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Understanding Kids' Headaches

Introduction

Cleveland_Clinic_Host: Today's Live Web Chat with A. David Rothner, MD, Director of the Pediatric/Adolescent Headache Program at Cleveland Clinic’s Children’s Hospital will begin at 12 noon EST. He will be answering a variety of questions about ‘Kids and Headaches.’

Did you know that headaches are among the most problems encountered in adolescents? Up to 30 percent of adolescents experience frequent migraine or tension headaches and half of those destined to suffer from migraines experience their first migraine before they turn 18. According to the National Headache Foundation, 10.3 million U.S. children between ages 5 and 17 have chronic headaches.

Dr. Rothner received his medical degree from the University of Illinois College of Medicine. Following completion of an internship and junior residency in pediatrics at the Presbyterian-St. Luke’s Hospital in Chicago, he completed a senior residency in pediatrics at Columbia Presbyterian Medical Center’s Babies Hospital in New York City. Dr. Rothner continued his training at the Neurologic Institute of Columbia Presbyterian Medical Center with a fellowship in pediatric neurology. He has been a member of the faculty in the Department of Pediatrics and Neurology at Cleveland Clinic since 1973.

To make an appointment with Dr. A. David Rothner, or any of the other specialists in our Center for Pediatric Neurology and Neurosurgery in the Neurological Institute at Cleveland Clinic, please call 216.636.5860 or toll-free 866.588.2264; visit us online at www.clevelandclinic.org/pediatricneurology

Cleveland_Clinic_Host: Welcome to our Online Health Chat with A. David Rothner, MD. We are thrilled to have Dr. Rothner here today for this chat. He is considered an expert in the field of children and headaches. Let’s begin with some general questions.


Understanding Kids Headaches

nystrom: How common are headaches in children?

Speaker_-_Dr__A__David_Rothner: Headaches are a lot more common in children and in teens than adults believe. In a recent study between 50-70% of children/teens had headaches in the previous month. In general, up to 10% of teenagers will have migraine, and at least twice that many will have occasional tension type of headaches.

nystrom: What kind of headaches do kids and teens get?

Speaker_-_Dr__A__David_Rothner: The most easily recognized headache is a migraine. A migraine an occasional severe headache where the child will often look pale, gets grouchy, is bothered by light and noise, does not want to eat, may become nauseated and vomit. In most kids it ends within two hours without intervention. Many children will fall asleep which almost invariably ends the migraine.

So called tension type headaches are occasional milder headaches without the characteristic features of migraine. Approximately 1% of teens will have constant chronic headaches which can be a very challenging problem. Headaches due to brain tumors or other serious problems inside the head are fortunately very uncommon.

newtonm: Do children get migraine headaches? At what age can they start?

Speaker_-_Dr__A__David_Rothner: Migraine headaches can even occur in infants. In a study focused from age 7-15 years of age, about 2% of 7 yr. olds had migraines and 7-10% had migraines by the age of 15. The frequency of migraine increases with age. Under the age of 12, it is a bit more common in boys. Over the age of 14 and forever after migraines are more common in women.

suttona: Will my son outgrow his migraines, or will he suffer from them all his life? My wife gets them, but they didn’t start for her until her early 20’s.

Speaker_-_Dr__A__David_Rothner: Once again, migraines run in families and are hereditary. Up to 30% of kids will lose their migraine headaches and they will not come back. Another 30% will have their migraines go into remission for several years, only to return when they are young adults. The last 30% may have ongoing migraine, sometimes more frequent, sometimes less frequent, their entire life.

Lifestyle changes have a lot to do with decreasing the burden of migraines over a person's life span.

In addition, watching weight, exercising regularly, and learning relaxation techniques are useful adjuncts to treating headaches.


Causes or Triggers of Headaches

mkf1958: My son is 13 years old, gets frequent headaches that we attribute to heat and treat with Tylenol. Seems to take care of it. He is going to summer camp today. Is there any other suggestions?

Speaker_-_Dr__A__David_Rothner: Yes - My first suggestion is that your child carry a bottle of water with him at all times. Inadequate hydration may contribute to headaches. In addition, camp life is hectic and if they can obtain 8 hours of sleep, wearing a hat when playing in the sun, not skipping meals, and time out during sports in order to drink even more water can help.

In all studies, the NSAID's like Ibuprofen® work better than Acetaminophen®. An adequate dosage of Ibuprofen® works better.

If your child is indeed having frequent recurrent headaches, I suggest that you have him evaluated by your family physician when he comes back from camp.

newtonm: My daughter (13) has migraines. When I let her drink pop, I give her diet pop. I have heard that NutraSweet can cause headaches. Is it better to let her drink regular?

