Pediatric Annals

Special Issue Article 

Integrative Management of Pediatric Primary Headaches

Anna E. Esparham, MD; Jennifer J. Dilts, DO

Abstract

Pediatric primary headache disorders are best treated using a comprehensive and integrative approach, due to the complex interactions between psychosocial and biological processes. Although more quality research is needed for treatment approaches to pediatric headaches, current practice management includes both pharmaceutical and nonpharmaceutical management. This article describes the integrative treatments used in a large regional pediatric headache program. Lifestyle approaches, nutraceuticals and dietary supplements, acupuncture, transcutaneous neurostimulation, relaxation, clinical hypnosis, biofeedback, and psychological services are discussed in detail for clinicians who may consider applying to their practice. [Pediatr Ann. 2019;48(6):e231–e235.]

Abstract

Pediatric primary headache disorders are best treated using a comprehensive and integrative approach, due to the complex interactions between psychosocial and biological processes. Although more quality research is needed for treatment approaches to pediatric headaches, current practice management includes both pharmaceutical and nonpharmaceutical management. This article describes the integrative treatments used in a large regional pediatric headache program. Lifestyle approaches, nutraceuticals and dietary supplements, acupuncture, transcutaneous neurostimulation, relaxation, clinical hypnosis, biofeedback, and psychological services are discussed in detail for clinicians who may consider applying to their practice. [Pediatr Ann. 2019;48(6):e231–e235.]

An integrative medicine approach, defined as the use of both conventional medicine and adjunctive complementary treatments, lends itself well to the treatment of pediatric primary headaches. The use of complementary and integrative therapies in children with headaches may be as high as 76%.1

This article is not inclusive of all complementary and integrative therapies but highlights the most common treatments used in a headache program at a Midwestern pediatric academic medical center. Headaches are highly prevalent in childhood, with 58% of children reporting a significant headache by adolescence.2 The most common primary pediatric headache disorders are migraines and tension-type headaches.3 Childhood variants of migraines include cyclic vomiting syndrome, benign paroxysmal torticollis, and benign paroxysmal vertigo. Headaches are considered to be a biopsychosocial disorder and migraines are a leading cause of disability.4 Thus, headaches are best managed by integrative, multidisciplinary, and lifestyle approaches.

Preventive and Abortive Management of Headaches

Most headache specialists agree that children and adolescents should start a preventive therapy if headaches occur more than 4 times per month, are difficult to abort, or interfere with school and/or normal daily activities.5 Preventive management may include daily medications, nutraceuticals, and/or dietary supplements to decrease headache frequency, duration, and/or intensity. In addition, preventive therapies can include procedures such as occipital or pericranial nerve blocks, acupuncture, and injection with onabotulinumtoxinA. Because many lifestyle behaviors may trigger headaches, the child or adolescent also needs to practice a tailored self-care regimen, including lifestyle strategies such as healthy nutrition and adequate physical activity, water, and sleep. All of these preventive therapies may also increase the efficacy of abortive treatments.

Abortive management of migraines may include the use of a triptan and/or headache “cocktail” such as a nonsteroidal anti-inflammatory drug (ie, naproxen, ibuprofen) combined with a dopamine receptor antagonist (ie, prochlorperazine, metoclopramide, promethazine) and diphenhydramine. It is important to note that these abortive medications need to be used at the earliest onset of migraine to be most effective. In addition, use of triptans, nonsteroidal anti-inflammatory medications, acetaminophen, or combination pain medications more than 10 to 15 times a month for longer than 3 months can result in medication overuse headache.6 Use of barbiturates and opioids can lead to worsening headaches and should not be used.6 There are several preventive and abortive treatments available to children and adolescents, but each patient may respond differently; hence, the need for a personalized approach and regular follow-up.

Lifestyle Strategies

Addressing lifestyle risk factors can significantly improve headache control. Poor nutrition, skipping meals, lack of sleep, smoking, stress, lack of water intake, caffeine intake, alcohol intake, and lack of physical activity all have an impact on headaches.7 Discussing lifestyle factors at each visit improves clinical outcomes for children with headaches.8 At the initial clinic visit, the provider and staff can gather information regarding the patient's lifestyle factors and review the lifestyle strategies. Using a website ( www.headachereliefguide.com) can be an efficient way to educate patients and families. At subsequent visits, it may be helpful to work with patients and families to choose one lifestyle factor to improve over the next few months. Using clinic staff (nurses and assistants) for education, both at discharge and when patients call into clinic with chief complaint of headache, is an effective use of resources. Consider using a “headache phone call template,” prompting staff to ask questions and provide guidance regarding medication adherence and compliance with lifestyle recommendations.

