Pediatric Annals

EDITORIAL 

A Pediatrician's View: Headaches and the Primary Care Pediatrician

William A Altemeier, III, MD

Abstract

My mother had terrible migraines. Although infrequent, when these occurred, the family rallied to do what we could. Her headaches were part of my early life and have helped me pay attention to this disorder. The headaches were usually predictable: she would be fine during some major family event, but once the crisis was over, the headache would come. For example, we knew everything would go well during packing and driving for a vacation. But as soon as we unpacked and settled in, the rest of the family could make plans to go somewhere while she stayed in a darkened quiet room until the attack ran its course. I don't have any trouble remembering that migraine is inherited. As an adolescent and young adult, my sister had recurrent episodes of unilateral paresthesia and hemiparensis. At the time, we feared these might be multiple sclerosis. But she is fine; in retrospect, these were basilar migraine. I have world class motion sickness, which has been associated with migraine,1 and my brother and sister still have occasional migraine headaches.

My sisters case brings up a principle: whenever presented with a set of strange neurologic signs or symptoms that recur in a patient who seems to be normal between episodes, consider migraine. Any feature of the aura of migraine attacks can be domi' nant and can occur without the headache.2 So when you see a patient with one of the following clinical pictures, probe for other signs of migraine in the child or family1"6; it is amazing how often migraine will be the diagnosis:

* attacks of blindness, double vision, or other visual disturbances with a normal ophthalmologic examination,

* spells of severe abdominal pain and vomiting with normal gastrointestinal imaging,

* acute hallucinations with a negative drug screen,

* sudden and reversible episodes of vertigo, ataxia, or changes in the level of consciousness from coma to confusion,

* remarkable cyclic attacks of vomiting, intractable to treatment, and

* reversible hemiplegia, hemiparesis, or ophthalmoplegia.

This issue of Pediatric Annals prepares the practicing pediatrician in several ways. David Rothner gives an up-to-date presentation of what we know and don't know of the pathophysiology of recurrent headaches. Mark Smith reminds us how common headaches are in his discussion of the evaluation and treatment of recurrent headaches. His guideline for when you need and don't need an EEG, neuroimagery, and sinus films are valuable in this cost-effective era. William Graf and Phillip Riback describe an excellent practical strategy for pharmacological treatment of headache. This includes the importance of starting with adequate doses of analgesics for both migraine and tension headaches.

Incidentally, consider aspirin instead of other acrossthe-counter analgesics for older childen who have frequent headaches and no risks for Reyes syndrome (ie, no signs of an infection). This is based on Perneger's recent report that people who take acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), frequently and over long periods, ultimately have an increased risk of end-stage renal disease, while those who take aspirin do not.7 Also, if you use NSAIDs, generic ibuprofen is much less expensive and seems to be equally effective compared with nongeneric NSAIDs. Smalley et al8 recently demonstrated a 53% savings ($12.8 million over 2 years) when Tennessee's Medicaid managed care program began requiring prior authorization to prescribe the more expensive nongeneric forms.8

Graf and Riback also give practical, useful guidelines to abort and prophylax migraine, including when the latter is necessary. Did you realize there is a syndrome of "status migrainosus?" I had seen patients with severe prolonged or almost continuous migraine headaches that were intractable to treatment, but was not aware of…

My mother had terrible migraines. Although infrequent, when these occurred, the family rallied to do what we could. Her headaches were part of my early life and have helped me pay attention to this disorder. The headaches were usually predictable: she would be fine during some major family event, but once the crisis was over, the headache would come. For example, we knew everything would go well during packing and driving for a vacation. But as soon as we unpacked and settled in, the rest of the family could make plans to go somewhere while she stayed in a darkened quiet room until the attack ran its course. I don't have any trouble remembering that migraine is inherited. As an adolescent and young adult, my sister had recurrent episodes of unilateral paresthesia and hemiparensis. At the time, we feared these might be multiple sclerosis. But she is fine; in retrospect, these were basilar migraine. I have world class motion sickness, which has been associated with migraine,1 and my brother and sister still have occasional migraine headaches.

My sisters case brings up a principle: whenever presented with a set of strange neurologic signs or symptoms that recur in a patient who seems to be normal between episodes, consider migraine. Any feature of the aura of migraine attacks can be domi' nant and can occur without the headache.2 So when you see a patient with one of the following clinical pictures, probe for other signs of migraine in the child or family1"6; it is amazing how often migraine will be the diagnosis:

* attacks of blindness, double vision, or other visual disturbances with a normal ophthalmologic examination,

* spells of severe abdominal pain and vomiting with normal gastrointestinal imaging,

* acute hallucinations with a negative drug screen,

* sudden and reversible episodes of vertigo, ataxia, or changes in the level of consciousness from coma to confusion,

* remarkable cyclic attacks of vomiting, intractable to treatment, and

* reversible hemiplegia, hemiparesis, or ophthalmoplegia.

