eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Headache

Kirsten A Bechtel, MD, Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital

Updated: Feb 3, 2008

Introduction

Background

Headache is a common reason for children to seek medical care. Headaches in children may be due to numerous causes, such as migraine and its variants, intracranial masses, or sinusitis. This article discusses the important and common causes of headache in the pediatric population.

Pathophysiology

Because the brain is insensate, headache is due to the stimulation of pain sensitive nerve fibers in large cerebral arteries and veins, the periosteum of the skull, the muscle and skin of the scalp, the sinus mucosa, the temporomandibular joint, the teeth, or the gingiva.

The pathophysiology of migraine headache is multifactorial. The onset of a migraine headache is thought to be mediated by cortical spreading depression (CSD), which is due to neuronal activation followed by suppression, which spreads over the cortical surface. A simultaneous change occurs in cerebral blood flow, characterized by hyperperfusion, followed by hypoperfusion. CSD is thought to be caused by either trauma or changes in the local concentrations of hydrogen ions, potassium, and glutamate. CSD activates CNS nociceptors, possibly through the release of nitric oxide, atrionatriuretic factor, activation of noradrenergic pathways, and/or changes in cerebral blood flow. CSD also causes neurogenic inflammation, which also stimulates the release of several different neurotransmitters that lead to cerebral vasodilatation and activation of CNS nociceptors.

Frequency

United States

Nearly 40% of Americans have a significant headache at some time. Children frequently complain of headache. Headaches are very common during childhood and become increasing more frequent during adolescence. The prevalence of headache, in general, ranges from 37-51% during the elementary school years and gradually rises to 57-82% by the high school years. Before puberty, reports indicate that boys are more frequently affected than girls, but, following the onset of puberty, headaches are reportedly more frequent in girls.
 

Mortality/Morbidity

Headache can cause significant disruption in a child's daily activities. For example, children with migraine headache are often not appropriately diagnosed and thus go untreated. In a large study looking at the prevalence of migraine headache, 31% of patients reported that they had missed at least one day of school or work in the previous 3 months. In this same study, more than half of patients reported that their productivity was reduced by 50%.

Clinical

History

A thorough history should be obtained in any child presenting to the ED with a headache. The history should describe headache onset, duration, severity, and associated symptoms. A family history of migraines may be helpful in clarifying the diagnosis. A medication history should also be sought.

