Headache (Migraine & Chronic)

Description

Other Names

Primary headache
Transformed migraine, chronic daily headache
Persistent daily headache

Diagnosis Coding

ICD-10

R51, headache

G43, migraine

The code "G43" requires additional digits, found at ICD-10 for Migraine, to describe the type of migraine. The code "R51" includes other types of headache; coding details can be found at ICD-10 for Headache.

Description

Episodic migraine headaches and chronic daily headache can significantly impact a child’s activities and behavior. Unlike the more commonly experienced headaches that occur infrequently, are self-limiting, and have little impact on the child’s quality of life, chronic daily headache is a specific syndrome where headaches have been present 15 or more days a month for 3 or more months. [Hershey: 2006] Migraine or tension-type headaches may "transform" into chronic daily headache.

Strategies for reducing headache frequency and severity include lifestyle modifications (such as stress management), trigger identification and avoidance, and preventive medication use. Treatment strategies include appropriate pain control (while avoiding NSAID medication overuse or narcotic exposure), anti-nausea medications, a low-stimulation environment (no light, reading, or electronics), and promotion of sleep.

A definitive cause for primary headaches, other than an inherited predisposition, is often unknown. Families may worry that the headaches are due to serious disease or a brain tumor, but this rarely is the case. The social and academic burden for children who are missing school due to headaches is immense. Parents can also experience significant emotional burden and economic stress if they are missing work to care for their child.

Prevalence

Headache - teenage girl experiencing discomfort as she holds her head
IStock/Tirachard Kumtanom
Chronic daily headache are thought to occur in about 1% of children and adolescents. [Lipton: 2011] Prevalence for migraines by age groups tend to range from: 3 to 7 years old—1 to 3%; 7 to 11 years old—4 to 11%; and 11 to ≥15 years old—8 to 23%. [Lewis: 2002] In childhood, headaches affect girls and boys about equally; in adolescence, girls have more headaches than boys. [Abu-Arafeh: 2010] Migraine and tension headaches are responsible for 91% of chronic pain in children. [Zernikow: 2012]

Genetics

Genetic studies have clearly shown that primary headaches (migraine, tension-type headache, and cluster headache) are multifactorial disorders characterized by a complex interaction between different genes and environmental factors.

Prognosis

Migraine is a chronic condition with a waxing and waning course. Preventive tactics can decrease their frequency, although many individuals will have migraine episodes or clusters throughout their life. Appropriate treatment when headaches are infrequent may reduce the risk of progression to chronic daily headache. [Jensen: 2010] [Winner: 2008]

Roles Of The Medical Home

The International Headache Classification (ICHD-2) for pediatric migraine (sensitivity is 84.4%) can help the medical home provider to diagnose and manage children with migraine headaches without specialty referral. [Ozge: 2011] If the headaches are unresponsive to treatment, become more frequent or severe, or are associated with a concerning history or exam findings, collaboration with pediatric neurology may be helpful. This may involve a single consultation leading to recommendations and a comprehensive treatment plan. Occasionally, long-term neurology management and/or other subspecialty involvement may be indicated.

Practice Guidelines

Ozge A, Termine C, Antonaci F, Natriashvili S, Guidetti V, Wöber-Bingöl C.
Overview of diagnosis and management of paediatric headache. Part I: diagnosis.
J Headache Pain. 2011;12(1):13-23. PubMed abstract / Full Text

Termine C, Ozge A, Antonaci F, Natriashvili S, Guidetti V, Wöber-Bingöl C.
Overview of diagnosis and management of paediatric headache. Part II: therapeutic management.
J Headache Pain. 2011;12(1):25-34. PubMed abstract / Full Text

Headache Classification Committee of the International Headache Society (IHS).
The International Classification of Headache Disorders, 3rd edition (beta version).
Cephalalgia. 2013;33(9):629-808. PubMed abstract / Full Text

Lewis, DW, Ashwal, S, Dahl, G, Dorbad, D, Hirtz, D, Prensky, A, Jarjour, I.
Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.
Neurology. 2002;59(4):490-8. PubMed abstract / Full Text

Lewis D, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein S.
Practice parameter: Pharmacological treatment of migraine headache in children and adolescents.
Neurology. 2004;63:2215-2224. PubMed abstract / Full Text

Helpful Articles

PubMed search for primary headaches in children, last 1 year.

