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Pediatric Headache: Keys to Diagnosis and Therapy

Pediatric Headache: Keys to Diagnosis and Therapy

Headache is a frequent complaint in a pediatric office. Almost 60% of our patients complain of headache at some point, and 8% of our patients will be found to have migraine.Colombo and colleagues2 suggest that there can be up to a 20-month delay before the correct diagnosis of migraine is made.3

How does the physician approach the child with headache? Our first job is to rule out secondary headache. Here, the time course can be very helpful. Rothner3 describes 4 different headache timelines (see Figure, below): 

• Acute
• Acute recurrent
• Chronic progressive
• Chronic nonprogressive

Time course of headache Think of secondary headache when you see a child with an acute or chronic progressive headache. In the pediatric population, an acute headache should make the physician think of an intracranial bleed or, much more likely, infection. The infection can be as minor as childhood viral illness or as serious as meningitis, but further consideration of the patient is required. Chronic progressive headaches suggest an evolving intracranial process. Children often describe the pain as being worse when intracranial pressure is increased, such as on awakening after being recumbent all night or with straining at bowel movements. An MRI scan should be strongly considered. Pediatric brain tumors are often in the posterior fossa, which are better visualized on MRI than on CT scan.

Only a small minority of patients present to the primary care office with the chronic non- progressive headache that is indicative of chronic migraine or chronic tension type headache (TTH). These patients can be therapeutic challenges and probably warrant a referral to a headache specialist or neurologist.

Most patients with headaches who present to the primary care clinician have acute recurrent type headaches. Although the great majority of these patients have TTH, most rarely come to the physician’s office. As such, always consider migraine in a patient who presents to the office with the acute recurrent headache pattern.

In children, migraine headaches can be unilateral or bilateral; they are often frontal and the pain is often described as steady or throbbing.

Given this scenario, how does one differentiate TTH from migraine? (Table 1 lists several clues.) Migraines have associated autonomic symptoms, TTH do not. The 3 most common autonomic symptoms are nausea (with or without vomiting), photophobia, and phonophobia. Patients may not volunteer that they are light sensitive, but when questioned, they will often say that they go in their room turn the lights off and lay down until they feel better.

Most pediatric migraineurs do not give a history of an aura, although some may report that they “felt funny” before the onset of headache. During your examination, ask about fever, constitutional symptoms or other neurologic symptoms associated with the headache, or any change in the headache character. Consider a more extensive evaluation if one or more of these “red flags” is present.

Table 1 – Clues to the diagnosis of pediatric migraine
If the headache is acute and recurrent with autonomic symptoms, the diagnosis is migraine
Most frequent autonomic symptoms are nausea/vomiting, photophobia, and phonophobia; patients typically want to lie down in a quiet dark room
Pediatric migraine usually does not present with aura
Pediatric migraine may be associated with dizziness, light-headedness, or pallor
Migraine duration is shorter in children than adults, may be bilateral, and may not manifest with throbbing pain

Most migraineurs have a family history of migraine. Keep in mind, however, that our patients’ parents and grandparents may not ever have received an official diagnosis. Thus the question “Does anyone else in the family suffer from headaches?” is more likely to elicit a helpful response than “Does anyone else in the family have migraines?”

The physical examination must include a good fundoscopic exam in addition to a focused neurologic evaluation. Imaging is only necessary if there are red flags in the history or significant neurologic or fundoscopic abnormalities.

Treatment Options
Once you are comfortable with the diagnosis, there are a variety of therapeutic options to consider. For a child with TTH, reassurance is often all that is necessary. Over-the-counter medications, such as acetaminophen, ibuprofen, or naproxen can be safely used for these patients.

Migraineurs usually require a multifaceted approach that employs prescription medications, nutraceutical agents, lifestyle alterations, and stress management along with other complimentary approaches to care.

