Chapters Transcript Video Headache in Children and Adolescents: From Evaluation to Treatment So, uh, like you heard, I'm Keeley Fitzgerald. I'm one of the pediatric neurologists. I've been here at UCSF for about a year and a half now. And I'm gonna talk about, um, headaches today, something that I see very often in clinic, and I suspect you all do too. Um, just a couple of housekeeping things. I don't have any disclosures. Um, I just want to share that we've had several new child neurologists start, uh, with our group in the past year. Um, we're now up to 17 neurologists on the East Bay side. So, um, we have lots of locations. Um, everybody's a bit spread out through, uh, Oakland, Walnut Creek, Brentwood, Ansey, and Ramon. Um, and so we are, uh, able to get patients in pretty quickly, uh, given all the new faces that we have. So, um, What we're gonna talk about today uh is headache classification and epidemiology. I'm gonna spend just a, a small amount of time on pathophysiology. We won't get too into the weeds there, but it's helpful to understand some of the treatments that we use. Um, we'll go through history exam and red flags. We'll talk about imaging and laboratory workup, and then get on to the acute and preventative strategies. So this is uh extremely common. Headache is an extremely common, uh, chief complaint that we see. Um, one of the leading, uh, neurologic complaints in the pediatric primary care setting and also the emergency department settings. Um, and, uh, almost 1 in 10 kids will have, uh, uh, will actually be diagnosed with migraines. So it's actually quite, uh, quite common, and that prevalence rises throughout adolescence. Um, by 15 years of age, up to 75% of kids will have experienced a notable headache, and, um, and by, um, 15 to 19 years, we have the highest prevalence among all of our pediatric age groups. But even kids as young as 3 to 7 can be diagnosed with migraine as well. Um, so, um, even those younger kids, uh, we see, we see quite often. So the international classification of headache disorders splits headache into primary uh headache disorders and then secondary headache disorders. With primary headache disorders, the headache is the disease and there's really no other underlying cause. With secondary headache causes, uh, secondary headache disorders, there is some other condition that's causing, um, The headache itself. And so the most common pediatric headache disorders are primary with migraine being the most common. Migraine without aura is the most common, and then followed by tension type headaches. Um, so about 99-95% of kids will have the primary headache type, and then the rest of those kids will have uh potential a secondary uh cause of symptoms. And one of the more common reasons for secondary headaches are medication overuse headaches. So we'll talk a little bit about that. And then infection is another um common cause of secondary headaches, uh, with URI type symptoms, um, leading to headaches, um, or more serious infections like meningitis or those other types of things. Um, so the clinical criteria, uh, for our two most common type of primary headache disorders, uh, is shown here. So migraine without aura and tension type headaches, and migraine without aura, uh, occurs in 75% of people with migraine. The aura, uh, component is seen in about 20 to 25% of people. Um, so without aura is much more common, and you actually have to have at least 5 attacks, um, to end up being diagnosed with migraine. Um, the migraine duration tends to last between 2 hours and 72 hours, um, in kids. Uh, in adults, it's slightly longer, so 4 hours to 72 hours. Um, the location is often bilateral in kids, and most of the time I hear kind of this frontotemporal pattern. And, uh, in adults, it's much more common to be unilateral. So we don't tend to see that unilateral pain until kids are a little bit older. The quality is pulsating and throbbing, and the intensity is moderate to severe. Um, and a key feature is that it typically gets worse with activity. So these kids are out and about, their headache symptoms get worse. You have to have at least nausea or vomiting and photophobia or phonophobia, um, to ultimately make the diagnosis. With tension-type headaches, um, we have to have at least 10 of those. The duration is a little bit more spread out, 30 minutes to 7 days, and these are typically bilateral. And the quality of the pain is a bit different. We often hear this pressing, tight, tightening kind of pain. Sometimes the rubber band around the head or the crown type of pain, um, around the head is what I commonly hear. The pain isn't as severe as those with migraines, more of a mild to moderate pain. And these tension-type headaches don't tend to be uh aggravated by routine activity, so that's another key feature, um, kind of differentiating the two. and then we don't tend to have the nausea, vomiting, uh, seen with tension-type headaches, and we might have phonophobia or photophobia, but usually we don't have both seen with tension-type headaches. And so just a couple of minutes spent on the pathophysiology, um, we