HEADACHE
| PEDIATRIC HEADACHE: A COMMON-SENSE APPROACH —Bonnie L. Bunch, MD, PhD, Assistant Professor of Pediatrics
and Adolescent Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls
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| Disclaimer: almost all medications discussed used off-label for treatment of headache in children
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| Why headaches important: pain; limitation or alteration in level of activity; reduced quality of life for patients and family;
significant source of parental anxiety—many people unaware of prevalence of headache in children; fear of serious underlying
problem
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| Types of headaches in children: migraine most common type of headache in children; chronic daily or tension-type
headache next most common; children with chronic daily headaches may have occasional migrainous exacerbations;
brain tumor rare cause of headache; eyestrain and sinus problems relatively rare causes of headache; cluster headaches
occur only in adults (not children)
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| Migraine (International Headache Society diagnostic criteria): migraine without aura (formerly, common
migraine)—in adults, 2 of 4 criteria (unilateral headache; throbbing or pulsating; moderate-to-severe pain [restricts activity,
lasts >30 min]; pain aggravated by certain maneuvers [eg, bending, climbing]) and nausea or vomiting, or photophobia
and phonophobia; migraine with aura—much less common in children; same criteria, with addition of aura; most auras
visual (nonvisual aura may present as dizziness or “funny feeling”)
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| Chronic daily headache (tension-type headache): mild-to-moderate pain (usually bilateral) that limits (but does
not prohibit) activities; lasts >30 min; pressing or tightening pain (like band around head), but not throbbing; not worsened
by physical activity; no nausea or vomiting; photophobia or phonophobia (not both); present >15 days/mo for >6
mo; often seen with migrainous exacerbations
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Diagnosis
| Overview: with good history, physician knows diagnosis or whether to worry; takes >5 min; headache diaries helpful, but
only if family diligent
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| Duration: ask about age at onset; if duration years—headaches usually not related to serious underlying problem;
months—more concerning, especially if increasing in severity or frequency; days to weeks—same as months; sudden
onset “this morning” always concerning, but there is first time for every headache sufferer
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| Frequency: number per unit of time; stable—usually not worrisome; stable long time, but now increasing—make sure
nothing new or overlooked; steadily increasing since onset—most worrisome pattern; consider possibility of pseudotumor,
Chiari malformation, tumor, other systemic disease, or psychosocial cause
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| Severity: use of pain rating scales common; child’s report can differ from that of parent (patient may minimize problem to
preserve activities); change in activity level good indicator; severity increasing or stable?
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| Quality: location and nature of pain; duration of episodes; >1 type? (many people have migraine and daily headache)
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| Associated symptoms: aura may be difficult to describe; neurologic deficit—before headache? during headache? always
present, even between headaches?
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| Temporal or seasonal pattern: may suggest trigger; caveat (fever most common cause of headache); summer vs
winter—in summer, problem likely related to hot, humid weather (many people with migraine sensitive to that); during
school year—headaches generally related to stress (for many children, school greatest source of stress); weekdays, weekends,
or both?—in adults, caffeine intake varies from weekdays to weekends; in children, weekend headaches often related
to sleep deprivation; time of day—late morning (frequently, child missed breakfast); after-school or early-evening
headaches often related to tension (headache that persists to next day suggests migraine); headaches in middle of night or
on awakening may be clue to tumor or other intracranial cause
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| More triggers: sleep deprivation—reduced hours of sleep or sleep disturbance (eg, snoring, sleep apnea); stress due to
school or family problems; hunger (especially due to inadequate breakfast; additional protein, fat may be indicated);
change in weather; strong or glaring light; odors (eg, perfume, insecticide, roofing tar); excessive activity; headache with
certain movements (eg, Valsalva maneuver) more serious; what about—chocolate, caffeine, red dye, hot dogs, television
viewing, and video games? some people sensitive; Koch’s postulate—identify one trigger and remove it to see whether
headaches stop; reintroduce trigger (if headaches return, trigger confirmed)
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| Family history (migraine): 80% or 90% of children with migraine have family history of migraine; increasing evidence
of genetic component (familial hemiplegic migraine linked to calcium channel gene); patients with epilepsy have
increased incidence compared to general population
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| Serious underlying conditions