• Migraine headache overview 
  • Because a migraine headache can be classified into several types, symptoms vary depending on the type. Many children with migraines have a previous history of motion sickness, paroxysmal dizziness, or vertigo. The prevalence of migraines is 5% in children and 17% in adolescents. Approximately 60% of all children with migraines are male. Nearly 70% of pediatric patients have a family history of migraine headache. Clinicians should suspect migraine headache in any child who presents with recurrent episodes of incapacitating headaches.
  • A possible relationship exists between children who have cyclic vomiting syndrome and migraine headache. A genetic predisposition also appears to exist for patients with cyclic vomiting syndrome and their family members to develop migraine headaches. Patients with cyclic vomiting syndrome, their mothers, and grandmothers may have a prevalence of migraine headache that is about twice that of the general population.
  • Classic migraine: Patients have a sharply defined headache that is preceded by motor or sensory disturbances, such as blurred vision, floaters crossing the visual field, or transient muscle weakness.
  • Common migraine: The headache is often less sharp and well defined. No preceding motor or sensory disturbance occurs. This type of migraine is observed more often in children.
  • Complicated migraine: In patients with complicated migraine, focal or diffuse neurologic deficits may occur with the headache. The 4 types of complicated migraine are as follows:
    • Hemiplegic or hemisensory migraine: The headache is accompanied by unilateral motor weakness or sensory disturbance (eg, paresthesias) that may persist for several hours after the headache has subsided.
    • Basilar migraine: The pathogenesis of basilar migraine involves vasoconstriction of the basilar and posterior cerebral arteries. This results in an occipital headache, as well as diplopia, vertigo, tinnitus, or ataxia.
    • Ophthalmoplegic migraine: In addition to a unilateral frontal headache, patients have an ipsilateral third nerve palsy and reversible monocular blindness. This type of migraine is rare in children.
    • Acute confusional states: Acute confusional states are an unusual type of migraine headache and are characterized by sudden onset of confusion, unresponsiveness, memory disturbances, disorientation, and dysarthria. This type of migraine headache is thought to be more common in boys.
  • Cluster headache: Headaches occur in groups or clusters. Nasal discharge, congestion, and a watery red eye are present on the same side of the head as the headache. Cluster headaches often awake a patient from sleep and most often occur in adolescents.
  • The diagnosis of migraine can be made if 3 of the following 6 symptoms are present:
    • Preceding motor, sensory, or vertiginous symptoms
    • Throbbing or pounding pain
    • Pain localizes to one side of the head
    • Associated nausea, vomiting, or abdominal pain
    • Sleep alleviates the pain
    • Family history of migraine
• Tension headache: Tension headaches are common in children. Distinguishing tension headache from migraine headache may be difficult, as many children with migraine headache also complain of neck pain. Distinguishing characteristics of tension headaches include the following:
  • They occur during times of obvious stress.
  • They involve the neck and occiput.
  • Pain is continuous.
  • No nausea, vomiting, or abdominal pain occurs.
  • Family history of migraine is less likely.
• Sinus headache
  •  Recurrent headaches occur in approximately 15% of children with sinusitis.
  • These patients complain of a throbbing headache that is worse in the morning or that occurs at the same time each day.
  • The pain may vary with changes in head position.
  • With ethmoid disease, pain may be referred to behind the ipsilateral eye.
  • With frontal sinusitis, pain may occur just above the inner canthi of both eyes.
  • A history of nasal discharge, congestion, and cough lasting more than 10 days is usually given.
  • Fever may be present.
• Head trauma
  •  Headaches frequently follow closed-head trauma.
  • The headache may appear acutely or be present for months after the initial injury.
  • Acutely, the patient may complain of headache shortly after the injury, which may worsen and be accompanied by vomiting, lethargy, or seizures; these may be the earliest symptoms of an intracranial hemorrhage.
  • In chronic cases, headache, dizziness, and personality changes may be present for months after the initial injury.
  • Headache is a key feature of the postconcussive syndrome.
• Intracranial masses: Distinguishing intracranial causes from extracranial causes of headache may be difficult. Patients with intracranial masses may complain of pain localized to the region of the mass. However, if a diffuse rise in intracranial pressure exists, the headache may be generalized. Some distinguishing historical features of intracranial masses include the following:
  • Severe occipital headache, sneezing, coughing, any Valsalva maneuver, or change in head position exacerbates the pain.
  • Pain is worse in the morning or awakens the patient from sleep.
  • Projectile vomiting without nausea and focal seizures may occur. However, morning headaches and projectile vomiting once thought to be hallmarks of raised intracranial pressure may also occur from etiologies other than intracranial masses.
• Benign intracranial hypertension (pseudotumor cerebri)
  • Benign intracranial hypertension produces headaches similar to headaches in conditions with raised intracranial pressure.
  • In addition to having pain worse in the morning and vomiting, patients may have vision problems (eg, diplopia) or gait abnormalities (eg, ataxia).
• Epilepsy: Children with a prior history of epilepsy may have a generalized or focal headache after a seizure. Headaches may also accompany the aura prior to a seizure.
• Meningeal irritation: Meningeal irritation due to inflammation, infection, or hemorrhage (eg, malignant hypertension [HTN], vascular lesions) results in the acute onset of diffuse severe headache. Neck pain or stiffness and alteration in consciousness may be present.
• Medication overuse headache (MOH): Chronic use of all medications used to treat headaches, such as analgesics or vasoconstrictors, can result in medication overuse headache. The International Classification of Headache Disorders (ICHD) has recently recognized this entity. It is defined as the development of a different type of headache or worsening of a migraine or tension headache, resulting in chronic daily headaches. It develops after use of medications such as analgesics or the triptans on more than 10 days per month or after use of over-the-counter (OTC) analgesics for more than 15 days per month for 3 months’ duration.

Physical

A thorough physical examination often can exclude systemic causes of headache.

• Attention should be paid to vital signs, especially presence of fever, elevated blood pressure, or bradycardia.
• A thorough neurologic examination should be performed to assess the level of consciousness and to evaluate cranial nerve dysfunction, hypertonia, hyperreflexia, hemiparesis, or hemiplegia.
• Perform funduscopic examination, looking for papilledema or subhyaloid hemorrhage.
• Look for nuchal rigidity.
• Check the head for hematomas or other signs of trauma.
• Search the skin for rashes or cutaneous lesions (eg, petechiae, purpura, Ash leaf spots, cafe-au-lait spots).
• Migraine headache
  • Most children with migraine headaches have a normal physical examination without focal deficits.
  • Some children with a complicated migraine may have focal neurologic abnormalities, such as weakness, third nerve palsy, or ataxia.
• Tension headache: Physical examination findings are usually normal. Pain on palpation of the posterior neck muscles may be noted.
• Sinus headache: Physical findings include pale edematous nasal mucosa, boggy turbinates, clear or yellow nasal discharge, pain with palpation of frontal or maxillary sinuses, and failure of these sinuses to transilluminate.
• Head trauma
  • In acute injuries, the child may have an altered level of consciousness, focal neurologic deficits, abnormalities in cranial nerve function (III, VI), and hemiparesis.
  • In chronic injuries, the physical examination findings often are normal.
• Intracranial masses
  • Patients with headaches due to intracranial masses often have focal neurologic abnormalities, especially if they have had headaches for several months.
  • These abnormalities include papilledema, sixth nerve palsy, ataxia, spasticity of the lower extremities, and indications of brain dysfunction regarding language, motor control, or vision (depending upon the location of the lesion).
  • Early in the course of the mass lesion, the physical examination findings may be normal.
  • Children with intracranial abscesses may have alteration of the level of consciousness only during the acute presentation.
• Benign intracranial hypertension (pseudotumor cerebri): These patients usually have papilledema and, occasionally, have other neurologic deficits (eg, sixth nerve palsy, ataxia, spasticity of the extremities).
• Epilepsy
  • Children with uncomplicated idiopathic epilepsy have normal physical examination findings.
  • Children with seizures due to metabolic or abnormal brain architecture may have baseline neurologic deficits (eg, hypertonia, hemiparesis).
• Meningeal irritation
  • Fever (meningitis), hypertension (malignant hypertension)
  • Altered consciousness, nuchal rigidity, or perivenous hemorrhage of the fundus (subarachnoid hemorrhage secondary to hypertension)

