State-of-the-Art Pediatrics

Headache Management: It Takes a Village

Author: Anna Esparham, MD, FAAP, DABOIM, DABMA | Division of Neurology | Medical Director, Headache Treatment Center | Medical Acupuncturist

Column Editor: Amita Amonker, MD, FAAP | Pediatric Hospitalist | Assistant Professor of Pediatrics, UMKC School of Medicine 

Children with primary headache disorders are best treated with a comprehensive and integrative approach owing to underlying biopsychosocial factors. The most common primary pediatric headache disorders are migraines and tension headaches. Fifty-eight percent of children report a significant headache by adolescence, and that percentage increases by the time they reach adulthood.¹

Other childhood variants of migraines include cyclic vomiting syndrome, benign paroxysmal vertigo, and paroxysmal torticollis.² Some research supports colic as a childhood variant of migraine.²

Diagnosing primary pediatric headache disorders helps the provider identify the most appropriate treatment plan. The International Classification of Headache Disorders (ICHD-3), a wonderful resource for providers, provides a classification for each type of headache (www.ichd-3.org).

Migraines and tension headaches have somewhat different therapeutic strategies. Here, we’ll focus on migraine headaches, as these are generally the most common presenting headache to a health care provider.

Managing headaches can be broken down into a two-part process: preventive and abortive management.  

Preventive Management:

Preventive treatment is generally started for most children and adolescents who have four or more headaches per month or headaches that cause significant interference with functioning.

The daily regimen usually consists of some combination of medications, nutraceuticals, dietary supplements, physical therapy and home exercise regimen, a healthy lifestyle, good sleep, hygiene, neuromodulation, and active relaxation. Other preventive therapies may include procedures, such as occipital and pericranial nerve blocks, acupuncture, injection with onabotulinumtoxinA (Botox^®), osteopathic manipulation, and massage.

The most common daily regimen that is started for most kids with migraines involves nutraceuticals. These medications consist of magnesium, riboflavin or vitamin B2, and coenzyme Q10 (CoQ10) due to their benefit and minimal risk and side effect profile.

Magnesium can be started at 10 mg/kg elemental magnesium (maximum of 500 mg), to be given once daily. Children 12 years and older can start with magnesium gluconate or glycinate 500 mg daily. Common side effects include abdominal pain, loose stools and diarrhea.²

Riboflavin, or vitamin B2, can be prescribed at 200 mg daily for young children and 400 mg daily for older children and adolescents. Riboflavin’s side effects are minimal and usually consist of bright yellow to orange urine discoloration.²

CoQ10 also has shown benefit for migraine prevention. The recommendation is to take 200 mg daily. A typical regimen is CoQ10 100 mg in the morning with breakfast and 100 mg after school. The side effect profile is minimal, but because CoQ10 can boost energy, some children report insomnia if taken too close to bedtime.²

Other preventive medications and supplements include melatonin 3-10 mg nightly, amitriptyline, topiramate, and beta-blockers: propranolol or atenolol.²

Acupuncture has been found by two Cochrane reviews in 2016 to be highly beneficial for preventing migraines and tension headaches.^3,4 Acupuncture can be performed once weekly for six sessions, then spaced out to semi-monthly and then monthly.

Cefaly^® and gammaCore^TM are two neuromodulation devices that can both prevent and abort migraines.⁵

Cefaly^®, a supraorbital (trigeminal nerve branch) transcutaneous electrostimulation device, does not require a prescription and can be found online for patients and families to purchase, though it is considered off-label use for children. Typical preventive use is 20 minutes daily, and typical abortive use is 60 minutes as needed at earliest onset of migraine.

GammaCore^TM, a non-invasive vagus nerve stimulator, is Food and Drug Administration (FDA) approved for prevention of migraines in adolescents between 12 and 17 years of age. A prescription is required. The device can be used up to three times daily for prevention and as needed for aborting a migraine.

Biofeedback, hypnosis or other forms of active relaxation, and cognitive behavioral therapy are all considered part of the preventive management plan to control migraines effectively.²

Generally, preventive therapies can take eight to 12 weeks to become effective, which is why it is important to set reasonable expectations with families and patients regarding their progress. Prevention is generally the key to resolving headaches, as most abortive medications need to be limited due to the risk of headache resulting from medication overuse.

Abortive Management:

Abortive management of migraine headaches can consist of triptans or a headache “cocktail” that consists of a nonsteroidal anti-inflammatory drug (NSAID) (e.g., naproxen, ibuprofen) or acetaminophen with a dopamine receptor antagonist (prochlorperazine, metoclopramide, promethazine) or diphenhydramine.^2,6 These abortive medications need to be taken at the earliest sign of a migraine to be effective. The combination of triptans, NSAIDs and acetaminophen must be limited to 10-15 times a month to avoid the development of a medication overuse headache.^2,6 Over-the-counter (OTC) analgesics and triptans can cause central sensitization and activate the pain pathways when used more than 10-15 times for three months or more.^2,6

Opioids and barbiturates are strongly discouraged as they can lead to worsening headaches, more so than triptans and OTC analgesics.

A typical abortive regimen:

Naproxen (up to 10 mg/kg/dose), prochlorperazine 5-10 mg, diphenhydramine 25-50 mg at earliest onset of migraine.

Triptans can be used in place of the headache cocktail or even with the headache cocktail. Rizatriptan is a common triptan used for children ages 6 and older.^2,6

Nerivio^®, a remote neuromodulation device, is an abortive therapy that comes with 12 treatments that last 45 minutes each. Nerivio^® is FDA approved for 12-17 years of age. A prescription is required and is more effective, like other abortive regimens, at the earliest onset of the migraine and costs only up to $49 per device.⁷

Headache management requires multiple approaches and emphasizes self-care as a large part of recovery and healing. Primary care physicians can begin management early to prevent headaches from becoming chronic and, thus, more difficult to treat. The Headache Relief Guide is an excellent resource for pediatricians (www.headachereliefguide.com).

References: 

1. Nieswand V, Richter M, Gossrau G. Epidemiology of headache in children and adolescents-another type of pandemia. Curr Pain Headache Rep. 2020;24(10):62. doi:10.1007/s11916-020-00892-6
2. Greene K, Irwin SL, Gelfand AA. Pediatric migraine: an update. Neurol Clin. 2019;37(4):815-833. doi:10.1016/j.ncl.2019.07.009
3. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. 2016(6):CD001218. doi:10.1002/14651858.CD001218.pub3
4. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016;4:CD007587. doi:10.1002/14651858.CD007587.pub2
5. Antony AB, Mazzola AJ, Dhaliwal GS, Hunter CW. Neurostimulation for the treatment of chronic head and facial pain: a literature review. Pain Physician. 2019;22(5):447-477.
6. Patniyot IR, Gelfand AA. Acute treatment therapies for pediatric migraine: a qualitative systematic review. Headache. 2016;56(1):49-70. doi:10.1111/head.12746
7. Nierenburg H, Stark-Inbar A. Nerivio^® remote electrical neuromodulation for acute treatment of chronic migraine. Pain Manag. Published online September 20, 2021. doi:10.2217/pmt-2021-0038