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 | Intracranial hemorrhage: arteriovenous malformation (AVM)—most common vascular malformation in children; high-
flow malformation; more likely to present with stroke-like symptoms and seizures than headache, but AVM leakage
can provoke headache; hemangiomas and venous angiomas—low-flow lesions; may cause bleeding
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| Brain tumor or other mass lesion: malignant tumors; benign tumors still troublesome because they take up space in cranial
vault; hydrocephalus
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| Infection: with acute onset of headache, consider possibility of meningitis, encephalitis, or brain abscess
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| Pseudotumor cerebri: common; most commonly associated with use of minocycline (acne medication)
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| “Worst headaches of your life”: in adults, source intracranial hemorrhage from aneurysm until proven otherwise (problem
uncommon before third decade of life)
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| Anatomic variants: Chiari malformation—cerebellum dips into spinal canal; occasionally occurs in children with spina
bifida; Klippel Feil malformation of cervical vertebrae—patients usually have short neck; can run in families
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| Underlying systemic illness: anemia; vasculitis or connective tissue disease; autoimmune disease (headaches start in adolescence);
celiac disease (headaches improve on gluten-free diet)
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| If confident headaches tension-type or migrainous: treat
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| If further investigation indicated: intracranial hemorrhage—computed tomography (CT) best; for sinus problems, CT of
sinus quickest imaging study; any other intracranial abnormality or Chiari malformation—obtain MRI; as exception,
MRI probably not needed in cases of old brain trauma, absent history of hemorrhage or skull fracture; some skull fractures
can lead to arachnoid cysts that put pressure on brain; laboratory tests—speaker usually does not order them, unless systemic
disease suspected; celiac screen if patient has gastrointestinal (GI) complaints or family history of celiac disease;
infectious causes of headache—acute presentation; when in doubt—consider consult with pediatric neurologist
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Treatment
| Overview: migraine—majority of children’s headaches migrainous; many medical and lifestyle-management options;
categories (abortive, prophylactic, or combination therapy); chronic daily headache—not many good medication options;
lifestyle management key; secondary headache—treat underlying disorder; if headaches persist, consider possibility
of comorbid migraine
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| Lifestyle management: ensure adequate sleep (in quantity and quality); patients with restless legs syndrome may have
ferritin deficiency; ensure adequate energy (younger children may need snacks into school-age years); identify and
avoid personal triggers; if exposure to heat or sun identified as trigger, patients should wear hats and dark glasses, and
take breaks from playing outside every hour; avoid stress and deal constructively with unavoidable stress
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| Stress management: exercise—regular, moderate, aerobic exercise helpful for almost every type of headache;
relaxation—even very young children can learn to use imagery, progressive relaxation, or meditation; school—be
alert to undiagnosed learning disability (especially dyslexia); social stressors—“children can be mean”
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| Abortive therapy: over-the-counter (OTC) and prescription medication; speaker avoids narcotics
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| Prophylactic therapy: current agents in widespread use—cyproheptadine (Periactin) works well for young patients (not
school-age children; problem of side effects); propranolol ( β-blocking effect reduces athletic performance); amitriptyline
most commonly prescribed prophylactic agent for school-age and older children (works well for most patients)
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| Rebound headache phenomenon: caused by large, frequent doses of any pain reliever (acetaminophen worst offender);
can occur with use of ibuprofen or naproxen; probably number one cause of treatment failure in headache therapy;
may need to discontinue analgesic “cold turkey”
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| Chronic headache: lifestyle modification most helpful; prophylaxis—selective serotonin reuptake inhibitors (SSRIs),
eg, fluoxetine (Prozac)
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| Conclusion: most childhood headaches migraines; most ominous signs include increasing frequency or severity of headache,
evidence of progression of headache, or progressive neurologic deficit; choice of treatment matter of family preference;
if imaging indicated, choose MRI
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| CHILDHOOD MIGRAINE: A COMPLEMENTARY AND ALTERNATIVE APPROACH —Thomas K. Koch, MD, Professor
of Pediatrics and Neurology, Oregon Health and Sciences University, Portland, Doernbecher Children’s Hospital
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| Primary headache: spectrum disorder; most common diagnosis in children with headache; some patients have typical migraine
pattern of intermittent severe headache (others have diffuse pain); some develop daily or weekly headache that causes
