Headaches are common during childhood and most frequently reported during adolescence. Both migraine and tension-type headaches, often occurring together in an individual, may present with significant pain, decreased academic performance and school absence, anxiety, depressed mood, family disruption, and high health care costs. These major problems are especially detrimental for a developing child learning self-esteem, identity, self-control, and personal coping strategies for stressful situations. However, a developing individual also presents a potentially more plastic nervous system and less biased student for pharmacologic and cognitive behavioral interventions.
Primary headache disorders, including migraine headaches and tension-type headaches, are common during childhood and most frequently reported during adolescence. The reported prevalence for migraine headache is estimated at 3% for age 3-7 years, 4-11% for ages 7-1 1 years, and 8-23% for ages 11->15 years. The mean age of onset for boys is 7.2 years, and, for girls 10.9 years. Of note, some researchers suggest that children less than 3 years may have a early common migraine headache disorder which presents as periodic irritability, head-banging or holding, change in sleep and behavioral patterns, abdominal pain, recurrent vomiting, and pallor. These migraine variants, now referred to as childhood periodic syndromes, include cyclic vomiting, abdominal migraine, benign paroxysmal vertigo, benign paroxysmal torticollis, acute confusional migraine, and acephalgic migraine.
The diagnosis of primary headache in children, including migraine with and without aura, is based on clinical criteria modified in 2004 by the International Headache Society. For migraine without aura, the criteria are:
Tension-type headache criteria for children are still evolving, but are based on adult description:
- At least 10 previous headache episodes fulfilling criteria 2-4. Number of days with such headache <180/year (<15/month)
- Headache lasting from 30 minutes to 7 days
- Headache with at least 2of the following pain characteristics:
- Pressing/ tightening (non-pulsating), quality
- Mild or moderate intensity (may inhibit but not prohibit activities)
- Bilateral location
- No aggravation by walking stair or similar routine physical activity
- Both of the following:
- No nausea or vomiting (may have anorexia
- Photophobia and phonophobia are absent, or one but not the other occurs
- Same as for migraine without aura (as above)
The clinical interview is essential and includes both open-ended and structured questions about headache duration, location, frequency, intensity, quality, triggers (puberty; diet; worries) associated affect ("How did you feel when you had your last headache?") and accompanying symptoms. Such a symptom checklist (McGrath, 2001) may include:
- aches or pins and needles in arms and legs
- dizziness: spinning; near-fainting;
- soreness in neck and shoulders;
- feeling of light bothering the eyes;
- seeing of bright white or colored spots, flashes, wavy lines, or dark/blank spots like a piece of puzzle has been removed;
- feeling that sounds bother you;
- feeling tired, wanting to sleep;
- feeling sick to your stomach and/or throwing up;
- feeling hot and sweaty;
- feeling the heart beat very fast;
These symptoms may variably accompany the pain or may occasionally occur independent of the headache.
For chronic pain problems, data related to childhood disability are elicited, such as pain interfering with sports, homework, going out with friends or to parties, doing chores, watching television, playing video games, and attending school.
Treatment includes pharmacologic and non-pharmacologic therapies and is initiated with patient and family education, possible removal of triggers, and if appropriate, changes in a disrupted lifestyle (school attendance, physical activity, sleep). Overuse of symptomatic analgesics is as prevalent in pediatrics as in the adult population, and analgesic rebound headache must be discussed before adding to a chronic headache disorder. If prophylactic medication is prescribed, it should be given every day, whether or not a headache is present. Attention to good health habits remains the primary therapy.
- Hydration: Children and adolescents need at least 4-8 glasses of fluid without caffeine per day. During a headache or increased activity, sports drinks ( with sugar and salt ) are recommended.
- Sleep: Fatigue and overexertion may trigger headaches. Most children require 8-10 hours of uninterrupted sleep each night and a regular sleep schedule.
- Diet: Children do best with regular and balanced meals. Foods that trigger headache are individual, and general exclusionary diets are not indicated.
- Activity: Sensible child activity schedules, without over-crowding or exposure to stressful and upsetting situations, are reasonable.
The goals of acute treatment are to reduce immediate pain and accompanying symptoms and to prevent recurrence or rebound. The pharmacologic agents with the most established efficacy are ibuprofen and acetaminophen. Current reports highlight the need for “ multicentered, placebo-controlled clinical trials to assess the safety, tolerability, and efficacy of medications” used for the treatment of pediatric migraine, an often sited deficiency in general pediatric pharmacology. Therefore, choices of acute medications are still, in part, based on adult patient guidelines, although there are increasing numbers of controlled, blinded and open-label pediatric trials showing safety and efficacy of triptans in children 12 years or older . There are no trials comparing the efficacy among the various triptans available. As in most pediatric headache studies, placebo effects may be as high as 50%, necessitating a large sample size to confirm efficacy.
Prophylactic and daily medical therapy is indicated for children with a minimum of 2-3 severe headaches per month associated with functional disability, such as school absence or withdrawal from desirable activities. The choice of appropriate agent, as previously described with symptomatic medications, is currently supported primarily by adult studies and the use of the same agents for non-painful conditions, such as seizures. All prophylactic medications have potential adverse effects, some of which may be useful, such as sedation or appetite suppression/stimulation. These agents require slow titration, frequent monitoring, anticipation of side-effects, and delay of patient and family gratification.
In the Boston Childrens’ Hospital Headache Program in Waltham, a collaboration between the departments of Anesthesia and Neurology, children and adolescents with chronic headache disorders are referred for medical and psychological evaluation, education, and formulation of a multidisciplinary treatment plan. Physical therapy is available on site for referral, as appropriate. Neuroimaging and laboratory testing are also possible at the Waltham facility. Concerns regarding school attendance, social functioning, sleep, and exercise are discussed in detail. Cognitive-biobehavioral strategies are emphasized. Adjuvant therapies, such as vitamin supplementation, medical acupuncture, and reiki are also presented. The Headache Program staff are experienced professionals trained in chronic pain management as well as pediatric pain psychology, pediatric neurology, and integrative therapies. The Medical Acupuncture Service, housed beside the Headache Program, is available for consultation. Staff also has expertise in minor regional anesthetic procedures, indicated for pediatric chronic pain. A quiet observation floor, open during weekdays, may be reserved for IV administration of medications for acute headache exacerbations.
Boston Children's at Waltham, 9 Hope Avenue, Waltham, MA 02453
The staff is also active in clinical pediatric headache research, including responses to biobehavioral, pharmacologic and adjuvant therapies, as well as sensory testing and functional brain imaging. Education is a priority, and the nursing, psychology, and medical staff present to regional, national and international conferences, school nurses and parent and patient groups.
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