Pediatric Annals

Headaches in Children

David H Rubin, MD; Stacey A Suecoff, MD; Kelly G Knupp, MD

Abstract

Headache is a common problem in children and adolescents and a cause of significant anxiety for parents and physicians. Studies of Swedish schoolchildren have indicated that 40% of children experience a headache by age 7, 75% experience a headache by age 15, and migraine (one of the most common causes of headache in childhood) occurs in 1% of children by age 7 and 5% of children by age 15.1 Studies in the United States have found that the highest incidence (246 per 100,000 person-years) of migraine headache occurs in boys ages 10 to 14.2 Approximately 20% of children in the US have chronic headaches.3

Although the majority of patients have benign causes of headaches, which can usually be diagnosed by a careful history and physical examination, radiologic evaluation using computed tomography (CT), magnetic resonance imaging (MRI), or both may be necessary in selected cases. Proper diagnosis, treatment, and close monitoring of these patients is extremely important to ensure that serious etiologies are not overlooked.

PRINCIPLES OF DISEASE

Several theories exist to explain the mechanisms of headache. The vascular theory proposes that headaches are produced by dilation of intracranial or extracranial arteries. The change in vessel diameter triggers the auras before and the pain during a headache; this dilation can be relieved by vasoconstrictive drugs, such as ergots. The neuronal theory proposes that headaches are due to a primary dysfunction of the brain - a wave of spreading neuronal depression is accompanied by decreased cerebral blood flow. Not surprisingly, serotonin (5-hydroxytryptamine, or 5-HT) may be a key mediator in this cascade of events. Serotonin agonists have been shown to relieve migraine pain. The trigeminovascular theory is an integrated hypothesis that combines elements of both theories. The trigeminal nerve makes synaptic connections with cerebral blood vessels, and the headache is an expression of this nerve-blood vessel interaction.4

CLINICAL FEATURES

Recent revisions in the International Classification of Headache Disorders (JCHD-IT) describe the classification of headaches as primary or secondary.5 Primary headaches include migraine, tension headaches, while cluster headaches and secondary headaches include acute infection, medication, posttraumatic, and vascular etiologies.5-6 Headaches also can be classified into several temporal patterns: acute, acute recurrent, chronic progressive, chronic nonprogressive, and mixed. An acute headache is new in onset and different from previous headaches; it can herald a broad range of conditions ranging from a viral illness to subarachnoid hemorrhage. Acute recurrent headaches can be expressed as periodic events separated by pain-free intervals. Chronic progressive headaches occur over weeks to months and can signify serious medical disorders such as brain tumors or arteriovenous malformations. Chronic nonprogressive headaches usually occur for years. Mixed headaches are a combination of acute recurrent headaches (migraine) superimposed on a pattern of daily chronic nonprogressive headaches.7-8

The medical history is critical in evaluating a child's complaints of headache. Both the patient and family should be asked about specific characteristics related to the headache. To assist clinicians, Rothner has created a "headache database" that can be used to formulate a diagnosis (Sidebar 1, see page 347).8

In addition to these important questions and their responses, the clinician must focus on a detailed history of the neurologic system for related symptoms (eg, lethargy, ataxia, seizures, weakness, visual disturbances). Finally, a general review of symptoms related to other organ systems is required for a complete patient history.

Warning signs of symptomatic headaches usually include new onset, occurrence with straining, athletic or other specific activity, association with other neurologic symptoms, change in headache pattern, nocturnal awakening, and bioccipital pain. Additional information related to the medical history, such as history of recent head trauma, neurologic or psychiatric disorders, hospital…

Headache is a common problem in children and adolescents and a cause of significant anxiety for parents and physicians. Studies of Swedish schoolchildren have indicated that 40% of children experience a headache by age 7, 75% experience a headache by age 15, and migraine (one of the most common causes of headache in childhood) occurs in 1% of children by age 7 and 5% of children by age 15.1 Studies in the United States have found that the highest incidence (246 per 100,000 person-years) of migraine headache occurs in boys ages 10 to 14.2 Approximately 20% of children in the US have chronic headaches.3

Although the majority of patients have benign causes of headaches, which can usually be diagnosed by a careful history and physical examination, radiologic evaluation using computed tomography (CT), magnetic resonance imaging (MRI), or both may be necessary in selected cases. Proper diagnosis, treatment, and close monitoring of these patients is extremely important to ensure that serious etiologies are not overlooked.

