Treating pediatric headaches
Children with chronic headaches require close attention and follow-up

DESPITE SLIM CHANGES, MANY PARENTS FEAR THE WORST Only a very small fraction of serious headache cases are possible tumors, but as neuro-oncologist Scott Pomeroy, MD, PhD, puts it: “If there is one diagnosis you don’t want to miss, this is it.” Tell-tale symptoms requiring rapid referral include: New neurological symptoms such as double vision and gait instability New extremity weakness or numbness Recurrent headaches that occur mostly at night or first thing in the morning, especially if associated with vomiting Headaches that escalate in frequency and intensity “If there is any question about the diagnosis or if the patient is not responding well to treatment, I do an MRI,” says Dr. Pomeroy.

This fall, the Pain Treatment Service at Children's Hospital Boston is launching a new, multidisciplinary clinic to help children with chronic headaches. “Although most persistent daily headaches are not life-threatening, they constitute a considerable burden for patients and their families,” says Navil Sethna, MB, ChB, associate director of the Service. “Most adolescents with them report their functioning and well-being are frequently impaired and their quality of life diminished.”

Chronic headaches can be difficult to treat, as they require multiple therapy modalities, patient and family education, and continuous support. And while adult headache centers are common, very few pediatric centers exist around the country. In fact, Children's new clinic is unique in New England. It consists of experienced practitioners in pediatrics, neurology, anesthesiology and pain medicine, as well as medical acupuncture and psychology. All of this goes to the various triggers that initiate and sustain headaches, and teaching patients behavioral and cognitive strategies to manage headaches.

“Since headaches are often complicated by depression or anxiety,” says Lisa Scharff, PhD, associate director of Pain Treatment Service, “the headache clinic also incorporates psychological treatments with demonstrated effectiveness for pain, including biofeedback and cognitive-behavioral therapies.”

Alyssa LeBel, MD, assistant in Anesthesia and Neurology, sees families every week with chronic headaches that affect their quality of life and lead to behavioral problems, missed school and work days, and other family disruptions. “Until recently,” says Dr. LeBel, “the typical model for treating children with chronic headaches was to rule out a tumor or other serious disorder and send the patient on his or her way. But these patients need a long-term plan and follow-up.”

In many cases that can be accomplished by a child’s primary care provider during regular office visits. “The key to effectively treating chronic daily headaches is to take a very good history,” says Dr. LeBel. “This will tell you whether the pain is the primary condition or secondary to some underlying systemic illness.”

Children’s experts also are encountering an increasing number of analgesic rebound headaches and headaches associated with depression; both of which were only common among adults until recently. Dr. LeBel recommends that care providers ask parents to keep a detailed diary of their child’s chronic headaches—noting precipitants, frequency, duration and the child’s description of the pain.

MIGRAINE MANAGEMENT “The good news about migraines is that effective treatment is available,” says Scott Pomeroy, MD, PhD, “It’s worth referring a child suffering migraines to a specialist if the episodes are affecting school attendance or other everyday activities.”Migraines may start early in childhood, with the average age of onset between 5 and 8 years. Before beginning treatment, make sure the child is suffering migraines rather than chronic stress/tension headaches. Signs and symptoms Migraines are episodic The pain may be throbbing or pounding in quality Migraines usually have other symptoms, such as nausea, vomiting or loss of appetite Some children have an aura before the migraine, such as a sense of flashing lights or a change in vision Migraines often run in the family Two options for treatment Preferred method: treat every headache early in its onset with age-appropriate dosages of simple pain relievers and migraine-aborting drugs. If this is ineffective or migraines occur too frequently, it is sometimes necessary to prescribe preventive medication that is taken daily.

While diagnosis of chronic stress/tension headaches is fairly straightforward, treatment does require close attention and follow-up.

“Prescribing a fairly effective medication such as ibuprofen is far easier than getting a family to change its lifestyle,” says Dr. LeBel, “but the best solution is to address underlying issues like family stressors, the child’s diet, sleep, hygiene and activity level, while managing the pain in a way that causes minimal side effects.”