NATIONAL HARBOR, MD. – A headache may hurt, but for most children, it’s nothing more serious than a pain.

The vast majority of pediatric headaches are not caused by space-occupying lesions in the brain, Dr. Marc DiSabella said at a meeting sponsored by the American College of Emergency Physicians. Even in the context of an abnormal neurologic exam, "only 4% have a space-occupying lesion, and most of them will also have an abnormal neurologic exam. So if you have a normal exam in a child with headache, that is a very reassuring thing."

Nevertheless, severe headaches can significantly impair almost every aspect of a child’s life, said Dr. DiSabella, a neurologist at Children’s National Medical Center, Washington, D.C. And treating headache is as much an art as a science; a good treatment plan includes behavioral strategies, daily preventive medications, and a choice of rescue therapies. Rescue treatments must be used cautiously so that they don’t provoke dependence or escalate the headaches into rebound.

When diagnosing the headache type, pay attention to the child’s clues.

"Tension-type [headache] is probably everything that migraine is not," he said. "Tension headaches are usually bilateral, pressing, nonpulsating pain. Activity does not worsen it, and rest doesn’t make it better."

Migraines, on the other hand, have some specific diagnostic criteria. According to the American Academy of Neurology, a migraine has at least two of these hallmark symptoms: unilateral or bilateral pain, moderate to severe pain, pounding or throbbing pain, and associated nausea, vomiting, photophobia, or phonophobia.

"I ask the child what makes the headache better. If they say they usually want to go into their bedroom and sleep, that is a big clue that it’s a migraine."

A family history of migraine makes the diagnosis even more likely. "Three-quarters of children with migraine have a parent with migraine."

Dr. DiSabella said he images only about 10% of his pediatric headache patients. Indications for MRI include:

• Migraines that are situated behind the ears. "Migraines are generated from the trigeminal nerve, and anything behind the ears can be bad news," he said.

• Abnormal neurologic exam or abnormal gait.

• New-onset headache.

• Migraine in the setting of no family history. "You really have to probe into the family history to get this information, though, and that might not be feasible in the ED."

• Headache with a substantial period of confusion or disorientation.

• Headache that is painful enough to wake the child from sleep (this is different from a child waking up in the morning with a headache).

• Headache accompanied by seizures.

Treatment is aimed at reducing the duration, intensity, and frequency of the headache, but medication should be used conservatively. "We want to moderate medication intake and improve quality of life. Migraineurs want the headache to go away, so medication overuse is very common. If patients are using rescue medication 15 or more days per month, they are at risk of developing daily migraines or a chronic background headache. Low regular use of these medications is much worse than high doses for a short period of time," Dr. DiSabella said.

Even ibuprofen and acetaminophen can cause a rebound headache. If a child already has medication overuse headache, recovery can take up to 6 weeks after starting a preventive regimen.

When a child with headache arrives in the emergency department, pain relief is the immediate goal. A non-oral route can be helpful with children. "Our emergency protocol is intravenous fluids plus Toradol [ketorolac] and Compazine [prochlorperazine]." Hydration is also key to headache relief. "I give them a sports drink in the ED. They like it, it’s noncaffeinated, and it does provide some electrolytes."

A combination of ketorolac and prochlorperazine is a very effective strategy, reaching 95% efficacy for pain relief. If the prochlorperazine strategy doesn’t work, intravenous valproic acid is worth a try. A 2005 study found that 39% of adolescents experienced pain relief after the first infusion of IV valproic acid and 57% after the second infusion (Headache 2005;45:899-903). "The faster you push it, the better it works," Dr. DiSabella said.

"How good are narcotics? Well, I don’t use them at all. They really result in a lot of overuse and abuse, and it’s my experience that patients get ‘wimpier’ every time they take one. The 7 out of 10 [pain] headaches will start to feel like a 10."

After stabilizing the pain, counseling is in order. "A three-tiered approach is the way to go – behavioral, prevention, and abortive. You can get a headache treatment plan worked up just like an asthma treatment plan."

Sample plans, including a patient information and instruction form and a medication chart, are available on the American Headache Society website. The group also provides an educational handout for parents.

Dr. DiSabella had no financial conflicts.

Nonnarcotic Pain Meds and Hydration Best for Pediatric Headache