This issue of Pediatric Annals prepares the practicing pediatrician in several ways. David Rothner gives an up-to-date presentation of what we know and don't know of the pathophysiology of recurrent headaches. Mark Smith reminds us how common headaches are in his discussion of the evaluation and treatment of recurrent headaches. His guideline for when you need and don't need an EEG, neuroimagery, and sinus films are valuable in this cost-effective era. William Graf and Phillip Riback describe an excellent practical strategy for pharmacological treatment of headache. This includes the importance of starting with adequate doses of analgesics for both migraine and tension headaches.

Incidentally, consider aspirin instead of other acrossthe-counter analgesics for older childen who have frequent headaches and no risks for Reyes syndrome (ie, no signs of an infection). This is based on Perneger's recent report that people who take acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), frequently and over long periods, ultimately have an increased risk of end-stage renal disease, while those who take aspirin do not.7 Also, if you use NSAIDs, generic ibuprofen is much less expensive and seems to be equally effective compared with nongeneric NSAIDs. Smalley et al8 recently demonstrated a 53% savings ($12.8 million over 2 years) when Tennessee's Medicaid managed care program began requiring prior authorization to prescribe the more expensive nongeneric forms.8

Graf and Riback also give practical, useful guidelines to abort and prophylax migraine, including when the latter is necessary. Did you realize there is a syndrome of "status migrainosus?" I had seen patients with severe prolonged or almost continuous migraine headaches that were intractable to treatment, but was not aware of this term or of the specific strategies for managing it.

Finally, articles on psychosocial factors of pediatric headache (Susanne Martin and Mark Smith), and behavior treatments of pediatric headache (Patrick McGrath and Graham Reid) remind us again that stress and somatization are essential parts of pediatric management in primary care. A large proportion of referrals to subspecialists, made because patients were resistant to management in the private orifice, turn out to be psychosocial or behaviorally linked disorders. McGrath and Reid provide practical guidelines for the primary care physician who has the patience and understanding to go more deeply into behavioral treatments. As you read this, think about your own coping methods. How do you handle the general stress of practice, the uncertainty of the future for medicine, and adapting to managed care? See if you use any of these coping strategies - this may at least increase reading retention. If you have not done much counseling in the past, you can't lose by giving it a careful try. Schedule extra appointment time and gradually increase the difficulty of cases you take on. Counseling makes more sense in managed care than in fee-for-service because the latter does not reimburse pediatricians very well for counseling while the former has incentives for reducing referrals.

One final theme was enlightening. First, although it is still useful to separate migraine and tension-type headaches, it does not seem to be absolutely necessary in practice to distinguish these two. This is because the management of the two types of headaches are similar: one should start with good doses of analgesics, and when this fails, the second line of treatment is to search for and address psychosocial stressors. Besides, both commonly coexist. So when you're not sure, you can start with these treatments anyway.

REFERENCES

1. Barron T. The child with spells. The Pediatric Clinics of North America. 1991;38:714.

2. Gilman S. Advances in neurology. N Engl J Med. 1992;326:1608-1616.

3. Hachinski VC, Porchawka J, Steele JC. Visual symptoms in the migraine syndrome.

4. Gordon GS, French JH. Basilar artery migraine in young children. Pediatrics. 1975;56:722-726.

5. Gascon G, Barlow C. Juvenile migraine presenting as an acute confusional state. Pediatrics. 1970;45:628-635.

6. Fleisher D, Matar M. The cyclic vomiting syndrome-a report of 71 cases and literature review. J Pediatr Gastroenterol Nutr. 1993;17:361-369.

7. Pemeger TV, Whelron PK, Klag MJ. Risk of kidney failure associated with the use of acetaminophen, aspirin, and nonsteroidal anti-inflammatory drugs. N Engl J Med. 1994;331:1675-1676.

8. Smalley WE, Griffen MR, Fought RL, Sullivan L, Ray WA. Effect of a priorauthoriiation requirement on the use of nonsteroidal anti-inflammatory drugs by Medicaid patients. N Engl J Med. 1995;332:1612.

10.3928/0090-4481-19950901-04

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