaging.
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  And Azra, is it a warning sign if you have one of those or two or?
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  Either one. Okay. Any of them? Yes. So if you have fever and headache, okay.
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  But if you have headache and neck stiffness, then that needs to go to the emergency
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  room. That could be a sign of meningitis.
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  And can a migraine have the symptoms of a stroke, but it's still just a migraine?
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  It's certainly possible. Those are called hemiplegic migraines or complicated
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  migraines or migraines with aura.
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  But with a stroke, usually the symptoms do not resolve within an hour.
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  With a transient ischemic attack, of course, it resolves within an hour.
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  But with a migraine, it's usually migraine with aura, like the aura will proceed
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  usually within that 60-minute period, followed by the headache,
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  and then it will resolve.
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  A TIA with also, yes, correct, resolved, but a stroke-like symptoms usually
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  wouldn't resolve within an hour.
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  So again, unless if it is the first time this happens, it needs to be seen.
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  Absolutely. A workup needs to be done. But if it is recurrent and there's a
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  family history and we already know about it, that it's happened many times,
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  then maybe we can chalk it off to hemiplegic migraines.
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  So any of those warning signs, the patient would need to get in for an MRI quickly
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  and send the patient to the ER.
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  Or if you have a way like here, you can call the pager number for pediatric
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  neurology and get a call back and you all can say, well, we can see this patient
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  right now or send the patient to the emergency room. Right.
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  Any other warning signs that we didn't touch on?
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  That other warning signs well
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  a seizure seizure like spell or altered
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  mental status you know like confusion
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  mental status changes all of those things are some things that need to be seen
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  like you know and also one term that they use usually for the adults is the
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  worst headache in my life like a bleed a subarachnoid hemorrhage go to the er
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  oh absolutely absolutely so.
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  What would you say to your five-year-old self now so have we come a long way you come a long way.
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  Yeah tell the five-year-old self i mean yeah the motion sickness was awful yeah
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  the vomiting with the car not knowing yeah that that's pretty awful but yeah
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  tell them man, it's all right, you survived.
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  Here's the thing, you know, according to American Headache Society,
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  you know, the criteria to meet a migraine, one of them is the MRI is normal.
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  So it wasn't a brain tumor, I survived. Still alive.
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  And I know it's often, like you said, not taken seriously.
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  And I've had migraines for many years, starting at a young age.
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  And it was recently, an optometrist was, he was saying, like,
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  well, we need to do something to figure out to stop the migraines.
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  And it had been so long since anyone had said that to me in medicine and that
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  he was taking it seriously. And then,
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  And then also that's when I talk to our neurology team and just some of those,
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  like avoiding lunch meats, aged cheeses, you know, really with lifestyle,
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  a lot can be done. Lifestyle, absolutely.
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  But why isn't it taken more seriously?
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  You know, that's a really good question, especially in children.
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  Right. I think the reason maybe is because some of us may assume that this is
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  being used for other gains.
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  For example, trying to get out of your work or trying to get out of school.
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  School. I mean, it's possible you have, you're being bullied at school.
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  You don't want to go to school.
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  So, and you do have a headache and you keep using it. So it's certainly possible.
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  So I always, you know, if the family will say, oh, we need a letter for school
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  so that they shouldn't be, they won't have to attend school.
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  I discourage that a lot.
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  Really do discourage that. What do you say instead? Usually what I say is that
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  they should be allowed to take their, I have a letter, like a template that
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  says they should be allowed to go to the nurse's office and rest in the nurse's office for an hour.
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  They should be allowed to carry a water bottle and bathroom breaks.
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  They should be allowed to take their medication in the nurse's office.
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  And once they feel better, they'll go back instead of missing school altogether,
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  like just not attending school. Because that's like checking out of life.
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  And then during my headache fellowship, I saw adults too.
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  And unfortunately, you know, they were unable to maintain a job. and
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  then headaches are multifactorial and usually
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  at a headache center you'll usually have
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  a psychologist psychiatrist a biofeedback specialist a therapist and the reason
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  for that at university of illinois we had an acupuncturist on staff the the
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  reason is because a lot of times migraineurs chronic migraine they will have
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  other pain disorders they will also have depression depression, insomnia,
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  obesity, other health conditions.
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  So you have to address, like Dr. Fox will often say, a whole person approach.
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  Not just, okay, I'll fix your headaches. I don't know about your irritable bowel
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  syndrome and your depression. Or somebody else is going to fix that. So that's not ideal.