them to miss school; problem of children who are missing school, and not responsive to sumatriptan (Imitrex) or other medications
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Nutritional Therapies
| Riboflavin (vitamin B2): used as prevention; adult dose for headache 400 mg/day (recommended daily allowance
[RDA] 1.7 mg); Schoenen et al, 1998—55 patients with migraine; ≈60% of patients had >50% reduction in headache or
headache impact; decreased frequency and intensity of headaches; any prophylactic medication (eg, cyproheptadine,
topiramate, valproic acid, or amitriptyline [Elavil], vitamin B2 ) takes time to take effect (weeks to 3 mo)
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| Magnesium: long history as medicinal for headache; 3 double-blind studies with daily doses of 360 to 600 mg/day (duration
2-4 mo); 2 studies showed efficacy (one did not); preliminary reports that magnesium may be helpful in children and
menstrual migraines; bottom line—some patients respond
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| Butterbur (Petadolex): action—anti-inflammatory effect; may affect leukotriene pathway; possible calcium channel
effect; Lipton et al, 2004—50 or 7 mg of Petadolex bid; significant improvement over 4-mo treatment trial; Pothmann et
al, 2005—only study of herbals and supplements for migraine in children; children 6 to 17 yr of age given 25 to 50 mg
bid; 4-mo treatment trial; significant improvement; safe medication; caveat—Petadolex must be ordered from Germany;
in United States, herbal supplements not FDA controlled (therefore, lack of quality control); potential side effects gas and
bloating
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| OTC products: MigreLief (vitamin B2 , magnesium, and feverfew); Migravent (vitamin B2 , magnesium, feverfew, and
butterbur); HeadacheFree (vitamin B2 , magnesium, and other vitamins)
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Physical Therapies
| Types: acupuncture; botulinum toxin type A (Botox); massage
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| Acupuncture: most important technique; traditional Chinese medicine (2000-yr history); in western medicine, not clear
how this works; variety of studies involving endorphins, activation of neurotransmitters, gate-control theory of pain;
still under active investigation; functional MRI (fMRI) used to measure effect on brain activation
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| National Institutes of Health (NIH) Consensus Development Conference Statement, 1997: acupuncture effective in adults
for postoperative and chemotherapy-associated nausea and vomiting, and postoperative dental pain; probably effective
as adjunct or alternative for painful conditions, including headache
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| Chronic headache prevention: typical treatment—usually takes ≥6 weekly 20-min sessions for 2-3 mo; 6 randomized trials
show efficacy that can last ≥1 yr; Vickers et al, 2004—401 patients with chronic headache; at 12 mo, headache
score reduction of 34% vs 16% in controls; acupuncture patients experienced fewer headache days per year, used 15%
less medication, and had 25% fewer visits to primary care provider; 15% fewer days of missed work
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| Migraine prevention: Vincent, 1989—sham-controlled study; 30 patients; significant efficacy; Linde et al, 2005—
acupuncture does not work; acupuncture compared to sham treatment and wait list (no treatment); with treatment, 51%
of patients had ≥50% decrease in headaches (for sham therapy, 53% of patients; wait list, 15%); authors’ conclusion—
acupuncture no more effective than sham in reducing migraines, although both more effective than wait-list controls;
speaker’s view—acupuncture had significant, clinically relevant benefit over no treatment; further research needed
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Behavioral or Mental Therapies
| Relaxation therapy: techniques—progressive muscle relaxation; meditation; guided imagery and visualization (effective
in children); yoga; migraine—5 controlled trials in children; relaxation has greater efficacy than psychologic placebo,
and equivalent to use of calcium channel blockers or serotonergic drugs; tension headache—effect of relaxation
more powerful than in migraine
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| Biofeedback therapy: techniques—thermal (hand warming) most common; electromyography (EMG); findings—
numerous studies suggest 30% to 50% improvement in migraine in adults; in speaker’s experience, same efficacy in children;
biofeedback at least equally effective for tension headache
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| Cognitive-behavioral therapy (CBT): teaching patients better coping skills; for migraine, equally effective in
adults and in children; in tension headaches, efficacy even better; Richter et al, 1986—placebo-controlled; compared
CBT to relaxation and sham therapy; 50 patients 9 to 18 yr of age; CBT had 50% efficacy
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| Practice parameter (evidence-based guidelines for migraine headache): report of the Quality Standards
Subcommittee of the American Academy of Neurology, 2000): “grade A” evidence for efficacy of relaxation therapy (in
adults), thermal biofeedback with relaxation, EMG biofeedback, and CBT
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Suggested Reading
Andrasik F et al: Brief neurologist-administered behavioral treatment of pediatric episodic tension-type headache. Neurology
60:1215, 2003; Borzy JC et al: Effectiveness of topiramate in the treatment of pediatric chronic daily headache.