McCrea N, Howells R.
Fifteen minute consultation: headache in children under 5 years of age.
Arch Dis Child Educ Pract Ed. 2013;98(5):181-5. PubMed abstract

Winner P.
Pediatric headache.
Curr Opin Neurol. 2008;21(3):316-22. PubMed abstract

Petrusic I, Pavlovski V, Vucinic D, Jancic J.
Features of migraine aura in teenagers.
J Headache Pain. 2014;15:87. PubMed abstract / Full Text

Spiri D, Rinaldi VE, Titomanlio L.
Pediatric migraine and episodic syndromes that may be associated with migraine.
Ital J Pediatr. 2014;40:92. PubMed abstract / Full Text

Rousseau-Salvador C, Amouroux R, Annequin D, Salvador A, Tourniaire B, Rusinek S.
Anxiety, depression and school absenteeism in youth with chronic or episodic headache.
Pain Res Manag. 2014;19(5):235-40. PubMed abstract / Full Text

Clinical Assessment

Overview

Children and adolescents with headaches require a complete medical history and physical examination, including a complete neurologic exam and funduscopic exam.

Screening

For Complications

Consider screening children and adolescents with headache for anxiety, depression, school difficulties, and bullying. Screening tools and management info can be found in the Portal’s module on Depression.

Presentations

Features of migraines in children may include:
  • Frontal and bilateral localization in children; more likely unilateral in adolescents and adults
  • Preceding aura (~33% in children and adolescents)
  • Nausea and vomiting
  • Throbbing quality of pain
  • Sensitivity to light and/or sound; may be inferred from behavior
  • Improvement with sleep
Childhood periodic syndromes that may represent variants of migraine headaches include:
  • Cyclic vomiting
  • Abdominal migraine
  • Benign paroxysmal vertigo of childhood
  • Benign paroxysmal torticollis of infancy
  • Colic [Gelfand: 2012]
Chronic daily headache is defined as:
  • Headache present 15 or more days per month AND
  • Present for 3 or more months [Hershey: 2006]
Chronic daily headaches can be the first presentation of headache (e.g., new persistent daily headache, often triggered by an illness or infection). It may also evolve (“transform”) from initially less frequent migraine or tension headaches.

Diagnostic Criteria

Children often do not have the characteristics of migraine headaches found in adults, and diagnostic criteria are different and less strict for children than for adults. The following criteria are from the International Headache Classification (ICHD-2). [Headache: 2004]

Migraine without aura
A. At least 5 attacks fulfilling criteria B–D
B. Headache lasting between 1–72 hours (untreated or unsuccessfully treated)
C. Headache that has at least 2 of the following characteristics:
  • Unilateral location (though commonly bilateral in children)
  • Pulsating quality
  • Moderate or severe pain intensity
  • Aggravation by, or causing avoidance of, routine physical activity (e.g., walking or climbing stairs)
D. During headache, at least 1 of the following:
  • Nausea or vomiting
  • Photophobia and phonophobia
E. Not attributed to another disorder

Migraine with aura

A. In addition to the criteria for migraine without aura, at least 2 attacks fulfilling at least 3 of the following:
  • No motor symptoms
  • One or more fully reversible aura sensory symptom (indication of focal cortical or brainstem dysfunction). Examples are visual symptoms (e.g., scotoma with shimmering edges) or sensory symptoms (e.g., speech disturbance or numbness in the hand, around the mouth, and sometimes the tongue). Aura symptoms can be negative (loss of vision) or positive (shimmering lights). It is very important to differentiate sensory symptoms from motor symptoms, as the presence of weakness, not just motor dysfunction due to altered sensory symptoms, is an exclusion criterion for migraine with aura.
  • Aura developing gradually over 4 minutes, or 2 or more symptoms occurring in succession
  • Aura lasts no more than 1 hour
  • Pain follows aura after less than 1 hour
Hemiplegic migraine
This is a rare type of headache, now considered a subtype of migraine with aura, and is essentially a diagnosis of exclusion of other causes of focal weakness, particularly stroke. Hemiplegic migraine has been linked to 3 different gene mutations and occurs in familial and sporadic forms.

Differential Diagnosis

Although a considerable amount of literature describes the differences between migraine and tension headaches, many experts believe that migraines, tension headaches, and chronic daily headache represent a continuous spectrum of pain caused by similar mechanisms.