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  Because it goes hand in hand.
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  And of course, we're talking about Dr. Brian Fox, who's on our pediatric neurology
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  team at the University of Texas Health Science Center, and Sheldon Gross, you mentioned.
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  Yes, Dr. Gross. So-
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  Does the Botox help with migraines only or other headaches?
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  You know, that's a really good question. Tension headaches too,
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  because if the thought process is it, if it will help relax the muscles too, yeah.
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  And then of course, rare, but occipital neuralgia.
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  You know, I don't have a lot of kids. I recently started working here,
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  but at the University of Illinois, I had only a few teenagers with trigeminal neuralgia.
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  But so I'm not sure Botox would help with that. but lidocaine
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  injections like specific injections for occipital neuralgia of
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  course have been used but again lidocaine kind
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  of patients will tell me will burn and the needle is so it's it's much more
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  uncomfortable than Botox so Botox I think people get intimidated because it's
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  31 sites oh my god 31 injections that's what intimidates anybody but once you
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  get that and you see oh it's a tiny itty bitty needle and it doesn't really
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  hurt in this area it only hurts in the the forehead area.
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  So, you know, once you get it and you see the benefit of it,
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  and it's only every 12 weeks, so it's not every month.
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  And is it important to do it right at that, about three months?
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  That's a great question. That's what they have suggested, but that's what patients
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  also tell me. When it starts working for them, they want to make sure they don't
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  miss their appointment.
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  And side effects that we should be aware of?
• 21:02
  Limited. I mean, if we don't do it right, you can have a droop,
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  you can have like an asymmetry. But again, we're not doing for for cosmetic reasons.
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  But over here in the forehead region, yes, it's possible.
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  You could correct that if there was a droop. With a droop, yeah,
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  it could cause, like for cosmetic reasons, if it's not done right,
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  it could cause it. It can cause a little bit of asymmetry.
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  But that doesn't apply so much to us because we're not really doing the face.
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  You know, we're not doing anything in this area. We're just doing the head, exactly, the head.
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  So yeah, the basic side effects could be bleeding. Now, if you have a bleeding
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  disorder, if you're on aspirin, then yeah, that could be. So we make sure we tell them, yeah.
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  And risk of infection minimal, but certainly it's possible.
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  So Azra, what about for our pediatric practitioner listeners,
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  what can be treated in the community pediatric setting?
• 21:56
  What are some of the symptoms and that where rather than referring out,
• 22:02
  let's try this first? That's a good question. I have noticed this about the
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  pediatricians here. They're pretty good like that.
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  You know, a lot of kids will come to us and they're already on,
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  you know, so the guidelines are, you know, if you have more than four severe migraines a month,
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  or for the past three months, you've had more than 15 days of headaches,
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  or even if you have less than four days of migraines, but they're pretty debilitating,
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  there's a family history of migraine, they're lasting a long time,
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  they're affecting the quality of your life.
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  25 then they've already started the
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  patient on topamax is the FDA approved one that
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  we talked about usually they do that one to two
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  milligram per kilo so for my older kids I'll just start with 25 it now comes
• 22:43
  in a liquid it comes in a extended release it comes in a sprinkle so that works
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  the ones I've noticed the pediatrician start which is actually a good choice
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  is topamax A lot of them will do periactin.
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  It's an anti-allergy apparently, but it works great for headaches too sometimes.
• 23:02
  And amitriptyline, Eleval. So that's what I've noticed.
• 23:06
  I've also noticed that they'll also just start the patient on as-needed medications,
• 23:10
  the prescription ones like Maxalt, which is also the FDA-approved Triptan for children.
• 23:15
  So they're already on it, which
• 23:17
  is good. Sometimes you just have to adjust the dose sometimes. times.
• 23:20
  So if you don't have, if there aren't any of those red flags present, try this first. Yes.
• 23:26
  And then what about lifestyle changes do you recommend?
• 23:30
  Absolutely. There, there are plenty of studies, especially in Europe with the
• 23:33
  exercise and, you know, weight loss and headache improvement.
• 23:39
  So I tell them once you start feeling better, I want you to,
• 23:42
  the older kids, I'll tell them cardio that raises your heart rate at least three
• 23:46
  days a week. I highly recommend that.
• 23:49
  And of course, like you said, avoiding aged meat, deli meat, aged cheese,
• 23:55
  brie, gouda, pepperoni, salami, all of those, tyramine, turkey,
• 23:59
  all of those, all your triggers, MSG containing foods, whichever ones are,
• 24:03
  anybody could be different. I know mine very well.
