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Thursday, January 31, 2019

A neurologist talks about kids and headaches

Treatments for advanced prostate cancer that’s metastasizing, or spreading in the body, are getting better, and men with the disease are living longer because of them, new research has found.

For years, the only available treatments for these aggressive tumors were androgen-deprivation therapies (ADT) that block testosterone, the male sex hormone that makes prostate cancer cells grow faster. Giving ADT slows cancer progression, but tumors typically develop resistance against it within three years and start growing again.

But then newer treatments for metastatic prostate cancer started showing up. A drug called docetaxel was approved by the FDA in 2004, followed by cabazitaxel in 2010, sipuleucel-T in 2011, abiraterone in 2011, and enzalutamide in 2012. Each of these drugs targets metastatic prostate cancer in different ways, and men who took any one of them in clinical trials lived longer than men who took ADT by itself.

For the current study, researchers set out to answer a unique question. They wanted to know if the combined market availability of these drugs was making a survival difference for men being treated for metastatic prostate cancer in the general population.

To find out, they divided men tracked by a national cancer registry into two groups. One group of 4,298 men had been diagnosed with metastatic prostate cancer between 2004 and 2008, and another equally sized group was diagnosed with the disease between 2009 and 2014. All the men in both groups were matched in terms of age, race, cancer stage at diagnosis, treatment, and other factors.

Results showed that the duration of survival before men died specifically from prostate cancer lasted approximately 32 months among those diagnosed during the earlier time frame, and 36 months among those diagnosed during the later one. Similarly, the duration of survival before men died from any cause after a metastatic prostate cancer diagnosis was 26 months between 2004 and 2008, and 29 months during the 2009–2014 time frame.

The authors acknowledge that the survival improvements are modest, but add they may not fully account for longer survival improvements from abiraterone and enzalutamide, which only came into widespread use at the end of the study period. Furthermore, men who respond extraordinarily well to the new treatments may live far longer than those who don’t. In general, the evidence provides “valid evidence in support of [newer] novel treatments,” the authors wrote.

Dr. Mark Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, says, “This study provides important information that men with advanced forms of prostate cancer are now living longer than they once did, sometimes years longer. Those of us who have been treating prostate cancer for decades appreciate this study’s fundamental finding that the improved longevity from newer cancer drugs is considerable.”
It’s been on the news recently: teens are eating Tide detergent pods — despite the fact that eating them can be lethal. They film themselves doing it; it’s the “Tide Pod Challenge.”

It’s not like they don’t know it can be dangerous. Besides the fact that it’s common knowledge that detergent isn’t food, there has been a lot of media coverage about the dangers of toddlers getting into them, about how Tide pods are not just poisonous but possibly lethal.

The media coverage, actually, is part of the problem. But the real problem is the adolescent brain.

Adolescence is a crucial moment in life, the transition between childhood and adulthood. The brains of adolescents reflect that transition. They have the ability to take in a lot of information, to learn quickly, that children have — and their brains are beginning to build the connections that adults have, the connections that make different parts of the brain work together more quickly and effectively. The last part of the brain to build those connections is the frontal lobe. This is important, because the frontal lobe is the part of the brain that controls insight and judgment, the part that controls risk-taking behaviors.

Basically, teens are quick learners without a whole lot of insight or judgment, and risk-takers. As frustrating as this may be for parents, teachers, and others who have to deal with teens on a daily basis, it makes evolutionary sense.

Teens have to learn so much as they get ready to become adults. They have to learn not only academic subjects, but how to navigate life: how to hold down a job, drive, pay bills, and everything else an adult needs to do to survive. It’s a staggering amount of information, really.

They also have to take risks. Just think about it: leaving home, getting a job, falling in love… it’s a lot of scary firsts. Those risks are hard to take when you fully understand how things can go wrong, and how we are all flawed and mortal. They are much easier to take when you think you are invincible.

Unfortunately, teens don’t limit their risk-taking to leaving home or falling in love. They take dumb risks, the same kind we took as teenagers. We took them because we thought we were invincible, and because our friends were watching and egging us on. That’s another part of teen reality: what their peers think matters a lot.

That’s where the media coverage comes in — more specifically, social media. Back when I was a teen, the group of friends watching and egging me on was relatively small, and most of them were people I’d chosen to be friends with, at least some of whom had some interest in my well-being. They were also there in person, and we could talk about risks before taking them.

With social media, today’s teens have potentially millions of people watching and egging them on, mostly people they didn’t choose, who are not there in person — and who have zero interest in their well-being. It’s “I dare you” in proportions we can’t measure or imagine, played out in the latest “challenge” (there have been plenty of them) and broadcast via their ever-present phones.