PRINCIPLES OF DISEASE

Several theories exist to explain the mechanisms of headache. The vascular theory proposes that headaches are produced by dilation of intracranial or extracranial arteries. The change in vessel diameter triggers the auras before and the pain during a headache; this dilation can be relieved by vasoconstrictive drugs, such as ergots. The neuronal theory proposes that headaches are due to a primary dysfunction of the brain - a wave of spreading neuronal depression is accompanied by decreased cerebral blood flow. Not surprisingly, serotonin (5-hydroxytryptamine, or 5-HT) may be a key mediator in this cascade of events. Serotonin agonists have been shown to relieve migraine pain. The trigeminovascular theory is an integrated hypothesis that combines elements of both theories. The trigeminal nerve makes synaptic connections with cerebral blood vessels, and the headache is an expression of this nerve-blood vessel interaction.4

CLINICAL FEATURES

Recent revisions in the International Classification of Headache Disorders (JCHD-IT) describe the classification of headaches as primary or secondary.5 Primary headaches include migraine, tension headaches, while cluster headaches and secondary headaches include acute infection, medication, posttraumatic, and vascular etiologies.5-6 Headaches also can be classified into several temporal patterns: acute, acute recurrent, chronic progressive, chronic nonprogressive, and mixed. An acute headache is new in onset and different from previous headaches; it can herald a broad range of conditions ranging from a viral illness to subarachnoid hemorrhage. Acute recurrent headaches can be expressed as periodic events separated by pain-free intervals. Chronic progressive headaches occur over weeks to months and can signify serious medical disorders such as brain tumors or arteriovenous malformations. Chronic nonprogressive headaches usually occur for years. Mixed headaches are a combination of acute recurrent headaches (migraine) superimposed on a pattern of daily chronic nonprogressive headaches.7-8

The medical history is critical in evaluating a child's complaints of headache. Both the patient and family should be asked about specific characteristics related to the headache. To assist clinicians, Rothner has created a "headache database" that can be used to formulate a diagnosis (Sidebar 1, see page 347).8

In addition to these important questions and their responses, the clinician must focus on a detailed history of the neurologic system for related symptoms (eg, lethargy, ataxia, seizures, weakness, visual disturbances). Finally, a general review of symptoms related to other organ systems is required for a complete patient history.

Warning signs of symptomatic headaches usually include new onset, occurrence with straining, athletic or other specific activity, association with other neurologic symptoms, change in headache pattern, nocturnal awakening, and bioccipital pain. Additional information related to the medical history, such as history of recent head trauma, neurologic or psychiatric disorders, hospital admissions, and medications, also is important. Furthermore, the description of the pain may be important. Lewis and Qureshi9 prospectively studied 150 children ages 2 to 18 who presented to an emergency department with the chief complaint of abrupt onset of a severe headache. Upper respiratory infections represented the most frequent cause of acute headache (57%). Serious disease was found in 15% of the patients and included brain tumors (2.6%), viral meningitis (9%), intracranial hemorrhage (1.3%), and ventriculoperitoneal shunt malfunctions (2%). Two clinical features, occipital location of pain and an inability of the patient to describe the quality of the head pain, were associated significantly with intracranial pathology (brain tumor and ventriculoperitoneal shunt malfunction).

A physical examination and a detailed neurologic examination, including vital signs, must be performed in a careful manner, with particular attention to those findings unique to children. The height, weight, and head circumference should be plotted with standard percentiles and a history of the child's prior growth. A change in the rate or direction of growth may indicate the presence of an intracerebral mass. Blood pressure should also be measured carefully, with special attention to age-appropriate cuff size and percentiles for age.

