Fifteen-minute consultation: Management of primary headaches in children

• Published in: Archives of disease in childhood. Education and practice edition Vol. 109; no. 3; pp. 112 - 114
• Main Authors: Alhashem, Roqiah, Byrne, Susan, Hall, Dani, Lumsden, Daniel E, Prabhakar, Prab
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health 01.06.2024; BMJ Publishing Group LTD
• Subjects: Adolescent; Adolescents; Analgesics; Anti-inflammatory agents; Antiemetics; Asthma; Best practice; Cardiac arrhythmia; Child; Child, Preschool; Children; Contraindications; Disease prevention; emergency care; Emergency medical services; Fatigue; Female; Functional foods & nutraceuticals; Headache - diagnosis; Headache - etiology; Headache - therapy; Headache Disorders, Primary - diagnosis; Headache Disorders, Primary - drug therapy; Headache Disorders, Primary - therapy; Headaches; Humans; Hypotension; Magnesium; Male; Migraine; Nausea; neurology; Nonsteroidal anti-inflammatory drugs; Overdose; paediatric emergency medicine; Pathology; Patients; Pediatrics; Prophylaxis; Protective equipment; Referral and Consultation; Side effects; Teenagers; Tension; paediatric emergency medicine; emergency care; neurology
• ISSN: 1743-0585; 1743-0593; 1743-0593
• DOI: 10.1136/archdischild-2022-324085

Relaxation techniques and biofeedback, for example, have demonstrated efficacy in the treatment of paediatric headaches, with improvements of up to 80%.4 A mixed picture of primary headache with analgesia-overuse headache can be caused by frequent use of analgesia, such as paracetamol and ibuprofen.5 Medication-overuse headache is seen in more than half of patients who suffer 15 or more days of headache per month.3 To avoid medication-overuse headache, the use of non-prescription analgesics or triptans in case of migraine headache should not exceed 2 days a week.4 The medication of suspect should be discontinued and the patient needs to be informed that their symptoms may worsen with abrupt withdrawal before they get better.2 6 There is no role for the use of opioids in the treatment of primary headache disorder and if a potent opioid was used or previous withdrawal attempts were unsuccessful, referral to a specialist is recommended.6 Case 2 A 14-year-old boy has been suffering from severe headaches since he started secondary school. Like tension headaches, advice on lifestyle and behavioural factors that affect headache frequency, as well as screening and management of psychosocial factors that may be attributed to headache persistence, should be included in the management to optimise the likelihood of successful treatment.2 6 Over-the-counter analgesics can relieve acute migraine in the majority of patients when administered early and in adequate amounts.3 A ‘migraine cocktail’ of a non-steroidal anti-inflammatory drug, antiemetic and oral fluids can be given orally at home.2 Intranasal sumatriptan can be considered as second-line treatment for severe acute attacks if there is no contraindication.7 If home treatment is unsuccessful, intravenous fluids and antiemetic can be administered in the emergency department.3 A headache diary can help identify migraine triggers.3 The Paediatric Migraine Disability Assessment Score is a tool to measure the degree of disability from headaches.2 When would you consider migraine prophylaxis? Pizotifen is a widely known migraine-prevention medication in the UK, particularly among children and adolescents, and can be trialled by the general practitioner.6 However, although it has been in use since 1970s, there is no compelling evidence of its effectiveness.6 The CHAMP trial by Powers et al demonstrated neither amitriptyline nor topiramate was superior to placebo in decreasing the number of headache days over a period of 24 weeks.8 Flunarizine has been proven effective in well-designed controlled trials, but is poorly tolerated and can lead to mood disorders.3 Although propranolol is recommended by the National Institute for Health and care Excellence (NICE), studies on its efficacy are conflicting7 and it is contraindicated in children with asthma, orthostatic hypotension and bradycardia.4 Non-pharmacological treatments include acupuncture, recommended by NICE in children over the age of 12 years if propranolol or topiramate is ineffective.6 If headache frequency is poorly controlled then the patient may be referred to a paediatrician with a special interest in headache.3 7 Assessment of the need for continued prophylaxis treatment is recommended after 6 months.6 Other non-pharmacological treatments include nutraceuticals and complementary therapies, widely used in children and adolescents suffering from migraine.9 Nutraceuticals are pill-based therapies described as health or medical interventions that are also foods or elements of foods.9 Though there is no conclusive evidence to support their efficacy, it is reasonable to consider using nutraceuticals with benign safety profiles and plausible mechanisms of action, such as coenzyme 10 and magnesium, if the patient is informed about the evidence status.9 Riboflavin, another nutraceutical, is recommended by NICE at high dose for migraine prophylaxis in people over the age of 12 years.6Table 2 Prophylactic treatments for migraine headache4 Prophylactic medication Side effects Level of evidence First line Pizotifen Weight gain, nausea, fatigue, drowsiness, feeling dizzy, weakness and dryness of mouth Weak evidence Propranolol Bradycardia, hypotension, decreased exercise tolerance, erectile dysfunction; contraindicated in patients with poorly controlled asthma and diabetes; caution in depression as can worsen mood Class II Conflicting results Topiramate Cognitive dysfunction, paraesthesia, weight loss, kidney stones, decreased perspiration, metabolic acidosis Class IV Second line Amitriptyline Somnolence, dizziness, overdose may cause cardiotoxicity, risk of suicidal ideation, must be weaned, fatigue, dry mouth Class IV Flunarizine Weight gain, sedation, low mood Class I Case 3 A 13-year-old boy presents with a history of left-sided temporal headaches for 3 months. There are a variety of forms of TAC, of which only paroxysmal hemicrania, lasting for up to 20 min occurring on average 20–40 times a day, and hemicrania continua, lasting for hours or days associated with milder autonomic symptoms, have been shown to be indomethacin sensitive.5 Other forms include cluster headache, short-lasting unilateral neuralgiform headache attacks with conjunctival tearing and injection and short-lasting unilateral headache attacks with cranial autonomic symptoms.2 Along with autonomic features, cluster headache is described as a stabbing headache that lasts 15–180 min and occurs 1–10 times per day, often on a daily basis for several days or weeks, before resolving for several weeks or months.4 Its estimated prevalence in children is between 0.03% and 0.1% with mean age of onset at 11–14 years.10 One hundred per cent oxygen via face mask and nasal sumatriptan have been described