Pediatric Primary Headache From A to Z

Future Directions in Treatment of Headache

The final presenter was Dr Lynn Kerr, who answered the question, "What's next in pediatric headache treatment?" The Childhood and Adolescent Migraine Prevention (CHAMP) study is a comparative effectiveness trial with three arms (topiramate, amitriptyline, and placebo) in patients aged 8-18 years. The trial was stopped prematurely (presumably because of significant differences in response among groups), but the results have not yet been released. Headache experts are awaiting these results, and Dr Kerr is hopeful that they will help headache practitioners standardize daily preventive treatment.

Another study that is under way is called the "glasses study," in which migraine-prone children wear sunglasses to see whether this will reduce the frequency of migraine. Emerging data on transcranial electrical and magnetic stimulation show that these methods may be able to abort migraine with aura. Stay tuned for more information on all of these areas of active investigation.

Pearls for Practice

For more in-depth reading, see a review of pediatric headache published in 2012 in Pediatrics in Review. It includes detailed tables with differential diagnoses; medications believed to cause headaches; and dosing of acute migraine drugs, antiemetics, and preventive medications.

Among the many take-home points for providers that can be put into practice quickly to improve the care of patients with headache are the following:

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  Use the SMART mnemonic as part of the initial headache history.
  
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  The "red flags" of the headache history are diplopia, loss of peripheral vision, tinnitus, morning headaches or headaches upon waking, positional components, confusion, swallowing difficulties, or "worst headache of their life."
  
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  The physical exam should include blood pressure and visual peripheral field examinations, as well as a focus on the neurologic exam.
  
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  Radiologic evaluation is rarely helpful in the evaluation of headache if the history and physical exam do not suggest a cause (except for acute-onset severe headaches); resources exist to help you choose the correct modality.
  
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  Develop a home treatment plan for patients with headache, making sure that they know when to use their home therapy and when to seek additional care in emergency settings.
  
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  NSAIDs (first line) and triptans (second line) with adjunctive antiemetics and antihistamines are the core of home therapies to treat migraine episodes.
  
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  In the ED setting, treat with NSAIDs, antiemetics, and antihistamines.
  
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  Institute aggressive hydration in the ED or inpatient settings.
  
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  Consider DHE for hospitalized patients, and assess response after the sixth dose.
  
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  Prophylactic options exist; pediatric outcome data are best for topiramate and amitriptyline, followed by cyproheptadine.
  
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  Behavioral and psychological comorbid conditions are common among patients with migraine and may need to be addressed to effectively treat the patient. Publicly available tools to screen for anxiety or depression should be a part of the headache assessment.
  
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  Managing patient and family expectations while forming a therapeutic alliance is critical to success.