Online Health Chat with Dr. A. David Rothner
October 8, 2010
Cleveland_Clinic_Host: 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 experience chronic headaches.
A. David Rothner, MD, is the Director of the Pediatric/Adolescent Headache Program at Cleveland Clinic’s Children’s Hospital. He 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.
Currently, Dr. Rothner is the Chairman Emeritus of the Section of Child Neurology at Cleveland Clinic. He is also Vice-Chairman of the Division of Education. He serves as a Fellow of the American Academies of Pediatrics and Neurology, and has served on the advisory boards of the Epilepsy Foundation of America and the March of Dimes. Dr. Rothner directs the Pediatric/Adolescent Headache Program and also directs the efforts of the Patient Education Program.
Dr. Rothner sits on the editorial board of Pediatrics Today and Headache Quarterly. He has published over 250 original articles, book chapters, tapes and reviews in the areas of epilepsy, headaches in children and general pediatric neurology. He is Co-Editor of the textbook, Headache in Children and Adolescents.
To make an appointment with A. David Rothner, MD or any of the other specialists in our Center for Pediatric Neurology at Cleveland Clinic, please call 216.444.5559 or toll free 866.588.2264. You can also visit us online at clevelandclinic.org/pediatricneurology.
Welcome to our Online Health Chat with Dr. A. David Rothner. We are happy to have him here today for our chat on Kids, Headaches & School Attendance. Let’s begin with the questions.
Migraine Headache Symptoms in Children
Sally34: I have heard that migraine symptoms may be different in children versus adults. Can you elaborate?
Speaker_-_Dr__David_Rothner: Migraine symptoms may indeed be different in children than in older teenagers, as well as in adults. Children have a lower frequency of migraine then do adolescents and adults. Their headaches tend to be more in the afternoon. They are less frequent in the morning. Children with migraine often have bilateral head pain across the head and in both temples. Their headache last a shorter period of time then do the headaches in adults. An example being that the child's headache may last 1 to 3 hours or until they fall asleep and an adult's migraine may last up to 72 hours.
Younger children tend to vomit more than adolescents and adults.
When children morph into teenagers, the headaches may become more severe, more unilateral and occur in the morning.
Basic methods of approaching children with migraine headaches include: education with the parents and the child, so they know what they are dealing with. It also includes management of stress. We closely examine every child's lifestyle. This means adequate sleep (8 hours), adequate hydration and adequate exercise. We try to avoid certain foods that have substances that aggravate headache. These might include caffeine, chocolate, lunch meats, aged cheese and MSG especially as found in Doritos and Ramen noodles. The majority of children can be treated intermittently - just when they have a bad headache and don't need to be put on preventive medicine.
My methods treating children with migraine symptoms include sedating the child after having them lie down in a cool dark quiet place and putting on a cold compress. I have them use diphenhydramine or Benadryl®, followed by (if needed) an anti-vomiting medication, followed by a nonsteroidal medication (such as Naproxen) only if they fail to respond to medications such as this.
I do not use tryptophans unless the above treatment fails. In young children, if the headaches are very frequent and unresponsive to this approach, I may consider preventive medication.
Cleveland Clinic Headache Center: A Multidisciplinary Approach
tidyme: At your headache center, is the treatment multidisciplinary? For example, my son has a lot of headaches. He saw his pediatrician and the headaches have no ‘physical’ cause. It was suggested they were caused by stress and tension. Does care in your treatment center include psychological treatment as well, that helps kids deal with their stress and tension?
Speaker_-_Dr__David_Rothner: The answer is yes, yes, yes! The first and most important factor is to rule out any serious underlying causes, which are a very rare cause of headaches in children.
The second factor is to differentiate migraines from chronic daily headaches or chronic tension-type headaches. Migraine is an episodic disorder with severe headache bothered by light, bothered by noise, and a desire to lie down. Migraine sufferers often have nausea and some vomiting. Tension-type headaches are much less severe and may occur multiple times per week to every day. Many of my patients having headaches are 24/7.
Medication should not be the initial approach to a child with chronic daily headaches. The first step is patient and parent education. The second is to look into stress issues occurring in the family oriented child, including school and bullying by friends. In many of my patients who have chronic daily headaches a visit is scheduled with one of our pain psychologists used to dealing with children.
I then look into lifestyle issues, including sleep, hydration and exercise.
We avoid the overuse of over-the-counter medicines. Over-the-counter medicines should not be used more than 2 days per week.
We then look at diet, excluding from the diet caffeine, chocolate, lunch meats, aged cheese, and foods containing monosodium glutamate (MSG).
So yes, we strongly recommend a multidisciplinary approach to the treatment of headaches.
If the patient has episodic migraine (one or 2 days a week or 2-4 times a month), we treat the patient with medication at the time of the headache.
If the patient has chronic daily headache, we use a multidisciplinary approach plus low doses of medications such as amitriptyline.
Frequent follow-up visits are necessary to make sure the treatment regimen is being followed and that the patient is improving.
Headaches and Spontaneous Intracranial Hypotension
austintx: My daughter is suffering mightily from residual migraine type headaches and neck tension from a spontaneous intracranial hypotension event this spring. She was hospitalized for 6 weeks between Baylor in Dallas and Cedars Sinai in LA, where the physician found and plugged the leak with an organic glue patch procedure. Does your headache group think they could help her overcome these headaches and return to normal health? She is 23, has no ongoing fluid leaks, and was otherwise in good health.
Speaker_-_Dr__David_Rothner: Spontaneous intracranial hypotension is really quite uncommon in children and adolescence, unless it's associated with something like a head injury or neck injury.
What it simply means is that he has a leak in the membranes covering the spinal cord, so that fluid leaks out. Patients tend to have headaches especially when they stand up or they strain and the headaches tend to get better when they lie down. The patient saw a doctor at Cedar Sinai in Los Angeles who has a major reputation for evaluating and treating patients with spontaneous intracranial hypotension. The other place that is famous for its work in this area is Dr. Mokri at the Mayo Clinic in Minnesota.
If there is no leak, the patient should be treated with a gradual rehabilitation program with slowly increasing exercises so that she can sustain walking and later even running. In addition, this patient should be treated as if she has chronic daily headaches. This should include dealing with stress and emotional issues. Simply having this much pain for this long a period of time creates stress and emotional issues, so that counseling could be helpful. In addition, we feel that things such as lifestyle changes: 8 hours of sleep, 6 glasses of water a day and a gradual exercise program are important.
The patient should stop overusing over-the-counter and pain medication as that frequently results in medication overuse headache. We put the patient on a diet with no caffeine, no chocolate, no nitrates and lunch meats, no tyramine (as in aging cheese) and no MSG as (found in Raman noodles and some of the snack foods). In addition, we have had some success with the use of amitriptyline beginning at low doses and working up to a milligram per kilogram. It is a slow process and these other factors are often more valuable than using medication.
At Cleveland Clinic we have a Headache and Facial Pain Clinic dedicated to the diagnosis and management of headache disorders. The Clinic specifically offers a unique treatment program for chronic headaches called IMATCH (the Interdisciplinary Method for the Assessment and Treatment of Chronic Headache).
You can read about the program on our site: my.clevelandclinic.org/headache_center/imatch.aspx
For an appointment or for more information, call 216.636.5860 or 866.588.2264. This site also has links for Fact Sheets that may be downloaded.
Another service Cleveland Clinic offers is MyConsult Online Medical Second Opinion service. The service offers an initial evaluation without having to travel here. More information may be found at this link: eclevelandclinic.org/myconsult
whowhatwhere: What is an abdominal migraine?
Speaker_-_Dr__David_Rothner: I think it is first important to emphasize that abdominal migraine is not just a stomachache. Secondly, abdominal migraine is not daily bellyaches.
Abdominal migraine is a poorly understood variety of migraine in which the child gets abdominal pain, usually in the area around the umbilicus from time to time, like once or twice a week, and it lasts about an hour. It is usually not associated with a headache at that time, but may be associated with nausea and even vomiting.
When I think about abdominal migraine, I usually think of that in the setting of a child who has the usual form of migraine with headaches bothered by light, bothered by noise, and nausea and periods and the child with abdominal migraine may have regular migraines and also in the stomach.
Once again, I think it's important to emphasize that abdominal migraine is not just frequent stomach aches and certainly is not daily abdominal pain.
Epilepsy and Headaches
kidstoo: My 14 year old son has epilepsy. He often complains about headaches. He gets them after a seizure, but also unrelated to a seizure. Are headaches and epilepsy related or are these two separate ‘conditions’? Could this be medication related?
Speaker_-_Dr__David_Rothner: There is no question that children with epilepsy have a higher frequency of headaches. There also is no question that children with headaches have a slightly higher incidence of epilepsy than the general population.
Children who have seizures will often developed headaches right after a seizure. This is called a postictal headache. At Cleveland Clinic, we have just completed a research project and feel that this happens in about 50% of children's seizures. The headaches following the seizure are often migraine-like and respond to treatment just like migraine.
The medications used to treat epilepsy, such as Topamax topiramate, or Depakote or Neurontin are often used in the treatment of headaches, although not FDA approved in children.
ADHD and Headaches
connie: My child takes medication for ADHD. The drugs can (and do) cause headaches. Do you know of any way to make these types of headaches happen less frequently?
Speaker_-_Dr__David_Rothner: A really terrific question! It is important to make sure that the headaches are indeed related to the medication and that the child really doesn't have two problems: ADHD and headaches.
If a parent thinks that the headaches are due to the ADHD medication, under the supervision of their doctor, they should discontinue the ADHD medications for a weekend or during a vacation period and see if the headaches disappear. In most circumstances, the parents will note that the headaches continue. In my experience, the ADHD medications cause headache when they are first started and cause headache when the child has been off the medication for a week or 2 and then is restarted under full dosage.
If there has been a vacation from the medication, the medication should be restarted at low dose and titrated upward. In this way, the headaches can frequently be avoided.
If despite what I just said, the youngster continues to have daily headaches, then the other measures that we use for daily headaches should be instituted and see if the headaches can be managed.
It then becomes a balancing act between the need to treat headaches and the need to continue the child on their ADHD medication or a different ADHD medication.
trying: I hate to overmedicate my daughter, but she gets frequent headaches during school. If I have her take a couple of pain relievers, such as Tylenol, before school every day, will this help prevent or lessen the severity of headaches while at school?
Speaker_-_Dr__David_Rothner: This is an absolute no-no. The daily use of over-the-counter medication often results in medication overuse headaches or rebound headaches. A child with daily headaches needs to be evaluated so that more appropriate measures can be instituted to evaluate and then treat her child's headache.
Once again over-the-counter medication should not be used more than twice a week, as it may actually make headaches worse.
Medications for Children with Headaches
connie: Is Periactin effective in preventing migraines in kids?
Speaker_-_Dr__David_Rothner: Periactin is also known as cyproheptadine. This medication is over 50 years old. It is an excellent, inexpensive, safe medication often used in the prevention of migraine. It is not used in any acute treatment of migraine with the child having migraine 2-3-4 times per week. If the usual modifications to dietary issues, stress issues and lifestyle issues don't seem to help, we may use Periactin.
Periactin is given only at night. Each tablet is 4 mg. I tell the parents to buy a pill cutter to give them one half tablet at night for 2 weeks, one tablet at night for 2 weeks and then one and a half tablets at night for 2 weeks. I then see the patient again.
I tell the parents that the only side effect from this medication is some sleepiness. Therefore, I give the medication at night. The other side effect is increasing the child's appetite. I therefore never give this medication to overweight children.
I see most of my patients in follow-up at 6 weeks. If the patient is doing much better with the lifestyle changes, dietary changes and low-dose Periactin, I don't raise the medication dose. If the patient is having no side effects but still is having frequent migraine, I go up to 2 tablets for 2 weeks and 2-1/2 tablets for 2 weeks and then up to 3 tablets. I monitor weight and side effects very closely. If the patient does well on this medication I may keep it up for 2-3 months. I then try to taper the medication slowly, hoping the patient's migraine headaches will be easier to control without daily medication.
Holistic and Alternative Treatments for Headaches
pennysaved: What holistic or alternative treatments do you suggest for kids with headaches? I don’t like my kids to take too much medication, if they do not have to.
Speaker_-_Dr__David_Rothner: Holistic or alternative treatments are defined as medications or methodologies not pharmacologic in nature that help with decreasing a child's headaches. My approach includes both holistic and alternative treatments. I start out with patient education. I think understanding your child's headaches goes a long way to relieving anxiety and beginning a management process.
After careful examination and maybe some tests, it is important to confidently reassure the parents and the child that no bad cause for the child's headaches exists.
Dealing with stress is a holistic treatment. So, for example, if there is a divorce in the family or other serious issues, for sure counseling can be of benefit. Some counselors use biofeedback which in the right circumstances can be a very effective in treating headaches.
Sleep and Headaches
pennycrane: What is the association between sleep and headaches?
Speaker_-_Dr__David_Rothner: Our experience has been that there is a tremendous relationship between lack of sleep and headaches. A child should have at least 8-8-1/2 hours of sleep that is restorative. This means that the child should fall asleep within one half hour of getting into bed and wake up only once during the entire night.
If the child takes longer to fall asleep and has multiple nocturnal awakenings, that can contribute to headaches being present. Lack of sleep can make migraine headaches worse and can prevent chronic daily headaches from getting better. I have a list of rules that I frequently give parents for good sleeping. Patient should go to bed every night at the same time 7 days per week. There should be no television in the room, no computer in a room, no cell phone with text messaging in the room and if there is an IPod, it should be used only to listen to music.
If your child continues to have sleep related difficulties I frequently will use doses of melatonin, which is a herbal preparation in order to help the child sleep. The melatonin needs to be taken 2 hours before bedtime and I use slowly increasing dosages. You should check with your physician to be sure of the details.
A Word about Concussions or Post Traumatic Headaches
Svensgirl: My son had a concussion during sports last fall. Now every time he complains of a headache I have been worried. Should he still be getting headaches post-concussion or could the headache be related to something totally different?
Speaker_-_Dr__David_Rothner: If the youngster has a head injury and develops a concussion and never had headaches before but is having headaches now, that youngster requires a complete neurological evaluation. As long as any of the symptoms of the concussion persist, that child should not be allowed to return to contact sports.
Headaches following concussion are called post traumatic headaches. Once a physical problem such as a subdural hematoma has been ruled out and if the headaches have been present for longer than 8 weeks, the patient should be treated as if they have chronic daily headaches. That means a complete evaluation, patient education, stress management, lifestyle changes, dietary changes and the judicious use of low doses of medication. The child once again should not be allowed to take over-the-counter medication more than twice a week.
It is important if the child has a concussion and the symptoms from the concussion are not gone, they not be allowed to return to play. If the child returns to play and the child has a second concussion this can cause severe neurological problems.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. A. David Rothner is now over. Thank you again Dr. Rothner for taking the time to answer our questions about Headaches & School Attendance.
Speaker_-_Dr__David_Rothner: Thank you so much for taking the time to chat with me today. I will do my best to answer some of the questions we were unable to get to today. These will be posted in the transcripts, so please check back!
austintx: Thank you very much for responding so thoroughly to my inquiry! We will be in touch with CC to follow-up shortly. Best regards.
- To make an appointment with A. David Rothner, MD or any of the other specialists in our Center for Pediatric Neurology at Cleveland Clinic, please call 216.444.5559 or toll free 866.588.2264. You can also 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.