Headache management in kids: ‘When to worry and what to do’

Key takeaways:

• Headache affects up to 51% of young children and 82% of adolescents.
• Effective headache treatment plans including acute and preventive measures are a must for this patient population.

ORLANDO, Fla. — Although children often suffer from headache, there are few controlled trials that include this unique patient population, leaving clinicians to rely on their experience rather than data, according to a presenter.

“Headache is frequent in the pediatric population ... treatment strategies can be a bit tricky,” Debra M. O’Donnell, MD, pediatric neurologist at Dayton Children’s Hospital in Ohio, told attendees at the American Neurological Association annual meeting. “The other thing that can get interesting in our population is the risk-taking behavior and unhealthy choices of our teenage population.”

According to statistics cited by O’Donnell, headache is the seventh most common cause of disability worldwide, which affects 37% to 51% of children aged 7 years and 57% to 82% of children aged 15 years. Migraine risk has a significant genetic factor, with the risk for children at 50% if one parent has migraine and 75% if both parents experience the condition. In addition, O’Donnell said, 2% to 3% of all patients with migraine convert from chronic to disabling per year due to a range of factors, including stress, caffeine use, sleep difficulties arising from stress or excessive screen time.

When managing children with headache, O’Donnell shared examples of “when to worry and what to do”:

• Nocturnal and early morning headaches are concerning in any patient.
• When preschool-aged children also present with belly pain and report “not feeling good,” this indicates they are worried about throwing up during their next meal but may not be able to communicate this information.
• Occipital location, particularly in children aged 5 years and younger, could indicate symptoms of posterior fossa tumors, and these patients may require imaging.

Once potentially more serious conditions are ruled out or managed, O’Donnell said clinicians can move forward with headache management, including preventive medications (for headache occurrence at least once a week) and rescue medications (for headache accompanied by severe pain, where daily activities are disrupted), the majority of which are off label.

Currently, preventive measures include vitamin B2 and magnesium, along with medications such as amitriptyline and gabapentin. The safety and efficacy of medications such as cyproheptadine, propranolol and topiramate are often dose- and age-dependent. Rescue medications beyond aspirin, ibuprofen and acetaminophen include the age-dependent sumatriptan, rizatriptan and zolmitriptan, as well as nasal dihydroergotamine spray, which is not approved for use in younger children but safe for adolescents.

Also available to parents and children is the SMART approach (sleep, meals, activity, relaxation, triggers), which takes into account a broader approach to healthier habits aimed at headache prevention.

“We have multiple places doing [clinical] trials on younger kids, which will hopefully be published soon,” O’Donnell said.