Patient Presentation
A 16-year-old female came to clinic for her health maintenance examination. She was overall healthy but had a past medical history of migraine without aura since 11 years of age. Her headaches had increased in severity and frequency around the time of puberty and she was started on topiramate. Since then her migraines only occurred approximately once every 2 months. The family history was strongly positive in the maternal side with her mother and maternal aunt both taking prophylactic migraine medication and migraines in her maternal grandmother. The pertinent physical exam showed a thin female in no distress. Her weight was 10%, height 25% and BMI was 18.5 and were appropriate with previous measurements. Her examination was normal.

The diagnosis of a healthy female with migraine without aura was made. She had seen something about a medical study that showed that there was a problem with topiramate for treating migraine. In the office, the pediatrician quickly found the study online and noted that the study didn’t find any benefit from the medication compared to placebo. “But,” he said, “It seems to help you. You have many fewer migraines. You’ve taken the medicine for a long time and it seems like this is consistent over time, plus you aren’t having any side effects.” He went on, “You could go off the medicine and see what happens. If the migraines stay the same, then obviously you may not need the medicine, but if they come back more often then you probably do. Unfortunately you have a big family history of migraine, so my guess is that you are going to need the medicine. Still it’s your choice.” The adolescent decided to continue the topiramate for the time being and was going to think about the options and talk it over with her mother. At a sick appointment 3 months later, the adolescent said that she continued the topiramate.

Discussion
Headache is pain in the scalp, forehead, orbits and temple. Facial and neck pain are usually excluded from this definition. It is a common problem with more than 6 million pediatric patients having migraine. Headaches can also have co-morbidities and more than 1 primary headache type can co-exist. The costs are high both economically and in the quality of life for the patients and families. A review of common headache types and indications for neuroimaging can be found here.

Treatment is necessarily multi-pronged. Patients should understand their diagnosis so they can understand what reasonably can be expected from treatment, how they can prevent headaches and how they can help to treat themselves once the headache occurs. When patients and families think about treatment for headache they usually think about medications, but the first treatment should be behavior and lifestyle changes. A balanced, consistent lifestyle is recommended for anyone but especially individuals with headache. Discussing the patient’s current daily schedule can help identify problem areas to work on. Often sleep does not receive enough priority. Making a new plan that prioritizes self-care first especially around sleep, eating, and exercise and then filling in the day with school, work and recreational activities should help prevent headaches.

Patients should:

• Participate in normal school, work and recreational activities as much as possible. Keeping involved also helps to mitigate stress from being behind on work and encourages social support by family, friends and co-workers.
• Regular, consistent sleep
• Regular, consistent exercise
• Regular meal and snack times
• Drinking adequate fluids (non-caffeinated) – a review of caffeine can be found here
• Taking care of other health problems. Illness can also often make headaches worse, so illness prevention measures should be used. Chronic health problems should be managed optimally and if medications are prescribed, they should be taken as directed.
• Avoiding triggers – these may be difficult to identify. Triggers for some people include alcohol, aspartame, caffeine, chocolate, monosodium glutamate, nitrites, or tyramine. Strict elimination diets or restriction of activities is usually not appropriate.
  Reasonableness should reign. For example, most patients can eat some foods with caffeine or chocolate. All patients should carry backpacks of reasonable weight, but those who know neck or shoulder pain triggers their headaches should certainly avoid heavy backpacks or use some type of roller bag.

Detailed symptom diaries can help with the diagnosis and management of headaches.
They can help to characterize the headache, timing, medication efficacy (both acute and prophylactic) or potential overuse. Lifestyle changes can also sometimes become evident.

Red flags that more evaluation and/or neuroimaging may be needed includes:

• First headache that is severe
• First headache is markedly different from previous headaches
• An increasing amount, severity, or symptoms of the headache over time
• Headache is worse in recumbent positions (e.g. lying down, sleeping or bending over) or with increased intracranial pressure (e.g. valsalva, coughing)
• Abnormal puberty or growth
• New onset seizures or change in seizure pattern
• New neurological signs (e.g. “…ataxia, cranial nerve deficit, head-tilt, papilloedema, visual impairment.”)

