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Evidence Based Strategies: Pediatric Headaches Giving You a Headache?

Column Author: Tess Schultz, DO | Pediatric Resident 

Column Editor: Angela D. Etzenhouser, MD, FAAP | Associate Director, Pediatric Residency Program

 

Although headache in the pediatric population is a common complaint in the primary care setting, little education on management is given to providers. Over 60% of children will complain of a headache, and about 8%-15% of children have migraines.1 Who should manage headaches? Primary care? Neurology? Both? This article aims to help the primary care physician feel more comfortable with pediatric headache and know when to refer their patient.

Headaches are classified into primary headache and secondary headache. Primary headaches include tension-type headaches, migraine and trigeminal autonomic cephalgias. Secondary headaches include headaches due to trauma, vascular disorder, infection, etc. Emergency red flag symptoms that require immediate attention/referral include thunderclap headache, meningismus, papilledema with focal signs or reduced consciousness, and acute glaucoma. Urgent symptoms include papilledema without focal signs or loss of consciousness, and relevant systemic illness. Other indicators of secondary headache are unusual headache precipitants (e.g., valsalva, positional, sex, cough) and unusual aura symptoms (e.g., dysarthria, vertigo, tinnitus, diplopia, ataxia).2

The definition of migraine can be remembered by the 5-4-3-2-1 rule: five or more attacks in a lifetime; headache lasting four hours to three days; two of the following: unilateral, pulsing/throbbing, limits activities, and moderate to severe quality; and one of the following: nausea, vomiting, photophobia, and phonophobia. Chronic migraine is defined as ≥15 migraine days per month for greater than three months.3

Migraines usually occur in three to four phases which include prodrome, aura, headache, then postdrome. Prodrome usually occurs 24-48 hours prior and can include yawning, mood swings, food cravings, GI symptoms, and/or body stiffness. Aura is present in only about one-third of migraine patients and can be visual or sensory, and can affect speech or language. The postdrome phase is most often characterized by moderate to severe fatigue, although some patients can experience mild elation or euphoria.2,3

Treatment should address both the acute symptoms and prevention. Acute treatment includes common analgesics such as ibuprofen, acetaminophen, naproxen, and ASA/acetaminophen/caffeine combination pills. Migraine abortive medications include triptans (5-HT1 agonist), anti-emetics, calcitonin gene-related peptide (CGRP) antagonists, and neuromodulators (vagal nerve stimulator, trigeminal nerve stimulator, transcutaneous electrical nerve stimulation units).2 It is important to note that rizatriptan (an acute migraine treatment) is approved by the Food and Drug Administration for children ≥6 years old and has straightforward dosing with available oral dissolving tablets. Nonsteroidal anti-inflammatory drugs (NSAIDs) and triptans have a synergistic effect when taken together for treatment.4,5 A key factor in the success of acute treatment is to take medications at the onset of headache or aura (if present). It is important to counsel patients to not take NSAID medications more than 10-15 days per month due to the risk of rebound headache.

Primary care physicians should consider preventive treatment for patients with four or more headache days per month, or for patients with fewer than four headaches/month if these are severe enough to cause significant life impairment. It is important to provide patients with multiple options for preventive “tools,” most of which can be layered to increase effect. These tools include lifestyle management, supplements, medication, neuromodulators and adjunctive therapy. The importance of lifestyle management cannot be understated. Stress management, mental health support, good hydration, adequate sleep, healthy diet, and physical activity all aid in the prevention of migraine. Magnesium supplementation at 400-500 mg daily has shown to help in prevention of migraine. Other supplements shown to have benefit are riboflavin and CoQ10. Note that supplements may take an average of eight to 12 weeks to provide improvement. Preventive medications include topiramate, beta-blockers, monoclonal antibodies, tricyclic antidepressants, and botulinum toxin for chronic migraine. Neuromodulators that disrupt the pain signaling pathway are becoming more common for both prevention and treatment of migraine. Adjunctive therapy such as acupuncture, cognitive behavioral therapy, physical/vestibular therapy, and biofeedback therapy are also helpful in preventing migraine.2,5,6

Headache in pediatrics is a common and an increasing problem. Pediatricians have an abundance of treatments to try before referral to a specialist. Knowledge of red flag symptoms and taking a good history is vital to triaging these patients. Treatments including NSAID medications and triptans are the mainstay of primary care acute headache management. Preventive treatment is more commonly managed by specialists; however, pediatricians can initiate treatment if they are comfortable. Prevention tools should include lifestyle management, and may also include supplements, medication, neuromodulators and adjunctive therapy.

References:

  1. Burch R, Rizzoli P, Loder E. The prevalence and impact of migraine and severe headache in the United States: updated age, sex, and socioeconomic-specific estimates from government health surveys. Headache. 2021;61(1):60-68. PMID: 33349955. doi:10.1111/head.14024
  2. Flowchart. American Headache Society. August 10, 2022. https://americanheadachesociety.org/flowchart
  3. Cutter EE. How to diagnose migraine. American Headache Society. January 2021. https://americanheadachesociety.org/wp-content/uploads/2022/05/AHS-First-Contact-HowToDiagnose_Migraine.pdf
  4. Guthrie CC, Nathani Y. Acute treatment of pediatric migraine. Pediatr Emerg Med Rep. Relias Media website. April 1, 2019. https://www.reliasmedia.com/articles/144150-acute-treatment-of-pediatric-migraine
  5. Hoover LE. Migraines in children: recommendations for acute and preventive treatment. Am Fam Physician. 2020;101(9):569-571. https://www.aafp.org/pubs/afp/issues/2020/0501/p569.html
  6. Understanding pediatric migraine. American Migraine Foundation. March 15, 2018. Accessed May 3, 2024. https://americanmigrainefoundation.org/resource-library/pediatric-migraine/
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