Headaches are a very common complaint in our patient population. Occurs in up to 90% of school-aged children by 18 years old. 20% of children 4-18 y/o report having had frequent or severe headaches in the past 12 months. Case
Headaches Headaches are a very common complaint in our patient population. Occurs in up to 90% of school-aged children by 18 years old. 20% of children 4-18 y/o report having had frequent or severe headaches in the past 12 months.
Case: a 15 y/o female presents for WCC today. The only concern from mother is that her daughter is complaining of frequent headaches. What questions do you have for her? What physical exam maneuvers will you perform?
Important aspects of the History:
See American Academy of Neurology recommendations & American College of Radiology Appropriateness Criteria attached.
Routine laboratory & imaging studies are not indicated
Neuroimaging of children with headaches in the absence of neurological abnormalities on exam and/or symptoms of neurologic abnormalities on history has a low yield of clinically significant findings = 0.0-1.2%2.
Neuroimaging should be considered in the following situations (AAN recommendations):
Abnormal neurological examination or other findings that suggest CNS disease
Other factors predictive of space occupying lesion:
Headache <1 month
Absence of family history of migraines
Chronic Daily Headache:
Present for >15 days/month for at least 3 months in the absence of detectable organic pathology
4 subtypes of daily headaches based on International Headache Society:
New Daily persistent
Most common acute & recurrent headache syndrome in children.
Prevalence increases from 3% (age 3 to 7 years) to 4-11% (7-11 years) to 8-23% (11-15+)
More common in females
Types of Migraines:
Migraine with Aura (formerly know as classic migraine):
Aura is present before headache- neurological deficit or disturbance, can be:
Familial Hemiplegic Migraine: Migraine with aura that includes motor weakness in a patient that has at least one first or second degree relative who has migraine with aura that includes motor weakness
Sporadic Hemiplegic Migraine: Migraine with aura that includes motor weakness in a patient without relative with same migraine
Migraine without Aura (formerly known as common migraine):
Contraindications: hx of stroke or TIA’s in family or patient, ischemic heart disease, peripheral vascular disease, uncontrolled HTN, use within 24hrs of ergotamine, concurrent administration with another 5-hT1 agonist or MAO, management of hemiplegic or basilar migraine
Sumatriptan + naproxen: recent study in Pediatrics showed combination was statistically improved outcome as compared to placebo in adolescents
Often preceded by another episodic headache disorder that has been treated with excessive amounts of acute symptomatic medications
Most often daily, more often upon awakening, improved with medication use
Use of analgesic > 2-3x/week in association with chronic daily headache (>15 days/month)
Criteria for diagnosis:
Headache x 15 days
Regular overuse for more than 3 months of one of the more acute/symptomatic treatment drugs
Ergotamine, triptans, or combination analgesic medications >10 days a month x 3 months
Simple analgesic or combination of ergotamine, triptans, analgesic opioids >15 days a month x 3 months without overuse of any single class alone
Headache has developed or worsened during medication use
Headache Diary App: iHeadache (Free)
Med helper pill reminder (Free)
Special thanks to Dr. Gerhart for providing me with additional information about migraines
The American Committee for Headache Education (www.achenet.org/) provides information and resources for patients and providers.
The American Headache Society (www.americanheadachesociety.org/) provides resources for clinicians.
The National Headache Foundation (www.headaches.org) provides information and resources for patients and providers.
References: Blume, HK. Pediatric Headache: A Review. Pediatrics in Review 2012; 33 (12): 562-576.
Bonthius, DJ. Approach to the child with headache. In: UpToDate, Drutz, JE (Ed), UpToDate, Waltham, MA, 2012.
Cruse, RP. Classification of Migraine in Children. In: UpToDate, Patterson MC (Ed), UpToDate, Waltham, MA, 2012.
Cruse, RP. Management of Migraine headache in Children. In: UpToDate, Patterson MC (Ed), UpToDate, Waltham, MA, 2013.
Derosier FJ, Lewis D, Hershey AD, Winner PK, Pearlman E, Rothner AD, et al. Randomized Trial of Sumatriptan and Naproxen Sodium Combination in Adolescent Migraine. Pediatrics 2012; 129 (6): e1411-e1420.
Garza, I. Medication Overuse headache: etiology, clinical features, and diagnosis. In: UpToDate, Swanson JW (Ed), UpToDate, Waltham, MA, 2013.