From the Guidelines
For pediatric daily headaches, I strongly recommend starting with lifestyle modifications and ibuprofen as the first-line medication for acute treatment, as evidenced by the most recent and highest quality study 1. When managing pediatric daily headaches, it's crucial to consider the unique aspects of migraine in children and adolescents, including shorter attack duration, bilateral headache, and prominent gastrointestinal disturbances 1.
Key Considerations
- Lifestyle modifications are essential, including ensuring adequate hydration, regular sleep patterns, balanced meals, stress management techniques, and limited screen time.
- For acute treatment, ibuprofen is recommended as the first-line medication, at a dose appropriate for body weight, as it has been shown to be effective in children with migraine 1.
- In cases where acute medication provides insufficient pain relief, referral to specialist care is indicated 1.
- Preventive treatment options, such as propranolol, amitriptyline, and topiramate, can be considered, although their effectiveness in children and adolescents has not been proven in clinical trials 1.
Treatment Approach
- Start with lifestyle modifications and ibuprofen for acute treatment.
- Consider preventive therapy in persistent cases, with options like amitriptyline, topiramate, or propranolol.
- Keep a headache diary to identify triggers and monitor treatment effectiveness.
- Cognitive behavioral therapy can be beneficial for stress-related headaches.
Important Considerations
- The evidence base for medication therapy in children and adolescents is confounded by a high placebo response in clinical trials, which may explain the low apparent therapeutic gain 1.
- Active follow-up is essential to determine outcome and review diagnosis and treatment strategies, with evaluation of treatment responses including effectiveness, adverse events, and adherence 1.
From the Research
Causes of Daily Headaches in Pediatrics
- Headaches in children may be due to primary or secondary etiologies, with common primary headache types including migraine or tension-type headache 2.
- Secondary headache causes are broad and include infections, trauma, vascular disorders, substance use/withdrawal, and psychiatric conditions 2.
- Tension-type headache (TTH) is the most common primary headache disorder, with a worldwide lifetime prevalence of 46% to 78% 3.
Diagnosis and Management
- A thorough understanding of the approach to the pediatric headache patient is essential to ensure appropriate diagnosis, evaluation, and management 2.
- The American Academy of Neurology (AAN) guidelines recommend against routine lab studies, lumbar puncture, electro-encephalogram (EEG), or neuroimaging in patients with no headache red flags by history and a normal neurologic examination 2.
- Diagnostic workup, including the key features to elicit on physical examination, when to order head imaging, and the use of other ancillary tests, is crucial in evaluating the pediatric patient presenting with headache 4.
- Current treatment modalities and their indications are reviewed, including acute and preventive treatments for migraine 5.
Treatment Options
- Nonprescription analgesics are indicated for management of episodic TTH, while prophylaxis should be considered for patients with chronic TTH 3.
- Amitriptyline is recommended as a first-line drug for prophylaxis of TTH 3.
- Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine, as well as migraine-specific treatments such as triptans and gepants 6.
- Preventive treatments for migraine include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA 6.