Children who present with daily or near-daily headaches are often referred to a headache specialist. They may have started out with intermittent migraine or tension-type headache, or present with a new headache that has not resolved. In this article, we present actual cases of children with chronic daily headache (CDH) and offer approaches that highlight treatment options. We touch on what is known about treatment and what lies ahead for these children. Although these patients may need to see a headache specialist to optimize treatment, the pediatric provider needs to be aware of the plan from the specialist and help with implementation.
CDH usually fits a chronic non-progressive pattern in which there is a steady background of headache, which is often punctuated by an acute spike reminiscent of migraine. Patients with daily or near-daily headache may need neuroimaging to rule out intracranial lesions, while patients with a good history for migraine and a normal physical examination do not require further workup.1
Three attempts at classification of CDH are worth summarizing. In 1994, Silberstein and colleagues divided CDH in adults into four categories:
- Chronic tension-type headache (CTTH)
- Chronic migraine (CM)
- Hemicrania continua (HC)
- New daily persistent headache (NDPH)
These categories were further subdivided into those with or without medication overuse.2
In CTTH, there is no history of migraine features before the transformation to daily headache or while daily headache is in place. In CM, there was either a previous history of migraine, or current spikes of migraine superimposed on the steady nonmigraine baseline. In HC, there is continuous one-sided headache and autonomic features. This headache typically responds to indomethacin. In NDPH, there is no transformation. The headache started abruptly as a constant pain and never left.
In 1996, Gladstein attempted to field test these criteria on a group of children with CDH and found that most had CM. Of interest, very few of the children had medication overuse, and the interval from initial headache to daily headache was only 2 years, as compared with 10 years in adults.3
In 2000, Koenig pooled data from eight pediatric headache centers and found that most of the children with CDH had a baseline of nonmigrainous headache with spikes of severe pain from time to time.4
Hershey presented data from his practice in Cincinnati and looked at prognostic outcome in CDH. He found that the group who did the best had headache not every day and not all day. The intermediate group had headache every day but not all day. The worst outcomes were in the children who had headache every day and all day.5
Our newest classification scheme, the International Classification of Headache Disorders-II (ICHD-II), does not include CDH as a separate category because it focuses on headaches as being either primary or secondary. As CDH develops, features can sometimes be blurred. So in this iteration, CDH is relegated to the appendix. In one who has chronic headache with occasional migraine spikes, two headache diagnoses are given. Most practitioners still rely on the Silberstein criteria for its usefulness, despite not being accepted into the ICHD-II.6 The following cases will help us focus on the diagnosis and treatment of chronic headache in children.
Clinical Vignette #1
Cheryl is a 15-year-old girl who has had a daily headache since September. She has a 5-year history of occasional migraine headaches. Initially, the migraines were occurring about once a month. Starting last year, there was an increase in the frequency of migraine to three times a week. Now, she complains of a daily headache. Since this daily headache has started, she has had trouble going to sleep, often taking 2 hours or more to fall asleep. She states that she has two types of headaches. First, she has very severe headache pain that she describes as a 10 out of 10 pain. These severe headaches resemble her migraines and occur three to five times a week. In addition, she has a daily, 24-hour-a-day, 7-days-a-week headache, which she describes as a 5 out of 10.
This girl would be described best as having a CDH because she has more than 15 headache days a month for more than 3 consecutive months. She would specifically have a chronic migraine form of a CDH.
Most patients, such as Cheryl, state that their migraines are severe headaches that are often bifrontal or bi-temporal. The headaches occur with a visual aura in about one-third of patients. Migraines are typified by significant avoidance of light (photophobia), sound (phonophobia), and strong odors (osmophobia). Patients often are nauseated and may vomit. During these severe headaches, sleep may be one of the only interventions that helps with the pain. They may additionally complain of allondynia, in which normal touch sensation now feels painful to them. Vertigo and dizziness also occur.
The daily headache component is frequently described as 24 hours a day, 7 days a week, although some patients may have occasional headache-free times. These 24/7 headaches do not always meet full criteria for migraine and are considered tension-type headaches by some physicians. However, many patients describe their severe migraines and the 24/7 headache as having the same characteristics, only differing in severity. This suggests that both headache types can be a form of migraine, differing only in the degree of pain.
The trigger factors that make the migraine worse are typically the same that make the intensity of CDH worse. Major trigger factors are lack of adequate sleep and stress caused by busy schedules. In many of our patients, the transformation from an episodic migraine to a daily headache occurs at the beginning of the school year. This is an extremely busy time, when teenagers are getting up at 6 a.m. to go to school; their schedules have increased because of in-school activities, homework, extracurricular activities, and social activities.
