#60: Pediatric Headaches – Making Them Less Aura-ble

August 17, 2022 | By Sam Masur

Summary

Feeling (beta-) blocked when trying to figure out how to care for your pediatric patients with acute or recurrent headaches? Hoping to prevent them from taking an unnecessary trip(tan) to the ER? Shade your eyes, because Dr. Gaitanis is about to shed some light on the key aspects of evaluating, diagnosing, and managing various types of pediatric headaches!

Credits

• Producer & Writer: Sydney Engel FNP & Clara Mao MD
• Executive Producer: Max Cruz
• Showrunner: Sam Masur MD
• Infographic: Sydney Engel FNP
• Cover Art: Chris Chiu MD
• Hosts: Justin Berk MD, Chris Chiu MD, Sydney Engel FNP
• Editor:Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): John Gaitanis MD

Headache Pearls

1. Migraine can be thought of as a wide-reaching sensory phenomenon – in addition to the classic photophobia, phonophobia, and vertigo, keep an eye out for patients who are very sensitive to taste and smell (e.g., overwhelmed in Bath & Body Works) or describe sensations like “feeling every heartbeat.”
2. When taking a history, pain location can be key to narrowing the differential. Many “red flag” headaches present bilaterally or over the vertex. 
3. Red flag signs and symptoms include severe and sudden onset, persistent pain with no episodes of quiescence, meningeal signs, waking from sleep, and neurologic changes. 
4. Physical exam should include mental status, cranial nerves, motor, sensory, and coordination. Practice fundoscopic skills regularly and keep a close watch for papilledema.
5. In the absence of red flag signs or symptoms, diagnosis is made clinically – it is very rare that labs or imaging will provide a cause for headache or identify a particular headache syndrome.
6. Abortive treatment options include NSAIDs, antihistamines, magnesium, and (when age-appropriate) triptans. Give families multiple options to try at home to avoid unnecessary ER visits. 
7. Lifestyle modifications (especially stress-reduction and sleep) are key to preventing primary headaches. Other preventative treatment modalities include cognitive behavioral therapy, various vitamins/minerals/supplements, prescription medications, acupuncture, and nerve stimulation. 
8. In select patients, migraine with aura may not be a full contraindication to starting oral contraceptive pills (OCPs). Data is predominantly based on higher-dose OCPs than those currently available, and there is lack of consensus as to whether the risks are mitigated by lower dose options. OCPs should still be avoided in any patients with hemiplegic migraines.

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Pediatric Headache Notes

Patient History

• Key history components include: location of pain, characteristics, onset, timing, duration, onset (sudden or gradual), associated factors (e.g., nausea, vomiting, waking from sleep, photo/phonophobia)
• In patients with limited verbal capacities, ask caregivers about severity (i.e., do they play through the headache?), timing, sensitivity to light/sound (i.e., do they cry less with lights off?), and loss of appetite.

History Red Flags

• Extreme severity, symptoms that “come out of the blue” with no similar history (concern for subarachnoid hemorrhage).
• Persistent symptoms with no periods of quiescence (concern for brain tumor).
• Symptoms that wake the patient from sleep, particularly if the patient is waking with vomiting and severe headache (concern for increased intracranial pressure).
• Associated neurologic symptoms (e.g., hemiplegia, inability to speak, visual loss), even if transient (concern for complex migraine or brain injury).

Physical Exam

• Pay attention to your immediate impression.
• Assess mental status, cranial nerves, motor and sensory function, coordination.
• Ophthalmoscopic exam for papilledema (Expert tips: Turn off the lights in the room, get close enough to the patient, and check this frequently to get practice). 

Primary Headache Subtypes

Expert note: Some people believe that all of these are different expressions of the same phenomenon. Many people can have more than one headache type, and multiple headache types can exist within the same family. 

