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Headache in Children

Tim Horeczko MD MSCR, Matthew DeLaney, MD, FACEP, FAAEM, and Matthieu DeClerck, MD
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Pediatric headaches are common. Thankfully the bad etiologies are rare. Having a consistent approach to the history and physical exam is essential to helping the clinician distinguish between the common, benign etiologies and the bad, rarer etiologies. Looking for the redflags in your history and exam will help make appropriate decisions on further workup and treatment. 

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Jacob D., MD -

I recently saw a healthy, straight "A" 12 year boy for a well child check. He has been getting moderate to severe, sharp, bilateral temporal headaches for 2 years. Usually occur while at school and last a couple of hours. At times they're so bad they bring him to tears. Takes ibuprofen and caffeine with relief. No red flags as listed in your notes. He eats a healthy, well balanced diet, drinks plenty of water, and sleeps well for the most part. He reads a lot. Screen time <2 hours per day. Denies blurry vision, but hasn't had his eyes checked in 3 years. Office eye exam unremarkable. Physical/Neurological exam normal.
Mom has a history of migraines.
Parents are divorced, but has a good relationship with mom and 2 younger siblings.

How much is too much ibuprofen and caffeine per day/month?
How do you recommend tapering kids off of ibuprofen/caffeine?
When would you consider prophylactic meds in kids?
When would your recommend Triptans?
When would you refer to Peds Neurology?

Thanks,
Jake

Jacob D., MD -

I forgot to mention that they occur almost every other day.

Neda F., MD -

Hi Jacob! Thanks for your question. We can't give medical advice about specific patients, and your questions are so substantive that they should be their own segment. I did reach out to Dr. Sol Behar, the host of Pediatrics RAP, for any input he might have. He pulled this information from a piece his podcast did on migraines in kids. We hope this is helpful!

"Rizatriptan is FDA approved for children 6 and above. Sumatriptan is approved for patients 18 and older. A newer medication, Treximet is a combination sumatriptan and naproxen is approved for children 12 and older.

When is preventative medication indicated? If two headaches a week or more, start thinking about adding preventative medication.

What preventative medication is best? Interestingly, recently published data suggests that the most commonly used preventative medications, topiramate and amitriptyline, were as equivalent as placebo when used for pediatric migraine. This study, a large, multicenter, randomized trial is known as the pediatric CHAMP study.

The impressive finding in this study is that 60% of patients had a decreased incidence of migraine headaches regardless of which treatment was given, including placebo.

Topiramate, an anticonvulsant, and amitriptyline, an antidepressant are sometimes chosen if the patient has other comorbid conditions that may also be treated with these medications. Other preventative medications include cyproheptadine, propranolol, and several vitamins.

Vitamins used include, but are not limited to, magnesium, riboflavin, coenzyme Q-10. Given the results of the CHAMP study, starting with vitamins is a nice option as there are minimal side effects. The dose of these vitamins is higher than the doses in a multivitamin.

Again, the combination of medications is often trial and error and should be given 2-3 weeks to see results. A headache log can be a helpful way for patients to keep track.

Powers SW et al. Trial of Amitriptyline, Topiramate, and Placebo for Pediatric Migraine. N Engl J Med. 2017 Jan 12;376(2):115-124. PMID 27788026

What are some non-pharmacologic preventative treatments? These treatments or lifestyle modifications, are more important than pharmacological ones and it is important to stress that medications may fail if these lifestyle modifications are not performed.

Lifestyle modifications include: good sleep hygiene, hydration (64-100 ounces of water per day), regular meals, avoiding caffeine, limiting screen time and avoiding stress as much as possible.

When should neurology be consulted? A neurologist should be involved if there is a complicated component to the migraine, if there is a strange aura type symptom, if the child is less than 5 or 6 years old and/or if there are acephalgic migraines not associated with a syndrome. Additionally, if there are any concerning neurological signs or symptoms with the headaches, such as a progressive headache, worsening vision changes, papilledema and/or first line treatments and lifestyle modifications are not working than neurology should be involved. "

Margot M. -

Jacob - It sounds like you are asking some really good questions, thinking about rebound HA, as well as other potential causes, and it is good to know there are prevention meds available to kids if they need them. Something else I would think about are school stressors. Do these headaches happen during school breaks and vacations? Even straight-A students can have a variety of stressors at school, from being bullied to seeing others bullied, to the stress of trying to maintain those grades, to worrying about what other kids think (in person and on social media).

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Are We Better in the Morning? Full episode audio for MD edition 188:54 min - 88 MB - M4APrimary Care RAP September 2019 Written Summary 580 KB - PDF

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