Speaker_-_Dr__A__David_Rothner: The issues with soda pop are many. Regular pop contains excessive sugar, which is not healthy. Second, any caffeine is not good, and even orange pop contains caffeine. Things like ginger ale, Sprite and 7Up are fine with moderation.

The easiest way to figure out if pop and/ caffeine/ and /or artificial sweeteners are playing a role in your child's diet. You should eliminate the artificial sweeteners completely and pop from her diet for 6-8 weeks. Bottom line, water is healthier.

brandie: What are the indicators that headaches are serious? How do I know that my daughter’s headaches aren’t just stress related? She really only gets them throughout the school year. During the summer, she gets very few.

Speaker_-_Dr__A__David_Rothner: The longer a headache has been present, without neurological symptoms or signs, the less likely it is to be a dangerous headache.The fact that it occurs more often during the school year and less during the summer is quite common. Issues at school are quite likely.

The 3 most common stressors in kids are school, parents, and 'so-called 'friends. Check for bullying at school. Straight 'A' students have the most self-imposed stress.

ajhatton: My daughter gets headaches with her period. What is the best way to help her with this? Tylenol® doesn’t usually work.

Speaker_-_Dr__A__David_Rothner: Some women have an increase in their migraines during the menstrual period. Some women have migraines only with their menstrual periods. This is likely due to the decrease in estrogen and progesterone that occurs just prior to the beginning of the menses.

From our research, it would seem that these problems as less prevalent in younger women and teens just beginning their reproductive life and more frequent in women in their 30's with migraine of long-standing.

Approaches to this problem include meticulous records of headaches and periods, determining when during the period the headaches are maximum (before the 1st day OR day 3-4). Many physicians begin by using long-acting NSAID's like Naproxen every 6-8 hours during the entire menses. Other physician may use long-acting triptans, like Amerge® and Frova® twice a day for 4-5 days. This is considered an off-label use of these medication not approved by the FDA.


Evaluation and Diagnosis

hunter: How do I know if my infant or young toddler is having headaches?

Speaker_-_Dr__A__David_Rothner: Making the diagnosis of headache in a non-verbal child, whether it is an infant who cannot speak or an older child who is developmentally handicapped, is challenging.

In an infant, a clue to migraine can be the episodic nature of the headache - for example, 1 every 2 weeks. The child may be fussy and irritable, even inconsolable, vomit and then fall asleep. If this occurs in a periodic fashion, and there is a strong family history of migraine in the mother, then migraine is a definite possibility. In such a case, medical consultation should be sought. If you find the child having such attacks twice a week, then medical attention should be sought in an urgent fashion.

Once a child can hold his/her head and state “my head hurts”, the ability to diagnose headache or migraine gets easier. If there are ANY underlying neurological symptoms such as one sided weakness, difficulty with balance, then urgent medical consultation is mandatory.

mommee: When should my children’s headaches start to become a concern?

Speaker_-_Dr__A__David_Rothner: The majority of headaches seen in children and adolescence are NOT due to a serious underlying cause. However, if there is fever, stiff neck, blurred vision, one-sided weakness, instability of gait or balance, excessive sleepiness, personality change, vomiting along with the headache, then a serious underlying cause should be considered. Urgent medical consultation is needed.


Treatment

trainor: My 5 year old son gets migraines 4-6 times a month. Is there a lower dosage of Imitrex®, or Amerge® that I can give him for the pain or anything else recommended for someone his age? Motrin/Tylenol doesn’t work. Usually throws it up and falls asleep.

Speaker_-_Dr__A__David_Rothner: That is a significant number of migraines per month for a 5 year old. My first thought would be lifestyle issues: sleep, hydration, diet.

Second, I would not use OTC (over-the-counter) meds more than twice per week. If he vomits OTC meds, I would use an anti-emetic like Zofran®, then wait 5 minutes and then give him an adequate dose of Ibuprofen®. My own preference is to also use Benedryl® as it often makes the youngsters fall asleep and shuts down the migraine.

There are no triptans (Imitrex®) that are approved by the FDA for use in a 5 yr. old. The FDA recently approved Axert® in adolescence between the ages of 12-17 years. None-the-less, some  use of triptans in an 'off label ' fashion. After consultation with your physician, the 5mg Imitrex®
nasal spray or one half of the 2.5mg Zomig® could be tried.

For children who do not respond to acute interventions and have frequent migraine, a preventive medication such as Periactin® could be considered. Please talk to your doctor.

nottingham: I really don’t want to start my young child (6years old) taking a lot of medication. But I also don’t want her to be in pain. Do you have non-medicinal remedies that are also effective?