Causes

• Migraine headache
  • Minor headache
  • Onset of menses
  • Sleep disturbances
  • Chemicals (eg, tyramine in cheese, chocolate, nuts, monosodium glutamate [often in Chinese food])
  • Children with epilepsy are at an increased risk of developing migraine headaches.
• Tension headache
  • A subgroup of patients with tension headaches has obvious symptoms of depression, such as depressed mood, feelings of worthlessness, anhedonia, or anorexia.
  • In this subgroup of patients, the headaches are relieved when the depression is treated.
• Benign intracranial hypertension (pseudotumor cerebri)
  • Expansion of 1 or more of the intracranial fluid spaces, such as the vasculature, the extracellular fluid compartment, or the cerebrospinal fluid (CSF) space
  • Several drugs, such as tetracycline, minocycline, penicillin, gentamicin, oral contraceptives, steroids, indomethacin, thyroid hormone, and lithium carbonate may be inciting agents.
• Meningeal irritation
  • Infection (meningitis)
  • Inflammation (eg, tumor)
  • Hemorrhage (eg, vascular malformation, malignant hypertension)

Differential Diagnoses

Other Problems to Be Considered

Pseudotumor cerebri
Lyme disease
Medication overuse headache (MOH)

Workup

Laboratory Studies

• Migraine headache
  • A thorough history and physical examination usually is all that is needed.
  • Laboratory, radiologic, or encephalographic studies are not useful to confirm the diagnosis of migraine but may help exclude other etiologies of headache. For example, an EEG may be helpful to exclude seizures in children with acute confusional migraines.
• Tension headache
  • A thorough history and physical examination is all that is needed to make the diagnosis of tension headache.
  • With a suggestive history and normal physical examination findings, no additional tests are required.
• Head trauma and headache due to a significant intracranial hemorrhage: A consumptive coagulopathy, such as thrombocytopenia, and prolonged prothrombin and activated partial thromboplastin times, may be evident.
• Intracranial abscess: Lumbar puncture may reveal elevated opening pressure, leukocytosis, elevated protein level, and low glucose level.
• Benign intracranial hypertension: Lumbar puncture reveals elevated opening pressure without leukocytosis or abnormalities in glucose or protein concentration.
• Meningeal irritation
  • In patients with meningitis, a lumbar puncture may show an elevated opening pressure, WBCs, low glucose level, high protein level (meningitis, encephalitis), and bacteria on Gram stain.
  • In patients with a subarachnoid hemorrhage, a lumbar puncture demonstrates hemorrhagic CSF that does not clear during the collection of the first and last tubes. Opening pressure may also be elevated.
  • Lumbar puncture is the most sensitive test in the diagnosis of subarachnoid hemorrhage.
• Check anticonvulsant levels in patients with a headache and a known history of epilepsy because adequate seizure control usually prevents the headache.
  

Imaging Studies

• Sinus headache
  • The diagnosis of headache due to sinusitis is suggested by a history of persistent upper respiratory infection (URI) symptoms lasting longer than 10 days.
  • Confirmation of the diagnosis may be made by means of sinus radiographs depicting air fluid levels in the sinuses. However, this test is not sensitive, and false-negative results are common.
  • CT of the sinuses is more sensitive but is usually more expensive. Note that there is a high prevalence of mucoperiosteal thickening in the paranasal sinuses of children in general and serves to emphasize that when soft tissue changes of the sinuses are present, it does not necessarily indicate whether these changes are due to either bacterial infection or inflammation from other causes, such as viral infection, allergy, or chemical irritation. Thus, CT should not be used to make the diagnosis of sinusitis but should only be obtained in children in whom antibiotic therapy does not ameliorate symptoms or in whom sinus surgery is considered after failing appropriate antibiotic therapy for sinusitis.
• Head trauma
  • Any abnormality on physical examination in children with head trauma and headache should prompt radiologic evaluation, such as CT, provided that the child has a protected airway and stable cardiovascular status.
  • An MRI may not reveal accompanying skull fractures.
• Intracranial masses are most often diagnosed by means of CT (with contrast to enhance subtle lesions) or MRI.
• Benign intracranial hypertension (pseudotumor cerebri)
  • CT findings may be normal or may show slit-like ventricles.
  • CT is usually needed to exclude other causes of increased intracranial pressure, such as tumors.
• Meningeal irritation
  • CT findings are positive in only about 90% of patients with subarachnoid hemorrhage. For this reason, a lumbar puncture should be performed despite unremarkable CT findings in patients thought to have a subarachnoid hemorrhage.
  • CT is the best initial study to demonstrate intracranial hemorrhage from malignant HTN or vascular lesions.
• Epilepsy
  • If the baseline neurologic examination changes, neuroimaging should be considered.
  • If this is the patient's first seizure and it is coincident with a headache, neuroimaging (eg, CT, MRI) is warranted, despite normal baseline examination findings, to exclude the possibility of an intracranial mass.

Other Tests

• Electroencephalography (EEG) is useful to assess the status of an underlying seizure disorder associated with headache.

Treatment

Emergency Department Care

• Migraine and tension headache
  • The goals of therapy are to relieve pain, alleviate nausea, and promote sleep.
  • Vasoconstrictive agents may be helpful, especially if the onset of headache has been recent.
  • Narcotic and nonnarcotic analgesics, sedatives, and antiemetics are helpful adjunctive therapy.
• The treatment of sinusitis includes appropriate antibiotic coverage, analgesics (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen), and nasal decongestants.
• Head trauma, intracranial mass/abscess
  • In the event of intracranial hemorrhage or an intracranial mass causing headache, appropriate airway management, with the goal of adequate oxygenation and hyperventilation to reduce cerebral blood flow and lower intracranial pressure is the immediate goal. Subsequent surgery is necessary to evacuate the lesion.
  • Analgesics are useful for chronic postconcussive headaches.
• To alleviate the increased intracranial pressure associated with pseudotumor cerebri, a lumbar puncture is used to reduce the volume of CSF. Carbonic anhydrase inhibitors decrease the production of CSF.
• The treatment goal of meningeal inflammation is to treat the underlying cause, such as HTN (antihypertensives), infection (antibiotics), or subarachnoid hemorrhage (surgical evacuation of intracranial hemorrhage; nimodipine can be used to reduce vasospasm).
  

Consultations

• Consultation with a surgeon is appropriate for headache caused by mass lesions, intracranial hemorrhage, or abscess.

Medication

If the diagnosis is not a surgical condition that requires immediate operative treatment, the emphasis of medical therapy should be to provide analgesia and to treat the underlying cause of headache. In patients with migraine, tension, and posttraumatic headache, the goals of therapy are to relieve pain, alleviate nausea, and promote sleep. Vasoconstrictive agents may also be helpful, especially if the onset of the migraine headache is recent.

Analgesics

These agents are indicated for the treatment of mild to moderate pain and headache. They are the mainstays of headache treatment.

Aspirin (Bayer Aspirin, Empirin)

Treats mild to moderate pain. Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2.

Dosing

Adult

325-650 mg PO q4-6h prn pain; not to exceed 4 g/d

Pediatric

10-15 mg/kg/dose PO q4h prn pain; not to exceed 60-80 mg/kg/d

Interactions

Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs

Contraindications

Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; because of association of aspirin with Reye syndrome, do not to use in children (<16 y) with flu

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in severe anemia, history of blood coagulation defects, or current anticoagulant use

Acetaminophen (Tylenol, Tempra)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, upper GI disease, or current oral anticoagulant use.

Dosing

Adult

325-650 mg PO/PR q4-6h prn; not to exceed 4 g/d

Pediatric

10-15 mg/kg/dose PO/PR q4-6h prn; not to exceed 2.6 g/d

Interactions

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; liver failure; G-6-PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

Ibuprofen (Advil, Motrin)

NSAID that is DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h prn pain; not to exceed 3.2 g/d

Pediatric

5-10 mg/kg/dose PO q4-6h prn pain; not to exceed 2.4 g/d

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Morphine sulfate

DOC for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Most potent of the opiate agonists and is useful for the acute management of headache due to migraine.
Various IV doses are used and are commonly titrated until desired effect obtained. Its use is cautioned in conditions with raised intracranial pressure.

Dosing

Adult

2.5-20 mg/dose IV q2-6h prn

Pediatric

0.05-0.1 mg/kg/dose IV q1h prn

Interactions

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult; increased intracranial pressure; severe renal or hepatic failure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Sedative

This agent promotes sleep in children with migraine headache.

