Headaches in Children

Gerry R. Gerry, M.D., F.A.A.P. Headache Medicine, U.C.N.S. Director, The Pediatric Headache Center Childrens Mercy South, Urgent Care Center Assoc. Professor of Pediatrics, USUHS

Headaches Are Common!!

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Epidemiology. --By age 7, at least 35% of all children have had headaches. --By age 15, more than 50% have had headaches.
Bille B. Migraine in school children. Acta Paediatr 1962:51 (suppl): 1-151.

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Plan:
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Discuss the differential diagnosis of headaches in children. Discuss new patient headache evaluation. Discuss common pediatric headache types. Discuss medical management of migraine headaches. Discuss lifestyle management of headaches. Case Studies.

Differential Diagnosis
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Headache can be a primary disease process or a symptom of an underlying disease process.. CNS tumor, abscess, aneurysm, AV malformation, pseudo tumor cerebri, CNS leukemia, neurofibromatosis, subdural hematoma, meningitis, encephalitis, sinusitis, altitude sickness, pheochromocytoma, poisoning, drug ingestion, arteritis, sleep apnea, seizures, medications, many others
Green, M. Pediatric diagnosis. Chapter 44.

Lifetime Prevalence of Common Headache Disorders:

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Primary
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Tension-type headache 78% Migraine 16% Fasting*** 19% Nose/sinus disease 15% Head trauma 4% Nonvascular intracranial 0.5%
Rasmussen et al.: J clinical Epidemiology, 1991

Secondary
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Is it a tumor??
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The annual incidence of brain tumor in elementary school age children is 3 per hundred thousand (0.003%)

Childhood Brain Tumor Consortium

3,291 children < 21 years wit h brain t um or n2,750 (62%) had HA nPapilledem a nAt axia nHem iparesis nAbnorm al eye m ovem ent s nAbnorm al DTRs n1 of 5 abnorm alit ies seen in: n97.7% wit h suprat ent orial t um ors n99% wit h infrat ent orial t um ors nLess than 1% wit h HA and brain t um or had NO ot her symptoms
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J Neurooncology 1991

Plan:
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Discuss the differential diagnosis of headaches in children. Discuss new patient headache evaluation. Discuss common pediatric headache types. Discuss medical management of migraine headaches. Discuss lifestyle management of headaches. Case Studies.

New Patient Evaluation

Where to start??????? ?

Careful History & Complete Physical Exam

Case Study
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16 year old female who developed problems with headache 1 year ago. No hx before then. Hx c/w migraine. Has been placed on several preventative medicines with no improvement. Pain medicines arent helping. Thought to be non-compliant. FamHx- several relatives with migraines. Prior Med Hx- Mildly obese, but otherwise healthy. Denies tob, Etoh, drugs. No OCPs.

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Dietary history-dieting. Skips breakfast. Has lost 30 pounds so far this year. Sleep ok, fluids ok, trying to exercise. Father also points out that she shakes all the time. Came to see me for a fourth opinion. Headaches are more frequent and severe.

Case Study
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Exam revealed total body tremor. Normal neuro and an enlarged thyroid gland. Thyroid function tests abnormal.

New Patient History: Characterize the Headache

When Did the Headaches Start? How Frequent? Getting Worse? Location, intensity of pain? Type of pain? Throbbing, stabbing? Duration of symptoms? Level of disability with headache?

New Patient History: Associated symptoms

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Visual--blurry, lines, spots, colors Nausea Emesis Photophobia Phonophobia Osmophobia Neck pain and stiffness (Common with tension type and over 35% of migraine) Muscle aches Unusual symptoms (dizziness, slurred speech, vertigo)

New Patient History: --What medical treatments have been tried?? --Did it help?? --What are they using now? --How often do they take it?

New Patient History

Prior Medical History!!! n Current Medications n Family History of ANY type of headache.
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New Patient History:

How Is the Child Between Episodes of Headache?? Normal--primary Headache Abnormal--secondary Headache

New Patient History

Lifestyle History n Dietary History n Sleep History n Social History n STRESSORS

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Case Study
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14 year old female with 2 year history of intermittent severe abdominal pain and severe fatigue which would last for up to 2 weeks at a time and then resolve. Episodes occurred about every two months. Sleeps all the time. No problems with eating during attacks. Feels normal in between episodes. Long GI work-up in the past. All normal. On H2 blockers during one event with some improvement. Most recent event associated with headache. Thought to be abdominal migraine.

Case Study
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Family Hx-No migraine, but older brother with severe depression. Dietary history. No breakfast. Usually skips lunch (sometimes cheese sticks) Eats evening meal on the run.(Fast food). Social history- A-student, student council, Competitive softball player in year-round league. Practice 2 hrs/night. Games all weekend. Dance lessons twice a week. Had to give up basketball. Free time--None.

Case Study
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Sleep history.
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Usually up till midnight or 1am doing homework. Gets up at 5 am to finish homework or study.

WILL MEDICINE FIX THIS????

Red Flags!
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Cranial nerve palsies Balance problems Changes in color vision Pain triggered by straining/valsalva (Chiari) Age< 3 years Post-trauma Neurocutaneous syndrome Bleeding disorder Atypical migraine symptoms

Not so helpful red flags

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Morning headache or awakens with headache. Morning nausea/emesis. Increasing headache frequency and/or severity. Occipital headache.

Other tests?????
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Laboratory evaluation??
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As indicated by the history and physical.

If the exam is normal and the history is straightforward, labs are rarely helpful.

Eye exam??
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Always a good test, but refraction errors rarely trigger headaches.

To Scan or not to Scan that is the question...

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If the exam is normal and the history is consistent with uncomplicated, acute recurrent headache, scans are not useful. 99.6% will have no significant findings on scan. If the exam is abnormal, if the history is suspicious for chronic progressive headache or if the headaches have atypical associated symptoms--scan. MRI??

Plan:
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Discuss the differential diagnosis of headaches in children. Discuss new patient headache evaluation. Discuss common pediatric headache types. Discuss medical management of migraine headaches. Discuss lifestyle management of headaches. Case Studies.

Classify the Headache

Based on History. n Based on Physical Exam findings.

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ACUTE RECURRENT HA

Primary Headaches: Tension-type Pain Migraine Cluster

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PROGRESSIVE (Chronic Daily Headache)

Analgesic overuse/rebound=80% P a i n Chronic Stress Other medications (Singulair)

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CHRONIC PROGRESSIVE HA

Pain

Neoplasm Hydrocephalus Pseudo tumor cerebri Abscess

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Primary Headache Classification

Tension-type headache (Tension HA) Migraine without aura (Common Migraine, 60-85%) Migraine with aura (Classic, < 20%) Complicated Migraine Basilar migraine Acute Confusional migraine Familial Hemiplegic migraine Alice in Wonderland syndrome Migraine aura without headache (Acephalgic migraine) Migraine Variants Benign Paroxysmal Vertigo of Childhood Cyclic Vomiting Lightning Strike Headache Abdominal migraine ?

Plan:
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Discuss the differential diagnosis of headaches in children. Discuss new patient headache evaluation. Discuss common pediatric headache types. Discuss medical management of migraine headaches. Discuss lifestyle management of headaches. Case Studies.

Proposed revised classification for Pediatric migraine without aura

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A. At least five attacks fulfilling criteria BD. B. Headaches lasting 1-48 hours. C. Headache has at least two of the following features:
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Bilateral or unilateral pain. Pulsating quality. Moderate to severe intensity. Aggravation by routine physical activity.

Proposed revised classification for Pediatric migraine without aura

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D. During headache, at least one of the following symptoms is present:

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Nausea and/or vomiting. Photophobia and phonophobia.

ICHD-2 2004 http://ihs-classification.org

Treatment for Migraine Headaches

Preventative Medicine n Acute Pain Medicine n Nausea Medicine n Lifestyle Therapy

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Migraine preventatives
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Only Topamax is specifically approved for prevention of migraine. Most migraine preventives were discovered incidentally from treatments for co-morbid conditions. Always keep possible comorbidities in mind when choosing a preventative

Preventative Medications:
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Indicated for patients with 5-6 or more significant headache days per month. Indicated for patients with fewer, but much more severe headaches. Goal is to interrupt the pain cycle. Try to find a med that may be helpful with associated comorbidities.

Preventative Medicine Expectations:

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Must be taken every day to achieve the desired improvement. Improvement doesnt happen overnight. Give the dose 2-3 weeks before deciding that its not helping. Adjust medicine dose as needed. Goal with preventative meds is to reduce headache frequency to fewer than 5 per month and decrease severity. Headaches will

Tricyclic Antidepressants
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Amitriptyline/Nortriptyline. Class 1 Evidence. Very effective at low doses. Start between 5-10 mg 2 hours before bedtime each night. Maximum benefit seen in 2-3 weeks. Side effects: Sleepiness, dry mouth, wt. Gain. Available in liquid form. Requires EKG at doses above 40mg

Beta Blockers
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Propranolol. Class 1 evidence. Good effect with low doses. Usual start point is 10 mg qhs or bid. Contraindicated with Asthma and diabetes. Side effects: Fatigue, exercise intolerance, depression. Sexual dysfunction. Available in liquid form.

Antihistamines
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Periactin. Class 3 evidence. Frequent starter medicine in younger kids. Start with 2-4 mg qhs. Advance to bid if necessary. Side effects: Sleepiness/fatigue, weight gain, moodiness.

Anticonvulsants
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Depakote. Class 1 evidence. Not a first line drug. Better if used in an ER form (pills only). Can use regular depakote (pills or liquid), but more side effects. Side effects: Headache, Nausea, weight gain, moodiness. (Pregnancy risks) Start at 10 mg/kg qday. Advance as needed.

Anticonvulsants
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Topiramate. Class 1 evidence. Not a first line drug. No liquid form. Does come in a sprinkle cap. Causes mild anorexia. Good for kids who are overweight. PCOS. Side effects: Nausea, fatigue, mental slowing at higher doses. Start at 25 mg hs. Advance to bid if needed. Try to keep dose below 100 mg.

Nutritional Supplements/Herbs

Nutritional Supplements/Herbs
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3 potential mechanisms to prevent migraine. Reduce brain neuronal hyperexcitability. Improve energy metabolism in the brain Reduce inflammation

Supplements
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Magnesium
Plays a central role in regulating vascular tone and neuronal excitability. Low magnesium causes calcium influx into neurons resulting in glutamate release. Low levels cause histamine release from mast cells. Reduced levels have been found in the blood and CSF of migraine patients. Daily intake of 400-600 mg per day may help reduce migraine frequency. Consider 200mg bid Magnesium Taurate or Glycinate for preventative therapy. Available in liquid.

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Edelstein et. al., Headache 2011; 51: 469-483 Taylor F. R., Headache 2011; 51: 484-501

Supplements
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Vitamin B-2 (Riboflavin) Improves mitochondrial energy reserves (ATP production) without changing neuronal excitability. 200 mg twice a day may help reduce migraine frequency.

Schoenen J, et.al., Neurology 50:466-470, 1998 Edelstein et. al., Headache 2011; 51: 469-483 Taylor F. R., Headache 2011; 51: 484-501

Supplements
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Coenzyme Q-10 An essential element of the mitochondrial electron transport chain. Recommend 150 mg per day. Clinical evidence suggests that taking this supplement every day reduces headache frequency by 50% after 2 months of therapy. No side effects. Costs around $20 per month.

Rozen,TD et. al. Cephalgia, 2002, 22, 137-141 Edelstein et. al., Headache 2011; 51: 469-483 Taylor F. R., Headache 2011; 51: 484-501
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Supplements
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Melatonin Especially helpful with sleep cycle problems. 3-10 mg 1 hour before bed time. Warn about catch up REM.

Supplements
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Butterbur Strong anti-inflammatory effect. Works well for seasonal allergies. Available in a pharmaceutical grade form=Petadolex. Give 50-75mg bid for prevention. Minimal side effects.
Headache 2005;45: 196-203

Supplements
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Omega 3 Fats. Fish oil/Flaxseed oil. 2-3 grams daily. Strong anti-inflammatory effect. Vitamin D 2000 IU daily. Strong anti-inflammatory effect.

Acute Pain medicines

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TREAT EARLY!! Give an adequate dose.

NSAIDS
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Naproxen Sodium--10 mg/kg q6-8 h prn.

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Liquid form for Naproxen. Liquid form. (Gel Caps) Medication overuse headaches

Ibuprofen--10-20 mg/kg q 6 h prn.

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Aspirin--10 mg/kg q4h prn. (Reyes syndrome.). Tylenol--15-20mg/kg. Will help child sleep.

Combination Medicines
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Fioricet: Tablets only.

Butalbital 50 mg, caffeine 40 mg, acetaminophen 325 mg. n 1 -2 tablets q 4-6 hours. n Overuse will cause rebound headaches. n Side effects: Dizziness, nausea, sleepiness.

Combination Medicines
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Midrin. Acetaminophen 325mg, Isometheptene (a sympathomimetic aminevasoconstriction) 65mg, dichloralphenazone (a mild sedative) 100mg. 1-2 capsules at onset. May give 1 additional capsule each hour thereafter as needed for pain. Max 56 caps in 24 hours. Drug is difficult to find.

Triptans
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Not approved for use in kids less than 18. Function by blocking the pain signal. NO antiinflammatory effect. Very specific action--agonist for vascular serotonin receptor subtype 5HT1D. Very expensive. Primary differences are in medication delivery, speed of action, duration of action, and potential for side effects. Side effect profile is similar. Dizziness, paresthesias, hot flashes, headache, neck pain, abdominal pain.

Nausea Medicines
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Reglan 5mg/tsp susp, 5 & 10 mg tabs Prokinetic Very effective. Few side effects with prn use.

Nausea Medicines
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Ondansetron (Zofran). 4-8 mg orally dissolvable tablet. Good choice for patients who develop emesis rapidly.

Plan:
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Discuss the differential diagnosis of headaches in children. Discuss new patient headache evaluation. Discuss common pediatric headache types. Discuss medical management of migraine headaches. Discuss lifestyle management of headaches. Case Studies.

Life-Style Therapy

The Healthy Brain Checklist:

1-Stress Management 2-Diet and Nutrition 3-Sleep Hygiene

Case study
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19 yo young man with a history of severe, intermittent headaches starting 5 years ago and now daily headaches for the last 2 years. Headaches are throbbing in nature and localized to the forehead and occipital area. Initially the headaches were not too difficult, but he developed worsening pain with nausea and emesis, photo and phonophobia, visual blurriness and numbness with tingling of his right hand and around his mouth. Sought medical attention after symptoms worsened.

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Seen by a Neurologist who diagnosed Chronic Migraine headache. Noted to have hypertension at visit. Full Renal work-up and U/S normal. UA, CBC, LFTs, TFTs, Lipid profile normal. Vitamin D level low. MRI of brain--normal

Case study
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AmitriptylineHeart racing-stopped. NortriptylineHelped initially, but over time the dose had to be increased in order to maintain benefit. Fatigue. InderalHelped initially, but over time dose had to be increased. Exercise intolerance. Felt Heavy

Case study
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TopamaxCaused severe mood swings. Stopped after 1 week. VerapamilHelped initially, but as the dose was increased, he started feeling bad and refused to continue taking it. Tried on multiple pain meds with some improvement. Currently off all medications, but has Trexamet it needed for severe head pain.

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Lifestyle was NEVER addressed.

Case study
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Lifestyle history: Freshman in college. Straight A student. Regular exercise. Plays guitar and sings in a singing group at school. No smoking, ETOH or drugs. Denies sexual activity. DietSkips breakfast due to lack of time. Sometimes gets coffee in the AM. Eats lunch on the run at around 1 PM. (Burger and fries, pizza, etc.) Drinks some water at the water fountain between classes. At evening meal, he tries to eat a fruit or vegetable. No vitamins or supplements.

Case study
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SleepGoes to bed between 2 and 3 AM. Doing schoolwork until 1011. Stays up playing video games with other guys at the dorm. No problems sleeping or staying asleep. Gets up at 730 to get to class by 8. On weekends, he will normally

Life-style therapy
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The Healthy Brain Checklist:

Lifestyle Therapy
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Stress Management. Mild to moderate fun exercise activity for 30 mins/day. May divide into 3 ten-minute sessions. Actively engage in activities that help you relax and unwind, ie. Hobbies, music, reading, meditation, etc. Breathing exercises. Brain wave therapy.

Lifestyle Therapy
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Diet. Avoid fasting! n Eat a breakfast containing something with protein or a complex carbohydrate. Dont skip! n Mid-morning, mid-afternoon and late evening HEALTHY snack. n Daily multivitamin (Other supplements). n Drink plenty of water. UOP q2-3h. n Limit foods and drinks that are high

Lifestyle Therapy
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Sleep Cycle. Maintain balanced sleep habits.

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Get enough sleep each night, around 8-10 hours. Not too much sleep. More than 12 hours. Keep the sleep cycle roughly the same 7 days a week.

Case study
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Dx: Chronic Migraine headache Tx: Butterbur 75 mg bid for prevention Tx: Naproxen Sodium 220mg tab, 2-3 tabs every 6-8 hours prn headache. Tx: Reglan 10mg q6h prn nausea. Supplements: Magnesium taurate, B-complex, omega 3 supplement,

Case study
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Lifestyle therapy Continue regular exercise. Continue playing guitar and singing for fun. Cant skip breakfast!! Must drink in the morning. Mid-morning healthy snack. Must drink water throughout the day. UOP every 2-3 hours. More fruits and

Case study
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Try to get more sleep and keep the sleep schedule consistent throughout the week. 2 weeks later, during finals, he was having major problems with headache. Taking all the supplements, but doing none of the lifestyle. Lifestyle treatments re-emphasized.

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Patient returned for follow-up. Taking all supplements without difficulty. Eats a granola bar with nuts and whole grains and drinks juice or water each morning. Has another granola bar after first class. Takes a water bottle to class with him and drinks it. Gets

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Moved his second semester 8 oclock class to the afternoon. First class is at 10. Wakes up at 9, so he has a full hour to get ready and make it to class. Goes to sleep by 1 AM every night. Gets 8 full hours of sleep nightly.

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Daily headaches stopped just over 3 months ago. Has had no headaches at all for the last 2 months.