• 24:06
  But you know, as they grow older, as the children grow older,
• 24:09
  they will realize that's even more.
• 24:11
  So basically, yeah, that water Water intake, increase hydration,
• 24:15
  sleep on time, eat on time, and avoid stress as much as you can.
• 24:19
  Yoga, stretching, exercise.
• 24:22
  And for three times a week, getting that heart rate up for, is it a certain
• 24:26
  amount of time? 30 minutes. Yeah.
• 24:28
  Yeah. American Headed Society's guidelines. Yeah. And of course, releasing endorphins.
• 24:34
  The goal in life is to be happy with what we have, not what the other person has.
• 24:39
  What we have and that that makes me think about
• 24:42
  i know in pediatrics now we love quotes i love
• 24:45
  quotes what quote would you like to say today
• 24:48
  i guess i'll say yeah this too shall pass this too shall pass and that's that's
• 24:56
  a great one for it can be can be depressing if it's something great yeah this
• 25:01
  too shall pass but also in those
• 25:03
  painful moments that we all experience in life or having a a hard day.
• 25:07
  Yes. And life doesn't really, I don't know, maybe it does, but I feel like life
• 25:11
  doesn't really stay the same.
• 25:13
  It kind of, some days you have a good day, some days you don't really have a
• 25:16
  good day, some days you have a migraine, another day you did really well and,
• 25:21
  you know, the patients are happy.
• 25:23
  Sometimes they're sicker kids on the floor.
• 25:26
  So days change, things fluctuate. So, but yeah, it do shall pass,
• 25:31
  especially the suffering.
• 25:33
  And as a doctor who has migraines and are doctor listeners, we also like to
• 25:39
  promote it's important to take care of yourselves. Do you want to say anything there?
• 25:44
  Yes, absolutely. Do what makes you happy. Do what makes you happy.
• 25:48
  Yeah. Take care of yourself and be kind to yourself. Be kind to yourself. Very important.
• 25:55
  And you enjoy traveling? Yeah, I do.
• 25:58
  I do. I travel I recently just January
• 26:01
  I was in Qatar where my sister is
• 26:04
  and then I went to Pakistan where my parents are probably
• 26:07
  be going to Canada sometime soon yeah nice have you been there before Canada
• 26:12
  yeah my brother lives there oh nice and and did you say you also like to cook
• 26:17
  I do yes yes yes but it's usually just traditional food that I know how to cook
• 26:23
  do you have a favorite Favorite dish?
• 26:25
  Yes, chicken karahi. Because it's so easy to make tomatoes and chicken,
• 26:29
  yeah, and some spices. That's it.
• 26:31
  Nice. Yeah. Over a certain type of rice or just... Yeah, you could do it with naan.
• 26:37
  Yes. Yeah, you could do it with basmati rice. Totally. Totally.
• 26:41
  And that, would you, I know we were just talking about like lunch meats and aged cheeses.
• 26:46
  Is it good for children or all of us to try to avoid that anyway?
• 26:49
  Or just if it triggers? Or do you want to say anything about that?
• 26:52
  You know, that's a good question.
• 26:53
  That's a good question. So processed foods should be avoided.
• 26:57
  Fresh home cooked meals is always better. And I know it's so hard to do,
• 27:00
  but it's very hard for me to do too.
• 27:03
  I try to do it at least once a week.
• 27:06
  But yeah, avoiding eating out. I don't know. So especially the fast foods, it's less than ideal.
• 27:14
  And that's so hard where it's so, for teenagers, as you know, that's what they want.
• 27:20
  It's highly palatable. That's true.
• 27:22
  But it is important to, I know one of our wellness doctor, pediatric wellness
• 27:27
  doctor, she was saying to say to the child, just not now, and try to have it
• 27:32
  be at least three months, like before they have the next fast food.
• 27:37
  What else would you, anything we didn't cover? that you would like to say to
• 27:41
  the pediatric practitioner, the community pediatric practitioner listener regarding headaches?
• 27:46
  Yeah, no, I'm very new here, but I think they're doing a really good job.
• 27:51
  Like I said, when I, you know, when the patient comes in, they're already on
• 27:54
  a pretty appropriate dose of daily prevention or appropriate dose of an as-needed pill.
