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1
Department of Paediatric ABSTRACT paediatrics and paediatric headache disor-
Neurology, Nottingham
Children's Hospital, Nottingham
Headache is very common in children and young ders in particular, the better the advice
University Hospitals NHS Trust, people. The correct advice and treatment you will give and the better will be the
Nottingham, UK requires consideration of a wide differential treatment options you can offer your
2
School of Medicine, University
of Nottingham, Nottingham, UK
diagnosis between primary and secondary patients.
3
Department of Paediatric headaches, and also of the different types of Headache can be thought of as pain
Neurology, Birmingham primary headache. The International referred to the forehead, orbits, temples
Children's Hospital, Birmingham,
UK
Classification of Headache Disorders gives useful or scalp, and does not usually cover pain
descriptions and diagnostic criteria that are isolated to the face or neck. Pain is a
Correspondence to especially useful for primary headaches. The complicated, all be it real, experience that
Dr William P Whitehouse, National Institute for Health and Care Excellence demands and deserves medical attention.
Division of Academic Child
Health, School of Medicine,
(NICE) Clinical Guideline 150 provides evidence- The International Association for the
E Floor East Block, Queen's based recommendations on treatments for adults Study of Pain defined it as an unpleasant
Medical Centre, Nottingham and young people from age 12 years. However, sensory and emotional experience asso-
NG7 2UH, UK;
william.whitehouse@
the same principles can be applied to younger ciated with actual or potential tissue
nottingham.ac.uk children when a specific diagnosis can be made. damage, or described in terms of such
Key recommendations from the NICE Quality damage.1 Therefore, pain can be caused
Received 10 August 2016
Revised 30 October 2016
Standards include, establishing a precise by actual or incipient tissue injury, a dis-
Accepted 2 November 2016 diagnosis if possible, avoiding, diagnosing and order of the pain pathways or an illness
Published Online First treating medication overuse headache, and behaviour, and in all cases is a powerful
20December2016
combining a triptan with a non-steroidal anti- interpersonal communication. It is not
inflammatory drug or paracetamol as the first- surprising then, that some drugs that are
line acute/rescue treatment for migraine with or very effective for pain associated with
without aura. Although rare in children and tissue injury, for example, opiates and
young people, it is important to diagnose new anti-inflammatory drugs, are often only
daily persistent headache, as it responds poorly partially effective in other situations.
or not at all to medication; and paroxysmal Psychological support and interventions
hemicrania as it responds very well to can make important contributions to
indomethacin but not to other commonly used restoring function in patients with pain
analgesics. When faced with difficulties in generally and especially in migraine.
reaching a precise diagnosis or in finding Acknowledging the condition, allaying
effective therapies, further advice should be fear and addressing worries will help ease
sought from a childrens headache clinic or the suffering.
specialist. Recent reviews of headache in child-
hood,2 3 and in preschool children,4
INTRODUCTION provide excellent summaries of the topic,
Although this article will focus on the and more comprehensive knowledge can
drug therapy of primary headaches, it is be gleaned from Childhood Headache
vital that prescribers understand how to 2nd Edition,5 and the Childhood
differentiate primary from secondary Headache Training courses run in the UK
headaches and also the varieties of by the British Paediatric Neurology
primary headache that will present in Association.6 The National Institute for
childhood. Diagnosis and therapeutic Health and Care Excellence (NICE)
To cite: WhitehouseWP,
decisions are often complicated by evidence-based guideline on headache in
AgrawalS. Arch Dis Child comorbidities, and different primary young people and adults is an accessible,
Educ Pract Ed 2017;102:58 headaches can coexist. So the more you succinct and invaluable resource, which
65.