Lifestyle Recommendations for Patients

Water. Increase water intake to half of the child's body weight (pounds) in ounces. For example, a child who weighs 50 pounds should drink at least 25 ounces of water daily. Older children and teens should drink at least 64 ounces of water each day.

Nutrition. Eat three wholesome and well-balanced meals each day. Meals should include healthy fats, protein, and complex carbohydrates. This regulates blood sugar, which improves headache control. Do not skip breakfast.

Sleep hygiene. Avoid naps. Avoid caffeinated drinks after 12 noon and limit caffeine intake to two beverages per week. Keep the bedroom cool and dark. Remove all electronic screens (including smartphones) from the bedroom and create a “charging station” for electronic devices in the kitchen or other common space. Reserve the bed for sleeping only; avoid doing homework on the bed. Develop a bedtime routine. Shut off all electronics 1 hour before bed. Relaxing activities, such as a warm shower or hot bath, reading for pleasure, or listening to calming music or a relaxation app are good activities for the 30 to 60 minutes before bedtime.

Physical activity. Find an activity that the patient enjoys, such as basketball, walking, jumping rope, or other activities that move the body. The activity should increase the heart rate (patient should be slightly short of breath) for at least 30 minutes, 6 days each week. Finding an exercise partner can be helpful. If appropriate, start a smoking cessation program and decrease alcohol intake.

Nutraceuticals and Dietary Supplements

The American Academy of Neurology (AAN) and the American Headache Society (AHS) guidelines recommend magnesium, riboflavin, and coenzyme Q10 (CoQ10) as preventive nutraceuticals for migraine headaches.9 Although high-quality research supporting pediatric nutraceutical use is lacking, headache specialists often recommend these nutraceuticals as first-line treatment due to low side-effect profile and patient and family preference. Nutraceuticals are trialed one at a time and often take 8 to 12 weeks to show full treatment effect. It is important to discuss this delayed onset of effect with families and patients and ensure that the nutraceuticals are taken daily, unlike the abortive medicines. Over-the-counter nutraceuticals and dietary supplements are not regulated by the US Food and Drug Administration (FDA), making it imperative to ensure that patients are using supplements that have good manufacturing practices.

Preventive Nutraceuticals and Dietary Supplements

Magnesium

Magnesium is a mineral (an essential cation) that plays a role in decreasing migraine pain transmission by regulating brain receptors, neuropeptides, and signaling molecules.10 Three forms of magnesium are frequently prescribed and available at most pharmacies: magnesium gluconate, magnesium carbonate, and magnesium oxide. Insurance coverage is variable and often families may need to obtain magnesium over- the-counter. Magnesium is available in powder, liquid, capsule, and tablet formulations. Magnesium gluconate is a liquid form of magnesium for children who cannot swallow pills. The elemental magnesium dose is 10 mg/kg, to a maximum of 500 mg, taken once daily. Adolescents can take magnesium gluconate at a dose of 500 mg daily or magnesium oxide at a dose of 400 mg daily. Common side effects include abdominal pain, loose stools, and/or diarrhea. Magnesium gluconate may have greater bioavailability and fewer side effects than magnesium oxide. Magnesium toxicity is rare at headache-prevention doses, but because magnesium is excreted through the kidneys, patients with kidney disease should consult their nephrologist.

Riboflavin

Riboflavin, or vitamin B2, plays a role in mitochondrial membrane stability and at high doses may prevent migraine headaches.11 Riboflavin can be prescribed at 200 mg daily for young children and 400 mg daily for older children and adolescents. Riboflavin is available over the counter in liquid, capsule, and tablet formulations. Side effects are infrequent, with the most common being bright yellow urine discoloration.

CoQ10

CoQ10 is a cofactor involved in the mitochondrial electron transport chain. Studies have demonstrated benefit in migraine prevention, especially in patients with low CoQ10 levels.12 CoQ10 has shown potential efficacy in treatment of pediatric migraine variants, including cyclic vomiting syndrome.13 CoQ10 can be found in gummy, soft-gel, and liquid formulations. The pediatric dosing recommendation is typically 100 mg twice daily, or up to 1 to 3 mg/kg per day. There are minimal side effects with CoQ10, but with CoQ10's energizing potential, insomnia may result if it is taken too close to bedtime. If difficulty falling asleep occurs, change dosing to once daily in the morning.