Hemiplegic migraine: Headaches with aura and numbness or paresthesias may be difficult to separate from hemiplegic migraine, which involves a limb, or limbs, that are numb and/or do not work well. A child with numbness may have difficulty walking. It is important to distinguish between the two.

New daily persistent headache: This is a type of chronic daily headache that starts suddenly and is often triggered by stress, illness, or surgery. Although the diagnosis is usually one of exclusion, the sudden onset is often worrisome to families and providers, so it is helpful for clinicians to know about this headache subtype. [Evans: 2012]

Medical Conditions Causing Headache (Migraine & Chronic)

Children with a long history of headaches, no chronic medical diagnoses (e.g., tuberous sclerosis or shunt-dependent hydrocephalus), no unusual historical findings (e.g., personality changes or seizures), and normal neurologic exams almost always have primary headaches without any underlying medical condition.

Tumor or subarachnoid hemorrhage: Children who have an acute progressive course of headaches, the “worst headache of their lives,” accompanying symptoms such as personality changes or seizures, or an abnormal neurologic exam may have underlying etiologies, such as tumor or subarachnoid hemorrhage.

Pseudotumor cerebri syndrome (previously called idiopathic intracranial hypertension) can be primary or secondary. [Friedman: 2013] In this condition, elevated cerebrospinal fluid pressure causes headaches and, if not treated, can lead to visual loss. This cause of headache is more common in obese adolescent girls, particularly if they are on hormonal therapy or certain acne treatments (e.g., minocycline, retinoic acid). Diagnostic criteria depend upon funduscopic evaluation, cranial nerve findings, neuroimaging studies, and /or performance of lumbar puncture for measurement of opening pressure.

Chronic dehydration is likely contribute to headache perpetuation.

Obesity and hypertension are associated with increased headache frequency and disability. [Hershey: 2009]

Comorbid Conditions

Anxiety and depression are associated with recurrent headaches. [Blaauw: 2015]

Motion sickness, including car sickness, is more common in individuals with migraine than in the general population. [Murdin: 2015]

Pearls & Alerts

Signs and symptoms that may signal intracranial pathology

Headaches that are worse in the morning; improve gradually with activity; aggravated by coughing, sneezing, or straining; associated with nocturnal emesis or a focal neurologic exam; occipitally prominent; or frequent, severe, or progressing may indicate pathology.

History & Examination

Family History

A family history of migraine-like headaches, particularly in female relatives, is common.

Current & Past Medical History

Identify clinical features, such as nocturnal or early morning headaches, that can suggest an underlying condition causing headache. Ask about general trajectory of the headaches. Headaches that come and go with a full return to baseline are generally primary and do not require further testing. Headaches that are acutely worsening over a short period without full return to baseline require further consideration.

Determine precipitating events and/or triggers, duration, frequency, character of headaches, and if there is use of oral contraceptive pills or antibiotics (e.g., for acne).

Developmental & Educational Progress

Ask if headaches are causing frequent school absences. Referral to behavioral medicine may be necessary.

Social & Family Functioning

Ask about family and social stressors that may be contributing to the cycle of headaches and missed school days. Though some families keep their child home from school because of headaches, this can be isolating and return to school should be encouraged.

Physical Exam

General

Other than demonstrating pain or distress if a headache is present, the child should appear normal.

Vital Signs

High BP may cause headache in children. Children that are dizzy with headaches should have orthostatic vital signs checked.

Growth Parameters

Check for overweight and obesity, which are associated with headaches.

HEENT

A thorough funduscopic exam is necessary to rule out increased intracranial pressure. Pain over the sinuses may be present in sinusitis. Rarely, refractive errors (astigmatism or far-sightedness) may be contributing to headaches and, if suspected, the child should be referred to optometry or ophthalmology. [Gil-Gouveia: 2002]

Neurologic Exam

The exam should be normal. An abnormal funduscopic examination or sixth nerve palsy suggests possible pseudotumor cerebri syndrome.

Testing

Laboratory Testing

Labs for thyroid function, CBC with differential, a complete metabolic profile, erythrocyte sedimentation rate, iron studies, Vitamin D, and coenzyme Q10 may be ordered in children whose headaches occur daily or almost daily. No research-based evidence suggests a standard lab panel for patients with classic migraine symptoms.