Chloral hydrate (Aquachloral)

CNS depressant. Mechanism of action unknown.

Dosing

Adult

500-1000 mg PO/PR; not to exceed 2 g/d

Pediatric

25-50 mg/kg/dose PO qd or bid prn; not to exceed 2 g/24 h in 2 divided doses

Interactions

May potentiate effects of CNS depressants, warfarin, and alcohol

Contraindications

Documented hypersensitivity; severe cardiac, renal, or hepatic insufficiency; history of porphyria; allergy to tartrazine dye

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

CNS depression, additive with other CNS depressants; SVT and ventricular arrhythmias have been reported during toxic doses; minimal respiratory depressant effects (isolated case reports in the literature); adverse reactions include drowsiness, hypothermia, dysarthria, ataxia, excitability, and generalized weakness; other adverse effects include rash, nausea, vomiting, severe abdominal pain, cardiac arrhythmia, confusion, hallucinations, and, rarely, convulsions

Vasoconstrictors

Although the pathophysiology is uncertain, abnormalities of the cerebral vasculature, causing vasoconstriction, and then vasodilation, is the most often cited mechanism for migraine. A reduction in regional cerebral blood flow during the aura and early headache phases of migraine has been demonstrated. This is the rationale behind the use of vasoconstrictive agents in the treatment of migraine. Therapeutic activity of the serotonin 5-HT1 receptor agonists (ie, triptans) in migraine is most likely attributed to agonist effects at 5-HT _1B/1D receptors. These specific receptor subtypes act on the extracerebral, intracranial blood vessels that become dilated during a migraine attack and on nerve terminals in the trigeminal system. Triptans have not been FDA approved for children younger than 18 years.

A recent report of the American Academy of Neurology quality standards subcommittee and the practice committee of the child neurology society has provided guidelines for treating migraine headaches in children and adolescents.¹

Ergotamine (Ergomar)

Alpha-adrenergic and serotonin (5HT1) antagonist and partial agonist (depending on receptor site). Causes constriction of peripheral and cranial blood vessels. Useful in classic and common migraine headache. Works best if used in early stages of migraine. Significant nausea and vomiting has been associated with its use.

Dosing

Adult

Oral: 2 tab PO at onset of attack and 1 tab q30min prn; not to exceed 6 tab per attack or 10 tab/wk
Sublingual: 1 tab SL at first sign of the attack and 1 tab q30min; not to exceed 3 tab/24 h or 5 tab/wk

Pediatric

1-2 mg SL at time of attack, repeat q30min; not to exceed 3 doses/d

Interactions

Increases effects of heparin and toxicity of nitroglycerin, propranolol, erythromycin, and clarithromycin

Contraindications

Documented hypersensitivity; hepatic or renal disease; peptic ulcer disease; sepsis; peripheral vascular disease; pregnancy; hypertension; PVD; not to be prescribed for hemiplegic migraine

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Strong uterine stimulant actions; avoid using prolonged regimens because of danger of causing gangrene or dependency; commonly causes nausea and vomiting

Sumatriptan (Imitrex)

Selective agonist for serotonin 5-HT1 receptors (probably 5HT_1D) in cranial arteries and suppresses inflammation associated with migraine headaches. Useful in common and classic migraine during early stages of headache.
As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use triptans in children. The decision to choose these drugs might be best reserved for consultation.

Dosing

Adult

Oral: 25 mg PO at migraine onset; if satisfactory response not observed in 2 h, an additional dose (not to exceed 100 mg) may be administered; administer an additional dose q2h if headache returns; not to exceed cumulative daily dose of 200 mg; individualize initial dose, may use 25, 50, or 100 mg; weigh possible benefit of higher dose with potential for risk of adverse effects
Injection: 6 mg SC; if satisfactory response not observed in 1 h, an additional 6 mg injection may be administered, not to exceed 2 injections/d
Intranasal: 5, 10, or 20 mg may be administered in one nostril; may administer 10 mg dose by administering a single 5 mg dose in each nostril; if satisfactory response not observed in 2 h, additional dose may be administered, not to exceed 40 mg/d

Pediatric

Not established; data limited, clinical trials have shown the nasal spray (5-20 mg) effective to treat acute migraine in adolescents

Interactions

Toxicity increases when administered concomitantly with ergot-containing drugs, selective serotonin reuptake inhibitors, and MAOIs

Contraindications

Documented hypersensitivity; ischemic heart disease; uncontrolled hypertension

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hypertensive crisis, coronary artery vasospasm, cardiac arrest, peripheral ischemia, and bloody diarrhea may occur rarely when administering medication; adverse effects include hot flashes, nausea, vomiting, and drowsiness

Zolmitriptan (Zomig, Zomig-ZMT)

For symptomatic relief. Selective serotonin (5HT1) receptor agonist in cranial arteries; elicits vasoconstriction and reduce inflammation associated with antidromic neuronal transmission in CH. High affinity for 5-HT _1D and 5-HT _1B receptor subtypes.
Can reduce severity of headache within 15 min of SC injection. As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use them in children. The decision to choose these drugs might be best reserved for consultation.