NSAIDs, triptans, and ergots are helpful for acute migraine attacks. The key with any of these medications is to use them immediately when one senses a headache coming on. If the patient waits to see how bad the headache is going to become before taking the medication, the outcome is less likely to be satisfactory. For sports-minded patients, l often use the analogy that it is easier to stop a running back in the backfield before he gets going than it is to chase him down once he has broken through the line and is running down field.

NSAIDs. In a general practice setting, some patients respond well to OTC naproxen. However, the recommended dose is usually inadequate-- both because it is inherently conservative and more importantly, because patients with migraine often have concomitant gastroparesis. They therefore require higher doses to get an adequate response.

Triptans. For patients who require more than OTC medications, triptans are usually employed (Table 2). These agents have shown good efficacy in children.  Note, however, that they have not yet received FDA approval for pediatric use except for almotriptan (which is approved for use in children 12 years and older).

Also, of note, there will soon be a transdermal sumatriptan patch available.

Table 2 – A summary of the triptans: dosage* and formulations
Triptan Formulation
  Tablet Melt Nasal Subcutaneous
Almotriptan 6.25/12.5
Eletriptan
Frovatriptan1 2.5
Naratriptan1 1 /2.5
Rizatriptan 5/10 5/102
Sumatriptan 25/50/100 5/10/203 4/64
Zolmitriptan 2.5/5 2.5/52 53

*All doses are in mg
1Frovatriptan and naratriptan have longer half lives and as such are not ideal for acute therapy. They are best utilized in menstrual migraine and treatment of resistant migraine
2Melts are helpful for patients who have difficulty swallowing pills; however they do not offer faster absorption
3Nasal sprays offer faster absorption, but most pediatric patients will not tolerate the taste
4Injectibles offer fastest absorption but have the obvious drawback, though needle-free forms are now on the market

Ergots. For the occasional patient who does not tolerate or respond well to triptans, an ergot in nasal spray form is available. Migranal is dihydroergotamine nasal spray. The usual dose is a single spray in each nostril at the onset of headache, which is repeated in 15 minutes. For smaller patients, it is possible to decrease the number of sprays.

Neutraceuticals. Of course, prescription pharmaceuticals are not the only options. Many nutraceuticals offer promise as adjunctive therapies or as sole therapies for patients who prefer not to use prescription drugs. Magnesium, riboflavin, Petasites (butterbur), Coenzyme Q10, and feverfew have all been studied and show promise of being beneficial to our patients, either individually or in combination.

Lifestyle modifications. More often than not, lifestyle issues contribute to the migraineurs’ problem. Our patients are often overscheduled, overstressed, not eating properly or drinking enough fluids, not sleeping properly, and/or not getting adequate exercise. These all have been shown to be co-morbidities of migraine and must be addressed if we wish to have lasting success with our patients. There is probably no medication that will help the high school senior who is worried about getting into college, involved in 4 after-school activities, getting 5 hours of sleep a night, and skipping breakfast and/or lunch on a daily basis. Obviously, this is an extreme, but these patients do exist. (See Lifestyle Measures that Can Help Control Pediatric Headaches on next page.) 

Pediatric headaches are generally an easy disease to diagnose, but the care plan takes time . . . time to discuss the diagnosis, the co-morbidities, the lifestyle issues, and treatments. However, when all of the contributing factors are considered and addressed and the patient is enlisted as an active participant in the process, a positive outcome can usually be achieved.

References:
1.Abu-Arafeh I, Razak S, Sivaraman B, Graham C. Prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies. Developmental Med  Child Neurol. 2010;52:1088-1097
2. Colombo B, Dalla Libera D, De Feo D, et al. Delayed diagnosis in pediatric headache: an Outpatient Italian survey. Headache. 2011;51:1267-1273.
3.  Rothner AD. Headaches in children and adolescents. Semin Pediatr Neurol. 2001;8:2–6.
4. Gladstein J. Pediatric headache. Curr Treat Options Neurol. 2006 8:451-456.
5. Taylor F. Nutraceuticals and headache: the biological basis. Headache. 2011;51:484-501.
 

 "Lifestyle Measures..." on next page...

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