Imaging

Magnetic resonance imaging (MRI) should be performed if the child has an abnormal neurological exam. In addition, a child with headaches for fewer than 6 months with an increasing trajectory of severity, no family history of migraine, and that wake them from sleep (this can also occur with migraine), may lead to a decision to perform imaging. Otherwise, no imaging is indicated. Often driven by family or provider concern, rather than clinical indications, imaging is increasingly being performed for headache and enforcement of guidelines may become stricter. [Streibert: 2011] [Rho: 2011] If brain imaging is to be performed, MRI is the preferred modality. [Bigal: 2011]

Other Testing

Although it is not a standard test in the evaluation of migraine, many clinicians will perform an echocardiogram looking for a patent foramen ovale (PFO). Children with migraine headache with aura have been shown to have a higher frequency of PFO than children with migraine without aura. [McCandless: 2011] At this time, the significance of this finding is not yet known, and migraine is not an indication for PFO closure.

Subspecialist Collaborations & Other Resources

Pediatric Neurology (see Services below for relevant providers)

Referral may be helpful for confirmation of diagnosis, headaches that are refractory to treatment, or chronic daily headache.

Pediatric Ophthalmology (see Services below for relevant providers)

Referral is important if pseudotumor cerebri syndrome is suspected. Refractive errors rarely cause headaches, but may be a contributing factor.

Treatment & Management

Pearls & Alerts

Avoid aspirin in younger children

Daily aspirin can be used as a preventive treatment in adolescents 15 years of age or older, especially in combination with other medications; due to concerns of Reye syndrome, aspirin use in younger children should be avoided.

Treatment for children with concussions

Headaches may recur for weeks to months after a head injury. Treatment consists of many of the same medications and techniques used in children with recurrent headaches, including rest, stress reduction, and preventive medications. Headaches Following Traumatic Brain Injury provides more details.

Chiari I malformations and arachnoid cysts are rarely a cause of headache

Chiari I malformations and arachnoid cysts are seen incidentally in many individuals without headache that are imaged for other reasons. In mild to moderate forms, traditional headache management should often be tried before an individual is referred to neurosurgery.

Narcotics should be avoided in all cases

The use of narcotics for chronic pain may lead to dependence and headaches that are resistant to other treatments.

Systems

Neurology

Chronic daily headaches are thought to result from physiological changes occurring in response to environmental stresses, a propensity to headaches, and sometimes a physiologic trigger such as an illness. Known risk factors are obesity, sleep disorders, anxiety, depression, female gender, and age. [Lipton: 2011] Frequent pain with the appropriate stressors initiates a feedback loop leading to sensitization of central nervous system pain pathways. [Mathew: 2011] Although this loop is understood on a physiologic basis, this cycle is very difficult to interrupt and management will usually require multiple modalities. It is important to assure families that no underlying serious condition is causing their child's headache and to explain that pain relief will not be immediate. Realistic expectations for pain relief and understanding the importance of lifestyle changes for the child/adolescent and family are critical for success.

Subspecialist Collaborations & Other Resources

Pediatric Neurology (see Services below for relevant providers)

Although infrequent migraines are usually best treated within the medical home, referral may be helpful for those with chronic headaches, for patients with atypical features, and for families who are very concerned about a larger health issue causing headaches.

Mental Health/Behavior

Children with chronic daily headache often have frequent school absences, mood disorders, and sleep problems that contribute to their headaches. By the time headaches have become chronic, treatment involves chipping away at various things that may be contributing. Management of migraines and chronic daily headache will include identifying triggers, avoiding triggers, and medical management. Stress is the most common trigger. [Neut: 2012]

Managing stress includes
:
  • Mitigation of environmental factors, such as artificial light or loud noises
  • Relaxation training, behavior modification, hypnosis, meditation, biofeedback, acupuncture, and similar interventions: An audio or visual stress relaxation guide for the child and parent may be helpful, although consistent use is a challenge. Yoga classes in community centers are fairly inexpensive and sometimes geared toward children.
  • Regular exercise e.g., walking 45 minutes 5–7 times/week
  • Adequate sleep, especially for adolescents who often start school before 8 a.m.
  • Assessment of activities: If extra-curricular activities are becoming too stressful, causing fatigue, or preventing lifestyle modifications that can prevent headache, families might want to rethink participation.
Many children and adolescents are particularly sensitive to not only stress, but also certain foods or additives.

