The following gives a practical guideline to headache therapy in children and adolescents. Many drugs that are helpful for headache have not received a specific FDA indication for this use, and often these have not been specifically approved for children. The risks, side effects, and problems associated with medications need to be fully explained to the family, as explained in the PDR or a similar reference. Only if the family understands the risks and side effects of a medication, and accepts these potential problems, is a medication given to the child.
Introduction
Headache is a common complaint among children and adolescents. The generally stated incidence of migraine at age 6 is 1%, and at age 10 is 4%. These figures may be low. Headache is a major health problem in adolescents. Migraine is a problem in children as young as ages 2 or 3. Gathering accurate data in this age group is exceedingly difficult, as parents usually attribute headaches and nausea to "the flu". Migraine in children and adolescents, and chronic daily headache (CDH) in adolescents, is a major problem, with much lost school time caused by migraine or daily headache. Depression and/or anxiety is common in adolescents with severe, frequent headaches, and in many cases the depression is exacerbated by the headaches. Approaching headaches in children and adolescents with counseling, and biofeedback-relaxation is often crucial. With adolescents who are missing a lot of school, getting a good psychotherapist involved is invaluable.
As with adults, the vast majority of the time we are dealing with either migraine or tension headache (if this occurs 15 or more days per month, we would term it chronic daily headache, or CDH). Organic etiologies need to be excluded, of course, and an MRI scan of the brain is necessary once in the life of most of the younger patients with frequent, severe headaches. Predictors of organic pathology in children include confusion or other mental status changes, no family history of migraine, and sleep-related headaches. Other predictors include severe vomiting, abnormal neurologic exam, and headache of less than 6 months’ duration. Organic pathology, the pediatric neurologic history, and the pediatric neurologic physical exam are beyond the scope of this booklet.
All of the usual migraine trigger factors, such as diet, should be discussed with the patient and family. Sleep and icepacks are usually helpful. Relaxation/biofeedback should be given to younger patients with frequent headache. Most children cannot learn and apply biofeedback before the age of 9, but some 7 or 8 year olds can learn simple breathing and imaging techniques that may help their headaches. Children usually want to hear three things from the physician: (1) cause of the headache, (2) treatment, and (3) reassurance that it is not serious. Individual counseling for the adolescent is often helpful. The incidence of hard-driving, perfectionistic behavior, and depression is increased in adolescents with severe headache. Children and adolescents may be in too many activities and feel extremely stressed. These issues need to be addressed. Children missing substantial blocks of time in school need to be assessed for depression, school phobia, and secondary gains. Counseling is indispensable.
We have two types of medication therapy: abortive and preventive. The decision as to how much medication to use depends upon the frequency and severity of the headaches and how much they bother the child or adolescent. Some children are simply not bothered by their daily headaches and tend to ignore them. Others may be incapacitated and miss an entire year of school. As with adult headache patients, in children and adolescents, abortive medication is used in the overwhelming majority of cases, without daily preventive medication. However, with frequent migraines that are more than mild, or moderate to severe daily headaches, daily preventive medication may be necessary. It is always reasonable to try biofeedback as the first step, with simple abortive medications, and attempt to avoid daily preventive medication.
When I do use preventive medication with children and adolescents, I always attempt to stop the preventive medication periodically, and to minimize medication. As with adults, the idea is to see if we may return to simply using abortive medication. However, if an adolescent has had headaches for a number of years, we are not so quick to jump off of a successful preventive. We always consider "natural" preventatives, particularly "Petadolex", with adolescents. (See "Natural" Section, under Migraines)
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