The child's head should be auscultated for bruits, and a skin examination should be performed for stigmata of neurocutaneous disorders such as neurofibromatosis. The neurologic examination should include particular attention to the child's mental status, coordination, language, and level of consciousness, as well as an age-specific detailed neurologic examination, including cranial nerves, gait, cerebellar, sensory and motor function, and deep tendon reflexes, and ophthalmologic examination, including pupillary reactivity, visual acuity, extraocular movements, and particularly a funduscopic examination, in an attempt to diagnose any intracranial pathology. A recent review of 3,000 children with brain tumors found 98% had abnormalities on a neurologic examination.10,11 Observation of the interaction between the patient and family may provide clues to potential family problems, depression, or anxiety.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis for headache may include diagnoses listed in Sidebar 2,7

Acute Headache

Acute headache is a common problem in children and adolescents and may accompany many infectious processes. In the absence of other signs of central nervous system (CNS) involvement, such as nuchal rigidity or alteration in level of consciousness, headaches in febrile children usually are not evidence of CNS infection. In fact, nonspecific viral illnesses represent the majority of diagnoses in the child presenting to the emergency department with an acute headache.

Care must be taken to exclude serious acute illnesses such as meningitis, encephalitis, hypertension, and subarachnoid hemorrhage. Patients with meningitis and encephalitis usually present with a history of headache accompanied by other systemic symptoms. Clinical findings range from subtle changes in a child's behavior to severe lethargy, seizures, and shock. Patients with mildly or severely elevated blood pressure may present with a history of headache or symptoms of altered mental status, visual disturbances, seizures, or stroke. These patients require rapid assessment to determine the etiology of their elevated blood pressure.

Patients with subarachnoid hemorrhage usually report the acute onset of a severe headache that frequently is the worst headache of their lives. Nuchal rigidity may be present on physical examination. Furthermore, there are usually, but not always, associated neurologic abnormalities or change in level of consciousness. The headache is maximal in the occipital area, with nausea, vomiting, lethargy, or altered mentation. Diplopia also is seen commonly on presentation. Focal neurologic deficits including hemiplegia, aphasia, seizures, abnormal brainstem reflexes, cranial nerve palsies, abnormal motor posturing, and visual field deficits also may occur.

The most common etiology of subarachnoid hemorrhage in young adults is a ruptured cerebral aneurysm. In younger children, rupture of an arteriovenous malformation that is near the subarachnoid space may cause subarachnoid and intraparenchymal hemorrhage. A common site of bleeding is the anterior cerebral artery, with resulting pressure on the third cranial nerve. Varying degrees of ptosis, lateral deviation of the eye, and pupillary dilation may be seen with this type of aneurysm.

If subarachnoid hemorrhage is suspected, CT of the head (noncontrast) should be performed as soon as possible. A head CT may be normal 5% of the time, especially if only a small amount of bleeding has occurred. If the CT does not show subarachnoid blood, a lumbar puncture (LP) must be performed. The first and last tubes are examined for cells to eliminate the possibility of a traumatic tap (in a traumatic tap the number of red blood cells would be expected to decrease by the last tube) and the presence or absence of xanthochromia, which is present in most cases of subarachnoid hemorrhage if the bleed is more than 6 to 12 hours old but not present in fresh blood as one would find, for example, in a traumatic LP.

Localized acute headaches commonly are due to sinusitis, otitis media, dental disorders, or head trauma. Dental disorders usually are accompanied by localized pain in the teeth, gums, or jaw. Temporomandibular joint dysfunction usually is seen with unilateral pain in the ear, jaw, or mouth. Headache associated with trauma must always be evaluated carefully for the possibility of subdural or epidural hematomas, fractures, and leptomeningeal cyst - a "growing" skull fracture in a child 3 or younger with a history of recent trauma that typically is not painful but does create a pulsatile mass. Ophthalmologic problems such as astigmatism, refractory errors, eye strain, and squint also occasionally are responsible for headaches in children. Other nonspecific causes of acute headache in the pediatric population may include medications, intoxications, and substance abuse.12

Migraine

The diagnosis of migraine is based on symptoms of intense, recurrent headaches separated by pain-free intervals, often associated with other complaints, such as nausea and vomiting. The newly revised classifications of migraine syndromes for pediatric migraine are provided in Sidebar 3.5,13

Migraine headaches are classified primarily into migraine with or without aura. Migraine without aura, also known as common migraine, is the most common type of pediatric and adolescent migraine. It is diagnosed when other disorders have been ruled out and the patient has more than five attacks that last 1 to 72 hours (untreated) plus a minimum of two additional criteria: unilateral location, pulsing quality, moderate to severe intensity, or headache aggravated by routine physical activities and accompanied by at least nausea or vomiting and photophobia and phonophobia.5 It is important to note that children do not have to necessarily meet the duration criteria, as their headaches are usually brief and bifrontal or bitemporal, while in adults, they shift in laterality.

Migraine with aura, previously known as classic migraine, is diagnosed when at least two episodes occur with the following criteria: reversible symptoms arising from focal cerebral or brainstem dysfunction; gradual development of the headache over more than 4 minutes or several symptoms that occur in succession; aura with a duration of less than 60 minutes; and the appearance of a headache either before, simultaneously with, or within 60 minutes of the aura. In children, auras are most commonly visual, but sensory, motor, and psychic auras do occur. Children also may have aura with no headache.5

Several other, less common, classifications of migraine exists. Hemiplegie migraine is characterized by the sudden onset of hemiparesis or hemisensory loss followed by headache in the contralateral hemisphere. This type of migraine is seen more frequently in children than adults. Even though symptoms usually last for hours or days, affected patients rarely are left with permanent deficits. Ophthalmoplegic migraine is characterized by severe unilateral eye pain and headache, followed by ipsilateral third nerve palsy of varying degree. Less commonly, the fourth and sixth cranial nerves may be affected. Basilar artery migraine, also common in children, presents with a combination of visual symptoms (eg, transient bilateral blindness, blurred vision) and visual hallucinations, vertigo, ataxia, loss of consciousness, and drop attacks. An acute confusional state consists of a change in personality, orientation or behavior. "Alice in Wonderland" syndrome includes distortions in body images and shapes. Objects either appear much larger (macropsia) or smaller (micropsia) before, during, or after a headache.

Migraine variants are common. Abdominal migraine is characterized by recurrent abdominal pain, nausea, vomiting, and recurrent headaches. Benign paroxysmal vertigo occurs with the sudden onset of vertigo, pallor, and nystagmus. Paroxysmal torticollis is defined as recurrent episodes of head tilt associated with headache, nausea, and vomiting. It should be noted that this is a diagnosis of exclusion; a child with a head tilt, vomiting, and headache must first be evaluated for a posterior fossa lesion. Ocular migraine is characterized by transient monocular visual blurring to blindness with bright flashes of light.13

Epilepsy and migraine headache are distinct clinical syndromes, yet they share several characteristics, such as aura, vertigo, nausea, pallor, loss of consciousness, drowsy postictal state, confusion, and transient focal neurologic deficits. The incidence of seizures is higher in migraine patients than in the general population. The differentiation of these two clinical entities may be difficult in certain cases. Headache as the sole manifestation of a seizure is uncommon; however, headaches frequently may follow tonic, tonic-clonic, and brief complex-partial seizures. Bifrontal throbbing headaches also may follow episodes of status epilepticus. Further neurologic evaluation including electroencephalogram (EEG) may be necessary to try to distinguish these two syndromes.

