Headaches
Headaches are a very common complaint in our patient population. Occurs in up to 90%
of school-aged children by 18 years old. 20% of children 4-18 y/o report having had
frequent or severe headaches in the past 12 months.
Case:
a 15 y/o female presents for WCC today. The only concern from mother is that
her daughter is complaining of frequent headaches. What questions do you have for her?
What physical exam maneuvers will you perform?
Important aspects of the History:









Current symptoms:
o Age of onset
o Mode of onset: sudden?
o Pattern
o Frequency
o Aura or prodrome
o Quality
o Location
o What makes it better/worse
o Wake up in the night (early Am is more specific for mass)
Associated symptoms: photophobia, phonophobia, nausea, emesis, dizziness,
flushing
Symptoms between headaches
Headache burden (missing activities, school, etc)
Change in vision, weight, sleep
Past head injuries
Meds tried, frequency
PMHx including medications & mental health
Family hx- don’t just ask if there is a family hx of migraines
o Headaches
o Neurological disorders (Fibromyalgia)
o Mental health disorders (depression, anxiety)
o IBS?
Important Aspects of Physical:





Vitals signs including BP & HR
Complete neurological exam including optic fundi, vision & visual fields
CV- murmurs
Skin- neurocutaneous disorders
Spine- evaluation for occult dysraphism, palpation along spinous processes for
tenderness, turtle move (evals c1/2 & c3-7)
1
Red Flags:








Progressive pattern of headache: becoming more severe and/or more frequent
New or different severe headache, change in clinical features
Increased headache with straining, coughing, or sneezing
Explosive or sudden onset of severe headache (< 6 months duration)
Sleep-related headache: headache waking the patient from sleep (especially just
before sunrise) or headache always present in the morning
Systemic symptoms: fever, weight loss, rash, joint pain
Secondary risk factors: immunosuppression, hypercoagulable state,
neurocutaneous disorder, cancer, genetic disorder, rheumatologic disorder
Neurological symptoms/signs: altered mental status, papilledema, abnormal eye
movements, or other neurological abnormalities
Etiology:
Common Causes:
1.
2.
3.
4.
5.
6.
7.
Infection: Virus or upper respiratory infection, sinusitis, strep throat, meningitis
Stress related or worsened
Head injury
Migraine
Cluster
Tension
Medication overuse (Reported in 20-36% of adolescents with daily headaches)
Less frequent causes:
1.
2.
3.
4.
5.
6.
7.
Space occupying lesion
Medications- SSRI’s, SNRI’s, OCP’s, glucocorticoids
HTN
Idiopathic intracranial HTN
Hydrocephalus
Intracranial hemorrhage
Chronic Meningitis
Chronic headache Evaluations:



See American Academy of Neurology recommendations & American College of
Radiology Appropriateness Criteria attached.
Routine laboratory & imaging studies are not indicated
o Neuroimaging of children with headaches in the absence of neurological
abnormalities on exam and/or symptoms of neurologic abnormalities on
history has a low yield of clinically significant findings = 0.0-1.2%2.
Neuroimaging should be considered in the following situations (AAN
recommendations):
1. Abnormal neurological examination or other findings that suggest CNS
disease
2. Other factors predictive of space occupying lesion:
2
a.
b.
c.
d.
Headache <1 month
Absence of family history of migraines
Gait abnormalities
Seizures
Chronic Daily Headache:



Present for >15 days/month for at least 3 months in the absence of detectable
organic pathology
Prevalence: 1.5%
4 subtypes of daily headaches based on International Headache Society:
o Chronic Migraine
o Chronic Tension-type
o New Daily persistent
o Hemicrania Continua
Migraines:



Most common acute & recurrent headache syndrome in children.
Prevalence increases from 3% (age 3 to 7 years) to 4-11% (7-11 years) to 8-23%
(11-15+)
More common in females
3
4
Types of Migraines:




Migraine with Aura (formerly know as classic migraine):
o Aura is present before headache- neurological deficit or disturbance, can
be:
 Ophthalmic
 Hemiparesthetic
 Hemiparetic
 Hemiplegic
 Aphasic
o Familial Hemiplegic Migraine: Migraine with aura that includes motor
weakness in a patient that has at least one first or second degree relative
who has migraine with aura that includes motor weakness
o Sporadic Hemiplegic Migraine: Migraine with aura that includes motor
weakness in a patient without relative with same migraine
Migraine without Aura (formerly known as common migraine):
o Patients typically have a prodrome consisting of pallor, alteration in
personality, or change in appetite or thirst
o Prodrome may proceed headache by several hours
Retinal Migraine: rare
o Sudden loss of vision or the perception of bright light or scintillations in
one eye followed within one hour by a migrainous headache.
o Can occur without the headache
o Vision usually returns, but permanent visual loss can occur.
Basilar Type Migraine:
o More common in adolescents than younger children, but can starts young
 Average age of onset = 7 y/o
 One study found children as young as 12-18 months
o Affects 3-19% of children with migraines
o Occipital headaches, combination of:
 Dysarthria
 Vertigo
 Diplopia
 Tinnitis
 Decreased hearing
 Ataxia
 Altered consciousness
 Simultaneous visual disturbances in both nasal/temporal fields
 Simultaneous bilateral paresthesias
Migraine Variants:
o Alice in Wonderland syndrome: headaches preceded or accompanied by visual
hallucinations, bizarre perceptual distortions, or impairment of time sense
o Confusional Migraine: Migraine associated with agitation, disorientation, and
aphasia that last longer than the headache
o Hemisyndrome Migraine: hemiparesis associated with migraine, but can be
other hemisensory symptoms.
5
o Non-headache symptoms precede headache by 30-60 min & may persist
after the headache resolves for hours
Migraine Evaluation:


Consider CBC, CMP, TSH/T4, ANA if indicated to evaluate for underlying
medical conditions (See AAN recommendations above)
Refer to headache specialist for:
o Abnormal neuro exam
o Transformation to chronic daily headache (>15days/month)
o Not responding to care
o Child being home schooled secondary to headaches
o Uncertain diagnosis
Migraine Treatment:



SMART headache management: acronym to remember behavioral changes
o S: sleep- same schedule, 8-10hrs at night
o M: meals- don’t skip meals
 Limit caffeine (max 12oz/day, goal is 0)
 Drink water (40-60oz/day)
o A: activity-regular exercise (3x/wk)
o R: relaxation
o T: trigger avoidance
 Food: cheeses, chocolate, lunchmeats, citrus, food additives etc
 Stress
 Limit medications (no more than 2x/wk- can cause overuse
headache)
Abortive Medications:
o Ibuprofen: 10mg/kg is safe & effective, better relief of headaches as
compared to placebo & Tylenol
o Tylenol: 10-15mg/kg
o Naproxen: 5-10mg/kg or max 500mg BID
o Triptans: off label
 Contraindications: hx of stroke or TIA’s in family or patient,
ischemic heart disease, peripheral vascular disease, uncontrolled
HTN, use within 24hrs of ergotamine, concurrent administration
with another 5-hT1 agonist or MAO, management of hemiplegic
or basilar migraine
 Sumatriptan + naproxen: recent study in Pediatrics showed
combination was statistically improved outcome as compared to
placebo in adolescents
 Most effective are: nasal sumatriptan & nasal zolmitriptan, but not
as well tolerated
o Antiemetics: may relieve nausea & emesis
Preventative treatments:
6
o Initiate at lowest effective dose, increase slowly until clinical benefits
without side effects
o Give adequate trial 2-3 months
o Avoid interfering medications
o Provide plenty of patient education, use of diaries
o Re-evaluations- consider tapering when stable for 6 months
o Medications:
 B-Blockers: Propanolol, nadolol, atenolol, metoprolol
 Clonidine (contraindicated in Asthma)
 Antidepressants: Amitriptyline, nortripyline, fluoxetine,
imipramine (less common)
 Anticonvulstants: Depakote (Valproic acid), Keppra
(Levetiracetam), Neurontin (Gabapentin), Topamax (Topiramate)
 Others: Riboflavin 50-400mg, Magnessium oxide (9mg/kg divided
TID) 250mg BID, Coenzyme Q 100mg, Cyproheptadine (.251.5mg/kg/day)
Complications of Migraines:
o
o
o
o
o
Chronic migraine
Status migrainosus
Persistent aura without infarction
Migrainous infarction
Migraine triggered seizure
Cluster Headaches:





Deep, continuous, explosive
Severe, debilitating headaches of short duration (15 min-3 hrs)
Commonly cause eye redness & tear production on side of headache, rhinorrhea
or nasal congestions, sweating, pale appearance, drooping of the eyelid
Appear repeatedly for weeks to months at a time
Rare <10 y/o (0.1% of headaches in 10-18 year olds)
Tension Headache:




Pressing tightness, located over the forehead (or band around head).
Mild to moderate, no throbbing
Lasts 30 minutes to several days
Not made worse with daily activities
Medication Overuse Headache:

AKA: Analgesic rebound headache, drug-induced headache, medication-misuse
headache
7





Causative agents: Opiates > butalbital containing combination analgesics >
aspirin/acetaminophen/caffeine combinations > NSAIDS
Often preceded by another episodic headache disorder that has been treated with
excessive amounts of acute symptomatic medications
Most often daily, more often upon awakening, improved with medication use
Use of analgesic > 2-3x/week in association with chronic daily headache (>15
days/month)
Criteria for diagnosis:
o Headache x 15 days
o Regular overuse for more than 3 months of one of the more
acute/symptomatic treatment drugs
 Ergotamine, triptans, or combination analgesic medications >10
days a month x 3 months
 Simple analgesic or combination of ergotamine, triptans, analgesic
opioids >15 days a month x 3 months without overuse of any
single class alone
o Headache has developed or worsened during medication use
Apps:
Headache Diary App: iHeadache (Free)
Med helper pill reminder (Free)
Special thanks to Dr. Gerhart for providing me with additional information about
migraines
Resources:
• The American Committee for Headache Education (www.achenet.org/) provides
information and resources for patients and providers.
• The American Headache Society (www.americanheadachesociety.org/) provides
resources for clinicians.
• The National Headache Foundation (www.headaches.org) provides information and
resources for patients and providers.
References:
1. Blume, HK. Pediatric Headache: A Review. Pediatrics in Review 2012; 33 (12):
562-576.
2. Bonthius, DJ. Approach to the child with headache. In: UpToDate, Drutz, JE
(Ed), UpToDate, Waltham, MA, 2012.
3. Cruse, RP. Classification of Migraine in Children. In: UpToDate, Patterson MC
(Ed), UpToDate, Waltham, MA, 2012.
4. Cruse, RP. Management of Migraine headache in Children. In: UpToDate,
Patterson MC (Ed), UpToDate, Waltham, MA, 2013.
8
5. Derosier FJ, Lewis D, Hershey AD, Winner PK, Pearlman E, Rothner AD, et al.
Randomized Trial of Sumatriptan and Naproxen Sodium Combination in
Adolescent Migraine. Pediatrics 2012; 129 (6): e1411-e1420.
6. Garza, I. Medication Overuse headache: etiology, clinical features, and diagnosis.
In: UpToDate, Swanson JW (Ed), UpToDate, Waltham, MA, 2013.
9