know and understand about general covers the diagnosis and management of
Review
Review
Table 1 Simple analgesics for the acute/rescue treatment of migraine with and without aura
Beware: Patients are susceptible to medication overuse headache, so use full doses but usually on no more than 2 days/week
1. Paracetamol
011 years Oral 20 mg/kg 46 hrly, max 75 mg/kg/day Tabs: 500 mg; dispersible tabs Hepatic impairment
120, 500 mg; Renal impairment
Oral suspension: 120 mg/5 mL,
250 mg/5 mL
Per rectum 40 mg/kg, then 20 mg/kg 46 hrly, Suppositories: 60, 125, 250,
max 75 mg/kg/day 500 mg
1050 kg Intravenous 15 mg/kg 46 hrly (max 60 mg/kg/day) Intravenous infusion: 10 mg/mL
>50 kg 1 g 46 hrly (max 4 g daily)
1218 years Oral 0.51 g 46 hrly, max 4 g/day
PR/intravenous doses as above
2. Ibuprofen (NSAID)
26 years Oral 100 mg three times a day, max 30 mg/kg/day Tabs: 200, 400, 600 mg; Gastro pain, bleeding, ulceration,
allergic reactions
711 years 200 mg three times a day, max Oral suspension: 100 mg/5 mL;
30 mg/kg/day, max 2.4 g/day Orodispersible melts: 200 mg
1218 years 400 mg three times a day, max 600 mg four
times a day
3. Diclofenac (NSAID)
118 years Oral/PR 0.31 mg/kg three times a day, Tabs: 25, 50 mg; Gastro pain, bleeding, ulceration,
max 150 mg/day Dispersible tabs: 10, 50 mg allergic reactions
Suppositories: 100 mg
218 years Intravenous/ 0.31 mg/kg twice daily max 150 mg/day Injection: 25 mg/mL
intramuscular
4. Ketorolac (NSAID)
115 years Intravenous (slow) 0.51 mg/kg (max 15 mg) stat then Injection: 30 mg/mL Gastro pain, nasty taste, flushing,
0.5 mg/kg (max 15 mg) confusion
6 hrly, max 60 mg/day for 48 h
1618 years 10 mg stat then 1030 mg 4 hrly,
max 90 mg daily for 48 hours
Some of the drugs/doses below are those suggested/used by the authors and may be outside the marketing authorisation. Always check usual reference
sources/guidelines when using unfamiliar medicines.11
Hrly, hourly; max, maximum; NSAID, non-steroidal anti-inflammatory drug; tabs, tablets.
Review
including healthy lifestyle habits (see box 4). We rou- probably at the level of the trigeminovascular system
tinely encourage the use of distraction (especially for and its connections.5 Offer a triptan taken together
mild and moderate headaches), cold or warm com- with ibuprofen or paracetamol (or both) for attacks of
presses and balms applied to the forehead and/or migraine with or without aura.7 These combinations
temples, for example, Tiger Balm White, 4-Head, are more effective and cost-effective than using either
etc. Excess caffeine, aspartame, monosodium glutam- in isolation.7 A nasal triptan, for example, sumatriptan
ate, nitrites, alcohol and chocolate can cause head- or zolmitriptan will have a more rapid onset of action
ache (and vomiting); however, the role of exclusion than oral or orodispersible formulations. The triptan
diets per se in childhood migraine is still unproven. can be repeated after 2 hours if required, but give the
patient and parent/carer clear instructions on the
GENERAL ACUTE/RESCUE TREATMENTS maximum dose, for example, two doses in 24 hours
Simple over-the-counter analgesics, paracetamol and/ and on no more than two days a week. A nasal
or ibuprofen are first-line treatments for symptomatic triptan may not be tolerated because of the taste or,
and most primary headaches, especially episodic very rarely, it can produce an unpleasant feeling or
tension-type headaches.7 Opiate analgesia should be dizziness. If this happens, it is worth trying an alter-
offered for severe symptomatic headaches where there native triptan or formulation. If tolerated, a triptan
is known tissue damage, for example, for post- should be tried for three different attacks before
operative pain, but is not recommended for primary giving up for lack of efficacy. Three different triptans
headaches. It seems less effective and more prone to should be tried before accepting that this class of
dose escalation and dependency in patients with medicine is ineffective for a particular patient.