That’s why the American Association of Poison Control Centers reported 86 intentional exposures to laundry detergent packets in the first three weeks of 2018. And those are just the ones that got reported.

YouTube has said it will take down any reported videos, which is good, but there will undoubtedly be another challenge. We can’t make social media go away, any more than we can change the adolescent brain.

We must realize that social media has changed the world adolescents are growing up in; while it has upsides like connectedness, it also can put them at risk. We need to find ways to use the power of social media for good, like the video the New England Patriots’ Rob Gronkowski has made telling teens not to eat Tide pods. We also need to spend more time with teens, both talking and listening. We need to help them navigate this new socially connected world; we need to help them understand where and how to draw the line, so that they stay safe. It’s not uncommon for a child to complain of a headache. But what should a parent do? When should you worry? What are features that are cause for concern and should prompt a call to the pediatrician, or even a trip to the emergency room? For kids with headaches, do they necessarily need to take medication, or are there other nondrug treatments that may be just as effective?
When to call your pediatrician

The cardinal rule for thinking about headaches is “first or worst.” In practical terms, if your child has never had a headache before, you need to evaluate carefully.

    Did he have any recent head trauma, such as a fall or a sports injury?
    Was she sick with a bad virus?
    Is he vomiting or does he have a fever?
    Is she unable to walk, talk, and eat normally?

If the answer to any of these questions is “yes,” it’s time to call the pediatrician. A concussion, a severe infection, or even a rare but more ominous cause for a headache could be the trigger. Many people worry about a brain tumor, but this is very unlikely. You should never be alone with worry about your child’s headache, and your pediatrician can help to steer you toward the best treatment.
Kids can experience migraine headaches

Children can and do get migraine headaches. The rate is estimated at 5.5%, but underdiagnosis may falsely lower the number. Think about migraine in particular if a parent has migraines, as there is a strong genetic link. Kids’ migraines are different than adults’: the pain can be on both sides of the head and not last as long. But just like in grownups, kids can be totally incapacitated with a migraine, with profuse nausea and vomiting and the need to lie in a dark room. It’s not possible to make a diagnosis after just one headache, though. Kids need to have at least two episodes to be diagnosed with migraine. Ibuprofen can be a very effective treatment once a headache hits, but don’t forget about ice, which can also relieve pain and decrease inflammation. A bag of frozen peas is lightweight, and the child can position it comfortably over his or her head.

There is a migraine-specific class of drugs called triptans that is used to stop migraines when they start. One formulation called zolmitriptan is approved for use in children. It comes in a nasal spray so it can be used for kids who can’t swallow pills. For children with frequent migraines, it may be necessary to try to prevent them. Certain medications are used for both children and adults, such as amitriptyline and topiramate. A recent study found that combining amitriptyline with a form of cognitive behavioral therapy (a type of mind-body work that helps to change a person’s response to pain and anxiety) can be more effective than the drug alone. And some children will respond to cognitive behavioral therapies alone as preventives. Health insurance often covers these treatments, so be sure to ask about options.
The more typical kid headache

Tension-type headaches are more common. The old name for these was “hat band headache” and that’s often what the pain is like. Kids describe pressure around their forehead or entire head, not the throbbing of a migraine. Often they can function, eat, go to school, and even play sports although they don’t feel well. Ibuprofen may help, and relaxation and fluids may be adequate to treat a tension-type headache.

Lots of parents are concerned about screen time triggering headache, and it’s a valid concern. Bright lights and screens definitely can trigger migraines in susceptible children and adults, but staring at a computer, phone, or iPad can trigger a headache for anyone if used for too long. Encourage limits on screen time, taking breaks, and getting up to stretch when working or playing games.

It’s important to ask about stress and anxiety when evaluating your child’s headache. School-avoidance headaches can be tough to diagnose. Careful questions and discussion with teachers and guidance counselors may help a parent figure out if a headache is actually a way for a child to avoid bullying or a difficult situation at school. This hopefully leads to intervention and resolution of the triggers.
The bottom line

If your child tells you she has a headache, take her seriously. Ask questions about type of pain, other symptoms, and recent events. Enlist your pediatrician to help make the right diagnosis. It may be useful to see a pediatric neurologist. And if the child has a fever, can’t stop vomiting, or tells you he has double vision or trouble moving his arms or legs, go directly to the emergency room. Chances of this are very rare. Most headaches are very treatable.

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