Headache in the Pediatric Patient


1. Abnormal neurological examination

2. Recent headache of less than 6 months with a progressive course

3. Atypical presentation of headache

 Intractable vomiting, headache wakening the child from sleep, vertigo, mental status changes, confusion, or other focal neurological complaints

4. Any child less than 6 years of age

5. Absence of family history of a primary headache disorder

6. New type of headache in a patient with history of recurrent headaches

7. First or worst headache

8. Systemic symptoms and signs

9. Occipital headache



When neuroimaging is warranted, an MRI is more sensitive in evaluating for a posterior fossa lesion, neoplastic disorders, vascular disorders, ischemia, and infection. A CT is highly sensitive in acute hemorrhage and is often ordered in the emergency room setting.

Historically, electroencephalograms were ordered in the diagnostic evaluation in children presenting with headache. An EEG is not recommended in the routine evaluation of a child with recurrent headaches because it is unlikely to improve the diagnostic yield in primary headache. In young children, however, atypical symptoms may be prominent, especially in children with periodic symptoms or migraine variants including the periodic syndromes of childhood. These syndromes, which are often precursors to migraine, can occur without an apparent headache and may make the clinician suspicious for an underlying seizure disorder. In such cases, the EEG is not warranted for the diagnosis of migraine, but to evaluate for a seizure disorder.

A lumbar puncture is also not routinely necessary when evaluating a child with headaches. However, clinical presentations such as those in which infection is present, there is a suspected increase in intracranial pressure such as in the presence of papilledema or there is a suspicion of a subarachnoid hemorrhage, all warrant a lumbar puncture.

Clinical laboratory testing is often not necessary in the evaluation of a primary headache disorder, unless a secondary cause is suspected such as an underlying anemia. It should be done prior to initiating some preventative headache therapies, as well as to monitor their toxicity and the patient’s compliance with such medications during treatment.



14.4 Treatment: Abortive Therapy


Management of migraine headaches requires a tailored regimen of pharmacological and behavioral measures that consider both the child’s headache burden and their level of disability. As published by the AAN practice parameter, abortive therapy should work fast and consistently and without headache recurrence and the need to use rescue medications, restore an individual’s ability to function, and care for themselves without the need to utilize other resources be cost-effective and have minimal side effects. Acute treatment should also effectively stop all features of migraine, including the associated symptoms. Furthermore, acute medication should be properly dosed based on the child’s weight. Children should be educated on the importance of treating early, even while in school, and ways to avoid the potential for medication overuse.


14.5 Treatment: Prophylaxis


Preventative medications should be limited to those children whose headaches occur with sufficient frequency or severity to warrant daily treatment. The goal of therapy should be directed at reducing headache frequency, reducing the progression to chronic daily headache, and decreasing associated pain and disability. Most clinicians require a minimum of 1 headache per week or three to four headaches per month to justify placing a child on a daily medication. Prophylaxis should also be considered if acute treatments are ineffective, not tolerated, contraindicated, or overused. Patients who report intensive and prolonged headaches (lasting > 48 h) should also be considered.

Children meriting prevention should be provided with appropriate education, thus enabling them to manage their disease and enhance personal control of their headaches. Clinicians should thoroughly discuss this long-term treatment plan so that families understand that the effort will be a long-term one and response will not be rapid, as the onset of improvement is often delayed in the pediatric patient. A typical goal of one to two headaches per month or fewer is recommended for a sustained period of 4–6 months. The doses of preventative agents must be titrated slowly to minimize side effects. Once an effective dose is reached, relief must be sustained for 2–3 months before considering an alternative medication. Once sustained relief is obtained, a plan to wean the child off the medication is also necessary. Both the clinician and family must establish a sense of functional disability before committing the child to a course of daily medication as therapy should also aim at the improvement of an overall quality of life.

Several classes of medications may be used for prophylaxis and include antidepressants, antiepileptics, antihistamines, and antihypertensives. The majority of these medications have been extensively prescribed for other conditions, including depression and other mood disorders, epilepsy, and other pain disorders, thus making their side effect profiles well described. When selecting an agent, one should take into account any comorbid conditions that may be present. Clear instructions should be given to families regarding the medication’s mechanism of action, possible side effects, and the importance of not missing doses. Clear titration instructions should be provided. It is important to remind families that it may take time, often several weeks, for the preventative to become effective. Slow titration over a period of 4–12 weeks may be necessary to assure that the child tolerates the medication with minimal side effects. If a trend of improvement is seen, the dose is then adjusted for optimal control. Treatment should not be abandoned until it has been given an adequate trial of at least 6–8 weeks on the full dose unless there are intolerable side effects. When improvement is sustained and a satisfying response is achieved over a period of 4–6 months, then the child may be slowly weaned off of the medication.


14.6 Behavioral Measures


Lifestyle modifications are often discussed with patients, including maintenance of good sleep hygiene, defined as regular bedtimes and waking times with sufficient sleep time. Maintenance of a regular diet also appears to be important. Regarding dietary restrictions, the American Headache Society only limits caffeine intake and does not restrict any type of food unless a very specific food trigger is identified. A balanced diet is beneficial and patients should be encouraged to avoid skipping meals. Patients are also often counseled on the importance of keeping well hydrated as dehydration is commonly identified as a headache trigger.


14.7 Summary of the Case


In summary, this is a 15-year-old girl with a history of depression and a long-standing history of headaches which have been increasing in frequency over the last 4 months. The headaches are intermittent but frequent, frontal and bitemporal in location, and associated with nausea and occasional vomiting, photophobia, and phonophobia. They are throbbing and moderate to severe in intensity. The headaches last from 4 to 48 h and are so disabling that she was forced to quit soccer. Her PedMIDAS score is 62, indicating severe disability. She has a family history significant for primary headache disorders, including migraines and tension-type headaches. Her general physical, neurological, and headache examinations are normal. She has had an MRI which was also normal. With no red flags reported in the history, a family history of primary headache disorders, and a normal examination, an MRI was likely unnecessary. Her headaches meet the ICHD-III criteria for migraine without aura and chronic migraine. She was instructed to treat her headaches early with an NSAID, namely, ibuprofen 600 mg (10 mg/kg), at the onset of her headache with a sufficient amount of fluid, such as 32 oz of water or a sports drink. This could be repeated after 4 h of the headache had not resolved. To prevent overuse of her abortive therapy, she was instructed not to take the ibuprofen more than 2–3 days per week. Due to the frequency and disability of her headaches, preventative medications are warranted. Because of her history of comorbid depression and current treatment with an antidepressant, medications that fall within the class of tricyclic antidepressants (e.g., amitriptyline) should be avoided. The decision was made to treat her with topiramate, slowly increasing to a dose of 50 mg twice daily over a 4–6-week period. Multiple lifestyle modifications were prescribed including increasing her fluid intake to eight to ten glasses of fluid per day and abstaining from caffeine. She was encouraged to exercise and become active once again. The importance of eating three meals daily was discussed, in addition to a regular sleep schedule, striving for 8–9 h of sleep per night.
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Jul 4, 2016 | Posted by in HEAD AND NECK SURGERY | Comments Off on Headache in the Pediatric Patient

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