Dosing

Adult

2.5 mg or 5 mg PO; repeat dose after 2 h prn; not to exceed 10 mg/d; may give dose lower than 2.5 mg by breaking scored tab in half
Oral disintegrating tablets: 2.5 mg dissolved on tongue once; may repeat dose after 2 h, not to exceed 10 mg/24 h
Intranasal: 5 mg administered in 1 nostril at migraine onset; may repeat once after 2 h if needed; not to exceed 10 mg/d

Pediatric

Not established

Interactions

Toxicity increases when administered concomitantly with ergot-containing drugs, selective serotonin reuptake inhibitors, and MAOIs

Contraindications

Documented hypersensitivity; ischemic heart disease and uncontrolled hypertension; do not administer within 24 h of taking another serotonin agonist or ergotamine or within 2 wk of taking an MAOI

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hypertensive crisis, coronary artery vasospasm, cardiac arrest, peripheral ischemia, bloody diarrhea, and death may occur when administering this medication

Naratriptan (Amerge, Naramig)

Selective 5-HT1 agonist with a long half-life. High affinity for 5-HT _1D receptor subtype. Duration of action up to 24 h with low headache recurrence rate. Useful for patients with slow-onset prolonged migraine, such as menstrual migraine.
As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use them in children. The decision to choose these drugs might be best reserved for consultation.

Dosing

Adult

1-2.5 mg PO at migraine onset; may repeat once after 4 h; not to exceed 5 mg/d

Pediatric

Not established

Interactions

Oral contraceptives may significantly increase serum concentrations and prolonged vasospastic reactions may occur, avoid concurrent use within 24 h of each other; toxicity may increase when administered concomitantly with ergot-containing drugs, selective serotonin reuptake inhibitors, and MAOIs

Contraindications

Documented hypersensitivity; ischemic heart disease; uncontrolled hypertension; cerebrovascular or peripheral vascular syndromes; severe renal impairment (CrCl <15 mL/min); severe hepatic impairment (Child-Pugh grade C)

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Chest, jaw, or neck tightness may occur after 5-HT1 agonist administration; atypical sensations over precordium (pain, tightness, pressure, heaviness) may occur (rarely associated with arrhythmias or ischemic ECG changes); evaluate patients with signs or symptoms suggestive of angina for presence of CAD or predisposition to Prinzmetal angina before receiving additional doses; monitor ECG if dosing resumed and similar symptoms recur

Rizatriptan (Maxalt, Maxalt-MLT)

Selective agonist for serotonin 5-HT1 receptors in cranial arteries and suppresses the inflammation associated with migraine headaches. High affinity for 5-HT _1D and 5-HT _1B receptor subtypes.
As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use them in children. The decision to choose these drugs might be best reserved for consultation.

Dosing

Adult

5-10 mg PO at migraine onset; may repeat dose after 2 h prn; not to exceed 30 mg/d
Oral disintegrating tab: 5-10 mg PO dissolved on tongue at migraine onset; may repeat dose after 2 h prn; not to exceed 30 mg/d

Pediatric

Not established

Interactions

Toxicity increases when administered concomitantly with ergot-containing drugs, selective serotonin reuptake inhibitors, and MAOIs

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hypertensive crisis, coronary artery vasospasm, cardiac arrest, peripheral ischemia, bloody diarrhea, and death may occur when administering this medication

Almotriptan (Axert)

Used to treat acute migraine. Selective 5-HT_1B/1D/1F receptor agonist. Results in cranial vessel constriction, inhibition of neuropeptide release, and reduced pain transmission in trigeminal pathways.
As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use them in children. The decision to choose these drugs might be best reserved for consultation.

Dosing

Adult

6.25-12.5 mg PO at onset of migraine; may repeat once, not to exceed 25 mg/d

Pediatric

<18 years: Not established
>18 years: Administer as in adults

Interactions

Toxicity may increase when used within 24 h of ergotamines or other 5-HT agonists; coadministration with SSRIs may cause weakness, hyperreflexia, or incoordination; CYP3A4 inhibitors (eg, ketoconazole, itraconazole, ritonavir, erythromycin) may increase plasma concentration and subsequent toxicity

Contraindications

Documented hypersensitivity; hemiplegic or basilar migraine; ischemic heart disease; uncontrolled hypertension

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Decrease dose and do not exceed 12.5 mg/d in renal or hepatic impairment

Frovatriptan (Frova)

Selective 5-HT1 agonist with long half-life. High affinity for 5-HT _1D and 5-HT _1B receptor subtypes. Has duration of action as long as 24 h with low headache recurrence rate. Useful for patients with slow-onset, prolonged migraine, such as menstrual migraine. Has long half-life (ie, 26-30 h), thus decreases recurrence of migraine within 24 h after treatment.
As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use them in children. The decision to choose these drugs might be best reserved for consultation.