Learning Point
Treatment options for headaches:

• Healthy lifestyle for all patients (see above)
• Non-medication treatment
  • Compresses – cold or warm
  • Distraction
  • Feverfew for migraine prophylaxis
  • Massage – head, neck or other areas of the body
  • Relaxation techniques
  • Acupressure/acupuncture
  • Cognitive behavioral therapy
• Medication
  • Mild, intermittent headache or tension headache
    • No treatment
    • Simple analgesics – acetaminophen, ibuprofen
  • Medication overuse headache
    • Withdrawal of the offending medication – patients should be warned that headaches will often worsen for next 1-2 weeks
    • Other lifestyle changes or distraction methods
    • Prophylactic medication sometimes used during this period
  • Migraine with or without aura
    • Acute treatment
      • Triptans with ibuprofen or naproxan (in adolescents) have been shown to be effective.
        • Triptans can be repeated after 2 hours if needed, but no more than 2 doses in 24 hours and no more than 2 days/week to prevent overuse
        • One paper offers, if a triptan is not tolerated because of dizziness, unpleasant feeling or bad taste, to try an alternative triptan or the same triptan but in a different formulation (i.e. nasal, oral, subcutaneous).
          They go on to say, “If tolerated, a triptan should be tried for three different attacks before giving up for lack of efficacy. Three different triptans should be tried before accepting that this class of medicine is ineffective for a particular patient.”

        • Triptans that have been studied in the pediatric population include almotriptan, rizatriptan, sumatriptan and zolmitriptan.
      • Antiemetics may also be necessary
    • Prophylactic treatment – usually for patients with 3-4 episodes/month of headache that are significantly impacting their lifestyle or are incapacitating
      • For women with migraine without aura who have menstrual cycle triggers, suppressive oral contraception may be considered. Use of a triptan (zolomitripan or frovatriptan) 2-3x/day on days migraines are expected can also be helpful.
      • Topiramate has been one of the first line medications used (in lower dosing than for epilepsy) but a study that was stopped early for futility and published in the New England Journal of Medicine in 2017 found that topiramate and amitriptyline had no significant improvement over placebo for pediatric migraine prophylaxis.
        All had high rates of placebo effect (50-60%) consistent with previous studies.

      • Other medications include propanolol, gabapentin, riboflavin and pizotifen

Questions for Further Discussion
1. What are cluster headaches and how are they treated?
2. What are indications for referral to neurology for headache management?

Related Cases

Disease: Headache | Migraine

Symptom/Presentation: Health Maintenance and Disease Prevention | Headaches

Specialty: Neurology / Neurosurgery | Pharmacology / Toxicology

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Headache and Migraine.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Nappi RE, Kaunitz AM, Bitzer J. Extended regimen combined oral contraception: A review of evolving concepts and acceptance by women and clinicians. Eur J Contracept Reprod Health Care. 2016;21(2):106-15.

Patniyot IR, Gelfand AA. Acute Treatment Therapies for Pediatric Migraine: A Qualitative Systematic Review. Headache. 2016 Jan;56(1):49-70.

Richer L, Billinghurst L, Linsdell MA, Russell K, Vandermeer B, Crumley ET, Durec T, Klassen TP, Hartling L. Drugs for the acute treatment of migraine in children and adolescents. Cochrane Database Syst Rev. 2016 Apr 19;4:CD005220.

Powers SW, Coffey CS, Chamberlin LA, Ecklund DJ, Klingner EA, Yankey JW, Korbee LL, Porter LL, Hershey AD; CHAMP Investigators. Trial of Amitriptyline, Topiramate, and Placebo for Pediatric Migraine. N Engl J Med. 2017 Jan 12;376(2):115-124.

Ng QX, Venkatanarayanan N, Kumar L. A Systematic Review and Meta-Analysis of the Efficacy of Cognitive Behavioral Therapy for the Management of Pediatric Migraine. Headache. 2017 Mar;57(3):349-362.
Whitehouse WP, Agrawal S. Management of children and young people with headache. Arch Dis Child Educ Pract Ed. 2017 Apr;102(2):58-65.

National Center for Complimentary and Integrative Health. Headaches. Available from the Internet at https://nccih.nih.gov/health/pain/headaches.htm (rev. 9/24/17, cited 10/31/17).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa