Pediatric Headache Treatment & Management

Some authors believe that early diagnosis and prompt initiation of optimal treatments (abortive and preventive) lead to better treatment outcome and prognosis and less disability for children and adolescents with migraine. ^[30] However, much less data are available for the pediatric age group than for adults. ^[43]

Treatment of a secondary headache is focused on its specific cause, but an additional, symptomatic therapy may be useful as long as the cause has not yet been eradicated. As for a primary headache, always consider a preventative treatment and a symptomatic therapy.

The short-term goals of therapy for migraine and tension-type headache are to relieve pain, alleviate nausea, and promote sleep. The long-term goals are to improve the patient’s quality of life by reducing the frequency and severity of headache episodes. The treatment of chronic daily headache (CDH) combines therapies that are used for tension-type and migraine headache.

Symptomatic treatment

Drugs used in symptomatic treatment should be chosen carefully according to headache type (eg, beta-blockers or cyproheptadine for migraine, amitriptyline for migraine or tension-type headache), frequency (eg, amitriptyline for more frequent/chronic headache), type of symptoms (cyproheptadine if prominent vomiting), adverse-effect profile (eg, no beta-blockers if asthma). It is advisable to include comorbidities in the choice, such as depression and insomnia, which a tricyclic antidepressant helps to control along with migraine.

Multiple levels of symptomatic therapy exist. The current opinion is that rather than using a step-care treatment starting with the least expensive drugs and then stepping up as needed, the stratified care approach is best; up front the patient situation is assessed and the severity and level of care needed is taken into account to decide on the most effective and overall cost-containing treatment.

Adjusting treatment is recommended until the most efficient regimen is found; this regimen would treat all symptoms, including the headache itself but also other complaints such as nausea, vomiting, and photophobia. Self-treatment can lead to medication-overuse headache. Therapy must be monitored by parents.

Triptans may be helpful in the treatment of these headaches, especially if the onset of headache has been recent. Narcotic and nonnarcotic analgesics, sedatives, and antiemetics are helpful adjunctive therapy, but an effort should be made to avoid excessive use of medications, particularly narcotics.

Sleep, darkness, and a quiet room are essential in managing acute migraine and tension-type headache. ^[44] In addition, encourage scheduled times for meals, bedtime, relaxation, and exercise. Individual treatment decisions should be based on the age of the child and receptiveness to behavioral techniques. Behavioral techniques can be highly effective for migraine and tension-type headaches. More focus is also being directed toward the use of complementary/alternative therapies such as acupuncture.

Acute tension headaches often respond to symptomatic treatments. Ibuprofen and acetaminophen are recommended to relieve headache pain. Avoid narcotics and other potentially addictive medications.

Eliminate identified precipitants; for example, alcohol, drugs, or caffeine may trigger headaches. Encourage appropriate lifestyle changes.

Lifestyle changes

The role of diet in headaches remains controversial. However, if a given food or beverage is associated with headaches, its avoidance has an obvious and significantly positive impact.

A study by Milde-Busch et al linked obesity and physical inactivity to childhood and adolescent headache disorders. ^[45] A lifestyle that includes physical exercise improves the quality of life of these patients in more than 1 way.

Regular sleep schedules, especially adequate amounts of sleep, have an effect on migraine control. A common tendency exists for teenagers to not sleep enough.

Stress relief

Stress, as a trigger and as a consequence of headache, is a logical target for nonpharmacologic therapy. Patients who are prone to tension headaches should attempt to minimize stress and may benefit from behavioral/relaxation therapy. Psychotherapy is indicated for any patient under significant stress. Consider family therapy in situations that involve divorce or illness of a sibling or when the family unit is a contributing factor.

Relaxation techniques with biofeedback of either cutaneous temperature with a finger probe or muscular contraction with an electromyography (EMG) needle are very helpful as adjunct therapy; they can even prevent headache on their own in the older child, granted that adequate cooperation can be obtained. Recommended treatment is 2-3 times weekly for 4-8 weeks. Usually, a physical therapist, or sometimes a psychologist with cognitive-behavioral skills, performs this therapy.

Regular physical activity can also reduce patient stress levels and is especially useful in cases of tension-type headache.

Abortive therapy

Abortive therapy uses medications to interrupt a headache after its onset. All abortive medications carry a risk of medication-overuse headache with excessive use in patients with frequent headaches.

Triptans

Sumatriptan (Imitrex), a serotonin 5-HT1 receptor agonist that causes vasoconstriction, among other actions, is effective in aborting migraine (about 70% efficacy in adults). It is available as an oral tablet, nasal inhalant, transdermal, or subcutaneous patient autoinjection system (vials for injection). The injected form of sumatriptan works faster than the nasal spray or the oral form. New, needleless parenteral forms of sumatriptan are also available.

Adverse effects of sumatriptan include the following:

• Tingling

• Dizziness

• Warm sensations

• Chest pain

• Cardiac arrhythmias

Sumatriptan is absolutely contraindicated for patients with cardiac disease, uncontrolled hypertension, hemiplegic and basilar migraines, or pregnancy.

In children aged 12-17 years, controlled clinical trials with oral sumatriptan failed to show efficacy. This is probably due to high placebo effect observed in pediatric migraine trials. This means that children seem to respond well to placebo, therefore obscuring the response to active medication. Pediatric and adolescent studies indicate efficacy with the nasal spray form of this medication. ^[46]

Subcutaneous sumatriptan has also been effective, although the manufacturer does not recommend the use of it in patients who are younger than 18 years. In children, the trial subcutaneous dose is 0.1 mg/kg/dose. Current autoinjection sumatriptan is available in 6 mg and 4 mg unit doses.

Several triptans are approved by the US Food and Drug Administration (FDA) to be used as abortive therapy in the treatment of pediatric migraine. A study by Linder et al provided evidence that almotriptan (Axert) is effective and well tolerated in adolescents with migraines; the drug gained FDA approval for this indication shortly after the study. ^[47] Other triptans that are approved for acute treatment of pediatric migraine include rizatriptan (Maxalt) in children aged 6-17 years ^{[48, 49]} and zolmitriptan (Zomig Nasal Spray). In the Spring of 2015 the FDA approved a combination of naproxen sodium and sumatriptan (Treximet) for the acute treatment of migraine with or without aura in pediatric patients 12 years of age and older. ^[50]

Clinicians usually use almotriptan, rizatriptan for pediatric migraine, and other triptans off-label in their daily clinical practice, even if they are not indicated by the FDA for children. These include, in no specific order, naratriptan (Amerge), eletriptan (Relpax), and frovatriptan (Frova).

Clinical trials of some of these medications in children are currently under way. For years in the author's practice, when children and adolescents have not responded to nonsteroidal anti-inflammatory drugs (NSAIDs) or other over-the-count (OTC) analgesics, he has treated them with triptans, with good results.

Isometheptene and ergotamines

Isometheptene (Midrin) and ergotamines are also available for abortive migraine therapy (Although Midrin was removed from the US market in 2011, a generic form has appeared on the market.). While scientific evidence for their efficacy is lacking, many clinicians have used these medications with success. They are most effective when administered at aura onset or at the start of the headache. Because aura is less common in pediatric migraine and because children may be less able to communicate early symptoms of a headache, administering these abortive therapies at the appropriate time can be difficult.

Ergotamines generally are not used for young children (aged 6 years or younger) and may cause GI upset.

Analgesics

Analgesics such as acetaminophen and NSAIDs can be used as abortive therapy. They seem to be particularly effective in the pediatric population, and they can be obtained without prescription. Less risk of medication-overuse headache (rebound or withdrawal headache) may be seen with long-acting NSAIDs such as naproxen sodium.

Prophylactic therapy

Although consensus does not exist regarding the criteria to start prophylactic treatment, frequency and severity will be the main factors to guide the decision. Consider prophylactic therapy when headaches are frequent enough to interfere with the patient's lifestyle. In deciding to begin prophylactic therapy, consider the risks of long-term drug use against the benefit of potential headache relief. The possibility of pregnancy should also be considered if prophylactic medication is prescribed. As with abortive therapy, several classes of pharmacologic agents are available for prophylactic treatment.

In general, the effect of prophylactic therapy is not immediate, often taking as long as 6-8 weeks before improvement occurs. Providing this information to the patient and his/her parents leads to improved compliance and more realistic goals. Giving an appropriate trial before attempting a new treatment is important.

Migraines are known to remit spontaneously in some patients during childhood. Every 6-12 months, reassess the need for continued prophylaxis. This can be achieved by tapering the medication until either the headaches resume or the patient remains headache-free off therapy.

On the other hand, parents and patients need to be aware that migraine headaches may be a lifelong condition, and they should expect that the headaches will reappear at some time during a patient’s lifetime, especially during situations of increased stress, such as puberty, marriage, or change of job.

Beta-blockers

Beta-blockers are commonly used as prophylactic therapy for childhood migraine; propranolol and nadolol are each effective. Nadolol has the advantage of being longer acting (given once daily). Beta-blockers are contraindicated in patients with asthma or diabetes, and they may cause depression in adolescents. If the patient is an athlete, beta-blockers may interfere with the patient’s performance.

