by Paul K. Winner, D.O., Co-Director Palm Beach Headache Center 5205 Greenwood Avenue - Suite 200 west Palm Beach, Florida 33407
Children and adolescents have not always received adequate pain control because of a reluctance to precribe drugs that had only been tested in adults. Now, in the "Decade of the Brain," we are accumulating studies and clinical experience with treating headache in children and adolescents, so that we may safely offer them the same quality of headache management that adults receive.
Adolescents, like adults, can suffer from chronic headaches that may be severe. More than 8 million children in the U. S. have migraine, resulting in an annual loss over 1 million school days. The National Headache survey found that 25 out of 1000 children between the ages of 6 and 17 report having frequent or severe headaches.
Controlling Occasional Headache
In general, headache frequency and severity tend to increase with age, and the majority of adolescents with severe headaches will tend to have one attack a month or less. For this reason, it is often possible to control headache in adolescents with abortive medication -those that stop an attack in progress- as opposed to preventive drugs that are taken daily.
Recently completed studies have shown that Sumatriptan (Imitrex) can provide excellent headache relief for adolescents (age 12 and up) with migraine, Injectable Sumatripan is preferable for adolescents who develop a severe migraine very rapidly. Those with a more gradual onset can use the tablets, and relatively low dose (25 mg) can be highly effective in controlling severe migraine in adolescents.
Moderated-to-mild headaches can be relieved with nonsteroidals anti-inflammatory (NSAID) drugs, such as naproxen (Anaprox DS). There are potential complications with long-term use of NSAIDs, but these non-sedating, non-addictive compounds have the advantage of generally allowing the adolescent to continue normal activities. The over--the-counter NSAIDs, such as ibuprofen (Advil, Mortin, Nuprin) can also be used. Their main disadvantage is shorter duration of action, about 2-4 hours compared to 8-12 hours for the prescription drugs.
Preventing Frequent or Severe Headaches
A small group of adolescents with headache cannot get adequate pain control with abortive drugs such as Sumatriptan or NSAIDs. These children may experience more frequent and severe migraines or they may have chronic daily headache (CDH). In adults, CDH is often linked to overuse of pain relievers, but this is much less common in adolescents. Occasionally a young person who does not have a history of headache or other chronic pain will wake up with a headache that never goes away. Studies are now beginning to investigate the occurrence of CDH in adolescents and to identify most effective approaches.
When intense, frequent headaches are disrupting the child's family, social and school activities, we consider using a preventive medication to bring the headaches under control. While this medication must be taken daily, in most cases it can be tapered off after 6 months to a year. The aim of this approach is to reduce the frequency of the headaches so that they can be adequately managed with abortive treatment or non-drug approaches.
Since, adolescents can differ so greatly in size, weight and development stage, the doctor must be conservative in choosing a dose appropriate for the individual, and these patients should be monitored more closely for side effects. If there are no contraindications, many of drugs used for headache prevention in adults, such as beta blockers, tricylic antidepressants, and calcium channel blockers, can be used in adolescents. A few precautions are needed. Young adolescents my develop signs of depression as a side effect of beta blockers, and it can go unnoticed unless the parents are observing the child for subtle changes in behavior. Tricylic antidepressants are generally safe and effective, but it is necessary to monitor for any signs of cardiac arrhythmia (irregular heartbeat), which is a possible side effect.
Adolescents Do Listen
Like adults, adolescents benefit from comprehensive approach to headache management that combines drug and non-drug strategies. The standard lifestyle approaches to headache prevention are equally appropriate for teenagers, such as avoidance of of known triggers, exercise, a regular schedule with good sleep habits, diet control when needed, and other good health practices. While it may be difficult at times to persuade them to pick up their clothes or to mow the lawn, our experience in treating adolescents has been that these young people are highly motivated to learn about the causes of their headaches and to take all the steps needed to get them under control.
