What is the approach and treatment for pediatric headache with normal blood pressure and eye examination?

Approach and Treatment for Pediatric Headache with Normal Blood Pressure and Eye Examination

For pediatric headaches with normal blood pressure and eye examination, ibuprofen should be used as first-line treatment, with triptans considered for adolescents with inadequate response to NSAIDs. 1, 2

Diagnostic Approach

• Take a detailed history to establish a specific headache diagnosis, focusing on headache characteristics, frequency, duration, and associated symptoms 1

• Identify potential migraine triggers including irregular sleep patterns, missed meals, dehydration, stress, and certain foods 2

• Assess for red flags that would necessitate neuroimaging, including:

  • Abnormal neurological examination
  • Sudden onset, severe "thunderclap" headache
  • Progressive worsening or change in headache pattern
  • Headache awakening from sleep
  • Headache with exertion, coughing, or Valsalva 3, 1

• Neuroimaging is generally not indicated for children with normal neurological examination and no concerning features, as studies show low yield (<1% relevant findings) 1

Acute Treatment

First-Line Options:

• Ibuprofen (10 mg/kg) is recommended as first-line treatment for children and adolescents with migraine 1, 2, 4
• Acetaminophen can be used as an alternative, though studies show ibuprofen is twice as likely to abort migraine within 2 hours 4
• Counsel patients to treat acute migraine early in the attack for best results 1

Second-Line Options (for adolescents):

• If NSAIDs are ineffective, consider triptans such as:
  • Sumatriptan/naproxen oral combination
  • Zolmitriptan nasal spray
  • Sumatriptan nasal spray
  • Rizatriptan orally disintegrating tablets (ODT)
  • Almotriptan oral 1, 2

Treatment Strategies:

• If one triptan is ineffective, try another or a NSAID-triptan combination 1
• For rapidly escalating headache pain, consider non-oral triptans 1
• For headaches with significant nausea/vomiting, use non-oral triptans or add an anti-emetic 1
• Avoid medication overuse (>10-15 days/month) as it can lead to chronic headaches 1, 2

Preventive Treatment

When to Consider Prevention:

• Frequent headaches (typically >4 per month)
• Disabling headaches that significantly impact quality of life
• Medication overuse headaches 1, 2

Preventive Options:

• Discuss with patients/families that placebo was as effective as studied medications in many trials 1
• Evidence supports:
  • Amitriptyline combined with cognitive behavioral therapy
  • Topiramate
  • Propranolol 1, 2
• Discuss potential side effects and, when relevant, teratogenic effects of medications like topiramate and valproate 1

Non-Pharmacologic Approaches

• Lifestyle modifications are essential:
  • Regular sleep schedule
  • Regular meal times
  • Adequate hydration
  • Stress management techniques 2, 5
• Behavioral interventions:
  • Relaxation techniques
  • Cognitive behavioral therapy 2
• Identify and avoid specific triggers 1, 2

Special Considerations

• For status migrainosus (severe headache lasting >72 hours), consider referral for intravenous therapy 6
• Approximately two-thirds of pediatric migraine patients improve with standard therapy, but one-third may require more specialized approaches 2
• Emergency department evaluation is warranted for severe, sudden-onset headaches or those with concerning neurological symptoms 7, 6