Tricyclic agents and cyproheptadine

Tricyclic agents (amitriptyline, nortriptyline) are frequently used for prophylactic therapy, especially in older children and adolescents. Nortriptyline tends to be less sedating than amitriptyline, but there are no well-conducted scientific trials demonstrating the efficacy of nortriptyline. There is, however, plenty of scientific evidence that amitriptyline is efficacious in migraine prevention. A paper presented at the American Academy of Neurology Annual Meeting in New Orleans (2012) showed that amitriptyline was safe and effective for migraine prevention in children and adolescents.

Cyproheptadine (Periactin), an antihistamine/antiserotonin drug, is also used, especially in younger children. Side effects include sedation, appetite stimulation, and weight gain.

No good scientific evidence supports the use of tricyclic agents or cyproheptadine in the pediatric population, but many clinicians have used these medications with success over decades.

Anticonvulsants

Anticonvulsants such as valproic acid, zonisamide, and topiramate have been used as prophylactic agents with reasonable success. These agents are especially useful when a seizure disorder coexists with migraines. Good scientific evidence exists to support the use of valproic acid and topiramate but is lacking for any other anticonvulsant. In 2014, the FDA approved the use of topiramate for the prevention of headaches in migraine patients aged 12-17 years.

Although some patients on topiramate complain of cognitive changes, the authors' own experience and published data ^[51] are consistent with the fact that cognitive changes are not common and topiramate is safe and effective in the pediatric population.

Calcium channel blockers

Calcium channel blockers (eg, verapamil) have been used in adults for migraine prophylaxis, but their efficacy in children is variable.

As previously mentioned, the treatment of CDH combines therapies that are used for tension and migraine headache. The patient should discontinue the use of OTC analgesics and all narcotics. Chronic, intermittent analgesic use may result in medication-overuse headaches. Tricyclic antidepressants appear to be most helpful for treating CDH in children. There are also data on topiramate and CDH. ^{[52, 53, 54]}

Psychological, behavioral, and relaxation interventions are also beneficial. Consider using these techniques concomitantly with tricyclic antidepressants. When the CDH pattern includes well-defined migraine attacks, abortive therapy may provide symptomatic relief. Late in 2012, the National Institutes of Health funded a study called CHAMP (CHildhood and Adolescent Migraine Prevention); the study was terminated early after interim analysis showed no significant difference in responder rates between subjects who received amitriptyline, topiramate, or placebo, and the occurrence of adverse events in patients who received study drug. However, neurologists continue to utilize these medications, as they have anecdotal observations of benefit. ^[55]

Sinusitis

The treatment of sinusitis includes appropriate antibiotic coverage, as well as the use of analgesics (eg, NSAIDs, acetaminophen) and nasal decongestants. Analgesics are also useful for chronic, postconcussive headaches, but there is the risk of medication-overuse headaches if analgesics are used 10 or more days per month.

Intracranial hemorrhage

In the event of an 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.

To alleviate the increased intracranial pressure associated with intracranial hypertension (pseudotumor cerebri), a lumbar puncture is used to reduce the volume of CSF. Carbonic anhydrase inhibitors decrease the production of CSF.

Meningeal inflammation

The treatment goal for meningeal inflammation is treatment of the underlying cause, such as malignant hypertension (antihypertensives), infection (antibiotics), or subarachnoid hemorrhage (surgical evacuation of intracranial hemorrhage; nimodipine can be used to reduce vasospasm).

Inpatient care is provided for individuals with CDH after outpatient treatment has failed. It usually is intended to initiate prophylaxis while intravenous (IV) symptomatic therapy is being administered and, sometimes, IV fluids in case of severe nausea and vomiting. Also, status migrainosus can justify a brief hospital stay for symptomatic treatment.

Headaches of unclear etiology that are severe and worsening, as well as worrisome symptoms and signs, also can justify hospitalization in certain cases.

Much has been written concerning food items that can trigger headaches, especially migraine. However, there is a high degree of variability, and good scientific explanations for correlations between food and headache is rare. Moreover, causative items most often contain multiple potential triggers.

Avoid food triggers, such as old, fermented cheese; citrus fruits; and monosodium glutamate (found not only in Chinese food but also, widely, in commercial preparations). In addition, caffeine excess and especially caffeine withdrawal can precipitate migrainous headaches. With regard to the association between migraine and chocolate, the possibility exists that this is far more frequently a consequence of sugar craving, part of migraine premonitory symptoms, than a trigger.

The primary care physician can manage a significant portion of pediatric headaches and can reserve neurologic referral for complicated headache patterns, headaches refractory to treatment, and headaches with a suspected structural etiology.

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

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

Note that an ophthalmologic consultation frequently is requested to evaluate for refractive abnormalities; although this scenario is possible, an excessive tendency exists to attribute headaches to this problem.