Headaches in Children and Adolescents
Children with headache are brought to medical attention by their parents primarily for reassurance that the headaches are not a sign of a brain tumor or serious illness. A thorough history, physical, and when appropriate, diagnostic testing will enable the practitioner to distinguish primary headaches form these of a secondary etiology. The less common primary headache syndromes as well as secondary headache disorders, can prove to be quite anxiety provoking not only to the patient and their parents; but also to the practitioner both to the degree to which the evaluation should be taken as well as appropriate therapy to be recommended.
The evaluation of the child, especially under the age of ten, requires creative techniques as well as input from the parents in order to obtain a complete history. It is important to determine whether there is more than one type of headache experience by the child. How many days missed from school can help determine the frequency, severity, and disability.
The incidence (the rate of onset of new cases) of migraine with aura in males is 6.6/1000 and peaks at 5 to 6 years of age. The peak incidence of migraine without aura in males is 10/1000 and peaks at 10 to 11 years. The incidence of migraine with aura in females is 14/1000 and peaks at 12 to 13 years. The incidence of migraine without aura is 18/1000 and peaks at 14 to 17 years in females. (1)
The overall prevalence of headache increases quite strikingly from preschool to adolescence. Headache prevalence by age 7 is 37 to 51%. At ages 7 to 15 the prevalence ranges from 57 to 82% (2,3,4). Migraine prevalence at age 7 is 1.2 to 3.2%. At ages 7 to 15 prevalence ranges from 4 to 11% (2,5,6). IHS migraine prevalence has been reported higher in boys than girls ages 3 to 7 but ages 7 to 11 the prevalence is equivalent. (5). Several studies suggest that migraine prevalence may be increasing (7,8,9).
Migraine headaches occur in 4-5% of school age children. Migraine in children as in adults, is a public health problem with an impact both to the sufferer as well as to society. Twenty percent of adults report the onset of migraine symptoms prior to the age of 10 and 46% before the age of twenty. In children, migraine prevalence is equal in boys and girls prior to puberty then changes to 3 to 1 women to men.
Why do so many children in adolescence suffer from migraine? Migraine is felt to be a heterogeneous autosomal dominant disorder with incomplete penetrance. Some cases of familial hemiplegic migraine have been localized to chromosome 19.
The diagnostic criteria published by the International Headache Society (IHS) provides explicit criteria for the diagnosis of migraine (Table 1)However, this does not characterize headaches in children separately and lacks sensitivity in this population. A revised classification of symptoms based on the IHS (Table 2) is currently being tested. Both the IHS and the new revised IHS-R (HIS-R) criteria require multiple headache attacks. The first migraine attack cannot always be differentiated by symptomatic headache due to, for example, infection, concussion or neoplasm. In children, especially younger, the duration of headache may be as little as one hour. Migraine headache are often bilateral (bifrontal or bitemporal particularly in the younger child. Headaches occurring in the occipital area are more unusual and may have an organic cause. Careful questioning of the parents and a little persistence is crucial in finding out what the child does, how their routine is altered during headaches. For example, will the child watch television during headaches? Does the headache interfere with the child's social activities and academic performance?
The associated symptoms of migraine are an integral part of the disorder and are essential to diagnosis. These include photophobia, phonophobia , nausea and vomiting. Nausea occurs in most migrainous headaches whether child or adult. Vomiting occurs in both but in children it may occur earlier in the headache episode. Adults often experience some photophobia and phonophobia, children are more likely to experience one of these symptoms.
The diagnosis of migraine with aura requires there be one or more fully reversible neurologic symptoms including visual, motor or sensory. This helps to distinguish migraine from progressive, organic disorder that require further diagnostic assessment. The aura should develop gradually over at least four minutes. It usuaslly lasts 20-30 minutes but may last as long as 60 minutes. If the aura is short in duration or rapid in onset, a paroxysmal event may be the cause.
