Pediatric Primary Care (116 page)

•  Staying hydrated.

•  Avoidance/discontinuation of caffeine.

•  Avoidance/discontinuation of overuse of abortive medications.

•  Stress reduction.

4.  Acute medication treatment.

a.  Medication should not be used more than 2, or at most, 3 days a week to prevent development of rebound headaches.

b.  Prevents or stops progression of headache.

c.  Use medication as early as possible to prevent escalation and to increase the drug's effectiveness.

d.  Mild to moderate pain: ibuprofen (NSAIDs with or without caffeine) or acetaminophen (Tylenol).

e.  Moderate to severe pain: triptans (contraindicated for migraine variant such as hemiplegic or basilar migraine), ergotamine, dihydroergotamine (DHE).

f.  Antiemetics to help relieve pain, nausea, vomiting.

g.  Steroid dose pack to break migraine status, prolonged migraine.

5.  Preventative medication treatment.

a.  Use when:

•  Recurring migraine that interferes with daily routine despite acute treatment (two or more attacks/month that produce disability and can last up to 3 days or more).

•  Failure, contraindication, or side effects from acute medications.

•  Overuse of acute medications.

•  Frequent headaches (more than 2/week) with risk for rebound headache syndrome.

b.  Medication options:

•  Antidepressants: amitriptyline (Elavil), fluoxetine (Prozac), duloxetine (Cymbalta).

•  Beta blockers: propranolol (Inderal).

•  Antihistamines: cyproheptadine (Periactin) (most effective in toddlers).

•  Calcium channel blockers: verapamil.

•  Anticonvulsants: valproic acid (Depakote), topiramate (Topamax).

I.  Follow up.

1.  Assess medication effectiveness, monitor for any possible side effects.

2.  When abortive medications do not elevate migraine, may need IM or IV abortive medications and fluids such as ketorolac (Toradol) or promethazine (Phenergan).

3.  Any neurological changes or progression in headaches.  

J.  Complications.

1.  Comorbid anxiety and/or depression.

2.  Medication side effects.

3.  Acute vascular disorder.

4.  High incidence of motion sickness.

5.  Sleep disturbance.

6.  Drop in school performance due to missed days, and inability to concentrate with a headache.

K.  Education.

1.  Migraine diagnosis and treatment (medications/possible side effects).

2.  Keep a headache diary, look for headache triggers.

3.  Know symptoms and when to treat headache.

4.  Limit use of abortive medications.

5.  Behavioral modifications, follow routine schedule.

6.  Daily school attendance.

7.  Reduce stress and avoid triggers.

8.  Empower patient and family to be involved and take control of their headaches and treatment.

VIII.  TENSION-TYPE HEADACHES

A.  Headache that presents with pressure/tightening quality and lacks migraine criteria.

B.  Etiology.

1.  Behavioral.

2.  Muscular.

3.  Vascular.

4.  May coexist with otherwise typical migraine headaches.

C.  Occurrence.

1.  Most common benign headache disorder.

2.  10-25% prevalence in childhood and adolescence.

3.  Boys and girls tend to suffer equally until age 11 or 12 when female preponderance occurs.

D.  Clinical manifestations.

1.  Episodic headaches occur less than 15 days/month.

2.  Chronic headaches occur more than 15 days/month.

3.  Can last 30 minutes to 7 days.

4.  Pain is mild to moderate (not severe).

5.  Pain is bilateral and described as pressing or tightening, may occur in a hat band distribution.

6.  Pain not aggravated by physical activity (unlike migraine).

7.  No nausea or vomiting.

8.  May have photophobia or phonophobia, but not both.

E.  Physical findings.

1.  Normal neurological exam, worrisome if abnormal.

2.  May see signs of pain: facial expressions, demeanor, increased heart rate and blood pressure.

3.  May be misdiagnosed as sinus headache.

F.  Diagnostic tests.

1.  Same as migraine.

2.  History/complaints consistent with tension-type headache criteria.

G.  Differential diagnosis.

H.  Complications.

1.  Depression.

2.  Poor academic performance, difficulty concentrating, missed school days and other activities.

I.  Treatment.

1.  Nonpharmacologic treatments.

a.  Healthy habits.

•  Adequate routine sleep schedule.

•  Balanced meals.

•  Regular exercise.

•  No caffeine.

b.  Psychophysiological therapy.

•  Reassurance.

•  Counseling.

•  Stress management.

•  Relaxation therapy.

•  Biofeedback.

•  Treatment of anxiety and/or depression.

2.  Pharmacotherapy.

a.  Acute treatment–not to be used more than 2 days/week.

•  NSAIDs.

•  Acetaminophen.

b.  Preventative treatment.

•  Amitriptyline (Elavil).

•  Selective serotonin reuptake inhibitors (SSRIs).

•  Muscle relaxers (tizanidine [Zanaflex]).

J.  Follow up.

1.  Assess medication effectiveness and any possible side effects.

2.  Any neurological change or headache progression.

K.  Education.

1.  As with migraines.

IX.  COMMON MEDICATIONS TO TREAT HEADACHES IN CHILDREN

A.  Preventative: