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11 Articles in Volume 15, Issue #4
Biofeedback: Information for Pain Management
False-Positive Screen for Marijuana
Hypnosis: Tool for Pain Management
Managing Headaches in Children and Adolescents
National Pain Strategy—A Positive Step Forward
Neuropathy in HIV Patients: Pain Management Concerns
Novel Treatment Device for Phantom-Limb Pain
Pain in Children
Pain Studies Program Emphasizes Pain Education as a Public Health Imperative
Targeting a Saboteur of Surgical Outcomes: Pain Catastrophizing
The History of Prolotherapy

Managing Headaches in Children and Adolescents

A balance of medication, therapy, and lifestyle changes is the most helpful for children with severe headaches to return them 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 occurs slightly more often among boys until the age of seven. By menarche, the prevalence of migraine in boys and girls is roughly equal. However, after menarche, migraine begins to predominate in girls, 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% to 80% of children with migraine headaches will experience disruption of their normal daily activities at home, in school, and in social settings. The burden of migraine also may result in the development or worsening of anxiety or depression. Because of quality of life (QoL) issues, early recognition and management of headaches in children and adolescents is crucial.

Headache disorders can be categorized as either primary or secondary. As in 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, although 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; as well as miscellaneous other causes: 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 often is enough to identify or rule out the most serious etiologies. The overwhelming majority of headache disorders are diagnosed via a thorough history and physical examination. A complete medical and psychiatric history, family history, medication history (including prescription, over-the-counter, and vitamins/herbals), allergy history, and social history also should be obtained.

Migraine tends to be underdiagnosed; 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—often are the key to an accurate diagnosis of migraine.

Potential indicators of organic pathology can include severe vomiting, a headache that awakens a child from sleep, and the absence of a family history of migraine. Progressive, unremitting daily pain, neurologic symptoms, and fevers also 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 who is suspected to have a primary headache disorder, laboratory investigation usually is not warranted beyond baseline labs. These usually include, but are not limited to, a complete blood count and metabolic panel.

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

MRI is the preferred test of the brain. It usually does not need to be done with contrast. MRI is important for those with new-onset headaches, atypical head pain, or abnormal neurological symptoms or signs.

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 EEG results usually are normal.

Lumbar puncture (LP) is indicated if meningitis, encephalitis, subarachnoid hemorrhage, or high-low pressure syndromes are suspected. Cerebrospinal fluid and pressure measurement also should be performed. In patients in whom 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 LP. We attempt to avoid the LP unless it is absolutely indicated. However, if meningitis or encephalitis is suspected in a toxic-appearing patient, treatment should not be delayed for the CT scan.

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 QoL. The combination of both pharmacologic and nonpharmacologic treatments is ideal for those with frequent headaches. Nonpharmacologic treatments are particularly important because they typically are more effective in children and help to minimize the use of medications and their related side effects.

Nonpharmacologic Treatments

Nonpharmacologic 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 physiologic disorder is of primary importance. It helps to say that“…migraines are a genetic medical condition, just as asthma or diabetes are…”

Children and their parents usually want to hear 3 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 usually is helpful to introduce the use of a headache diary as a means to identify specific triggers. Of course, some triggers (eg, 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 and 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 also can 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 3 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. Children and adolescents who miss substantial school time or social activities need to be assessed for depression, school phobia, and secondary gains. Counseling for children and family-centered therapy for children and their parents often are helpful in promoting active coping and are an indispensable augmentation of 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 years cannot learn and apply biofeedback, but some as young as 7 years of age can learn simple breathing and imaging techniques.

Pharmacologic Treatment

There are 2 types of pharmacologic treatment for headaches: abortive and preventive. Decisions about 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 extensive school time.

As with adult headaches, headaches in children can be treated with abortive medication 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. Table 1 contains a list of first-line abortive medications.

It always is 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. To minimize medications, start at a low dose of a daily preventive agent and slowly titrate up to reasonable efficacy. Table 2 contains a more complete list of criteria for the use of preventive medication. Table 3 lists first-line preventive medications.

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 to minimize medications. In choosing a preventive, comorbidities (anxiety, depression, GI problems, etc) determine which medication we select. As with adults, the idea is to see if the patient can return to using abortive medication only. 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.

Conclusion

Many children and adolescents have episodic migraines that respond easily to abortive medications. The challenge is 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 also is measured by how much we help the child return to normal functioning in home, school, and social life.

Last updated on: May 8, 2015
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Pain in Children

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