Headache (Migraine & Chronic)

Description

Other Names

Migraine headache
Migraine headache with aura
Chronic daily headache
Persistent daily headache
Primary headache
Transformed migraine

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 trigger identification and avoidance, lifestyle modifications (increasing hydration and improving sleep, exercise, and nutrition if necessary,) and behavioral health techniques such as distraction/relaxation techniques and cognitive behavioral therapy. 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. [Anttila: 2018]

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. Although the frequency of migraine/chronic headache is about the same in children/adolescents and adults, it is not necessarily the same population at these stages that continues to have headaches. In one study [Monastero: 2006] almost half (41%) continued to have migraines, about 1/3 went into remission (39%) and about 1/5 (20%) transformed from migraine to tension headache. 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 can help the medical home provider 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.

Many neurologic considerations can be addressed by the Medical Home before referral, including sleep hygiene, adequate hydration and sufficiently frequent calorie intake, use of electronics/screen time, psychosocial stressors at home or school. A request to the school for 504 accommodations might include the ability to use a water bottle and the bathroom when necessary, or reduced homework (e.g., a shorter essay or every other math problem) so the amount of missed work due to absence or incapacity does not add to stress. The patient and family will often have useful ideas regarding accommodations. Communication with the school is particularly important when the child has already missed a lot of school. In general, it is best to avoid withdrawing from school but, if this has already occurred, coaching and support from a behavioral health specialist will be key.

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

National Institure for Health and Care Excellence.
NICE Pathways: Management of Headaches.
2013; https://pathways.nice.org.uk/pathways/headaches#content=view-index&pat...
A British evidence-based algorithm developed for care of headaches in people age 12 and older.

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. Catastrophization of pain by either the youth/adolescent or the parents may worsen headache; the Pain Catastrophizing Scale (PCS) may be helpful to identify this. [Crombez: 2003]

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) – children and parents rarely identify aura – this needs to be specifically asked about
  • Nausea and vomiting
  • Throbbing quality of pain
  • Sensitivity to light and/or sound; may be inferred from behavior
  • Improvement with sleep
  • • Migraines in children may be as short as one hour
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., numbness in the hand, around the mouth, and sometimes the tongue) or difficulty speaking. 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 or accompanies aura
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.

Migraine with aura

Auras (vision changes, sensory symptoms, or difficulty speaking before/or with migraine headache pain) need to be specifically inquired about as children/families often don’t realize its importance and don’t volunteer the information. If migraine with aura is present, oral contraceptives pose more of a risk for stroke and although not necessarily disallowed will need to be discussed by the prescribing physician. Additionally, individuals with migraine have a slightly higher lifetime risk of stroke, which is even higher in those with aura. [Gelfand: 2015] See Migraine, Stroke and Heart Disease.

History & Examination

Family History

A family history of migraine-like headaches, particularly in female relatives, is common. You may have to probe a little for this history as families will often downplay it as they don’t see it as connected. For instance, the mother may say that she had headaches when she was an adolescent or that she only gets headaches with her periods.

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). Ask about how often the child/adolescent is taking pain medication of any kind, including acetaminophen, ibuprofen, etc.

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. If you aren’t comfortable with the fundoscopic exam, a referral to ophthalmology for a dilated exam is always appropriate. There are many normal variations that look abnormal but are within the normal range that ophthalmology can help sort out.

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 found, incidentally, in many individuals without headache that are imaged for other reasons. In those with mild to moderate malformations, traditional headache management should often be tried before an individual is referred to neurosurgery.

Medication overuse or rebound headache

Medication should be used for acute treatment of headaches no more than 2-3 times a week because more frequent use (regardless of medication or mechanism) may increase headache frequency. Many individuals with chronic daily headache have a component of medication overuse headache where episodic headaches turned into daily ones. Before other treatments can be successful, children and youth with headaches need to be weaned from these medications. Interestingly, most of these individuals will tell you that they don’t help much anyway.

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 and may cause medication overuse headache.

Children who have missed a lot of school

Children who have missed a lot of school will need help, likely from a behavioral health provider, for a return-to-school plan. Social anxiety on school return may be a concern. A gradual return may be necessary.
At every visit, consider:

  1. Lifestyle factors, including sleep, hydration, etc.
  2. Reviewing the rescue plan (ibuprofen, acetaminophen, naproxen, triptan, anti-nausea medication, medication for sleep) and when to seek Emergency Department care for IV treatment
  3. Could medication overuse be a factor?
  4. What stressors or anxiety may be contributing? Might cognitive behavioral therapy be helpful?