Melatonin

Melatonin is a neurohormone produced by the pineal gland to induce sleep. Melatonin has been shown to have anti-inflammatory, immunomodulatory, analgesic, and circadian regulation effects.14 More recently, melatonin has been studied for primary headache disorders, including a few studies for pediatric migraines. Melatonin can be found in gummy, liquid, powder, capsule, or tablet formulations, as well as immediate- and sustained-release formulations. Melatonin may be considered for patients with migraine headaches, especially those with delayed sleep onset. Although optimal dosing may differ among patients, pediatric studies suggest a nightly dose of 3 to 6 mg.15 The most common short-term side effects include drowsiness, gastrointestinal upset, and increased enuresis. There is still scant data on long-term effects of melatonin with chronic use.14

Butterbur

Butterbur is a root extract from the butterbur plant (Petasites hybridus) that may decrease inflammation associated with migraine pain. However, butterbur was removed from the 2012 AHN/AHS guidelines due to the risk of hepatotoxicity.9 Butterbur may contain pyrrolizidine alkaloids (PA) that are hepatotoxic. Although supplement manufacturers label their products as free of PA, extreme caution must be used because supplements are not regulated by the FDA. The butterbur dosing for prevention of migraines was recommended at 25 to 75 mg twice daily for at least 4 months.16 Side effects may include belching, nausea, and abdominal pain.16 However, due to changes in extraction of PAs, it is unclear if the current butterbur supplements are safe.

Abortive Dietary Supplements

Feverfew

Feverfew is an herbal supplement known for its anti-inflammatory properties, and it has been studied for both migraine prophylaxis and as an abortive treatment. A 2015 Cochrane review showed efficacy of feverfew in migraine prophylaxis, although higher-quality evidence is still lacking.17 One study showed that a sublingual formulation of feverfew and ginger (Lipigesic M; PuraMed BioScience, Schofield, WI) was an effective abortive treatment for migraine patients between the ages of 13 and 60 years.18 When taken at the earliest onset of a migraine, this formulation was found to decrease pain scores and reduce associated symptoms, such as nausea, light sensitivity, and/or noise sensitivity. Cady et al.18 found that this formulation of feverfew and ginger had a low side-effect profile and was compatible with other abortive migraine treatments. Adverse effects include allergic reaction, oral numbness, and nausea.18

Ginger

Ginger is obtained from a plant root and is known to have anti-inflammatory and analgesic properties. Ginger has been studied more recently in randomized controlled trials as an adjunctive abortive treatment for migraines in adults.19,20 When added to intravenous ketorolac, 400 mg of ginger (5% active gingerols/20 mg gingerols) improved functioning and decreased migraine pain.19 In another randomized controlled trial of 100 adult patients, 250 mg of ginger was compared to 50 mg of sumatriptan, and it was found that both were equally effective in decreasing active headache severity.20 Side effects include heartburn, belching, and abdominal pain. Ginger should not be taken with any anticoagulants or platelet inhibitors, due to increased risk of bleeding.

Acupuncture

Acupuncture, formerly primarily associated with traditional Chinese medicine, has expanded into conventional medical systems and is now known as “medical acupuncture.” Medical acupuncture training programs for physicians and mid-level providers, typically 300 hours in length, incorporate many acupuncture modalities into a comprehensive course. After completing an acupuncture training course, physicians may obtain board certification in medical acupuncture. Cochrane reviews find that acupuncture is beneficial for migraine and tension-type headache prophylaxis.21,22 Children and adolescents typically tolerate acupuncture well. Usually patients undergo acupuncture once weekly for 6 to 8 weeks, as results are cumulative. Sessions are then continued less frequently, usually monthly or twice monthly. Acupuncture is a forgiving therapy with minimal risks and side effects, although acupuncture-associated vasovagal response, euphoria, rebound pain, visceral puncture, forgotten needles, bruising, bleeding, and skin infection have been reported.23