Chronic Progressive Headache

The chronic progressive headache category is composed of disorders that cause progressive severe headaches in children. The development of increased intracranial pressure (ICP), which can be caused by brain tumors, pseudotumor cerebri, hydrocephalus, brain abscess, and intracranial bleeding, is a significant problem caused by these types of headaches. Headaches that awaken the child or are present when first awakening are a classic symptom of increased ICP Impaired venous outflow in the supine position leads to excess fluid (blood, CSF, or edema) inside the skull, causing increased pressure. Nocturnal or morning emesis may also suggest increased ICP The physical examination may show symptoms of increased ICP (eg, papilledema, brisk reflexes, cranial nerve deficits, upgoing toes, decreased level of consciousness) as well as focal symptoms related to the location of the lesion (eg, hemiparesis, ataxia, visual field deficits).

Headaches may be the first symptom of a brain tumor and occur with increasing frequency with age. In one study, 18% of children up to age 5, 52% of children ages 6 to 10, and 68% of children ages 11 to 20 who had brain tumors presented with headaches.14 The authors also found a significant delay in the diagnosis of brain tumors. Only 38% of primary brain tumors were diagnosed within the first month after the onset of symptoms. In another study, 62% of 3,291 children diagnosed with brain tumors had headaches before the diagnosis of their brain tumor.10,15 More than 50% of these children had at least three associated symptoms, such as nausea, vomiting, visual effects, problems walking, weakness, or changes in personality, school performance, or speech. The most common neurological findings were papilledema, abnormal eye movements, ataxia, abnormal tendon reflexes, and an abnormal visual examination.

Clinical findings of pseudotumor cerebri (idiopathic intracranial hypertension) are secondary to increased ICP and include papilledema, sixth cranial nerve palsy, and visual field obstruction. This condition is more common in females and in younger compared with older age groups. It also is associated with obesity, otitis media, head trauma, vitamin A, steroids, oral contraceptives, tetracycline, menstrual irregularities, diseases that produce obstruction of the CSF pathways, and obstruction of the major venous sinuses. By definition, neuroimaging is normal. The LP usually demonstrates elevated opening pressure, often more than 20 cm H20, and normal CSF protein and glucose. Neuroimaging should precede an LP when increased ICP is suspected. Treatment may include diuretics and repeated LP to remove CSF7 Hydrocephalus may be related to a previous episode of meningitis, subarachnoid hemorrhage, or head injury or may be congenital, such as seen with aqueductal stenosis.

Brain abscess can result from meningitis, head trauma, chronic otitis media and sinusitis, or septic embolization in children with cyanotic congenital heart disease. Focal neurologic signs as well as fever and headache may be present in these patients, but the patient may look surprisingly well. This problem is considered a neurosurgical emergency, as abscesses can grow quickly. Before an LP is performed and the opening pressure is measured, CT of the head should be performed to determine if there is a mass lesion. When an abscess is suspected, intravenous contrast must be administered to look for a ring-enhancing lesion. The abscess may be missed without contrast. CSF findings usually include 10 to 200 leukocytes/mm3, slightly elevated protein, and normal glucose levels. The CSF smear and culture usually do not reveal any organisms.

Subdural hematoma usually is associated with head trauma. Symptoms include those associated with increased ICP; seizures and other focal neurologic deficits also may be present. The diagnosis is confirmed by neuroimaging. Postconcussive headaches are common. These headaches may be severe and associated with dizziness and vomiting. Bleeding and hydrocephalus must be considered in these cases. Chronic progressive headache also may be a symptom of systemic diseases such as hypertension, collagen vascular disease, hypothyroidism, Lyme disease, mononucleosis, or inborn errors of metabolism.

Chronic Nonprogressive Headache

This type of headache is seen commonly in the adolescent population. Included in this category are patients with tension headaches, muscle contraction headache, depressive equivalents, and conversion headaches. Symptoms include bilateral or frontal headache; nonthrobbing, pressing, or bandlike tightness of mild to moderate intensity; and the absence of nausea, vomiting, or aura. These headaches are classified further as either episodic (10 episodes but fewer than 15 per month, lasting 30 minutes to 7 days) or chronic (more than 15 episodes per month for greater than 6 months).

