What are the management options for headaches in pediatrics?

Management of Pediatric Headaches

The management of pediatric headaches should begin with accurate classification into primary or secondary headache types, followed by appropriate non-pharmacological interventions as first-line treatment, with pharmacological options reserved for more severe or frequent headaches. 1, 2

Diagnostic Approach

Initial Assessment

• Document headache characteristics:
  • Location (unilateral vs. bilateral)
  • Quality (pulsating, throbbing, pressure)
  • Intensity (mild, moderate, severe)
  • Duration (hours to days)
  • Frequency (episodic vs. chronic)
  • Associated symptoms (nausea, vomiting, photophobia, phonophobia)
  • Triggers (stress, lack of sleep, certain foods)
  • Relieving factors

Red Flags Requiring Immediate Attention

• Thunderclap headache (sudden onset, maximal intensity within seconds to minutes)
• Focal neurological deficits
• Altered mental status
• Neck stiffness
• Headache following trauma
• Headache worsening with Valsalva maneuver
• Headache awakening from sleep
• New onset headache in children under 6 years

Imaging Considerations

Neuroimaging is generally not recommended for children with primary headaches and normal neurological examinations 1, 3. The yield of brain MRI in children with primary headaches is very low, with less than 1% having relevant findings to explain headaches 1.

When to Consider Imaging:

• Presence of red flag symptoms
• Abnormal neurological examination
• Suspected intracranial pathology
• Thunderclap headache (immediate non-contrast head CT)
• Suspected subarachnoid hemorrhage or stroke

Management of Primary Headaches

Non-pharmacological Approaches (First-line)

1. Lifestyle modifications:

   • Regular sleep schedule
   • Adequate hydration
   • Regular physical activity
   • Avoidance of meal skipping
   • Reduction of caffeine intake
   • Stress management

2. Behavioral interventions:

   • Relaxation techniques
   • Biofeedback training
   • Cognitive behavioral therapy (CBT)

Acute Pharmacological Treatment

1. First-line medications:

   • NSAIDs (ibuprofen) - evidence supports efficacy in children 2, 4
   • Acetaminophen - safe option, especially in younger children

2. Second-line medications:

   • Triptans - FDA approved options include:
     • Rizatriptan (approved for children ≥6 years)
     • Almotriptan, zolmitriptan, and sumatriptan/naproxen (approved for adolescents) 4

Preventive Treatment

Consider preventive treatment when:

• Headaches occur ≥4 days per month
• Headaches significantly impact quality of life
• Acute treatments are ineffective or contraindicated

Preventive medication options:

• Topiramate - probably more effective than placebo for reducing headache frequency 5
• Propranolol - possibly more effective than placebo for achieving ≥50% reduction in headache frequency 5
• Amitriptyline plus CBT - more effective than amitriptyline plus headache education 5

Management of Secondary Headaches

Secondary headaches require identification and treatment of the underlying cause:

• Sinusitis: Appropriate antibiotics if bacterial infection confirmed
• Post-traumatic headache: Rest, gradual return to activities, symptomatic treatment
• Intracranial pressure disorders:
  • Pseudotumor cerebri: MRI with contrast to evaluate for secondary signs of increased intracranial pressure 1
  • Chiari malformation: MRI of brain with sagittal T2-weighted sequence of craniocervical junction 1
• Vascular disorders: Prompt neuroimaging and appropriate intervention

Special Considerations

Chronic Headaches

For headaches occurring ≥15 days per month for >3 months:

• Evaluate for medication overuse
• Consider multidisciplinary approach including psychology
• Implement comprehensive lifestyle modifications
• Consider preventive medications

Medication Overuse

• Common pitfall in management
• Defined as regular use of acute medications ≥10-15 days per month
• Treatment involves gradual withdrawal of overused medications
• Implementation of appropriate preventive strategies

Common Pitfalls to Avoid

1. Failure to obtain neuroimaging for patients with red flag symptoms
2. Dismissing severe, sudden-onset headaches
3. Failure to recognize chronic migraine
4. Overlooking medication overuse
5. Inadequate dosing of acute medications
6. Insufficient trial duration for preventive medications (typically 2-3 months needed)

By following this structured approach to the management of pediatric headaches, clinicians can effectively diagnose, treat, and improve outcomes for children suffering from this common condition.