Speaker_-_Dr__A__David_Rothner: Yes. Number one to prevent headaches, lifestyle changes may be needed. These would include a regular schedule, no missed meals, 8-9 hours of sleep, 4-6 glasses of water per day, not overusing OTC medications (certainly not more than twice weekly), exercise and diet. Stay away from chocolate, all forms of caffeine, nitrates (which are in all luncheon meats) excessive aged cheese and MSG found not only in Chinese and Spanish food, but also found in Doritos and Ramen Noodles. Some physicians also have the child stay away from artificial sweeteners as well.

When the child has a headache, they should be placed in a cool, dark, quiet room, a cold compress should be applied and then medication used. Depending on the circumstances, I use Benedryl® as a sedative, Zofran® for nausea and vomiting and Ibuprofen® for pain.

If the headaches are frequent, prolonged, or unresponsive to the above measures and interfering with the child's normal daily activities, consideration should be given to using a preventive medication. Consult your family physician.


Chronic Daily Headaches

Lucy: My daughter is 20 years old and has been suffering from severe headaches for at least the last 3 1/2 years and diagnosed with "Chronic Daily Headaches." My daughter has had a head CAT Scan and MRI that did not show any abnormalities and also two EEG's 1 of which showed possible spike waves on the right temporal lobe. A reevaluation showed no abnormalities. Do you think another MRI is necessary or would the MRI (done 2 years ago) be sufficient to feel there is no abnormality? When chronic, daily headache becomes "unbearable" in a 20 year old, while away at college, (U of I Champaign, IL) what should I advise as a mother 120 miles away?

Speaker_-_Dr__A__David_Rothner: Chronic daily headaches are becoming increasingly frequent in our society and may affect 1-4% of teens. They are the most difficult headache type to treat. After evaluation they are not found to have an underlying medical cause.

These headaches are most frequent in young women, are even more frequent in straight 'A' students or students who are overly active in extra-curricular activities. If the headache associated with excess school absences or over use of medication, it becomes very tough to treat. The initial approach is to make sure there is no physical abnormality. If the patient has a normal exam and a negative MRI, that is sufficient to determine the lack of physical abnormality as the cause.

Stress always plays a major role. In my practice, all of these patients are seen by a psychologist who specialize in children with chronic pain. Patient and parent education is critical and I usually give the parents and the patient material to review.

Lifestyle changes are critical as described above and include regular schedule, adequate sleep, adequate hydration, regular exercise, the avoidance of over-use of OTC medication and a special diet.

I suggest that all parents real a book titled "Conquering Your Child's Chronic Pain" by Lonnie Zeltzer, MD and Christina Blankett Schlank. I also suggest that the patient get a copy of the book "Be the Boss of Your Pain" by Culbert and Kajander.

Stress reduction is critical! In addition, with chronic daily headaches, I find the use of low-dose Amitriptyline® useful.

At Cleveland Clinic, for patients who do not respond to these therapies, we have a wonderful 3 week in patient rehabilitation program. Our Children's Hospital Pediatric Pain Rehabilitation Program is the only one of its kind regionally. Nationally, it is the only program that consists of both an in-patient AND out-patient component.  For more information about the program or our Children's Hospital Pediatric Pain Rehabilitation Program, please call 216.636.KIDS (5437) or visit us online at clevelandclinic.org/KIDS

For your daughter away at college, I cannot emphasize enough the need for a regular schedule, 8 hours of sleep, counseling and dietary discretion. She should not use OTC meds to treat headaches more than twice weekly.


Cluster Headaches

Speaker_-_Dr__A__David_Rothner: I also want to address Cluster Headaches in Children.

There are a group of headaches that are rare in teens called the TAC's (Trigeminal Autonomic Cephalgias.) They include cluster, paroxysmal hemicrania, hemicrania continua and SUNCT (Short-lasting Unilateral Neuralgiform Headache with Conjunctival Injection and Tearing). These are headaches that are shorter in duration, that are often localized to one part of the head and recur multiple times per day.

If your child's headache seems to fall into this category, referral to a pediatric neurologist headache specialist via your primary care physician as the diagnosis and treatment options fall out of the usual realm of primary care physicians.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. David Rothner is now over. Thank you again for taking the time to answer our questions about children and headaches.

Speaker_-_Dr__A David Rothner: This was an excellent opportunity to discuss headaches in the children and adolescent population. Thank you for having me.


More Information

  • To make an appointment with Dr. A. David Rothner, or any of the other specialists in our Center for Pediatric Neurology and Neurosurgery in the Neurological Institute at Cleveland Clinic, please call 216.636.5860 or toll-free 866.588.2264; visit us online at clevelandclinic.org/pediatricneurology.
  • A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult.
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Additional websites for further information about headaches in children and adolescents are:

This chat occurred on July 27, 2009. 

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