Dosing

Adult

2.5 mg PO once at onset of migraine attack; may repeat at intervals of 2 h prn; not to exceed 7.5 mg/d

Pediatric

<18 years: Not established
>18 years: Administer as in adults

Interactions

Toxicity may increase when used within 24 h of ergotamines or other 5-HT agonists; coadministration with SSRIs may cause weakness, hyperreflexia, or incoordination

Contraindications

Documented hypersensitivity; hemiplegic or basilar migraine; ischemic heart disease; uncontrolled hypertension

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hypertensive crisis, coronary artery vasospasm, cardiac arrest, peripheral ischemia, bloody diarrhea, and death may occur

Eletriptan (Relpax)

Selective serotonin agonist. Specifically acts at 5-HT_1B/1D/1F receptors on intracranial blood vessels and sensory nerve endings to relieve pain associated with acute migraine.
As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use them in children. The decision to choose these drugs might be best reserved for consultation.

Dosing

Adult

20-40 mg/dose PO at onset of migraine; if initial dose ineffective, may repeat dose once after 2 h; not to exceed 80 mg/d

Pediatric

<18 years: Not established
>18 years: Administer as in adults

Interactions

Potent CYP3A4 inhibitors (eg, ketoconazole, itraconazole, nefazodone, troleandomycin, clarithromycin, ritonavir, nelfinavir) may increase toxicity; concurrent administration with ergot-containing drugs may increase vasospastic reactions

Contraindications

Documented hypersensitivity; severe hepatic impairment; age >65 y; administration within 72 h of potent CYP3A4 inhibitors

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Patients with known or suspected coronary artery disease may have increased risk of myocardial ischemia, infarction, or other cardiac or cerebrovascular events (5-HT¹ agonists may cause coronary vasospasm)

Antiemetics

These agents are useful in the treatment of symptomatic nausea.

Promethazine (Phenergan)

Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system. Antiemetic and antihistaminic actions that alleviate nausea and vomiting and promote sleep.

Dosing

Adult

12.5 mg PO/PR tid and 25 mg hs
25 mg IV/IM; repeat prn in 2 h; switch to PO as soon as possible

Pediatric

<2 years: Contraindicated
>2 years: 0.25-0.5 mg/kg/dose PO/IV/IM q6h

Interactions

May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension

Contraindications

Documented hypersensitivity; children <2 y (incidences of death due to respiratory depression)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma

Metoclopramide (Reglan)

Metoclopramide promotes gastric emptying and has antiemetic effects, which are useful to treat the nausea and vomiting associated with migraine.

Dosing

Adult

5-10 mg PO/IV/IM tid

Pediatric

0.1 mg/kg/dose PO/IV q6h prn

Interactions

Anticholinergics may antagonize effects of metoclopramide; opiate analgesics may increase metoclopramide toxicity in CNS

Contraindications

Documented hypersensitivity; pheochromocytoma; GI hemorrhage, obstruction, or perforation; history of seizure disorders

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adverse reactions include drowsiness, diarrhea, and hypotension; caution in history of mental illness and Parkinson disease (acute dystonic reactions are more common at higher doses); caution in seizure history

Follow-up

Further Outpatient Care

• Chronic recurrent headaches should be referred to either a pediatric neurologist or a neurosurgeon, depending on the cause.
  

Patient Education

• For excellent patient education resources, see eMedicine's Headache Center. Also, visit eMedicine's patient education articles, Causes and Treatments of Migraine and Related Headaches and Migraine Headache in Children.

Miscellaneous

Medicolegal Pitfalls

• CT scans do not always identify subarachnoid bleeds. Therefore, remember to perform a lumbar puncture despite negative findings on CT scan for patients suspected of having a subarachnoid bleed.

References

1. Lewis D, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein S, et al. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology. Dec 28 2004;63(12):2215-24. [Medline]. [Full Text].

2. American Academy of Pediatrics. Clinical Practice Guideline: Management of sinusitis. Pediatrics. 2000;108(3):798-808.

3. Bechtel K. Acute mental status change due to acute confusional migraine. Pediatr Emerg Care. Apr 2004;20(4):238-41. [Medline].

4. Bille BS. Migraine in school children. A study of the incidence and short-term prognosis, and a clinical, psychological and electroencephalographic comparison between children with migraine and matched controls. Acta Paediatr Suppl. May 1962;136:1-151. [Medline].

5. Clement PA, Bluestone CD, Gordts F, Lusk RP, Otten FW, Goossens H, et al. Management of rhinosinusitis in children. Int J Pediatr Otorhinolaryngol. Oct 5 1999;49 Suppl 1:S95-100. [Medline].