Migrainous have been reported to have nonspecific EEG abnormalities. Some of them are now believed to be normal variants such as 14 and 6 phantom spike, others are felt to be a benign rolandic pattern which often does not require treatment. Migraine presentations that a practitioner may encounter includes: hemiplegic migraine, basilar migraine, ophthalmoplegic migraine, benign paroxysmal vertigo, cyclical vomiting, and benign torticollis.
Hemiplegic migraine often begins in young children, the familial form requires a first degree relative that suffers identical attacks. This disorder has been linked to Chromosome 19 in 50 to 60% of individuals. Hemiplegic migraine is sometimes referred to as "football headache' because attacks may be triggered by a mild head injury. The headaches usually follows the hemiparesis with the hemiparesis lasting from hours to days. Attacks occur infrequently and may be associated with dysarthria, aphasia, altered levels of consciousness that are frequently associated with visual symptomatology.
Basilar migraine most often occurs in adolescent females with a positive family history of migraine. Brainstem symptomatology: bilateral visual symptomas, tinnitus (ringing of the ears), vertigo and ataxia are common. In half the patients, bilateral weakness and parasthesias which may be very frightening to both the parents and the patients are noted.
Ophtalmoplegic migraine with ptosis and 3rd nerve palsy although more common in young children, can occur for the first time prior to one year of age. The 3rd nerve is invloved in 80% of these cases, attacks last anywhere from 30 minutes to a month. Ophthalmoplegic migraine is a diagnosis of exclusion. Organic disorders may provoke similar symptoms with differential including sphenoid sinus tumor, orbital and sphenoid sinus granuloma, Tolosa Runt, internal carotid artery aneurysm and chronic sinusitis.
Benign paroxysmal vertigo, a child will suddenlly turn pale, seem frightened, grab somthing for stability often have nausea and vomiting. a quick glance may note nystagmus, attacks are very short, usually 1-2 minutes. They usually occur monthly and resolve as the child bnecomes older. If the attacks do not improve with time, are atypical or have residual deficits, a complete workup is recomended. There should be no loss of consciousness, and a positive family history of migraine.
Cylical vomiting usually starts between the ages of 4 and 8 and occurs at regular intervals approximately monthly although it can vary from 15 to 60 days. Vomiting may occur with or without a headache. This condition is not progressive although if there is worsening a thorough examination including a complete GI workup, an MRI scan of the brain is suggestive.
Bening torticollis is a condition of recurring attacks of head tilt in infants for no apparent cause. Extremely frightening to parents when withnessed for the first time. Attacks usually begin before 12 months of age and the infant may or may not appear sick. Often the condition is short-lived and will resolve spontaneously. A good prognostic sign for benign disease is the ability to move the head to mid-position. However, if the head tilt is always one-sided or the position is fixed, there may be an organic underlying cause and a complete workup is suggested.
Tension-type headache may be hard to differentiate from migraine in children, as some of the symptoms will overlap. A characteristic tension-type headache is identified by a bilateral (2-sided) pressing tightness ocurring anywhere on the cranium or suboccipital region. The headache is non-throbbing sensation of pain and mild to moderate in intensity, and lasts from 30 minutes to several days. It is not accompanied by nausea or vomitting and it is not aggravated by routine physical activity. Although it can be associated with either photophobia (sensitivity to light) or phonophobia (sensitivity to sound). Rather than using traditional terms such as muscle contraction headache, tension headache or stress headache, a new IHS classification employs the term "tension-type" and gives it a rather complex definition for more accurate descriptions.
While cluster headache is very rare under the age of 10, it has been reported in children as young as 3. Therefore it should be included among the differential diagnoses of primary headaches,although not at the top of the list. Cluster headache becomes more apparent between the ages of 10 to 30, and from 20 we see the usual rate of 9 males to 1 female.
Treatment in Childhood Headaches
The treatment of headaches in children requires both pharmacological and non-pharmacological modalities to be utilized in together. Prevention of incapacitating acute migraine attacks is helped by a comprehensive approach of elimination of known triggers, appropriate use of non-pharmacologic modalities such as biofeedback or relaxation training, appropriate pharmacologic acute migraine treatment and when necessary instituting prophylactic (preventative) therapy.