Pediatr Neurol 33:314, 2005; Brna P et al: The prognosis of childhood headache: a 20-year follow-up. Arch Pediatr Adolesc
Med 159:1157, 2005; Emiroglu FN et al: Assessment of child neurology outpatients with headache, dizziness,
and fainting. J Child Neurol 19:332, 2004; Linde K et al: Acupuncture for patients with migraine: a randomized controlled
trial. JAMA 293:2118, 2005; Lipton RB et al: Petasites hybridus root (butterbur) is an effective preventive treatment
for migraine. Neurology 63:2240, 2004; Mazzotta G et al: Cost assessment of headache in childhood and
adolescence. J Headache Pain 6:281, 2005; Pothmann R, Danesch U: Migraine prevention in children and adolescents:
results of an open study with a special butterbur root extract. Headache 45:196, 2005; Richter IL et al: Cognitive
and relaxation treatment of paediatric migraine. Pain 25:195, 1986; Schoenen J et al: Effectiveness of high-dose riboflavin
in migraine prophylaxis. A randomized controlled trial. Neurology 50:466, 1998; Silberstein SD: Practice parameter:
evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards
Subcommittee of the American Academy of Neurology. Neurology 55:754, 2000; Termine C et al: Alternative therapies
in the treatment of headache in childhood, adolescence and adulthood. Funct Neurol 20:9, 2005; Vickers AJ et al:
Acupuncture for chronic headache in primary care: large, pragmatic, randomized trial. BMJ 328:744, 2004; Vincent CA:
A controlled trial of the treatment of migraine by acupuncture. Clin J Pain 305, 1989.
Educational Objectives
| The goal of this program is to improve the management of headache in children. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. Formulate a plan for evaluation and management of a child with headaches.
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| 2. Recognize common patterns in pediatric headache syndromes.
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| 3. Describe recent research on the efficacy of selected nutritional therapies for managing migraine headaches in children.
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| 4. Assess the efficacy of physical therapies for managing migraine.
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| 5. Recognize the potential role of behavioral therapies in managing migraine.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the following has been disclosed: Dr. Koch has participated in the speaker’s bureau
for Ortho-McNeil Pharmaceuticals.
Acknowledgments
Dr. Bunch was recorded at the Fourth Annual Regional Pediatric Symposium of the Black Hills, presented June 22-23,
2007, in Rapid City, South Dakota, by the Sanford School of Medicine of the University of South Dakota, Sioux Falls,
Creighton University School of Medicine, Omaha, NE, and Saint Louis University School of Medicine, St. Louis, MO, in
affiliation with SSM Cardinal Glennon Children’s Medical Center, Sioux Falls, and Children’s Hospital of Omaha, NE; Dr.
Koch was recorded at the 40th Annual Advances and Controversies in Clinical Pediatrics, presented May 31-June 2, 2007,
in San Francisco, CA, by the Department of Pediatrics, University of California, San Francisco, School of Medicine. The
Audio-Digest Foundation thanks Drs. Bunch and Koch, and the sponsors for their cooperation in the production of this program.
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