Systems

Neurology

Chronic daily headaches are thought to result from physiologic changes in response to environmental stresses, a propensity to headaches, and sometimes a 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 the physiology of this loop is understood, the 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. Although it is possible that a child/family can do this on their own, sometimes a coach from Behavioral Health in the form of cognitive behavioral therapy may be helpful.
  • Many children with frequent headaches are perfectionists and need to be taught pacing of activities, etc. Cognitive behavioral therapy with a behavioral health professional may be helpful. This is not counseling in the traditional sense but practical behavioral tools.
  • Regular exercise e.g., walking 45 minutes 5–7 times/week [Krøll: 2018]
  • Adequate sleep, especially for adolescents who often start school before 8 a.m. This should be actual sleep, and not just time spent in bed with an electronic device.
  • 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

Headache prevention 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 (PhD, PsyD) (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 have been recommended for years for when headaches are occurring more than 3 days per month. [Winner: 2008] However the recent CHAMP study, [Powers: 2017] [Powers: 2017] a randomized, double blinded study of children and adolescents in centers across the country, found that these medications aren’t helpful. The same headache center that ran the CHAMP study (the University of Cincinnati Headache Group) also have information strongly supporting the use of cognitive behavioral therapy in headache management. [Kroner: 2017] [Amos: 2014]

The only exception to the lack of efficacy for medication prevention of headaches may be the new medication erenumab (AIMOVIG) which is given as a preventive by once monthly injections for either frequent episodic migraines or chronic daily headaches. This has not yet been tested in the pediatric population however and it in the $6000 to $7000 dollar range.

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.

A 31-injection protocol for Botulinum toxin (Botox) injections has been approved for individuals down to 18 years of age and older 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]
  • 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.
  • Many insurance companies require failure with 3 preventive medications before approving botox injections, including one antiepileptic, usually topiramate, one anti-depressant, usually amitriptyline, and one “heart drug,” usually propranolol, despite the lack of evidence for their efficacy.

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), almotriptan (Axert), rizatriptan (Maxalt), 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, metoclopramide, prochlorperazine, and ondansetron. 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. The Primary Children’s Hospital protocol (I will send separately) is one example of intravenous treatment for children/adolescents with severe migraine. Note that it does not include narcotics.

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 Management (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 (the main side effect is diarrhea), coenzyme Q, 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 Management (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), and creation and implementation of a 504 plan. 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

National Institure for Health and Care Excellence.
NICE Pathways: Management of Headaches.
2013; https://pathways.nice.org.uk/pathways/headaches#content=view-index&pat...
A British evidence-based algorithm developed for care of headaches in people age 12 and older.

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

Algorithms/Care Processes

Pediatric ED Patient with Headache, Concern for Migraine (PDF Document 97 KB)
The ED protocol for headache was developed in cooperation with Pediatric Neurologists and Emergency Department (ED) physicians at Primary Children’s Hospital in Salt Lake City, UT. It offers an algorithm, with several choices for physicians in the ED, for a non-narcotic “migraine cocktail” including IV fluids, pain medication, medication for nausea/vomiting, and medication to help induce sleep when needed as well as a follow-up plan if the cocktail doesn’t work. This algorithm is also given to families who live at a far distance from the hospital for use in their local Emergency Rooms.

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 in Idaho

Select services for a different state: MT, NM, NV, RI, UT

Developmental - Behavioral Pediatrics

See all Developmental - Behavioral Pediatrics services providers (2) in our database.

Headache Clinics

We currently have no Headache Clinics service providers listed; search our Services database for related services.

Pain Management

See all Pain Management services providers (6) in our database.

Pediatric Integrative Medicine

We currently have no Pediatric Integrative Medicine service providers listed; search our Services database for related services.

Pediatric Neurology

See all Pediatric Neurology services providers (3) in our database.

Pediatric Ophthalmology

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

Physical Therapy

See all Physical Therapy services providers (29) in our database.

Psychiatrist, Child-18 (MD)

See all Psychiatrist, Child-18 (MD) services providers (13) in our database.

Psychologist, Child-18 (PhD, PsyD)

See all Psychologist, Child-18 (PhD, PsyD) services providers (8) in our database.

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

Authors & Reviewers

Initial Publication: August 2015; Last Update: July 2018
Current Authors and Reviewers (click on name for bio):
Authors: Lynne M. Kerr, MD, PhD
Denise Morita, MD
James Bale, MD
Reviewers: Gary Nelson, MD
Meghan Candee, MD
Authoring history
(Limited detail is available on authoring dates before 2014.)
2013: first version: Meghan Candee, MDR
AAuthor; CAContributing Author; SASenior Author; RReviewer

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A British evidence-based algorithm developed for care of headaches in people age 12 and older.

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J Headache Pain. 2012;13(1):61-5. PubMed abstract / Full Text

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

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Pediatric headache.
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