primary headaches, with associated incapacitating sed- Although sumatriptan and zolmitriptan are the only
ation, constipation, nausea and itching. See tables 13 triptans currently in the BNF C,11 and only sumatrip-
for most useful medicines for migraine with or tan has marketing authorisation (a licence) for young
without aura. people aged 1218 years, there are no particular con-
Give the child or young person a headache diary to traindications to triptan use in this population or
use.12 This will help establish their headache diagno- younger children, for example, of primary school age.
ses and whether the current acute/rescue and prophy- We will occasionally use triptans, in the smaller doses
lactic treatments are working. available, in younger children off-label, in accord-
ance with the UK Royal College of Paediatrics and
MIGRAINE WITH OR WITHOUT AURA Child Health advice to use the best treatment available
Triptans are a class of serotonin irrespective of pharmaceutical company marketing
(5-hydroxytryptamine) 1B/1D/1F receptor agonists, strategies, especially when no licensed product of
which exert a particular antimigraine attack effect, that class is available.13
Table 2 Antiemetics for the acute/rescue treatment of migraine with and without aura
5. Cyclizine
25 years Oral 0.51 mg/kg three times a day, Tabs: 50 mg; Drowsiness, dystonia is rare
Per rectum max 3 mg/kg/day, max single dose Suppository:12.5, 25, 50, 100 mg;
Intravenous 25 mg Injection: 50 mg/mL
Subcutaneous
611 years 25 mg up to three times a day
1218 years 50 mg up to three times a day
6. Domperidone
218 years Oral/ 250 mg/kg three times a day, Tabs: 10 mg Avoid in hepatic impairment
35 kg Per rectum 10 mg three times a day, Suspension: 5 mg/5 mL Can prolong QT-interval, so caution in heart
>35 kg Suppository: 30 mg disease, or with other drugs that can do the
same
7. Prochlorperazine
511 years Oral 250 mg/kg up to three times a day Tabs: 5 mg; syrup: 5 mg/5 mL Dystonia, akathisia, tardive dyskinesia, all
Per rectum 5 mg three times a day Suppository: 5, 25 mg rare
Intramuscular 6.25 mg, max three times a day Buccal prep: 3 mg tabs placed high
between upper lip and gum
1218 years Oral 510 mg, max three times a day Injection: 12.5 mg/mL
Per rectum 12.525 mg three times a day
Buccal 12 tabs twice daily
Intramuscular 12.5 mg up to three times a day
Some of the drugs/doses below are those suggested/used by the authors and may be outwith the marketing authorisation. Always check usual reference
sources/guidelines when using unfamiliar medicines.11
Tabs, tablets.
Review
Table 3 Triptans: specific acute/rescue treatments for primary headaches
Beware: To avoid medication overuse headache, use on no more than 2 days/week
8. Sumatriptan
69 years Oral 25 mg at onset, repeat once after at least Tabs: 50 mg Cardiac disease.
2 hours if needed, max 2 days/week Tingling, tightness, flushing,
dizziness, nasty taste (nasal
1018 years Oral 50100 mg at onset, repeat once after at Injection: 6 mg/0.5 mL spray)
least 2 hours, max 2 days/week Nasal spray: 10 mg /0.1 mL actuation
Subcutaneous 6 mg at onset, repeat once after at least (2 and 6 unit dose sprays available)
1 hour, max 2 days/week
Intranasal 1020 mg at onset, repeat once after at least
2 hours, max 40 mg/day, max 2 days/week
9. Zolmitriptan
1218 years Oral 2.55 mg at onset, repeat once after at least Tabs: 2.5 mg Cardiac disease.
2 hours, max 10 mg/day, max 2 day/week Orodispersible: melts 2.5 mg Tingling, tightness, flushing,
Intranasal 5 mg at onset, repeat once after at least Nasal spray: 5 mg /0.1 mL actuation dizziness, nasty taste (nasal
2 hours, max 10 mg/day, max 2 day/week spray)
Other triptans include rizatriptan (halve the dose if on propranolol), almotriptan, eletriptan, frovatriptan, naratriptan, with less experience in children and
young people
Used together with NSAID or paracetamol.
Some of the drugs/doses below are outwith the marketing authorisation. Always check usual reference sources/guidelines when using unfamiliar
medicines.11
Max, maximum; NSAID, non-steroidal anti-inflammatory drug; tabs, tablets.
Review
recognise as they are very painful and incapacitating, seen more often in young people aged 1218 years
and their pathology and treatment is different from than in younger children, and may be mistaken for an
migraine. However, effective first-line treatment is epilepsy, or psychogenic non-epileptic attacks, or
available, so if you are unfamiliar with them do con- other medically unexplained illness behaviour.15 High
sider referring to a paediatric or adult headache clinic, flow (12 L/min) 100% oxygen by a non-rebreathing
depending on the patients age and local resources, face mask with a reservoir bag is usually very effective
for diagnostic and treatment advice. acutely. When indicated, home and ambulatory
Cluster headache,8 especially when lacking some of oxygen will need to be provided.7 Triptans, subcuta-
the typical features (ie, probable cluster headache), is neously or nasally can also help.7
Table 4 Prophylactic treatments for primary headaches: migraine with or without aura, episodic tension-type headache, chronic
migraine, chronic tension-type headache
Regular prophylactic treatments
1. Topiramate (antiepileptic)
218 years Oral 0.5 mg/kg slowly up to 10 mg/kg/day, Tabs: 25, 50, 100, 200 mg Weight loss, paraesthesia, fatigue,
max 10 mg/kg/day, max 200 mg/day Sprinkle caps: 15, 25, 50 mg drowsiness, impaired memory. There is a
smaller risk of teratogenicity than with
sodium valproate.
2. Propranolol (-blocker)
24 years Oral 200500 mg/kg twice daily, max 4 mg/kg/day Tabs: 10, 40, 80, 160 mg Avoid abrupt withdrawal
Oral solution: 5, 10, Avoid in asthma
58 years 10 mg twice daily, increasing to 30 mg twice daily 50 mg/5 mL Sleep problems
812 years 20 mg twice daily, increasing to 40 mg twice daily
1218 years 30 mg twice daily, increasing to 60 mg twice daily
3. Gabapentin (antiepileptic)
212 years Oral 1020 mg/kg three times a day Caps: 100, 300, 400 mg Avoid sudden withdrawal
Tabs: 600, 800 mg
1218 years 300 mg three times a day, then up to max 1.2 g
three times a day
4. Sodium valproate (antiepileptic)
118 years Oral 10 slowly up to 40 mg/kg/day, max 1.5 g Tabs: 100, 200, 500 mg Weight gain, tremor. Avoid in young
twice daily Oral solution: 200 mg/5 mL females of 12 years and more because of
teratogenicity, intellectual disability after
fetal valproate exposure and irregular
periods.
5. Flunarizine (calcium channel blocker, in the UK only on a named-patient basis)5 17 18
59 years Oral 0.10.3 mg/kg/day, 2.55 mg once daily, Tabs: 5, 10 mg Give as evening dose
(2040 kg) max 10 mg once daily Sedation, weight gain, tremor, irregular
periods
1018 years 10 mg once daily
(>40 kg) max 20 mg
6. Amitriptyline (tricyclic antidepressant)
611 years Oral 1020 mg at night Coated tabs: 10, 25, 50 mg Dry mouth, sedation, blurred vision,
Oral solution: 25 mg/5 mL constipation
1218 years 2550 mg at night Beware risk of cardiovascular fatality in
overdose
Review
Paroxysmal hemicranias8 is another TAC experi- are ineffective and/or not tolerated, consider a triptan
enced rarely in children from preschool to secondary twice or three times a day, on the days migraine
school ages, which is very effectively treated with indo- attacks are expected, even if that is a few consecutive
methacin (combined with omeprazole, or ranitidine or days. Good evidence for this approach exists for zol-
similar). Response to indomethacin is so typical that it mitriptan and frovatriptan.7
is formally a diagnostic criterion,8 so children with
some but not all the typical features should be tried PROPHYLACTIC TREATMENTS FOR TACS
with indomethacin, for example, for 23 weeks. Cluster headache and probable cluster headache in
children and young people are generally best diag-
PROPHYLACTIC TREATMENT FOR MIGRAINE nosed and treated in specialist paediatric or adult
Because episodic tension-type headache, migraine headache clinics. There is good evidence to support
without aura and migraine with aura are on a con- verapamil as a prophylactic.7
tinuum,16 it is unusual to find someone with episodic Paroxysmal hemicrania responds within a few days
tension-type headache requiring prophylactic treat- of reaching an effective dose of indomethacin.8 This is
ment who does not also have migraine with or true for some cases not fulfilling all the diagnostic cri-
without aura. Similarly, chronic tension-type head- teria, that is, probable paroxysmal hemicrania.
