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10 Articles in Volume 10, Issue #1
An Overview of CRPS
Balancing Evidence, Efficacy and Stakeholder Values in Practical Pain Care
Biopsychosocial Approach to Management of Total Joint Arthroplasty Patients
Dextrose Prolotherapy Injections for Chronic Ankle Pain
Genetic Influences on Pain Perception and Treatment
Headache in Children and Adolescents
Hormone Replacements and Treatments in Chronic Pain: Update 2010
Opioid Treatment 10-year Longevity Survey Final Report
Therapeutic Laser in the Treatment of Herpes Zoster
Use and Effectiveness of Spinal Cord Stimulation

Headache in Children and Adolescents

A multidisciplinary approach—a balance of medication with therapy and lifestyle changes—is the most helpful for children with severe headaches to help them return to normal functioning in home, school and social life.

Headache is a common complaint among children and adolescents. The prevalence of migraine in those with headache varies by age and gender throughout childhood and adolescence. Migraine begins earlier in boys than in girls and, until the age of seven, migraine occurs slightly more often among boys. By menarche, the prevalence of migraine in boys and girls is roughly equal. However, after menarche, migraine begins to predominate among females and this gender separation increases even further in late adolescence.

Headaches, especially migraines, have a significant impact on the lives of young people. Approximately 65-80% of children with migraine headaches will experience disruption of their normal daily activities at home, in school and other social settings. The burden of migraine may also result in the development or worsening of anxiety or depression. Because of quality of life issues, early recognition and management of headaches in children and adolescents is crucial.

Headache disorders can be categorized as either primary or secondary. As with adults, the vast majority of headaches in children and adolescents are primary headache disorders: migraine (with or without aura), tension-type headache and chronic daily headache.

Secondary headache disorders, al-though much less common, may be due to various organic etiologies which can range from the relatively benign to the serious. Such underlying organic conditions include:

  • bacterial causes: acute febrile illness, rhinosinusitis, dental abscess, intracranial and extracranial infections;
  • systemic illness: hypertension, diabetic ketoacidosis;
  • miscellaneous: head or neck trauma, vascular malformations, subarachnoid hemorrhage, intracranial mass lesions, etc.

Diagnostic Approach

Although headache can be a presenting symptom of underlying organic pathology, accurate information from the patient and family is often enough to identify or rule out the most serious etiologies. The overwhelming majority of headache disorders are diagnosed by a thorough history and physical examination. A complete medical and psychiatric history, family history, medication history (including prescription, over-the-counter, and vitamins/herbs), allergy history, and social history should also be obtained.

Migraine tends to be under-diagnosed; patients and their parents often attribute headaches and nausea to “the flu” or dismiss them as “sinus headaches.” Careful attention must be paid to the patient’s description of headache onset, timing, frequency, duration, severity, quality, location, precipitating factors, and aggravating or alleviating factors. Associated symptoms—especially nausea, vomiting, photophobia and phonophobia—are often the key to an accurate diagnosis of migraine.

Potential indicators of organic pathology can include severe vomiting, a headache which awakens a child from sleep, and the absence of a family history of migraine. Also, progressive, unremitting daily pain, neurologic symptoms and fevers are important. If any of these red flags are present, the appropriate laboratory and imaging investigations should be performed.

In a patient with an unremarkable history, where a primary headache disorder is suspected, laboratory investigation is usually not warranted beyond baseline labs. These usually include, but are not limited to, a complete blood count and metabolic panel.

Neuroimaging studies are usually not indicated in children with a normal neurologic examination and a history consistent with a primary headache disorder, especially migraine or tension-type head-ache. These children will not usually have significantly abnormal findings on head CT scans or intracranial MRIs. A small percentage may have incidental and/or unrelated findings, but routine neuro-imaging is not absolutely indicated in children with typical primary headaches.

Usually, electroencephalography (EEG) is not helpful in the routine diagnostic assessment of pediatric headache patients. However, an EEG should be performed on patients with an atypical migraine aura, episodic loss of consciousness, or symptoms suggestive of a seizure disorder. Background slowing may be seen during some migraine attacks, but the EEG results are usually normal.

Lumbar puncture (LP) is indicated if meningitis, encephalitis, subarachnoid hemorrhage, or high-low pressure syndromes are suspected. Cerebrospinal fluid and pressure measurement should also be performed. In those patients where increased intracranial pressure is suspected—or in those with focal neurologic deficits—a head CT scan or similar neurologic imaging modality should be performed prior to a lumbar puncture. We attempt to avoid the LP unless absolutely indicated. However, if meningitis or encephalitis is suspected in a toxic-appearing patient, treatment should not be delayed in order to perform the head CT scan first.

Biopsychosocial Approach

For those with more severe or frequent headaches, a comprehensive biopsychosocial approach is needed. This approach requires the collaboration of medical and behavioral specialists working together to improve a patient’s overall functioning and quality of life. The combination of both pharmacologic and nonpharmacologic treatments is ideal for those with frequent headaches. Nonpharmacologic treatments are particularly important as they are typically more effective in children and help to minimize medications and side effects.

Non-pharmacologic Treatments

Non-pharmacologic modalities consist of patient education, lifestyle strategies, behavioral interventions, physical therapy, etc. Patient education should be the first step taken. Legitimizing the headache as a physiological disorder is of primary importance. It helps to say “…Migraines are a genetic medical condition, like asthma or diabetes…”

Children and their parents usually want to hear three things from the physician: (1) the cause of the headache (including triggers), (2) the treatment and prognosis, and (3) reassurance that a primary headache disorder is not serious. It is important that realistic goals and expectations are set. Children and their parents should understand that there are no miracle cures for headaches.

It is usually helpful to introduce the use of a headache diary as a means to identify specific triggers. Of course, some triggers (e.g., weather changes, stress, hormonal influences) cannot be avoided, but certainly many—such as missing meals, bright lights/sunlight, undersleeping/ oversleeping, foods, perfume, cigarette smoke and certain types of physical exertion—can be managed. Headache diaries should record the frequency and severity of headaches as well as document the efficacy and side effects of treatments. Using a diary will improve the patient’s or parents’ recall of the headaches and make office visits more productive. They can also help persuade children and adolescents of the need for lifestyle changes.

Lifestyle strategies should include an emphasis on proper diet, exercise, and sleep habits. Headache patients do better with regular schedules, eating three or more meals per day, and going to bed and awakening at the same time every day, including weekends. Daily exercise can be particularly helpful; patients should strive for at least 30 minutes of exercise per day. Generally, headache patients do better with low impact exercise such as swimming, walking, biking, and yoga.

Behavioral interventions—such as psychotherapy, counseling and relaxation techniques—may be helpful for many adolescents who experience significant stress in their lives. Overscheduling adds to the usual adolescent stressors. The incidence of hard-driving perfectionistic behavior and depression is increased in adolescents with severe headache. Child-ren and adolescents who miss substantial blocks of time in school or social activities need to be assessed for depression, school phobia, and secondary gains. Counseling for children, as well as family-centered therapy for children and their parents, are often helpful in promoting active coping and is an indispensable augmentation to medical therapy.

Relaxation techniques such as biofeedback, deep breathing, and imaging should be encouraged. Most adolescents can learn relaxation techniques from books or audiovisual aids that are readily available. However, seeing a therapist who teaches biofeedback is much more effective. Most children under the age of 10 cannot learn and apply biofeedback, but some as young as seven can learn simple breathing and imaging techniques.

Pharmacologic Treatment

There are two types of pharmacologic treatment for headaches: abortive and preventive. Decisions on medication will depend upon the frequency and severity of the headaches and how much they bother the patient. Some children are not overly bothered by their daily headaches and tend to ignore them. Others may be incapacitated and miss an entire year of school.

As with adult headaches, abortive medication is used in the overwhelming majority of cases without daily preventive medication. Patients should be encouraged to use their abortive medication early, while their headaches are mild. Early intervention is a key step in successful use of migraine abortives. See Table 1 for a list of first line abortive medications.

Table 1. First Line Abortive Medications for Migraine and Tension-Type Headaches in Children and Adolescents
Under 12 years of age:
1. Ibuprofen. Effective, and available as a liquid, but GI upset is relatively common.
2. Acetaminophen. Well tolerated, safe, but not as effective as ibuprofen. Chewable tablets and liquid are available. Due to its relative safety, acetaminophen is the usual primary abortive used in young children.
3. Naproxen. (Naprosyn, Aleve). Effective abortive that is non-sedating and is available as a liquid. However, GI side effects are common. (Aleve = OTC = 220mg).
4. Midrin. Capsules (acetaminophen 325mg/dichloralphenazone 100mg/isometheptene 65mg): ½ or 1 capsule PO q 4 hours prn. These are very large capsules, but may be taken apart and sprinkled into apple sauce or juice. Sedation is common, as is lightheadedness. GI upset, although not common, occurs at times.
5. Caffeine. Either used by itself, or with an analgesic, caffeine is useful for tension and migraine headache. In children, soft drinks containing caffeine are helpful. Side effects are minimal when caffeine is used in very limited amounts.
6. Triptans. Off-label, but are occasionally used in low doses at ages 10-11.
Over 12 years of age (includes the above plus the following):
7. Triptans. Almotriptan (Axert tablets) is the only one FDA-indicated in adolescents. Triptans are generally more effective than analgesics. Contraindicated in complicated migraine and in those with cardiovascular risk factors. Potential side effects include flushing, chest tightness, paresthesias, nausea, and somnolence. More effective when taken early. May be combined with NSAIDs (ibuprofen, naproxen).
8. MigraTen. (Generic available.) Acetaminophen, isometheptene, caffeine. Similar to Midrin, but non-sedating.

It is always reasonable to try biofeedback together with simple abortive medications as the first step and attempt to avoid daily preventive medication, if possible. However, with frequent migraines, or for moderate to severe daily headaches, daily preventive medication may be necessary. In order to minimize medications, start at a low dose of a daily preventive and slowly titrate up to reasonable efficacy. Table 2 has a more complete list of criteria for the use of preventive medication. Table 3 lists first line preventive medications.

Table 2. Criteria for the Use of Prevention Medication
1. The headaches interfere significantly with the child’s functioning socially or at school. The extent of how much the headaches bother the child is a major consideration.
2. Failure of non-pharmacological approaches (watching triggers, biofeedback, etc.).
3. The child’s and parent’s willingness to utilize daily medication with possible side effects.
4. Willingness of the child and parents to change medication, if necessary.
5. Failure of abortive medication to effectively treat the headaches; continued frequency of headaches, daily or near-daily.

Table 3. First Line Preventive Medications for Migraine, Tension-Type, and Chronic Daily Headaches in Children and Adolescents
Under 12 years of age:
1. Cyproheptadine. Safe, but efficacy is questionable. It is usually well-tolerated but fatigue and weight gain may be a problem. Not as useful in children over the age of 11. It may be dosed once a day and is available in liquid form.
2. NSAIDs. (Ibuprofen, naproxen.) Ibuprofen and naproxen may be utilized as daily preventives or as abortive for both tension and migraine headaches. The lack of sedation renders these very helpful for daily use. GI side effects are relatively common, and when these are used on a long-term basis, regular blood tests for hepatic enzymes and renal function need to be done.
3. Petadolex. (Age 9+.) A form of the herb butterbur. Good evidence for efficacy in migraine. Widely used in Europe; available for over 35 years and regarded as safe. One tablet (50mg) daily; may increase to two. Occasional mild GI upset. May be ordered through www.petadolex.com, 1-888-301-1084.
4. Magnesium oxide. Available OTC as “Kid Calm.” Mild, but effective for some. Safe in this age range. Usual dose is 100–200mg a day.
Over 12 years of age:
5. Petadolex. See above.
6. Topiramate. Useful for both migraine and CDH, lower doses (e.g., 25-50mg qHS) are often effective; may be pushed to 100-150mg daily. Potential side effects include cognitive slowing, paresthesias, decreased appetite/weight loss, and rarely acute glaucoma, renal stones, and acidosis. Cognitive side effects often limit use.
7. Divalproex. Useful for both migraine and chronic daily headache (CDH), lower doses (e.g., 250mg) are usually used with some efficacy. May be pushed to 750-1000mg daily. Potential side effects include GI upset, sedation, weight gain, tremor, dizziness, and alopecia. Blood tests should be performed periodically for hepatic enzymes.
8. Gabapentin. Useful for both migraine and CDH, lower doses (e.g., 100-300mg BID to TID) are often effective. Potential side effects include dizziness and weight gain, although it is usually very well tolerated by most people, especially at the lower doses recommended.
9. Tricyclic Antidepressants. Effective for migraine and CDH. Nortriptyline and amitriptyline are commonly used. Usually well tolerated in low doses and safe for long term use. Cognitive side effects, dry mouth, drowsiness, dizziness, and weight gain are common. Usual dose of amitriptyline is 10-50mg daily. Protriptyline does not cause weight gain, but is somewhat less effective. Blood tests should be performed periodically for hepatic enzymes and renal function.
10. Propranolol. Generally well tolerated. Fatigue and decreased exercise tolerance may be a problem. Usual dose is 20-80mg daily. With doses less than 60mg qd, BID dosing is required which is inconvenient for children.
11. Verapamil. A calcium channel blocker that is effective for migraine and occasionally CDH. Generally well tolerated, with constipation common. Convenient once per day dosing with the sustained release formulations. Usual dose ranges from 80mg once a day up to 240mg ER q day.

Realistic goals and expectations for medications need to be discussed. For abortive medications, the goal is to achieve significant relief (>70%) as quickly as possible. When preventive medications are used, the goal is to reduce headache frequency and severity by 30% or more and to improve functioning. Patients may note that the efficacy of their abortive medications improves with the use of a daily preventive.

When preventive medications are used in children and adolescents, it is prudent to periodically attempt to discontinue the daily preventive in an effort to minimize medications. As with adults, the idea is to see if the patient may return to simply using abortive medication. However, if an adolescent has had headaches for a number of years and has found a preventive that works, the usual practice is to continue it long-term.


Many children and adolescents have episodic migraines that respond easily to abortive medications. The challenge is in dealing with those who have frequent and debilitating headaches. A multidisciplinary approach is the most helpful for patients with severe headaches: a balance of medication with therapy and lifestyle changes. Management of headache disorders is a trial and error process; there is no “cookie cutter” approach. Although decreasing the frequency and severity of headaches is important, success is ultimately measured by how much we help the child return to normal functioning in home, school and social life.

Last updated on: August 7, 2014
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