Acute migraine therapy for children over the age of 12 is compatible to adult therapy. In most cases, an adjustment of the dosage is all that is necessary. However, in children under 12, interventions must be substantially modified.
In children under 6, a limited amount of Tylenol works well with few problems. The headaches are usually short-lived and generally resolve with sleep. In older children, oral therapy such as acetaminophen, nonsteroidals such as ibuprofen, and combination analgesics butalbital containing compounds may be useful provided there is no significant nausea present. It is important to avoid aspirin because of its correlation to Reye's syndrome in children under the age of 15.
In acute, incapacitating migraines, it has been known that dihydroergotamine mesylate and Sumatriptan injectibles (Imitrex) have been effective in children. A recent study has demonstrated the efficiency of Sumatriptan oral tablets in the adolescent patient poplulation (12 and under) to be 73% effective in the relief of headache pain in four hours with 80% relief in disability.
Note: the injectible forms of both DHE and Sumatriptan are adjusted for weight depending on age.
Antimetics are often useful in this population either oral or suppository forms. Phenergan suppository is often effective while in older children, treatments may be necessary. Compazine is used with caution in this age group due to the higher incidence of extra pyramindal side effects. Opiods can be utilized in this patient population with caution and supervision.
Prophylactic Pharmacologic Therapy
If a child is absent from school excessively, cannot use abortive medicines, or the abortive medicines are ineffective, you will have to consider prophylactic pharmacologic therapy. As with the acute therapy, age plays a role in the selection of these medications. The treatment must be individualized with attention to dosages. At our facility we have had excellent results with beta blockers, specifically propranolol (Inderal). Beta blockers have been approved for migraine prophylactics and double blind studies in adults have demonstrated their efficacy. There have been 3 double blind, crossover studies of propranolol in children. In one study the medication found to be effective although in the other two it was no more effective than controlled. We start the initial dose quite small, then increase gradulally until we get a therapeautic response or side effects prohibit increasing the dosage. There is often a delay in the patient's clinical response of several weeks and this must be discussed with both the patient and the parents. Periactin is often used as a preventative in young children with its most common side effects being drowsiness and weight gain.
The antimigraine effects of tricyclic antidepressants seem to be independence of antidepressant effects. The side effect profile, especially cardiac, limits its usefulness as a first line medication in children. The trcyclics amitriptyline and nortriptyline in our facility have proven to be effective. No controlled studies in children have been reported.
Double-blind placebo controlled trials using calcium channel blocker nimodipine and migraine prophylactics in children ages 7-18 years note significantly reduction of both frequency and duration of migraine attacks as compared to placebo.
There have been recent double-blind control studies on the effectiveness of sodium valproate as a prophylactic treatment for migraine. These studies have been conducted in adults, however, we must be cautious with the use of this medication, especially in children under the age of 10. The side effects of hepatic toxicity and pancreatitus need to be addressed with the family. The effectiveness of Phenobarbital, phenytoin and carbamazepine have been documented in older literature. It is not known if seizure patients were included in the study populations. However, anticonvulsants can be used effectively in children who are refractory to the above prophylactic therapies.
Several studies evaluating biofeedback and relaxation training have demonstrated a beneficial effect in the management of pediatric headache. The frequency of attacks were consistently modified, as high as twice that scene in adults. These therapies are proven to be effective and work well on mature children, usually over the age of 9.
Discuss appropriate therapeutic goals with both the patient and the parents. While medications may be limited for younger children, there are more options for the adolescent such as the newer SRTI agonist medications., those available today and also those that are under study. Parents and patients need to know other options so that if the headaches recur in 2 or 3 years they will be able to return to appropriate therapy rather than continuing to suffer.
*Note: Dr. Winner is one of North America's top pediatric headache neurologists. Treatments may vary in your country. Please consult a pediatric headache neurologist. See our "Find-a-Headache-Doctor" link.
Published on the Help For Headaches Web Site