Illustrations by Brian Stauffer
Despite the challenges in diagnosis and treatment, migraines and other headaches in young people can be managed.
Sixteen-year-old Sydney Kessel of Lafayette Hill, PA, has had severe headaches since mid-November of last year. Since then, the high school sophomore has not been able to attend school regularly or join her teammates in playing tennis and lacrosse.
“Headaches in children (up to age 12) and adolescents (up to age 18) are hard to diagnose, and we have few approved drugs for treatment,” says Stephen Silberstein, M.D., Fellow of the American Academy of Neurology (AAN), and professor of neurology and director of the Jefferson Headache Center at Thomas Jefferson University in Philadelphia, PA.
Migraines occur in 5 to 10 percent of children and 10 to 20 percent of adolescents. In general, headaches in children tend to be shorter in duration than headaches in adults, as well as more diffuse—in other words, felt all over the head instead of on just one side.
Despite the challenges in diagnosis and treatment, headaches in young people can be managed.
* Too little sleep or sudden changes in sleep patterns
* Skipping meals
* Changes in hormone levels, such as during menstruation
* Drinking or eating too much caffeine, such as in soda, coffee, tea, and chocolate
* Consuming certain foods, such as cheese, nuts, pizza, chocolate, fatty or fried food, or anything with the food additive MSG
* Sensory stimuli, such as bright lights, loud sounds, or unusual smells
In both children and adults, headaches are classified as either primary or secondary. “Primary headache is a headache unto itself, like migraine or tension-type headache,” Dr. Silberstein says. “Secondary headache, on the other hand, is a symptom of another disorder such as meningitis, sinusitis, or brain tumor.” Children experience a higher proportion of secondary headaches, in part because they have more infections.
Primary headaches largely consist of migraine, tension-type, cluster, and chronic daily headache (see box, “Types of Primary Headache”). Children, adolescents, and adults can all experience these types of headaches.
Migraine headache occurs in 5 to 10 percent of children and 10 to 20 percent of adolescents (more commonly females). Hormones may be a factor, as many females first experience headaches around the time they begin menstruating. Migraine frequently recurs and causes moderate to severe pain. Adults normally feel migraine on one side of the head, but children may feel the pain on both sides. Genes may predispose certain people to migraines.
Tension-type headache affects 15 percent to 20 percent of adolescents and a lower percentage of children (estimates vary from 1 percent to 24 percent of children). Sometimes called muscle-contraction headache, it is often described as feeling like a vise tightening around the head. Tension-type headache frequently occurs on both sides of the head and is characterized by mild to moderate pain.
Cluster headache, which is rare in children and adolescents, is characterized by severe, sudden pain that normally occurs in cyclical patterns (clusters) at the same time each day or night. People may experience these headaches for weeks or months but then go into remission, during which no headaches occur. Cluster headache is normally felt on one side of the head (often behind the eye) and may be accompanied by a tearing eye and a stuffy nostril (generally on the same side as the pain). Four times as many males as females experience these cluster headaches. Because it runs in families, cluster headache is believed to have some genetic basis.
Chronic daily headache occurs more than 15 days a month. (Headaches occurring less than 15 days a month are called episodic.) Chronic daily headache, which occurs in approximately 3.5 percent of children and adolescents, is divided into chronic migraine, chronic tension-type, and hemicrania continua. Hemicrania continua is a daily, continuous headache felt on only one side of the head and sometimes associated with stuffy nose, droopy eyelid and red, teary eye on the affected side; it frequently responds to the pain medication indomethacin.
New daily persistent headache begins distinctly and does not wane. The frequency—among children, adolescents, and adults—is difficult to determine. Some experts believe it is more common in adolescents than adults. In addition, more females than males have new daily persistent headache. The pain is mild to moderate and felt on both sides of the head. New daily persistent headache has been associated with viral illnesses such as mononucleosis, the flu, and gastrointestinal infections, or may result after surgery or traumatic brain injury.
For more Neurology Now coverage of headaches, go to http://bit.ly/xvm4th .
Secondary headaches are more varied and can be more dangerous, because they are often due to conditions such as brain tumor, fluid that causes increased pressure on the brain (hydrocephalus), bleeding, traumatic brain injury, or meningitis (inflammation often caused by bacteria). Correctly diagnosing a headache as either primary or secondary is therefore extremely important.
“We treat whatever is the underlying cause of the problem,” says Nina Schor, M.D., Ph.D., chair of the department of Pediatrics at the University of Rochester and AAN member. “In the case of a primary headache, such as a migraine without any other condition that might be causing it, we treat the migraine itself. But in the case of, say, a headache caused by a tumor, we treat the tumor. If the treatment for the tumor will take a long time to be effective, we might treat the headache in the short-term just to give symptomatic relief.”
Diagnosing headaches in general can be challenging because many of the headache types share symptoms, according to Dr. Silberstein. But diagnosing headaches in children can be especially tricky. “Particularly in younger children, the challenge is that they often can't communicate their pain very well,” Dr. Silberstein says.
It can be difficult for young children to pinpoint exactly where their headaches occur. “Frequently, when I ask children where the pain is, they look at me like I'm crazy and say, ‘In the head,’” Dr. Schor says.
Nonetheless, brain imaging is usually not necessary to diagnose primary headaches—in children, adolescents, or adults. “Generally, by taking a thorough history, and doing a complete neurologic examination in the office,” says Dr. Schor, “we can figure out which children need to have other testing done, to make sure this isn't a secondary headache.”
As part of the history, some neurologists ask younger patients to draw pictures of their headaches, while others use facial charts (pictures ranging from a child smiling to a child crying; see below) to help the children depict their pain. Feedback from parents can be helpful, but ultimately a diagnosis usually results from close interaction between doctor and patient.
Christina Szperka, M.D., director of the Headache Center at Children's Hospital of Philadelphia and Junior Fellow of the AAN, says, “My primary tool is the routine history and physical examination. I ask a lot of details about the onset of the headache, the pattern of it, associated features, and how it's impacting the child and family's life. Then I perform a physical examination, looking for any abnormalities, including evidence of sinus problems, arthritis, or infection. In addition, I look in the back of their eyes to see if there's any sign of pressure as the result of things like sinusitis or hydrocephalus.”
It was based on such a history and physical exam that 16-year-old Sydney Kessel was diagnosed with new daily persistent headache. Kessel had never previously had any problem with headaches. The pain was mainly behind her eyes, ranging from the right side to the front of her face and sometimes making its way to “the core” of her head.
Although primary headache syndromes like the one Kessel is experiencing are painful and at times debilitating, the good news is that they don't seem to negatively affect brain development. “I'm not sure that question has fully been answered,” Dr. Szperka says, “but we don't have any evidence that headaches change brain development long term.”
Dr. Schor agrees. “In fact, in the vast majority of cases in which the child has been impaired with pain or discomfort or vomiting during the episode, between headaches those children are completely, utterly, totally normal.”
Young patients often encounter challenges in finding effective treatment. After visiting a neurologist around the time of her headache's onset, Kessel was put in the hospital and treated with ketorolac (Toradol), a powerful non-steroidal anti-inflammatory. It provided some relief for about three hours. (Children and adolescents are not usually hospitalized for headaches, Dr. Szperka says, but it does happen on occasion.)
Migraines in children may be felt on both sides of the head, whereas adults typically feel them on one side only. Also, while an adult migraine usually lasts between 4 and 72 hours, children often have migraines that last for just an hour. Many adults with migraine experience an aura (such as flashing lights), while children do so much less frequently. On the other hand, children may experience flashing lights, dizziness, vertigo, or motion sickness without the accompanying headache.
Conditions called migraine equivalents also exist in children. The child may not have a headache, but the triggers and treatments are similar. These include benign paroxysmal vertigo (periodic dizziness), abdominal migraine (recurrent stomach pain), and cyclic vomiting syndrome (repeated vomiting).
On a subsequent emergency room visit to another hospital, Kessel was treated with dihydroergotamine (DHE), an injectable drug that affects blood flow in the brain. It also provided temporary relief. However, after being admitted to the pediatric floor, the nurses there didn't feel comfortable giving Kessel DHE, so the family waited.
“She couldn't get treated, and yet there she was in a hospital bed for 24 hours, doing nothing,” says Shirley Kessel, Sydney's mother. “That's one of the problems with being a young headache patient. You can fall between the cracks.”