1) Migraine 

• Think of this as a sensory phenomenon with trigeminal nerve etiology – look for associated photo/phonophobia, vertigo, and smell/taste sensitivity, extreme sensitivity to the point of “feeling every heartbeat”. (Expert tip: Ask if the patient is uncomfortable going into Bath and Body Works or in similar highly sensory experiences) 
• The presence of aura (usually visual) is supportive of this diagnosis. One common version of this is blurring or a black spot that slowly grows over the course of a few minutes. This is believed to be a result of spreading depression (cortical depolarization) that occurs at a rate of 3 mm/minute (which translates to a very slow progression compared with the rapid onset of symptoms in a seizure).
• Expert opinion: While oral contraceptive pills (OCPs) have historically been contraindicated for patients with migraine with aura, the true risk of this is now debated. This guidance was created using data from patients taking OCPs with a very high estrogen content. It is less clear whether OCPs containing low-dose estrogen significantly increase stroke risk (Calhoun & Batur, 2017). Furthermore, OCPs can be very helpful for patients with catamenial migraines (ie., migraine related menstrual cycle). 
• Hemiplegic migraines (less common) usually begin with a visual scotoma and then progress to unilateral sensory and motor symptoms over the course of 20-30 minutes. Triptans and OCPs should be avoided for these patients due to stroke risk. 

2) Tension-Type Headache

• Symptoms are frequently bilateral.
• Symptoms are more common later in the day.
• Can be related to posture or neck strain during the course of the day.
• Lacks the sensory symptoms (e.g., nausea, vomiting, photophobia) associated with migraine. 

3) Cluster Headache

• Rare in children.
• Unilateral, severe symptoms that are shorter in duration.
• Multiple episodes over short time span.
• “Like a kidney stone” – look for patients that are unable to get comfortable at all.
• Responds to oxygen therapy. (Expert tip: Try giving oxygen to patients in the E.R. who are pacing/writhing with head pain).

Differential Diagnosis (i.e., causes of secondary headaches) 

• Dangerous, “can’t miss” differential diagnoses include meningitis, brain tumor, and intracranial bleeding.
• Location is key! Try to localize the headache first, and use this to determine your differential diagnosis
• Many concerning headaches are bilateral or over the vertex – this is because conditions that cause increased intracranial pressure often “stretch” the meninges, which is the primary source of pain.
• Chronic suboccipital headache may be indicative of Chiari malformation. The significance of this finding on imaging depends on the size and severity of symptoms (see below).
• Unilateral headaches are generally more trigeminal in nature (see “migraine” above). 
• Consider the role of sinus symptoms, and eye strain, but don’t wait for an ophthalmologic assessment to initiate care if the headache is more consistent with one of the primary subtypes. 

Diagnostic Testing

Diagnosis of primary headache is clinical – it is very rare that labs or imaging will provide insight into the etiology of the headache, and they are not helpful for identifying a specific headache syndrome.

Imaging

• Main objective is to evaluate for causes of secondary headache. 
• If the patient has a normal neurologic exam, the rate of abnormality within the brain on imaging is extremely low (Lewis & Dorbad, 2001; Dao & Qubty, 2018).
• In terms of Chiari malformations, size matters. Smaller malformations/those without syrinx development may not affect CSF flow or cause headache, whereas the development of a cervical cord syrinx is more likely to indicate a significant abnormality (Langridge et al., 2017).
• Adding contrast dye to MRI is rarely indicated for pediatric headaches – this is primarily used to identify meningitis, which should be done via lumbar puncture. 

Labs

• The main rationale for checking labs is looking for larger systemic issues underlying the headache, such as lyme disease or lupus.
• Expert opinion: In patients with signs/symptoms concerning for generalized inflammation, Dr. Gaitanis will check a CBC, sedimentation rate, and lyme titers. He considers testing for lupus only if there are other distinct features that raise concern for this diagnosis 

Disparities

• Less than 50% of Black patients with migraines are properly diagnosed and receiving treatment, compared with 50% of Latino patients and more than 75% of white patients (Kiarashi et al., 2021).
• There is no biological reason for these disparities; instead, this is a result of structures of systemic racism and barriers to care. 

Acute Treatment

Start abortive therapy as soon as possible after the onset of headache. Expert tip: If you are confident about the diagnosis of migraine, give families at least 3-4 options they can try at home to avoid unnecessary (and uncomfortable!) ER visits

Treatment options

• NSAIDs: Dr. Gaitanis advises starting with ibuprofen or ketorolac for most migraine or tension-type headaches. Evidence suggests that these work better than acetaminophen, although both have good efficacy (Hamalainen et al., 1997).
• Antihistamines: Cyproheptadine, diphenhydramine, or hydroxyzine 
• Magnesium: The mechanism for this may have to do with prevention of abnormal nerve firing. Many different formulations are available, one option with relatively few GI side effects is magnesium oxide dosed at 200-400 mg for an adult-sized person or 9 mg elemental magnesium/kg/day. 
• Triptans: Rizatriptan is FDA approved for ages 6+, sumatriptan is approved for ages 12+. Intranasal agents may be more effective than oral agents when available. 
• Other: Some providers will add prochlorperazine or metoclopramide to break severe or persistent acute headaches. These agents have the benefit of causing sleepiness, which can also be helpful. 