aches8 would not usually require prophylactic treat- Treatment should be combined with omeprazole or
ment, but if it did the diagnosis should be reviewed, ranitidine or similar drug to reduce the risk of gastro-
thinking of a symptomatic headache (eg, idiopathic intestinal adverse effects, particularly ulceration and
intracranial hypertension, sinusitis, etc), or more likely
chronic migraine.8
When incapacitating headaches, particularly
Test your knowledge
migraine with or without aura, occur three or four
times a month or more, depending on their severity
and impact, offer a daily prophylactic medication. Select the best single answer:
The choice will depend on preferences and comorbid- 1. Pain
ities. Most drugs should be titrated up if starting low A. is an unpleasant sensory experience caused by
doses prove to be ineffective, and the drug should be tissue injury
reduced or abandoned if there are adverse effects or B. involves an emotional experience component as
relatively high doses prove to be ineffective. Avoid well as (A)
combinations of prophylactic treatments, except C. includes the description of (B) but with potential
during switching (see table 4). or actual tissue injury
Topiramate is effective for patients with chronic D. includes the description of (B) even in the
daily headache, for example, in adults with chronic absence of potential/actual tissue injury
migraine.19 It is also a first-line prophylactic treatment E. is not definable, but can reliably be recognised.
for migraine with or without aura in younger chil- 2. Medication overuse headache
dren,20 as well as in young people and adults.7 A. can happen with primary and secondary
Although recommended doses are lower than those headaches
often used for epilepsies, these patients are at no more B. can happen with prophylactic and acute/rescue
risk of adverse effects than children with epilepsies. analgesia
The risk of teratogenicity in young women is signifi- C. can happen when acute/rescue analgesia is used
cantly less than for sodium valproate. on more than 14 days a month
Other drugs with reasonable evidence of efficacy in D. can happen when acute/rescue analgesia is used
migraine in children and young people include pro- on more than 20 days a month
pranolol and gabapentin.7 Some weaker evidence is E. is best treated with gradual withdrawal of the
also available for valproate,7 flunarizine,17 18 amitrip- offending medication.
tyline7 and riboflavin.7 Unfortunately, there is no 3. A triptan with a NSAID
good evidence for pizotifens efficacy7 despite being a A. is the most effective treatment for attacks of
licensed and popular treatment in the UK and it cer- migraine with or without aura
tainly seems to work well for some children and B. is recommended for new daily persistent head-
young people, in the authors experience. Moreover, ache and migraine without aura
as it is now off-patent, it seems unlikely that a prop- C. is recommended for migraine with aura in young
erly powered trial will ever be funded, unless a novel people 16 years of age or older
formulation is developed and patented. D. should not be used before trying at least one
NSAID and one triptan on its own
MENSTRUAL-RELATED MIGRAINE E. should not be used together at the same time.
Some young women have predictable menstrual-
The answers are after the references
related migraine.8 If first-line acute/rescue treatments
Review
bleeding. It can be continued for 23 weeks then 6 Childrens Headache Training (CHaT). http://www.bpna.org.
stopped, but will need to be reinstated promptly when uk/headache/ (accessed 14 Feb 2015).
the paroxysmal hemicrania relapses. The paroxysmal 7 National Institute for Health and Care Excellence (NICE).