Since the onset of her headaches last year, Kessel has been prescribed amitriptyline (Elavil), nortriptyline (Pamelor), cyproheptadine (Periactin), divalproex sodium (Depakote), dihydroergotamine mesylate (Migranal), and a nerve block. (A nerve block involves the injection of a local anesthetic in order to control acute pain.) None have offered anything other than brief, temporary relief of her pain. Botox made her headaches worse. The only thing that provided significant relief was the corticosteroid prednisone (Deltasone). However, this steroid cannot be used long-term due to significant side effects (including weight gain, brittle bones, and risk of gastrointestinal bleeding).
“Part of the problem is that relatively few studies have been done on headache in children and adolescents,” Dr. Silberstein says. “So we tend to use the same drugs as we use in adults.”
Still, “for a child of any age, there is a medication that can be tried or used,” Dr. Schor says. “The age dictates which medication is most likely to work and least likely to have side effects.”
Treatments for headaches in young people are often three-fold, focusing on acute treatment of the episode, preventive medications aimed at curbing future episodes, and maintenance of healthy habits.
“For acute treatment I will use anti-inflammatory medicines like ibuprofen or migraine-specific medicines called triptans,” Dr. Szperka says. “And sometimes I'll use medicine for nausea.”
“For young people experiencing at least one headache a week that is interfering with their lives,” Dr. Szperka says, “a number of preventives are available, including antiepileptic drugs or antidepressants. Sometimes we try vitamin supplements.”
However, many of these therapies are off-label, meaning they are not approved by the U.S. Food & Drug Administration (FDA) specifically for treating headaches in children or adolescents.
As is the case with all medications, side effects are a concern. “These drugs have similar side effects to what you see in adults,” Dr. Schor says. “That's the reason I try to reserve the preventive medications for children who have frequent or incapacitating migraine, and I tend to limit how frequently they're allowed to take a symptomatic medication of any kind. I also start with as low a dose as I can.”
Other, nondrug treatments for pediatric headaches are what Dr. Szperka calls healthy habits. It is critical to ensure that children get enough sleep and exercise and try to avoid foods (or situations) that seem to trigger their headaches. (See box, “Common Headache Triggers in Children.”)
Some studies indicate vitamin supplements such as riboflavin or magnesium may help treat headaches, although the research is far from confirmed. In certain cases, children may be able to manage headache symptoms with biofeedback, a mechanism of teaching relaxation to try to prevent or relieve pain.
None of these treatments are a cure-all, however, and doctors can't be sure which one might work. “I wish there was a crystal ball that would tell me which patient will respond to which class of medication, but unfortunately we don't have that, for children or adults,” Dr. Schor says. Dr. Szperka notes that one-third of chronic migraine sufferers in pediatric headache clinics “fail to respond to at least two preventive medications.”
The Kessels, thankfully, have found the neurologist they needed. “She is exploring every possible potential cure for Sydney,” Shirley says, “including referring us to psychiatry, psychotherapy, and a holistic M.D.”
While the exact cause of Kessel's headache is unknown, her doctors think it may be related to the case of mononucleosis she got over just months before the pain began. Genetics may also play a role, as Kessel's sister, mother, and grandmother have experienced similar headaches.
Moreover, Kessel's headaches may improve with time. “As many as half of patients with childhood headaches outgrow them in time,” Dr. Schor says. “That's a big light at the end of the tunnel.” She adds that the vast majority of children whose headaches continue into adulthood will have them only intermittently.
“The good news is that 85 percent to 94 percent of children and adolescents with headache treated with a multidisciplinary approach through a pediatric headache clinic report significant improvement over five years,” Dr. Szperka stresses. “I see my role as speeding that process up and holding their hand, emphasizing that it will get better.”
Dr. Schor feels optimistic about the treatment of headaches. “The genes responsible for some headaches are being identified, and the hope is that we can identify drugs that can alter the expression of those genes,” she says.
For children and adolescents thought to have a secondary headache disorder, advances in brain imaging now allow neurologists to identify serious problems in the brain in some children with headaches, such as brain tumors and infections, and get treatment started quickly. “And when it comes to migraine treatment, we're way ahead of where we were even 10 years ago,” Dr. Schor says. Still, we have a long way to go, as the Kessels' experience shows. Ultimately, more research of headache medications for children and adolescents is needed. For current clinical trials on headache disorders in children, visit: http://1.usa.gov/11HZ2Nf .