The typical teenager may need 9 to 10 hours of sleep per night. A helpful metric to determine if the child has received enough sleep is to as ask if they feel tired or rested when they wake up in the morning. Many are quite tired, even after awakening from a “full” night’s sleep. Often, the patients will have difficulty falling asleep. There are several challenges to sleep in the teen patient. An increase in pain can make it harder to sleep. There is a natural tendency for teens to stay up late, and school usually requires an early rise time. Worry about school absence may exacerbate the problem. Interventions can include discussions of sleep hygiene (avoid caffeine late in the day, turn off the TV while going to bed), use of melatonin, and education of how much sleep is needed. A big mistake we may make is to keep these children from school, thereby eliminating the need to wake up at a regular time.
We also ask our patients if they routinely miss meals (many teens often miss breakfast), are affected by the weather, have specific food triggers, if they realize that they may get worse headaches just before their menstrual period, and we discuss motion sickness. Stress and worry are frequent in migraine patients and aggravate the patient’s headaches.
Assuming a negative workup (magnetic resonance imaging, MRI, plus tailored other tests), one must now focus on disability as measured by absenteeism and presenteeism. Absenteeism is reflected simply as days of work/school missed. Presenteeism refers to the child who goes to class but cannot concentrate because of head pain. This can be measured by dropping school performance. The more disabled the patient, the more aggressive to be in the treatment plan. If there is medication overuse, it must be dealt with either aggressively (cold turkey approach) or gradually (slow wean approach).
Preventive medications can be used daily to decrease the background frequency of headaches and, hopefully, to prevent future severe headaches (see Table, page 426). Patients expect these medications to make them headache-free instantly. Headache doctors are pleased if these medications can reduce the frequency of the headaches by 50% or more and anticipate that it will take weeks, sometimes months, for the benefits to be appreciated. The highest quality evidence in migraine trials shows that topiramate can be effective in adolescents with migraine at a dose of 100 mg a day, but that 50 mg a day is no more effective than placebo.7 Other studies support the use of amitripty-line, typically given at a dose of 0.5 to 1 mg/kg/day.8,9 Other choices, including propranolol and riboflavin, can be used as well (see Table, page 426).10
Table. Preventives Used in the Treatment of Chronic Daily Headache
Biobehavioral approaches, such as biofeedback, relaxation, hypnosis, and yoga, work well for the motivated patient, but do not work at all for those who will not practice.11 Herbal medicine and vitamins have a role for those who prefer this route.12 Acupuncture works but is not for everyone.13
Patients would like to get back to a headache-free life quickly, but from a practical aspect, this is often hard to accomplish. In the experience of these authors, it is usually necessary first to improve sleep, as it is nearly impossible to get patients headache-free on only 6 or 7 hours of sleep per night. After sleep improves, the most severe migraine-like headaches often become less frequent. A reasonable expectation is to reduce the frequency of the severe headaches to a rate of one to two per month, which is the frequency of migraines in the average patient with episodic migraine. Finally, the all-the-time headache will start to reduce in intensity, and the patient will experience more and more headache-free periods. Even under the best of circumstances, this improvement may take months to accomplish.
Getting back to school is a significant challenge for many patients. After weeks to months of the CDH, the children withdraw from school, develop worsening sleep habits; they also become less active, are lightheaded with standing, and less functional. We encourage patients always to maintain at least some footprint in the school, even when they have daily headaches. It is useful to ask the family to define what specific target symptom is keeping the child from school. When it is the occasional migraine headache, then it may be beneficial to generate a 504 plan with the school and allow the child to leave the classroom during a severe headache, go to the nurse’s office to rest briefly and to receive appropriate medications, and then to try and return to class in 20 to 30 minutes. For patients with very frequent severe headaches, or for those who have been out of school for many months, it is useful to start the children back to school with partial days, sometimes attending only one or two classes a day with lunch, or at the end of the day, so the children can get adequate sleep.
It is difficult for many families to comprehend that the head pain can persist for such a long time, that there are no abnormalities on diagnostic testing, and that the prescribed medications are not immediately effective. It is not unusual for these patients to see multiple doctors because of this frustration. To limit this frustration, it is useful to spend adequate time with the patient and their family in discussing CDH. The discussion should include describing what CDH is, how secondary causes of headache have been ruled out, the role of medications, when not to use pain relievers, the role of non-medication approaches (such as biofeedback or physical therapy), and what the family should expect in the near term and long term (see Sidebar).
- Ask patients to identify each headache type
- Identify multiple target symptoms, such as sleep problems, dizziness or anxiety, since these may be just as disabling as the headaches
- Educate family about chronic daily headache
- Set reasonable expectations for family
- Offer a multidisciplinary approach to treatment, with appropriate follow-up
Key Points in Chronic Daily Headache Treatment
Clinical Vignette #2
Robert has had no significant previous headache history until September 24, when he developed a flu-like illness. The flu-like illness has resolved, but since that day, he has developed a daily headache and significant dizziness when standing. These symptoms have persisted for months and kept him from school.
NDPH occurs in patients with no previous headache history (although there is frequently a family history of migraine). Patients develop a persistent headache that persists for months to years.14 This headache may have characteristics of chronic migraine, as in the first vignette or, alternatively, just the 24/7 headache. Patients can often remember the specific day, sometimes the specific hour, when their headache first developed. The onset of this headache is often, but not always, associated with a physiologic stress, frequently a flu-like illness or mononucleosis.15
There is sparse literature about treatment of this form of new-onset headache compared with CTTH or CM. Treatment approaches are similar to that described for our first patient, Cheryl, with the added problem of dizziness that often accompanies this type of headache. There is almost an autonomic system distress that affects not only headache, but blood pressure, and temperature homeostasis.
Patients with NDPH or other forms of CDH often complain of two types of dizziness. One type is typically position independent, lasting for minutes to hours, and is usually present during severe migraine attacks. There is often a component of vertigo associated with this, and the etiology is likely migrainous.
A second type of dizziness may occur all the time and is associated with standing up (orthostasis). These forms of orthostatic intolerance may be called a postural orthostatic tachycardia syndrome, or neurocardiogenic syncope. With standing (or during a tilt table test), these patients exhibit symptoms associated first with tachycardia and (in some patients) with a drop in their blood pressure. Patients report feeling lightheaded, loss of vision, nausea, and fatigue with a change in position. In occasional patients with this history, antibodies to nictotinic acetylcholine receptors have been noted.16
Treatment of orthostatic intolerance can include increasing fluid and salt intake. Some authors recommend at least eight 8-oz glasses of fluid per day (64 oz or more total), although this will vary by the patient’s needs. Other approaches can include using beta-blockers to reduce tachycardia associated with these symptoms, or alternatively alpha-adrenergic agents, such as midodrine to increase blood pressure.17
Other general lifestyle approaches are helpful for the symptoms of orthostatic intolerance, poor sleep, and CDH. This includes having the child establish a routine in life, both for sleep and returning to school, even if it means returning to school only on a part-time basis to start. Aerobic exercise on a daily basis can be accomplished by almost all of our patients, although in those ill for a long period of time, it is best to start slowly (eg, 10 minutes per day) and gradually increase as tolerated to a target of 30 minutes/day for most patients.
Clinical Vignette #3
Katie is a 13-year-old who has a left posterior headache after a basketball injury. She previously had no significant headache history. While playing basketball, she slipped and hit the left side of the back of her head on the floor. Since then, she has developed frequent left-sided headaches with photophobia, nausea, and the need to go to a dark room and rest. In addition to her five headaches per week, she has developed difficulties concentrating and feels that she is forgetful.
Posttraumatic headache is common, with many patients developing frequent migraine or tension-type following after a head trauma. The severity of the trauma does not seem to predict the development of these headaches. In general, most patients show gradual resolution of their headaches with time. However, some patients can have headaches for months to years.
The evaluation of a posttraumatic headache requires additional consideration. A neuroimaging study should be performed to rule out an intracranial hemorrhage. A carotid artery dissection can occur with sudden flexion injuries of the head, as may be seen in divers or wrestlers. This can be investigated with a magnetic resonance angiography (MRA) of the neck vessels. Patients experience focal nerve injury with head trauma, and the patient in this vignette may also have neuralgia of the left greater occipital nerve.
In patients complaining of memory or concentration difficulty, an evaluation by a neuropsychologist may be helpful to find ways the school district can provide additional support for the child. Comorbidities, such as anxiety or depression, are frequent in patients with CDH, but head trauma can often exacerbate these symptoms. Psychologists, particularly those with past experience in the area of headaches or head trauma, can be of great help to the patient.
In this particular case, amitriptyline is often a first-line treatment for headache prevention. Topiramate is an excellent preventive, but adult studies show that 10% to 20% of patients have difficulties with word finding with this medication. All the general principles we discussed for Cheryl apply to Katie as well.
There may be added pressure put on Katie by her coaches or parents to return to competitive sports. Having a second concussion has been shown to be detrimental to final outcome, so judicious return to athletics must be considered on a case-by-case basis. American Academy of Neurology (AAN) and American Academy of Pediatrics (AAP) guidelines can be used to help reach a reasonable understanding when conflict about return to sports becomes an issue.18
CDH among adolescents is a common problem and can be a daunting clinical challenge. These three cases represent examples of the type of CDH patterns frequently encountered and the management regimen options. Reducing pain and functional disability requires a supportive family, a healthy lifestyle, including regular sleep, exercise, and meal schedule, biobehavioral strategies, such as biofeedback, guided imagery, or cognitive control techniques, coupled with a judicious blend of daily preventive medications and analgesics (ie, naproxen or triptan) at the appropriate point in the headache pattern (see Figure).