Common food triggers are
:
Strong cheeses Foods with MSG (monosodium glutamate)
Nuts High carbohydrate meals
Sugar Chocolate
Pizza Shellfish
Processed meats (bacon, hot dogs, pepperoni) Caffeine and alcohol

Preventing headaches also includes:
  • Adequate hydration: It might be helpful for individuals with headache to follow a regimen such as a glass of water an hour while awake. Children and adolescents can assess their hydration status by looking at the color of their urine. Adequate hydration is suggested by clear or light-yellow urine.
  • Constant blood sugar levels: Eat small, frequent meals that have a low glycemic index - to avoid quickly rising and falling blood sugar during the day. Avoid skipping meals.
  • Weight reduction: In individuals who are obese, losing weight leads to a decreased headache frequency. [Hershey: 2009] [Robinshaw: 1996]
  • Keep headache journals with possible triggers noted: The cornerstone of migraine treatment is understanding the pattern of migraines and the triggers that may be causing them.
Examples of headache journals:

Subspecialist Collaborations & Other Resources

Developmental - Behavioral Pediatrics (see Services below for relevant providers)

Referral for frequent, recurrent headaches is often necessary to break the cycle and to initiate beneficial lifestyle changes. Treatment of comorbid psychiatric issues may also prompt referral.

Physical Therapy (see Services below for relevant providers)

Referral for ongoing home exercise program may be helpful for some children with chronic daily headaches, especially those with prolonged decreased activity due to headache.

Psychologist, Child-18 (see Services below for relevant providers)

Counseling may be helpful to address the consequences of, or factors contributing to, headaches. Depending on expertise, this professional might help organize non-medical management. Psychologists who specialize in imagery and biofeedback techniques are an excellent resource.

Pharmacy & Medications

Pharmaceutical treatment focuses on either prophylactic or acute management of headaches.

PROPHYLACTIC MANAGEMENT
Preventive medications are taken daily in an attempt to decrease the frequency and intensity of future headaches. They should be considered when headaches are occurring more than 3 days per month. [Winner: 2008] Efficacy and side effects of preventive medications are difficult to predict; therefore, medication should be prescribed with timely feedback and anticipation of trial and error. Their use in children is off-label—check all dosing and safety information before prescribing. The best medication for the age and weight of the child with the least amount of potential side effects is initiated at a low dose, which is then increased slowly at 1- or 2-week intervals. ("Start low and go slow.") A common approach is to start with cyproheptadine in children up to 10 years of age, topiramate in adolescents or in children over 10 who are overweight, and amitriptyline in adolescents with normal weight, low weight, or comorbid depression.

An adequate trial of a single preventive medication takes 6 to 8 weeks. If the medication is not successful, it can be tapered quickly (to 1/2 of the current dose for 3 days), stopped, and another one started. The goal of preventive medications is to decrease the headaches to a manageable frequency (< 2 a month). This goal should be discussed before initiating treatment. After this frequency has been achieved, continue the medication for 3-6 months before considering weaning. Some experts suggest treating for an entire school year to re-establish a pattern and expectation for attendance and performance. Wean by reducing the dose by about 1/4 at weekly intervals. If headaches return, increase to the effective dose for longer than the initial treatment before weaning again. Behavioral therapies and lifestyle changes should be continued indefinitely.