Preventative Management 

Consider starting preventative therapies if headaches are impairing the patient’s quality of life (e.g., missing school or social activities). Usually this is around 3+ headaches/week, but for some patients with severe headaches this may be less frequent.

Non-pharmacologic

• Have patients/families keep a headache diary to identify triggers (e.g., sleep deprivation, skipping meals, certain foods such as red dye, nitrates, or MSG).
• Lifestyle: Adequate sleep, hydration, physical activity, healthy diet, stress reduction 
• Therapy: In studies, CBT is at least as effective as prescription medications (Van Diest & Powers, 2019). 
• Acupuncture: Some evidence indicates efficacy as a treatment modality (Doll et al., 2019)
• Supraorbital nerve stimulator: Administers trigeminal stimulation (can be used for abortive or preventive management). There is some evidence for efficacy, but they are expensive and not consistently covered by insurance (Riederer et al., 2015).
• Botox is approved for patients older than 18 years with 15 days a month or more of migraine. This is hard to get approved for younger patients. 

Over-the-counter medications

• Magnesium* (9 mg elemental Mg/kg/day or 200-400 mg daily)
• Riboflavin* (50-400 mg/day)
• CoQ10* (1-3 mg/kg/day or 100 mg/day)
• Butterbur (50-150 mg/day, caution hepatotoxicity risk) (Prieto, 2013)
• Cyproheptadine (0.2 to 0.4 mg/kg/day divided twice daily) – this can particularly helpful if the patient has co-occurring allergies, difficulty sleeping, or GI symptoms 

*Note: Doses vary significantly between studies. See Yamanaka et al., 2021 for a recent literature review with doses included.

Prescription medications 

• No currently approved prescription medications have been shown to be very effective in pediatric migraine (Oskoui et al., 2019). Part of this is due to the high rate of improvement in placebo arm (as high as 60% in some trials!) (Powers et al., 2017).
• Consider the side-effect profile when selecting a medication. 
• Expert opinions on medications and dosing (for older children) – start low and go slow:
  • Topiramate: Start at 25 mg at bedtime, then increase to 50 mg – there is usually some evidence of efficacy by this point. Rarely requires the dose levels required for managing seizures. Side-effect consideration – can be helpful for obesity. 
  • Propranolol: Usually dosed three times daily. Side-effect consideration – can be helpful for postural tachycardia syndrome (Raj et al., 2009).
  • Amitriptyline: Start at 10 or 12.5 mg daily at bedtime. Increase by up to 10 mg every 3 to 5 days until reach a dose of 50 mg daily or side effects occur. Side-effect consideration – can be helpful for sleep issues. Avoid if the patient experiences chronic lightheadedness. Check EKG prior to starting. 

Emerging therapies to watch: CGRP inhibitors (none yet approved for kids <18, three options are now approved for adults). For ages 18+, these seem to be very well tolerated with fairly good efficacy (Vandervorst et al., 2021). Dr. Gaitanis will consider using these off-label in patients 15+ if other treatments have failed.

Goal

Listeners will explain the basic evaluation, differential diagnosis, and management of headaches in pediatric patients.

Learning objectives

After listening to this episode listeners will be able to…  

1. Explain differences between primary headache subtypes and recognize their implications for treatment.
2. Recall red flag signs and symptoms in pediatric patients with headache. 
3. Recognize racial disparities in the diagnosis and treatment of headache.
4. Create initial treatment plans for pediatric patients with acute headaches in both the acute and primary care setting.
5. Identify prophylactic treatment options for recurrent headaches in pediatric patients.

Disclosures

Dr. Gaitanis reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Engel S, Gaitanis J, Cruz M, Masur S, Chiu C, Berk J. “#60: Pediatric Headaches – Making Them Less Aura-ble”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ August 17, 2022.