6. Cooney BS, Grossman RI, Farber RE, Goin JE, Galetta SL. Frequency of magnetic resonance imaging abnormalities in patients with migraine. Headache. Nov-Dec 1996;36(10):616-21. [Medline].

7. Fleisher DR, Matar M. The cyclic vomiting syndrome: a report of 71 cases and literature review. J Pediatr Gastroenterol Nutr. Nov 1993;17(4):361-9. [Medline].

8. Haslam R. Headaches-migraine. Behrman RE, Kleigman RM, Arvin AM, eds. Nelson's Textbook of Pediatrics. WB Saunders; 1996:1702-3.

9. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia. 1988;8 Suppl 7:1-96. [Medline].

10. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24 Suppl 1:9-160. [Medline].

11. Hoffman G. Headache and facial pain. Tintinalli JE, ed. Emergency Medicine: A Comprehensive Study Guide. 4^th ed. 1996:1008-14.

12. Kaniecki RG, Totten J. Cervicalgia in migraine: prevalence, clinical characteristics, and response to treatment. Cephalalgia. 2001;21:296.

13. Landy S. Migraine throughout the life cycle: treatment through the ages. Neurology. Mar 9 2004;62(5 Suppl 2):S2-8. [Medline].

14. Laurell K, Larsson B, Eeg-Olofsson O. Prevalence of headache in Swedish schoolchildren, with a focus on tension-type headache. Cephalalgia. May 2004;24(5):380-8. [Medline].

15. Lee LH, Levey EB. Formulary/special drug topics. In: Barone MB, ed. The Harriet Lane Handbook. Mosby Publishing Co; 1996:480-643.

16. Lewis DW. Headaches in children and adolescents. Curr Probl Pediatr Adolesc Health Care. Jul 2007;37(6):207-46. [Medline].

17. Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. Jul-Aug 2001;41(7):646-57. [Medline].

18. Neinstein L, Milgrom E. Trauma-triggered migraine and acute confusional migraine. J Adolesc Health. Aug 2000;27(2):119-24. [Medline].

19. Olesen J, Larsen B, Lauritzen M. Focal hyperemia followed by spreading oligemia and impaired activation of rCBF in classic migraine. Ann Neurol. Apr 1981;9(4):344-52. [Medline].

20. Packer RJ, Berman PH. Emergency Medicine. Neurologic emergencies. In: Fleisher G, Ludwig S, et al, eds. Textbook of Pediatric. 1993:582-4.

21. Prensky A. Headache. Oski F, DeAngelis C, Feigin R, Warshaw J, eds. Principles and Practice of Pediatrics. 1990:1947-50.

22. Ramadan NM. Targeting therapy for migraine: what to treat?. Neurology. May 24 2005;64(10 Suppl 2):S4-8. [Medline].

23. Silberstein SD, Olesen J, Bousser MG, Diener HC, Dodick D, First M. The International Classification of Headache Disorders, 2nd Edition (ICHD-II)--revision of criteria for 8.2 Medication-overuse headache. Cephalalgia. Jun 2005;25(6):460-5. [Medline].

24. Stickler GB. Relationship between cyclic vomiting syndrome and migraine. Clin Pediatr (Phila). Jul-Aug 2005;44(6):505-8. [Medline].

25. Welch KM. Contemporary concepts of migraine pathogenesis. Neurology. Oct 28 2003;61(8 Suppl 4):S2-8. [Medline].

26. Wober-Bingol C, Wober C, Wagner-Ennsgraber C, Karwautz A, Vesely C, Zebenhoizer K, et al. IHS criteria for migraine and tension-type headache in children and adolescents. Headache. Apr 1996;36(4):231-8. [Medline].

27. Zidverc-Trajkovic J, Pekmezovic T, Jovanovic Z, Pavlovic A, Mijajlovic M, Radojicic A, et al. Medication overuse headache: clinical features predicting treatment outcome at 1-year follow-up. Cephalalgia. Nov 2007;27(11):1219-25. [Medline].

Keywords

headache, migraine, migraine headache, tension headache, sinus headache, sinusitis, head trauma, intracranial mass, benign intracranial hypertension, pseudotumor cerebri, epilepsy, meningeal irritation, headache causes, headaches in teenagers, basilar migraine, cyclic vomiting syndrome, CVS, ophthalmoplegic migraine, cluster headache, medication overuse headache, MOH, hemiplegic migraine, hemisensory migraine, common migraine, classic migraine, complicated migraine 

Contributor Information and Disclosures

Author

Kirsten A Bechtel, MD, Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital
Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

William G Gossman, MD, Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Consulting Staff, Department of Emergency Medicine, Creighton University Medical Center
William G Gossman, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

© 1994- by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)