• 28:00
  I think the only thing is we need to tell families, which is really not so much
• 28:04
  a problem here, but we need to tell them about medication overuse headaches,
• 28:08
  you know, we don't want them to be on Tylenol, Aleve, Advil,
• 28:12
  BC powder, Excedrin, any of those more than two, three days a week.
• 28:17
  Because if the child is taking it that much, then they need to be on a daily
• 28:20
  preventative medication. And medication overuse headaches are harder to treat.
• 28:24
  So yeah. And can those medications then be causing medications? Exactly.
• 28:30
  There's studies on it. It causes activation of the microglia in the brain,
• 28:36
  and they appreciate pain even more.
• 28:38
  So that's it. Medication over euthanics is a real diagnosis.
• 28:42
  Wow. And it can be causing more pain. Absolutely. You appreciate it even more.
• 28:46
  Yeah. The 600 milligrams is not working. Now you need 800 of ibuprofen.
• 28:50
  So, you know, it's not a good cycle to be in. It's not a good cycle.
• 28:54
  And it's hard on the liver. Exactly. Exactly. Exactly.
• 28:59
  What would you say to parents where a lot of our pediatric practitioner listeners,
• 29:03
  they're counseling parents about headaches, anything you would want to say?
• 29:06
  Like, so, you know, what you just mentioned is crucial.
• 29:10
  And it's such an honor to be talking to you today and being here.
• 29:13
  Thank you so much. Thank you so much for having me. I really appreciate you. I do.
• 29:18
  What would you want the community pediatric practitioner to say to parents?
• 29:23
  Parents you know i would say
• 29:27
  don't keep asking your
• 29:30
  child do you have a headache how how bad is it is it is it a 10 no don't see
• 29:35
  what the child is doing look at the child observe the child you know because
• 29:42
  if it's mild headache and they're watching tv playing video games and you ask
• 29:47
  are Are you okay? Are you okay?
• 29:49
  You know, parents, they love their kids more than anything else in the world.
• 29:53
  So of course they don't want their kids to suffer.
• 29:55
  But I think it's a very thin, fine line. It's a very thin, fine line.
• 30:00
  And I let the patient dictate the course of the management.
• 30:04
  If they're able to, like, you know, usually migraineurs are type A personality.
• 30:08
  They're usually doing very well there.
• 30:10
  So it depends. How bad is it? Does it need to be treated? How How soon does
• 30:14
  it need to be treated? Can we just start with lifestyle modification?
• 30:17
  Why give you a daily pill? You know, I don't like to give pills unless absolutely necessary.
• 30:23
  And if we can get away with lifestyle modification and vitamin supplementation
• 30:27
  with magnesium, coenzyme Q10, butterbur, riboflavin, and increased water intake,
• 30:33
  sleep hygiene, identifying triggers, removing stressors, then that's awesome.
• 30:37
  You know? Yes. Yes, and how important that sleep is where a lot of times it's
• 30:44
  not put as a priority. That's right. It's not.
• 30:47
  And these electronics, like, you know, everybody's house, right?
• 30:51
  Even though you're in bed, but you're still on your phone, you know,
• 30:55
  you're checking stuff out.
• 30:56
  And social media wakes us up. Checking an email wakes us up.
• 31:00
  Exactly, exactly. Social media is a little bit of a problem.
• 31:05
  And we don't get that deep sleep. That's right.
• 31:09
  Even if we do fall asleep after that. We also, in this Pediatrics Now news feed,
• 31:13
  there's an episode on how to get a great night's sleep.
• 31:17
  And it's written by, a sleep doctor was on the show.
• 31:21
  And he was also on the front page of the New York Times. But his book,
• 31:24
  The Sleep Prescription. So he talks about that social media and electronics in general before bed.
• 31:31
  So you can find that in this news feed for pediatrics now. I would love to listen
• 31:35
  to that. Yeah, I feel like we heal when we sleep.
• 31:38
  You know, you feel better if you have a good, well-rested night's sleep.
• 31:42
  So it's very important. You can't survive without sleep.
• 31:45
  Yes. Can you tell me a little bit about how you got here to San Antonio?
• 31:50
  So I finished my fellowship at UT Southwestern, Dallas, Texas,
• 31:53
  in epilepsy and child neurology, and then headache at Baylor, Dallas.
• 31:57
  And then right after that, I went to Illinois.
• 32:01
  Yeah, and I really enjoyed my job. For a short while, I did come back to Houston, the Woodlands area.