Ouster Headache

Cluster headache is a distinctive headache syndrome more commonly seen in males. The syndrome is rarely seen in those younger than 10. Cluster headache is characterized by one to several attacks recurring each 24 hours, over several weeks to months, with headache-free periods between the cluster headaches. The headache-free periods may last from months to years. The pain is throbbing, severe, and unilateral; occurs over the same orbitotemporal region; and is associated with ipsilateral scleral injection, lacrimation, nasal stuffiness, and, less often, partial Horner's syndrome. The pain lasts 30 minutes to several hours and can occur at any time of day or night.

EVALUATION

The diagnosis of a specific headache syndrome usually is determined by the history and physical examination. The acute presentation of a severe headache in a child needs to be differentiated from other clinical presentations. The primary concern is to eliminate the possibility of an intracranial lesion or serious extracranial pathology. When considering subarachnoid hemorrhage, acute or chronic meningitis, idiopathic intracranial hypertension, or other systemic conditions, LP with measurement of opening pressure may be indicated. Neuroimaging should precede a lumbar puncture if there are any signs of increased intracranial pressure, mental status changes, nuchal rigidity with or without alteration of consciousness, or lateralizing features.16,17

Skull radiographs and EEG are of limited value in the routine emergency department evaluation of children with chronic headaches. EEG is of limited use owing to problems in both sensitivity and specificity; the test may be abnormal in a large number of otherwise normal patients with headache and may be normal in patients with well-documented epilepsy. CT and MRI are extremely helpful when used appropriately.

Radiology

CT and MRI of the head are excellent imaging instruments to evaluate patients with headaches.716 In a recent review of related studies to determine recommendations for neuroimaging, variables that predicted the presence of a space-occupying lesion included headache of less than 1 month duration, absence of family history of migraine, abnormal neurologic findings on examination, gait abnormalities, and occurrence of seizures.16

MRI is particularly useful in detecting abnormalities in areas not well visualized on CT, such as the sella turcica, temporal lobes, posterior fossa, and cervicomedullary junction. MRI also is advantageous because of its superior ability in detecting arteriovenous malformations and low-grade tumors. In general, an MRI provides superior anatomic detail compared with CT scan. However, a patient cannot be closely monitored during MRI. Therefore, CT is the method of choice in the potentially unstable patient. Additionally, CT is actually superior to MRI in the detection of acute bleeding.

Indications for the use of neuroimaging are described in Sidebar 4 (see page 350). The evaluation of the child with a CSF shunt includes, if possible, a comparison of ventricular size with previous CT scans. Enlarged ventricular size alone does not always mean there is a shunt obstruction; it also can occur in normally functioning shunts.11,18

Laboratory and Special Procedures

LP, with the measurement of opening pressure, may occasionally be helpful in the evaluation of patients with headache. However, if the possibility of mass lesion exists, radiologic imaging should precede the LP. The LP is a necessary procedure to determine the presence of an infectious process, hemorrhage, or, in the case of pseudotumor cerebri, elevated pressure.

In a patient with suspected chronic progressive headaches, the headaches may be a symptom of a systemic disease. Laboratory tests that should be considered include complete blood count, urinalysis, erythrocyte sedimentation rate, antinuclear antibody, liver function studies, thyroid function studies, serum lipids, serum magnesium, lactate and pyruvate, and a Lyme disease titer.

MANAGEMENT AND DISPOSITION

Treatment of primary childhood headaches requires attention to initial pharmacologic management as well as reassurance, removal of potential triggering factors, and initiation of a behavioral management program, including attention to sleep, diet, hydration, and exercise.19 A headache diary is important to help the patient identify potential triggers and the effects of medications. Common triggers include reduction in sleep, perimenstrual stress, missed meals, and foods such as caffeine, chocolate, processed meats, alcohol, hard cheeses, red wine, monosodium glutamate, yeast extracts, nuts, figs, aspartame, and sauerkraut. Children with primary headaches are not admitted for care unless the diagnosis is uncertain and a serious cause of secondary headache is being considered.

