Clinical FAQs: Headaches and Migraines

How Common are Headaches in Pediatric Practice?

Headaches associated with muscle tension or minor acute illnesses happen in nearly all children. Migraines are reportedly present in 1 to 3 percent of 3- to 7-year-olds; 4 to 11 percent of 7- to 11-year-olds; and 8 to 23 percent of 11- to 15-year-olds. Migraines are more prevalent in males than females before puberty, with a female preponderance in adolescence (Bille, et al 1962-1994).

In some children, migraines present in an atypical or "variant" pattern, with cyclic vomiting, recurrent abdominal pain, symptoms of dizziness or vertigo. 

When do Headaches Require Treatment or Evaluation?

As over 90 percent of school-aged children can experience headaches, these are some common symptoms that are screened for and may warrant further evaluation if positive:

• Any sign of serious infection such as a stiff neck, rash or very high temperature
• Rapidly progressive headaches that are new onset or represent a change in a previously stable headache pattern
• Any headache that has neurological signs associated with it such as motor weakness, inability to speak or seizures
• Any changes in the patient's physical abilities (such as new onset clumsiness or coordination problems)
• Headache associated with weight loss, or other possible associated symptoms such as thyroid disease
• Headache in someone who is immunocompromised
• Anyone with an abnormal neurological exam screened by a physician
• Headaches associated with seizure, syncope, exertion, trauma, substance use or confusion
• Headaches that awaken the child from sleep often

Tonia Sabo, MD
Assistant Professor of Pediatrics, Section of Child Neurology

What Are the Indications for Prophylactic Migraine Medicines?  Which Ones Are the Best?

Typically, a patient with debilitating migraines is a candidate for prophylactic medicines. An easy way to define the degree of impairment is to ask about days of school missed. Usually, we will offer daily medication to patients who miss one or more days of school per month. At follow-up visits, the change in this number can help to judge the success of your intervention.

• For patients who are 5-10 years of age, a good first-line agent is cyproheptadine (2 mg QHS to start). Be aware that this medication can have an appetite stimulant side effect. 
• Older children can try amitriptyline (10-20 mg QHS to start; usually we get an EKG to rule out prolonged QT prior to starting).
• Teens can try valproic acid or topiramate (25 mg qhs to start). 

Each of these medicines has its own side-effect profile that needs to be considered and discussed with the family (for instance, Topamax is a poor choice in a thin patient or a patient with a history of eating disorder). 

A key element to success is educating the patient and family about the realistic expectations of therapy, especially the fact that most of these medicines take 4-6 weeks before taking full effect. Many of these medicines will need to be titrated up over time. Early abandonment of these therapies often leads to poly-pharmacy and confusion about the effectiveness of each medication.

Once a patient has failed 1-2 of these medicines at a full dose, a reconsideration of the diagnosis and a referral to neurology are in order.

Timothy J. Bernard, MD
Assistant Professor, Co-Director, Pediatric Stroke Program