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The pediatric headache clinic at Children's Hospital Boston at Waltham opens in December to evaluate and
treat challenging pediatric headache problems.
The staff includes
specialists
from Clinical Psychology, Anesthesiology, Neurology, Nursingand Consulting Physical Therapy. Here, Alyssa LeBel, MD,
a Children's neurologist and pain management specialist and a
co-director of the
clinic (with
Anna Minster, MD, and
Navil Sethna, MD), discusses pediatric headaches and treatment options.
How common are headaches in
pediatric practice?
Up to 90 percent of school-age children report headaches (Mayo Clinic, 2007). Migraines are reportedly present in 1 to 3 percent of 3- to 7-year-olds; 4 to 11 percent of 7- to 11-year-olds; and 8 to 23 percent of 11- to 15-year-olds. Migraines are more prevalent in males than females before puberty, with a female preponderance in adolescence (Bille, et al 1962-1994). In 10 percent of children, migraines present in an atypical or "variant" pattern, with cyclic vomiting, recurrent abdominal pain, benign paroxysmal vertigo, torticollis or confusion/dysphasia. Presenting with chronic daily headache pain is increasingly recognized as a source of significant pediatric disability, noted to be present in 23 percent of 7- to 16-year-olds in one report (Laurell, et al 2004).
When do headaches require treatment?
If they're disruptive to childhood activities. In patients with daily headaches, pain is often accompanied by decreased academic performance, school absence, anxiety, depressed mood, family disruption and frequent emergency room visits. Fortunately, most headaches in children are primary, episodic and benign disorders, usually characterized as migraines, migraine variants and tension-type headaches. More worrisome secondary headaches may be associated with systemic or central nervous system infection, toxins, hypertension, hypoglycemia, trauma, vascular thrombosis, intracranial hemorrhage, tumor, pseudotumor
cerebri, hydrocephalus, Arnold-Chiari malformation and craniofacial disorders.
What treatments do you recommend?
The first line of treatment is 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 (NSAIDs, Tylenol) is as prevalent in pediatrics as it is 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 four to eight 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 eight to 10 hours of uninterrupted sleep each night and a regular sleep schedule.
- Diet: Children do best with regular and balanced meals. Foods that trigger headaches 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 recommended.
When should pediatricians refer?
Although most pediatric headache problems are well managed in the primary care setting, referral should occur for these reasons: consideration of secondary diagnoses; inaccessibility of diagnostic testing; patient hardship, such as school absenteeism; analgesic overuse; familial distress; or interest in a biobehavioral treatment approach.
Historical "red flags" include first or worst reported headache; abrupt onset; significant change in headache pattern; new headaches in a child 5 or younger without a family history of migraine; history of cancer, HIV or immunosuppression; headaches
associated with seizure, syncope, exertion, trauma, substance use or confusion; or recent history of fever, weight loss or rash. Concerning features on examination include: meningismus, diplopia or visual loss, papilledema, seizures or change in mental status, hemiplegia or fever. Of note, patients with a longstanding history of primary headache may develop a secondary disorder with new signs and symptoms, such as Lyme encephalopathy in a patient with common migraines.
What new treatments are offered at Children's headache clinic?
We highly recommend nonpharmacologic therapies in the treatment of both acute and chronic pediatric headache because they don't have significant side effects and are so efficacious. Such modalities include biofeedback with relaxation therapy and cognitive-behavioral therapy. These modify the multiple factors that trigger migraine attacks, exacerbate pain, prolong disability and maintain the cycle of repetitive headache episodes. Current research interests are evaluation of family dynamics contributing to pain, efficacy of cognitive-biobehavioral therapy for treatment of headaches, sleep disturbance associated with chronic pain and neuroimaging of pain.
For more information on the headache clinic, visit childrenshospital.org/waltham.
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