Prophylactic medications
Cyproheptadine (Periactin) is an antihistamine that is thought to prevent migraine through its antiserotonergic properties. It is often the first choice for migraines in children up to about 10 years of age.
  • It is generally started at 1-2 mg before bedtime (HS), and then increased to 2-4 mg HS after 1 week, max of 8 mg nightly. The 2 mg dose is used for younger children, and the 4 mg is used for older children. It is available in 4-mg tablets and as a syrup (2mg = 5ml).
  • Cyproheptadine may increase appetite and be useful in a picky eater who is underweight. It should be used cautiously in an overweight child. Drowsiness or weight gain may be limiting factors.
Topiramate (Topamax) is an anti-seizure medication that is FDA-approved for the prevention of headaches in adults and children 12 years or older (although it is often used off-label for children 10 years and older). [Lipton: 2011]
  • Start slowly, with a 15-mg capsule or half of a 25-mg tablet HS for one week, and then increase to 25 mg or 30 mg HS. Increase dosage only after sufficient time to gauge efficacy - usually 6 weeks.
  • Though effective for many patients, some sense a decreased ability to multi-task, word-finding difficulty, or memory impairment when taking topiramate.
  • It is an appetite suppressant and can cause weight loss, which may be a beneficial side effect in overweight adolescents. Patients should stay well hydrated to avoid the theoretical possibility of kidney stones.
Amitriptyline: Many clinicians obtain an EKG before starting to rule out prolonged QT syndrome; an EKG should always be obtained with 50-mg or 75-mg doses. Patients and families should be warned about orthostatic hypotension and its low therapeutic ratio: A fairly small overdose can be lethal.
  • Start at 12.5 mg or 25 mg and gradually increase the dose until effective (or to a maximum of 50 mg in children or 75 mg in adolescents).
  • Amitriptyline may cause weight gain, but it is less likely to do so than valproic acid. It is given at bedtime and causes drowsiness, which may be a helpful side effect in those with sleep dysregulation. [Couch: 2011] [Isik: 2007]
Valproic acid is an anticonvulsant used to treat seizures and mood disorders or to prevent migraines in children 7 years or older.
  • It is not only used in its oral form as a preventive agent, but also in the IV form as an acute rescue option.
  • Generally, dosing is initiated at 15 mg/kg/day in 2 divided doses (maximum 250 mg/dose) and increased gradually up to a maximum dose of 1,000 mg a day.
  • A long-acting form (Depakote ER) is available for children 12 years or older.
  • Major risks of valproic acid include hepatotoxicity and pancreatitis.
  • Valproic acid is linked to a higher incidence of birth defects and should be used with caution in adolescent females. It causes weight gain and should be avoided in overweight children.
Propranolol is a nonselective beta blocker (class II anti-arrhythmic) that decreases heart rate and blood pressure. This is typically reserved for older adolescents who have not had benefit from trials of other headache prevention agent. It should be used with caution in patients with comorbid asthma or depression.
  • Start at 40 mg twice a day and gradually increase weekly up to maximum of 240 mg once a day, as tolerated.
  • Common side effects include hypotension, dizziness, fatigue, and exercise intolerance.
Gabapentin (Neurontin) is an anti-seizure medication that is also used to treat neuropathic pain. The benefit of gabapentin in childhood migraine is not well established.
  • It is often started at 5 mg/kg once a day, and then gradually increased to 2, then 3, times per day. It is available in various capsule or tablet forms and as a 250 mg/5ml oral solution.
  • Side effects include peripheral edema, rash, dizziness, nausea, constipation, and sedation.
Botulinum toxin (Botox) injections have a 31-injection protocol that has been approved for individuals down to 18 years of age for chronic daily headache; it is the only treatment approved for chronic daily headache. While not FDA-approved for use in children, one study showed a statistical improvement in headache frequency in children. [Kabbouche: 2012] Insurance companies are often reluctant to approve this expensive treatment, and they often require a trial of multiple classes of other preventive medications first.
  • Onset and duration of benefit varies widely with repeat injections generally required every 3 to 4 months.
  • Side effects may include headache exacerbation, pain at injection site, and facial paresis.
A pediatric neurologist may prescribe levetiracetam, zonisamide, verapamil, or aspirin when the medications listed above have not been successful.


ACUTE MANAGEMENT
Acute medications target pain or attempt to abort onset of pending headache, and they should be used as close to the start of the headache as possible. Families should know that using these medications more than 2 to 3 times a week might cause medication rebound headaches that can be difficult to differentiate from chronic daily headache. Evidence for the pharmacological treatment of acute migraine in children is poor; evidence for adolescents is better, but still limited.

Acute (rescue) medications
Non-steroidal anti-inflammatory drugs (e.g., aspirin, ibuprofen, and naproxen sodium): Except for acetaminophen, each of these is best taken with food, which may be difficult for adolescents who skip meals or feel nauseous. Naproxen sodium (Aleve) liquid or caplets may work faster than other preparations.

Triptans (serotonin receptor agonists) are often very effective, but expensive and may not be covered by insurance. [Eiland: 2010] Options include sumatriptan (Imitrex) 6-mg intramuscularly (IM), 20 mg by nasal spray, or 25- to 50-mg orally; almotriptan (Axert) 6.25 mg or 12.5 mg orally; rizatriptan (Maxalt) 5-10 mg orally; and others.

New preparations that contain naproxen and sumatriptan may be especially helpful; Treximet is the first medication with this combination approved for the acute treatment of migraine with or without aura in pediatric patients 12 years of age and older.

Caffeine, taken along with any of the above, is sometimes helpful. Possible ways to get caffeine include Excedrin, soda, or even espresso shots.

