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Clinical Consult: Headache

Headache is exceedingly common in pediatric practice and a significant source of parental worry (“Could it be a brain tumor?”). A detailed patient history and exam should seek to differentiate between primary and secondary headache and identify any “red flags.” Imaging is performed when there is an indication the headache could be attributed to a structural brain lesion. A diagnostic workup is not needed if the history is reassuring and the exam normal.

Clinical examination for headache

Most headaches are benign primary headaches, and include migraine, tension-type headache and, less often, cluster headache. Rarely is headache the sole presenting symptom of a more serious disorder.

A careful history can identify potential headache triggers (which often can be addressed with lifestyle changes) and/or signs of an underlying disorder. If the child is very young, you may need to spend more time interviewing the family. The history should ascertain:

  • the onset and pattern of the headaches
  • the frequency and severity of headaches over time
  • location of the headaches
  • other symptoms associated with the headache (migraines, for instance, tend to be accompanied by gastrointestinal and autonomic changes)
  • association with triggers—These can include an inappropriate sleep schedule (too much or too little sleep), skipped meals, dehydration and certain foods (5 to 10 percent of headaches have a known food trigger). Migraines can also be triggered by bright light, loud noises, weather changes and the menstrual cycle.
  • experience of stress—Ask older children about school and family worries, amount of homework, etc.
  • family history of headache

A neurological exam can detect signs that may indicate headache secondary to a more serious condition, such as brain tumor, subdural hematoma, a cerebral or vascular malformation or infection. Observe head tilt and check for unilateral weakness or numbness and diplopia. An eye exam including funduscopy can detect papilledema, a sign of increased intracranial pressure.

When to image

In most children who present with headache, imaging studies are completely normal. However, a child should be referred for neuroimaging if you spot any of these “red flags”:

  • new, dramatic onset of headache
  • a marked increase in headache severity or frequency over time
  • headache exclusively in one location
  • headaches that wake the child up in the middle of the night, or occur first thing in the morning
  • headache provoked by coughing, straining or sneezing, or headache provoked or aggravated by the Valsalva maneuver
  • headache that is worse when the child is in a horizontal position; this may be a sign of increased intracranial pressure
  • papilledema
  • unilaterial weakness or numbness, diploplia, abnormal eye movements or focal motor or sensory changes on neurological exam
  • imbalance, confusion, incoherent speech, seizure

MRI is the imaging test of choice, but children should be referred for CT if you suspect bleeding or fracture. If you suspect a subarachnoid hemorrhage, a lumbar puncture should be performed. EEG is not indicated unless you suspect seizures.

Treating primary headache

Benign primary headaches can often be prevented by maintaining good sleep hygiene, eating on a regular schedule, drinking adequate fluids, cutting back on caffeinated drinks and avoiding triggers. Migraine and tension-type headache often can be treated effectively with over-the-counter medications (acetaminophen or, preferably, ibuprofen; naproxen and Excedrin are also options).

If the over-the-counter medications are not effective for migraine, consider using migraine-specific medications from the triptan group. Seven are now available. Two have FDA approval for use in children: almotriptan (Axert®), for children 12 years and older; and rizatriptan (Maxalt®), for children 6 years and older. In addition, zolmitriptan (Zomig®) and sumatriptan (Imitrex) have extensively studied in children and proven to be safe. Some triptans come in a convenient nasal spray formulation, and some in dissolvable formulation.

“It is important to treat headache at its onset,” says Anna Minster, MD, of the Department of Neurology at Boston Children’s. “The pathogenesis of headache, and specifically migraine, is such that when the pain signal passes a certain point, the abortive medications are less effective. But they still should be tried.”

Avoid narcotic-containing medications, as they pose a high risk of dependency as well as rebound headache or medication overuse headache. They are also less effective for migraine than migraine-specific treatments.

Abortive medications should be used no more than two to three days per week, and triptans for migraine no more than six days per month. You may seek advice about abortive medications from Boston Children’s attending neurologist at 617-355-6178.

Preventive medications for headache

Preventive treatment should be considered if headaches are intrusive (becoming more frequent and interfering with the child’s daily life) and/or if abortive medications are becoming less effective. Options for migraine and tension-type headaches include:

  • Cyproheptadine. This prescription antihistamine is more effective in children under 9. It is preferably given in the evening; if given twice daily, one third of the dose should be taken in the morning. It can cause fatigue, weight gain and increased appetite.
  • Low-dose tricyclic antidepressants (amitryptiline, nortryptiline). Start with a small dose (10 mg) and increase gradually, explaining to the family that it may be some weeks before they see improvement.
  • Beta blockers (propranolol, timolol).  Again, start low (1 mg/kg/day) and go slow. These medications are contraindicated in asthma, and can unmask depression in teenagers and decrease physical endurance.
  • Certain anticonvulsants (topiramate, gabapentin, valproate [Depakote]) can also prevent headache in children.

There are some recent reports that vitamin B2 and magnesium can be useful in headache prevention. Cognitive behavioral therapy, biofeedback and, in some cases, acupuncture, can be very effective.

When to refer

If headaches remain hard to manage, the Boston Children’s Department of Neurology, at several locations, and our multidisciplinary headache clinic, located at Boston Children’s Waltham, offers evaluations. The hospital is also piloting shared, integrated care models for headache.

The future of pediatrics will be forged by thinking differently, breaking paradigms and joining together in a shared vision of tackling the toughest challenges before us.”
- Sandra L. Fenwick, President and CEO
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