Treatment of migraine headache includes analgesics, vasoconstrictors, sedatives, antiemetics, and other modalities. The patient should be placed in a quiet and safe environment. Simple analgesics and rest are the first line of treatment for patients with migraine as well as nonmigraine headache.19"23 These medications include appropriate doses of acetaminophen (10 to 15 mg/kg/dose, or 650 to 1,000 mg for patients 12 or older), and the nonsteroidal anti-inflammatory drugs (aspirin 10 to 15 mg/kg/dose, or 650 to 1,000 mg for patients 12 or older; Ibuprofen 5 to 10 mg/kg/dose, or 400 mg for patients 12 or older; or naproxen 2.5 to 5.0 mg/kg/dose, or 250 to 300 mg for patients 12 or older).

For severe migraine episodes, more potent analgesics may be needed. Ketorolac tromethamine (Toradal), a nonsteroidal anti-inflammatory, may be used parenterally when vomiting is present (0.5 mg/kg IV or intramuscular [IM] as a single dose; maximum dose 30 mg). Other options include codeine (0.5 to 1.0 mg/kg/dose every 4 to 6 hours orally; maximum dose 60 mg) or oxycodone (0.05 to 0.15 mg/ kg/dose every 4 to 6 hours orally; maximum dose 5 mg every 6 hours). However, many suggest that opioids should be avoided due to rebound headaches and dependence.

Combination medications, such as Fiorinal (butalbital, aspirin, and caffeine), Fioricet (butalbital, acetaminophen, and caffeine), and Midrin (isometheptene, acetaminophen, dichloralphenazone), also are effective. The dose is 1 to 2 capsules in children older than 12. Caution should be used in prescribing these medications. In addition to producing an analgesic effect, these medications may produce alterations of emotional state, sedation, and psychological dependence.

In the adolescent population, vasoconstrictor drugs may be used rarely; however, this class of medications is more commonly used in the adult population. If severe vomiting is present, antiemetic agents such as promethazine (children older than 2: 0.25 to 0.5 mg/ kg/dose IV, IM, or orally as needed; maximum dose = 25 mg) every 4 to 6 hours as needed), metoclopramide (1 to 2 mg/kg/dose every 2 to 6 hours as needed), and prochlorperazine (children weighing more than 10 kg or older than 2: orally as needed: 0.4 mg/kg/24 hours, divided into three to four doses per day; or IM: 0.1 to 0.15 mg/kg/dose three to four times per day). One must be aware of the potential for dystonic reactions with these agents.

Sumatriptan (Imitrex) is a selective 5-HT1 receptor agonist that can mediate cerebral vasoconstriction and block inflammatory response. It can be administered orally, intranasally (which may benefit those patients who cannot take oral preparations due to vomiting), or subcutaneously A recent review of medication trials of triptans in children with migraine highlighted the important fact that there were some results of randomized clinical trials with no difference found in outcome between the control and experimental groups.22

When evaluating these studies, it is important to consider route of administration (eg, oral, intranasal, subcutaneous), age of study participants, length of time of current headache, length of time of a history of chronic headache, and other potentially confounding variables. In one pediatric study, there was a 78% response rate within 60 minutes using a single subcutaneous administration of 0.06 mg/kg.24 In another study, nasal sumatriptan (5 to 20 mg repeated in 2 hours; maximum dosage 40 mg/ day) was shown to be moderately effective in a randomized clinical trial in an adolescent population,25 along with oral preparations of 25 to 50 mg (repeat in 2 hours; maximum dosage 200 mg/day). In that study, headache relief 1 hour after receiving medication was significantly greater for patients taking 10 mg (56%) and 20 mg (56%) of sumatriptan nasal spray, compared with placebo (41%; P < .05). Headache relief at 2 hours postdose was reported by more patients using 5 mg of sumatriptan nasal spray (66%) compared with placebo (53%; P < .05). It is interesting to note that a large percentage of the placebo group also had headache relief noted at both 1 and 2 hours post-dose.