Antiemetics may also be needed. Options include promethazine 25-50 mg (1mg/kg) by mouth, as a suppository, or intramuscularly; metoclopramide 5-10 mg by mouth, as a suppository, or intravenously (IV); prochlorperazine 2.5-5 mg by mouth; and ondansetron 4 mg under the tongue. Promethazine, metoclopramide, and prochlorperazine may also have some direct effects on migraine. Pretreatment with diphenhydramine or hydroxyzine 15 minutes or so before the antiemetic can prevent dystonic reactions sometimes associated with these medications. Ibuprofen, along with an antiemetic that also helps the child sleep, is an effective and safe option for children younger than 12 years of age.

Occasionally, children and adolescents with debilitating daily headaches that have not responded to other therapies are treated in the emergency department or admitted to the hospital to "break" the headache with IV dihydroergotamine (requires insurance preauthorization to assure payment). The admission is usually done during the week using a standard protocol. Patients may also be evaluated by physical therapy, nutrition, behavioral health, and other subspecialists to ensure a comprehensive approach. Families should be aware that this protocol is not an instant fix, and ongoing management will be needed. A child neurologist should evaluate patients before being referred for this therapy.

Subspecialist Collaborations & Other Resources

Pediatric Neurology (see Services below for relevant providers)

May be helpful for children who do not respond to medication and behavioral therapy.

Pain Clinics (see Services below for relevant providers)

Alternative therapies may be accessed at some pain clinics depending on their expertise.

Learning/Education/Schools

All children with migraine or chronic daily headache should have a written headache management plan to inform and guide care in case they get a headache at school or experience a headache that leads to an emergency department visit.

Because medications are more likely to control pain if taken at the beginning of a headache, affected children and adolescents should have medication available at school. The medical home provider often will need to fill out a school form to allow the administration of medication in the school setting. Transitioning a child to online or home schooling because of headache can be isolating. Maintenance of a regular school/work/play routine is encouraged for promotion of health and to avoid long-term social, academic, and work-related consequences.

Complementary & Alternative Medicine

Some individuals are helped by dietary supplements such as a vitamin B complex, acidophilus (as prescribed on the bottle), magnesium oxide 400 mg - 500 mg daily (the main side effect is diarrhea), coenzyme Q 100 mg - 200 mg 2 to 325132513 times daily, Petasites (butterbur), and others. [Hershey: 2007] For more information, see [Schiapparelli: 2010]. A Cochrane trial found that acupuncture is more successful than placebo in the prevention of migraine headaches. [Linde: 2009] Tinted glasses may also be helpful, especially in those individuals with light sensitivity. See FL-41 Tinted Lenses (Moran Center, UUMC) for more information.

Subspecialist Collaborations & Other Resources

Pediatric Integrative Medicine (see Services below for relevant providers)

May be helpful to direct components of management including traditional and complementary modalities in a safe and evidence-based manner.

Pain Clinics (see Services below for relevant providers)

Most neurologists are not expert in these therapies; consultation with a specialist in integrative medicine, or a pain clinic familiar with these techniques, may be helpful.

Frequently Asked Questions

When is brain imaging indicated?

Brain imaging, generally brain MRI without contrast, is advised when one or more red flags (e.g., worst headache of one’s life, rapid worsening, lack of family history, personality changes, or new focal neurologic exam findings) are present. Results are unlikely to change management in a patient with a long-standing history of headache, positive family history, and normal neurologic exam.

How can a child with frequent headaches stay on track in school?

Children with frequent headaches may benefit from lifestyle modification strategies (e.g., increasing sleep, reducing over-extension into too many activities), behavioral health involvement (to address concurrent mood disorder), creation and implementation of a 504 plan, and use of a headache prevention medication. Transitioning a child to online or home schooling because of headache can be isolating and should be avoided. Maintenance of a regular school, work, and play routine is encouraged for promotion of health and to avoid long-term social, academic, and work-related consequences.

What causes headaches?

Migraine headaches are thought to result from the interplay of genetic factors and environmental triggers. The headache seems to be due to increased blood flow in the blood vessels in and around the brain. This increased blood flow may lead to a release of chemicals that cause inflammation, leading to pain and activation of the sympathetic nervous system, which leads to nausea, vomiting, diarrhea, cold hands and feet, and sensitivity to light and sound.