Diagnosis and management of headaches in young people and
hemicrania may settle in months or continue for
adults. September 2012. https://www.nice.org.uk/guidance/
years. Relatively low maintenance doses can often
cg150 (accessed 14 Feb 2015).
work.21 If indomethacin is not tolerated, further 8 Classification Committee of the International Headache
expert advice should be sought. Society. The international classification of headache
disorders, 3rd edition (beta version). Cephalalgia 2013;
CONCLUSIONS 33:629808.
The management of children and young people with 9 Ahmed MAS, Martinez A, Cahill D, et al. When to image
headache therefore depends on the correct diagnosis neurologically normal children with headaches: development
and differential diagnosis. This article for the of a decision rule. Acta Paediatr 2010;99:9403.
Medicines Update has focussed on drug treatments. 10 HeadSmart. http://www.headsmart.org.uk/ (accessed 14 Feb
However, it is important to stress that drug treatment 2015).
11 BNF and BNF C. https://www.medicinescomplete.com/about/
is not always needed, and certainly prophylactic treat-
subscribe.htm (accessed 14 Feb 2015).
ment is not usually needed in migraine with or
12 BPNA Headache Diary. http://www.bpna.org.uk/audit/
without aura, and almost never needed in tension-type Headache%20diary.PDF (accessed 14 Feb 2015).
headache. Acute/rescue treatments for severe and 13 Fox A, Sammons for the RCPCH. The use of unlicensed
incapacitating primary headaches and for secondary medicines or licensed medicines for unlicensed applications in
headaches with tissue damage will be needed, but the paediatrics. December 2013. http://www.rcpch.ac.uk/system/
correct choice depends on the precise diagnosis. files/protected/page/The%20use%20of%20unlicensed%
Resources to help in the diagnosis and holistic man- 20medicines%20or%20licensed%20medicines.pdf (accessed 14
agement have been sign-posted. Feb 2015).
14 Artto V, Nissil M, Wessman M, et al. Treatment of hemiplegic
Acknowledgements We are grateful to all our patients and their migraine with triptans. Eur J Neurol 2007;14:10536.
families, our students and teachers and especially to colleagues
15 McNabb S, Whitehouse W. Cluster headache-like disorder in
who have taught us so much about childrens headaches: Dr
Judith Hockaday, Dr Richard Newton, Dr Ishaq Abu-Arafeh, childhood. Arch Dis Child 1999;81:51112.
Dr Dilip Nathan, Dr Rachel Howels and colleagues on the 16 Viswanathan V, Bridges SJ, Whitehouse W, et al. Childhood
NICE gc150 guideline development group. headaches: discrete entities or continuum? Dev Med Child
Contributors WPW reviewed the literature, wrote most of the Neurol 1998;40:54450.
first draft and reviewed and edited the article following editors 17 Sorge F, De Simone R, Marano E, et al. Flunarazine in
and reviewers suggestions, read and approved the final version. prophylaxis of childhood migraine. A double-blind,
SA reviewed the literature, compiled the first draft of the tables
and helped edit the article following the editors and reviewers placebo-controlled, crossover study. Cephalalgia 1988;8:16.
comments, read and approved the final version. 18 Mohamed BP, Goadsby PJ, Prabhakar P. Safety and efficacy of
Competing interests None declared. flunarazine in childhood migraine: 11 years experience, with
emphasis on its effect in hemiplegic migraine. Dev Med Child
Provenance and peer review Commissioned; externally peer
reviewed. Neurol 2012;54:2747.
19 Silberstein S, Lipton R, Dodick D, et al. Topiramate treatment
of chronic migraine: a randomized placebo-controlled trial of
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Arch Dis Child Educ Pract Ed 2017 102: 58-65 originally published online
December 20, 2016
doi: 10.1136/archdischild-2016-311803
These include:
References This article cites 14 articles, 1 of which you can access for free at:
http://ep.bmj.com/content/102/2/58#BIBL
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Notes