Transcutaneous Electric Nerve Stimulation

Transcutaneous electrical nerve stimulation (TENS) units are commonly used to treat pain. Cefaly (CEFALY-Technology, Searaing, Belgium) is a TENS device that is approved by the FDA to treat migraine pain. It has indications for both preventive and abortive migraine treatment.24,25 Cefaly uses a self-adhesive electrode that attaches to the forehead and stimulates the trigeminal nerve, modulating and preventing migraine pain. Currently, Cefaly is being used off-label for pediatric populations. Many families and patients are agreeable to Cefaly because it does not involve needles or taking daily medication, and it has few side effects. Although insurance does not cover the cost of Cefaly, physicians may write a prescription for patients to buy Cefaly online. Additionally, pediatric providers may choose to have Cefaly available for use in their clinics. Side effects include intolerance to the feeling of Cefaly on the forehead, fatigue, and skin irritation.

Relaxation Therapies

Relaxation therapies include diaphragmatic breathing, mindfulness/meditation, progressive muscle relaxation, autogenic relaxation, aromatherapy, and guided imagery. Stress is a significant headache trigger, and relaxation therapies play a role in preventing and aborting pediatric headaches.26 Relaxation therapies can be taught to children and adolescents during clinic visits and should be practiced at home most days of the week. A headache website ( www.headachereliefguide.com) developed by Dr. Jennifer Bickel and Dr. Mark Connelly at Children's Mercy Hospital-Kansas City, contains a “relaxation section” that explains and teaches several relaxation therapies. Additionally, aromatherapy can be used both in clinical settings and at home to promote relaxation.

Clinical Hypnosis

Although hypnosis is generally thought of as controlling the minds of others, clinical hypnosis guides patients in self-directed emotional regulation and relaxation and may be particularly helpful for children with headaches.27 Clinical hypnosis cultivates the mind-body connection, helping patients to foster a sense of awareness and well-being. A training program exists specifically for pediatric practitioners (the National Pediatric Hypnosis Training Institute). Pediatric practitioners certified in clinical hypnosis can offer this during office visits, with recommendations for home practice.

Biofeedback

The United States Headache Consortium Guidelines has recommended (grade A evidence) biofeedback, relaxation, and cognitive behavioral therapies for migraine prophylaxis.28 Biofeedback is a self-regulation strategy that may help decrease migraine frequency, duration, and pain intensity in children.29 Biofeedback uses audio-visual equipment to teach self-regulation of autonomic functions (decreasing sympathetic overdrive) that are related to stress and pain, such as heart rate, respiratory rate, muscle tension, and skin temperature. Biofeedback is generally more successful for children age 8 years and older due to their ability to grasp abstract concepts. Biofeedback teaches awareness of how stressful thoughts can induce sympathetic overdrive symptoms (decreased heart rate variability, increased sweating, decreased extremity temperature: “cold hands”), and how relaxation cues or mindfulness can promote parasympathetic activation (relaxation). Some pediatric medical centers have practitioners certified in biofeedback, offering a referral source for primary care physicians.

Psychological Services

Cognitive-behavioral therapy improves headache frequency and intensity.30 Referrals to mental health specialists, including psychologists and licensed counselors with pediatric expertise, are especially helpful for pediatric headache patients who have comorbidities of anxiety and depression. Social workers are a great addition to a headache team, and they can often write letters to schools suggesting headache-appropriate accommodations and, when, indicated, a 504 plan. A 504 plan is a set of written guidelines that schools develop to ensure that students with disabilities get the support they need to succeed in school.

Conclusion

Primary pediatric headache disorders are effectively treated with an integrative medicine approach, including lifestyle modification, nutraceuticals and dietary supplements, physical medicine and relaxation techniques, and psychological services. Further clinical research is needed in this area, specifically for pediatric patients.

References

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Authors

Anna E. Esparham, MD, is an Assistant Professor, Department of Pediatrics, Division of Child Neurology-Headache Section. Jennifer J. Dilts, DO, is an Assistant Professor, Department of Pediatrics, Division of Child Neurology-Headache Section. Both authors are affiliated with Children's Mercy Hospital-Kansas City and have faculty appointments at the University of Missouri-Kansas City School of Medicine.

Address correspondence to Anna E. Esparham, MD, Children's Mercy Hospital-Kansas City, 2401 Gillham Road, POB 1st Floor Child Neurology, Kansas City, MO 64108; email: aeesparham@cmh.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20190516-01

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