Issues Related to Headache (Migraine & Chronic)

Resources

Information for Clinicians

The American Headache Society (AHS)
A professional society of healthcare providers dedicated to the study and treatment of headache and face pain. The Society's objectives are to promote the exchange of information and ideas concerning the causes and treatments of headache and related painful disorders.

Helpful Articles

PubMed search for primary headaches in children, last 1 year.

McCrea N, Howells R.
Fifteen minute consultation: headache in children under 5 years of age.
Arch Dis Child Educ Pract Ed. 2013;98(5):181-5. PubMed abstract

Petrusic I, Pavlovski V, Vucinic D, Jancic J.
Features of migraine aura in teenagers.
J Headache Pain. 2014;15:87. PubMed abstract / Full Text

Rousseau-Salvador C, Amouroux R, Annequin D, Salvador A, Tourniaire B, Rusinek S.
Anxiety, depression and school absenteeism in youth with chronic or episodic headache.
Pain Res Manag. 2014;19(5):235-40. PubMed abstract / Full Text

Spiri D, Rinaldi VE, Titomanlio L.
Pediatric migraine and episodic syndromes that may be associated with migraine.
Ital J Pediatr. 2014;40:92. PubMed abstract / Full Text

Winner P.
Pediatric headache.
Curr Opin Neurol. 2008;21(3):316-22. PubMed abstract

Clinical Tools

Assessment Tools/Scales

International Headache Classification (ICHD-2)
Diagnosis information organized from broad to very detailed about primary headaches; secondary headaches; cranial neuralgias; central and primary facial pain; and other headaches.

Patient Education & Instructions

Headache information websites such as Kids Help (ACHE), and others, may be useful for families.

Headache Treatment in the Hospital (IHC, PCH) (PDF Document 63 KB)
What you and your child may experience during headache treatment in the hospital; Intermountain Healthcare, Primary Children’s Hospital.

Patient/Family Questionnaires/Diaries/Data Tools

Headache Log (Our Family Doctors) (PDF Document 28 KB)
Printable record with areas to note time of onset, activity prior to headache, location of headache, duration, pain scale, medication taken and its effectiveness, triggers, and associated symptoms.

Headache Diaries (ACHE)
Daily, weekly, and monthly formats; American Headache Society's Committee on Headache Education.

Headache Diary (National Headache Foundation)
Simple, printable headache recording form with instructions on its use.

Information & Support for Families

Family Diagnosis Page

Information on the Web

Kids Help (ACHE)
Educational sheets and resources for families who are affected by disabling headaches; American Council for Headache Education, sponsored by the American Headache Society.

Causes of Headaches (KidsHealth)
Includes tips for how to help your child when he or she has a headache and when to call a doctor; sponsored by Nemours.

Children's Headache Disorders (National Headache Foundation)
Information focusing on treatment without medication.

Information about Food Triggers (WebMD)
Answers to often asked questions about food triggers, migraines, and headaches.

Headaches in Children (Cleveland Clinic)
Basic information about headaches for families, including when it is important for a child with headaches to be seen by a physician.

Headaches in Children (University of Utah)
Information about different types of headaches, how diagnosis is made, and usual treatment methods.

Headaches (Cincinnati Children's)
Information about chronic, daily, and tension headaches in children.

Support National & Local

National Headache Foundation
A nonprofit with comprehensive information on headaches and migraines; focused on support and finding cures.

Services for Patients & Families

Developmental - Behavioral Pediatrics

See all Developmental - Behavioral Pediatrics services providers (5) in our database.

Pain Clinics

See all Pain Clinics services providers (3) in our database.

Pediatric Integrative Medicine

See all Pediatric Integrative Medicine services providers (1) in our database.

Pediatric Neurology

See all Pediatric Neurology services providers (10) in our database.

Pediatric Ophthalmology

See all Pediatric Ophthalmology services providers (8) in our database.

Physical Therapy

See all Physical Therapy services providers (62) in our database.

Psychiatrist, Child-18

See all Psychiatrist, Child-18 services providers (28) in our database.

Psychologist, Child-18

See all Psychologist, Child-18 services providers (151) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors

Authors: Lynne M Kerr, MD, PhD - 8/2013
Denise Morita, MD - 5/2013
James Bale, MD - 12/2012
Reviewing Authors: Gary Nelson, MD - 4/2016
Meghan Candee, MD - 4/2016
Content Last Updated: 4/2016

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