Another randomized clinical trial in children (age 12.4 ±2.4 years, mean ± standard deviation [SD], range 8.1 to 17.5) compared nasal sumatriptan (10 mg for body weight between 20 kg and 39 kg and 20 mg for body weight greater than 40 kg) with a placebo.26 After 1 hour, headache relief was observed significantly more often by those assigned to the sumatriptan group (51% versus 39%; P = .014). Note that in this study as well, a moderate but lower percentage (39%) compared with the Winner study25 of the control group also found relief from their headache 1 hour postdose, with the best results after 2 hours. This suggests that the drug may be more efficacious in children with a longer duration of headache.

Sumatriptan should be avoided in people with any present or prior cardiac disorders or hypertension and in patients who have received an ergot alkaloid in the preceding 24 hours. Other new 5HTl agents such as zolmitriptan (Zornig), at doses of 2.5 mg and 5 mg, compare favorably with sumatriptan. Cluster headaches, which are brief and may not respond to oral therapy, may be treated with inhalation of oxygen 4 to 5 L/min, caf ergot, or sumatriptan.8

The use of pharmacologic agents for the prophylactic treatment of migraine headache in children requires careful observation and follow-up evaluation by the child's family and physician. The indications to use these medications include more than two to three headaches per week and interference with lifestyle, particularly missed school days or inability to participate in social activities. Because of the high spontaneous remission rate in childhood migraine, the placebo effect of many medications is very high. Controlled studies are extremely limited. Medications that have been used include propanolol (initiated slowly, 2 to 4 mg/ kg/day divided three times a day; contraindicated in asthma); amitriptyline (initiated slowly, 25 mg at bedtime for adolescents; obtain a baseline echocardiogram first); calcium channel blockers; anticonvulsants (particularly valproic acid; topiramate and zonisamide also have Food and Drug Administration indication for migraine; topiramate comes in sprinkle caps); cyproheptadine; and naproxen sodium. Cyproheptadine, valproic acid, and naproxen are available in liquid form, which is valuable in the pediatric population. Methysergide should be avoided in children because of serious side effects, including retroperitoneal fibrosis. Amitriptyline may be useful for adolescents with a diagnosis of migraine and muscle contraction headaches and in children with depression and headaches.23

SUMMARY

Headache is an incredibly common complaint, but a detailed evaluation is necessary to diagnose some life-threatening diseases that may have their initial presentation in this manner. The evaluation and management of pediatric headaches requires close attention to a detailed "headache history," physical, neurological, and ophthalmologic examinations, and, when indicated, specific neuroimaging studies. Close follow-up of those patients with headaches is mandatory, whether they are placed on long-term or short-term medications. It also is important to appreciate the potential co-existence of headaches with other chronic disorders, such as asthma or diabetes.

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20. Powers S, Andrasik F Biobehavioral treatment, disability, and psychological effects of pediatric headache. Pediatr Ann. 2005; 34:(6):461-465.

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22. Damen L, Bruijn J, Verhagen A, et al. Symptomatic treatment of migraine in children: a systematic review of medication trials. Pediatrics. 2005;116(2):e295-e302.

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24. Linder SL. Subcutaneous sumatriptan in the clinical setting. The first 50 consecutive patients with acute migraine in a pediatric neurology office practice. Headache. 1996; 36(7):419-422.

25. Winner P, Rothner DA. Saper J, et al. A randomized, double blind, placebo controlled study of sumatriptan nasal spray in the treatment of acute migraine in adolescents. Pediatrics. 2000;106(5):989-997.

26. Anonen K, Hamalainen M, Rantala H et al. Nasal sumatriptan is effective in treatment of migraine attacks in children; a randomized trial. Neurology. 2004;62(6):883-887.

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