Figure. Reducing Pain and Functional Disability Requires a Supportive Family, a Healthy Lifestyle, Biobehavioral Strategies, Coupled with a Judicious Blend of Daily Preventative Medications and Analgesics at the Appropriate Point in the Headache Pattern.
- Lewis DW, Ashwal S, Dahl G, et al. Quality Standards Subcommittee of the American Academy of NeurologyPractice Committee of the Child Neurology Society. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002;59(4):490–498.
- Siberstein SD, Lipton RB, Solomon S, Mathew NT. Classification of daily and near-daily headaches: proposed revisions to the IHS criteria. Headache. 1994;34(1):1–7. doi:10.1111/j.1526-4610.1994.hed3401001.x [CrossRef]
- Gladstein J, Holden EW. Chronic daily headache in children and adolescents: a 2-year prospective study. Headache. 1996;36(6):349–351. doi:10.1046/j.1526-4610.1996.3606349.x [CrossRef]
- Koenig MA, Gladstein J, McCarter RJ, Hershey AD, Wasiewski WPediatric Committee of the American Headache Society. Chronic daily headache in children and adolescents presenting to tertiary headache clinics. Headache. 2002;42(6):491–500. doi:10.1046/j.1526-4610.2002.02124.x [CrossRef]
- Hershey AD, Kabbouche MA, Powers SW. Chronic daily headaches in children. Curr Pain Headache Rep. 2006;10(5):370–376. doi:10.1007/s11916-006-0062-7 [CrossRef]
- Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24Suppl 1:9–160.
- Lewis D, Winner P, Saper J, Ness S, et al. Randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of topiramate for migraine prevention in pediatric subjects 12 to 17 years of age. Pediatrics. 2009;123(3):924–934. doi:10.1542/peds.2008-0642 [CrossRef]
- Hershey AD, Powers SW, Bentti AL, Degrauw TJ. Effectiveness of amitriptyline in the prophylactic management of childhood headaches. Headache. 2000;40(7):539–549. doi:10.1046/j.1526-4610.2000.00085.x [CrossRef]
- Descombes S, Brefel-Courbon C, Thalamas C, et al. Amitriptyline treatment in chronic drug-induced headache: a double-blind comparative pilot study. Headache. 2001;41(2):178–182. doi:10.1046/j.1526-4610.2001.111006178.x [CrossRef]
- Lewis D, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein SAmerican Academy of Neurology Quality Standards SubcommitteePractice Committee of the Child Neurology Society. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology. 2004;63(12):2215–2224.
- Andrasik F. What does the evidence show? Efficacy of behavioural treatments for recurrent headaches in adults. Neurol Sci. 2007;28Suppl 2:S70–S77. doi:10.1007/s10072-007-0754-8 [CrossRef]
- Taylor FR. Headache prevention with complementary and alternative medicine. Headache. 2009;49(6):966–968. doi:10.1111/j.1526-4610.2009.01447.x [CrossRef]
- Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev. 2009;(1):CD001218.
- Mack KJ. New daily persistent headache in children and adults. Curr Pain Headache Rep. 2009;13(1):47–51. doi:10.1007/s11916-009-0010-4 [CrossRef]
- Mack KJ. What incites new daily persistent headache in children?Pediatr Neurol. 2004;31(2):122–125. doi:10.1016/j.pediatrneurol.2004.02.006 [CrossRef]
- Murali HR, Mack KJ, Kuntz NL. Acquired orthostatic intolerance and alpha-3 ganglionic acetylcholine antibodies in an adolescent girl. Clin Auton Res. 2009;19:298.
- Johnson JN, Mack KJ, Kuntz NL, Brands CK, Porter CJ, Fischer PR. Postural orthostatic tachycardia syndrome: a clinical review. Pediatr Neurol. 2010;42(2):77–85. doi:10.1016/j.pediatrneurol.2009.07.002 [CrossRef]
- Cohen JS, Gioia G, Atabaki S, Teach SJ. Sports-related concussions in pediatrics. Curr Opin Pediatr. 2009;21(3):288–293. doi:10.1097/MOP.0b013e32832b1195 [CrossRef]
Preventives Used in the Treatment of Chronic Daily Headache
||0.5–3 mg/kg/day; 25–150 mg/day
||Patients metabolize at different rates; Need for EKG and drug levels at higher doses; weight gain
||1–2 mg/kg/day; 100–200 mg/day
||Decreased appetite, difficulty in thinking and word finding
||1–2 mg/kg/day; 60–120 mg/day
||Occasional exercise intolerance, irritability, nightmares, asthma, sexual side effects
|Riboflavin (vitamin B2)
||200 mg twice daily
||Give with food to prevent upset stomach
||Weight gain; teratogenic; rare liver and pancreatic problems
||Constipation, dizziness, need to follow QT interval on EKG