More often than not the child who presents with recurrent or chronic headaches will be experiencing migraines. Pediatric migraine is very common; in fact, it is one of the top five health problems for children. General pediatricians treat the majority of these children, up to 90%. There are not enough pediatric neurologists in the United States to take care of all of these children. For example, given the prevalence rate of 10%, an estimated 60,000 children and adolescents experience migraine out of the 2.4 million people in the Cincinnati draw area for my institution. Obviously, they cannot all be referred to a specialist.
The most important thing for you to do is to rule out secondary headaches. Differentiate primary headaches (such as migraine and tension headaches) from secondary ones, being skeptical of the secondary presentations. If a secondary etiology is suspected and the headaches do not resolve, then reassess, but the headaches may be primary ones.
Ask patients and parents about headache symptoms because often the symptoms are initially missed. Standardized criteria such as the American Academy of Neurology practice parameters on the treatment of migraine headache in children and adolescents can guide your diagnosis and management (Neurology 2004;63:2215–24). If the clinical picture does not fit these criteria, consider further evaluation of the child.
After your differential diagnosis, perform a complete neurologic examination. If findings are abnormal on the neurologic exam, consider an MRI. Such imaging also may be warranted for children with exclusively occipital headaches, if they experience a crescendo or abrupt change in headaches, or if they lack a relevant family history.
Almost all other tests are less useful and do not help prior to referral to a pediatric neurologist. We do not need EEGs, sinus x-rays, or CT exams, which have lots of unnecessary radiation. We routinely check riboflavin and coenzyme Q10 levels, but this may be beyond the level of general pediatricians.
Referral to a specialist is appropriate when the above strategies are not working and if the headaches do not improve. Also refer if a child has chronic daily headaches (defined as 15 or more days per month), if a child is missing a lot of school or other activities of daily living, and/or if the history and diagnosis do not seem to fit the presentation.
Optimal treatment is a standardized strategy that incorporates acute and preventive pharmacologic strategies, as well as biobehavioral treatments.
Appropriate NSAID use, for example, can aid a child with an acute presentation. For example, prescribe 10 mg/kg of ibuprofen at onset, and do not exceed three dosages per week. In addition, be familiar with at least one triptan at appropriate dosing (an adult dose for teenagers).
Also be comfortable with at least one age-appropriate, preventive agent. Amitriptyline is the easiest to use. The recommended dosage regimen is 1 mg/kg titrated up slowly (over a period of 8–10 weeks) for about 2–3 months at full dose to allow sufficient time for clinical effect. I also advise against the use of cyproheptadine for teenagers with migraines because of the appetite effect.
Adequate fluid intake without caffeine, exercise at least three to four times per week, and sufficient regular sleep (8–9 hours, for example) are important components of biobehavioral treatment. In addition, educate patients and parents about the importance of a healthy, balanced diet. Instruct patients not to skip meals. We do not recommend avoidance of particular foods, and the evidence supports this stance. It is more important to make healthy food choices.