• 32:08
  But then I went back to the same job. That was my first job.
• 32:11
  And then I just came here. I just needed a change.
• 32:14
  I still love my old job. I have wonderful, absolutely wonderful colleagues.
• 32:19
  Couldn't ask for better. But this is an amazing team of doctors.
• 32:23
  Genuinely, like Dr. Gross, Dr. Larry, Dr.
• 32:26
  Fox, both our nurse practitioner, Dr. Lavin and Daniel, they're wonderful.
• 32:32
  Even our program coordinator. I feel like the doctors actually care for the patient.
• 32:37
  They genuinely do. Yes. And I know, congratulations, the pediatric neurology
• 32:41
  team recently won the People's Choice Award by the Express News,
• 32:45
  San Antonio Express News here in San Antonio.
• 32:47
  So that's really exciting. And that I see that customer service,
• 32:51
  compassionate care on a regular basis.
• 32:55
  And it's so important. Before we go, is there.
• 32:58
  One thing that you would want to say about, you know, this definitely does not
• 33:02
  need to be referred out because when I talk to community pediatricians, I hear a lot of that like,
• 33:08
  well, I don't want to send a patient who doesn't need to be seen by them.
• 33:13
  Or is it okay even if the parent's worried and the patient is concerned,
• 33:19
  having a pediatric neurologist tell them what the pediatric,
• 33:24
  you know, community pediatrician would say anyway is okay.
• 33:28
  Yeah, exactly. Whatever makes the parents comfortable.
• 33:32
  You know, if the parents just want to hear it, if it's a child who's had one
• 33:36
  headache in the past six months, but mom is very anxious because the cousin had a brain tumor.
• 33:41
  We see kids like that all the time. Okay, if it makes her feel better, sure, sure. Sure.
• 33:45
  They don't need to be seen by a headache specialist for one headache in a year,
• 33:49
  but if it makes them feel better, you know, then absolutely, absolutely.
• 33:55
  They should talk to us, absolutely.
• 33:58
  How does it feel being here after having headaches starting as a child and then
• 34:04
  now having all this education, training, experience, and being able to help
• 34:09
  children on a daily basis? It's a privilege.
• 34:13
  You know, our patients, it's a privilege to be able to be involved in their
• 34:19
  life because they teach us every day.
• 34:22
  You know, they really, they're better than the textbook, right?
• 34:25
  You learn, you learn how to interact, you learn social cues,
• 34:30
  you learn different pathology, what medicines work for this patient or not for this patient.
• 34:35
  So yeah, patients are the best educators.
• 34:39
  Dr. Azra Akbar with the University of Texas Health Science Center and University
• 34:43
  Hospital, thank you so much for being here on Pediatrics Now.
• 34:46
  Thank you. I really appreciate it. Thank you. Thank you, Holly. Great job.
• 34:54
  I'm Holly Wayment. Thank you so much for listening. Click on the link for free
• 35:00
  credit that may include CME, MOC, or ethics credit, depending on our topic,
• 35:04
  our website is pediatricsnowpodcast.com.
• 35:08
  My email address is on there. Please email me with episode ideas or comments.
• 35:14
  Coming up next week,
• 35:16
  A deep dive into concussions. He's a sports medicine specialist with a passion
• 35:22
  to help people with concussions.
• 35:24
  I was an athlete for high school basketball, middle school football,
• 35:28
  and concussions are fairly common, especially in contact sports.
• 35:33
  Studies and data has shown that football, of course, has a high rate of concussions,
• 35:38
  but you can also see it in sports you don't even think about,
• 35:42
  cheerleading and soccer.
• 35:43
  That's coming up next week on Pediatrics Now, cases, updates,
• 35:47
  and discussions for the busy pediatric practitioner.
• 35:52
  In this news feed, you'll find an episode called The New Asthma Guidelines.
• 36:00
  What were they thinking?
• 36:01
  I interview a doctor who was on the expert panel for those guidelines, and he explains them.
• 36:08
  Also in our Pediatrics Now news feed, how to get a good night's sleep.
• 36:13
  If you search the newsfeed, you can find that episode where this doctor talks
• 36:19
  about the best ways, seven days to your best night's rest.
• 36:23
  It can be great advice for you and for your patients.
• 36:28
  That's in the Pediatrics Now newsfeed in this podcast. It's called The Sleep Prescription.
• 36:33
  I'm Holly Wayment. Thank you so much for listening to Pediatrics Now.