really think about migraine now as being a, a complex neurovascular disorder, um, which involves abnormal brain excitability and activation of the trigeminal nerve system, followed by inflammation around the blood vessels in the meninges in a genetically susceptible brain. So, um, the first step is generally to have this genetic Susceptibility and we know that there are several um at-risk low side that have been identified um in genes that can cause um various um uh increased um cortical excitability um and things like vascular functioning, synaptic plasticity, so there's various genetic uh susceptible low side we found, um, but we don't have specific genetic testing that we're doing for migraine as of, as of yet. So we know that these people just have a much more uh hyper-excitable brain. It makes it much easier for this migraine pathway to activate at baseline. Um, and so even if there's not a clear family history, although a lot of the time there is, I try to reiterate to families that we likely have the underlying genetic tendency to have migraine, um, new change in the child's genes that maybe they didn't get from the parents, um, but that's usually the first step. And then once we have that genetic predisposition, a trigger can initiate the migraine attack. Um, sometimes those triggers are more easily, easily identifiable than others. Some, for some kids, it's really hard to pick up on specific triggers. Um, but the trigger doesn't cause the pain per se, but it increases again that neuronal excitability within the cortex and the brain stem. Um, and then following that step, for some people, 25%, will go on to have the aura phase, which is caused by cortical spreading depression, uh, in which we have depolarization, uh, which causes temporary suppression of our neuron of our brain activity, and that results in the, the typical aura symptoms. Most of the time we're talking about a visual aura, seeing the central scotoma or um a blurring uh spot or a bright spot in the vision. Um, some people have sensory or speech symptoms, but the oraphase comes prior to the pain symptoms, so usually 5 to 60 minutes beforehand. And then the next step is uh the trigeminal vascular activation, and this is the essential step that really drives home the, um, the full migraine cascade and causes uh the typical migraine pain and other symptoms that we see. Um, and so the trigeminal nerve fibers innervate the meninges and they become activated by these various neuropeptides including CGRP, substance P, and neurokinin A. CGRP is one of the, uh, is a particularly important, um, agent because we're using that as a target for our newer migraine treatments. Um, following that step, we have, uh, those vasopeptides then cause vasodilation and increased vascular permeability and cytokine release and those other things, which then goes on to, uh, activate and sensitize those trigeminal nociceptors, and then that pain signal travels through the trigeminal pathways to the brain, um, causing our symptoms of migraine. Um, contrasting that with tension type headaches, so there is a little bit of overlap between tension type headache and migraine in terms of pathophysiology, but there's some distinct, uh, differences. Um, we typically think about tension type headache as being, uh, more of a, a pain processing disorder kind of driven by peripheral. Myofascial nociception and central sensitization, so you can have some of that trigeminal vascular activation but not quite as much as we see with migraine. And so oftentimes these peripheral trigeminal nociceptor nociceptors will get activated. Um, and then, uh, with recurrent headaches, we get central sensitizations where we have more, uh, pain activation, more pain signals that get sent, um, resulting in the ability to tolerate lower pain thresholds and, um, and then we have this descending, uh, pain inhibition and altered pain modulation that's impaired. Um, so that's all I'm gonna say about the pathophysiology. Um, again, this is kind of helpful to target, uh, when we talk about treatments. Um, one other headache type I'm gonna just mention because it's very common, it's something we see frequently in clinic is the medication overuse headache. And so, um, the medication overuse headache occurs. is when we are using over the counter medications or triptans or a combination medication for more than 15 days a month. And so those headaches that they're trying to treat get worse or in the context of this regular use of medication. And so typically the pattern is that they've been doing it for 3 months or more. Um, and so we really try to educate parents and, uh, and help them understand that, uh, more medicine isn't always better. And if we're using things like, uh, uh, acetaminophen or ibuprofen more than 15 days a month, we're at risk for developing a medication overuse headache on top of what they're already experiencing. Um, and if we're using triptans or some of the combination analgesics, things like acetaminophen with caffeine, those types of things, um, if we're using those more than 10 days a month, and we can often, uh, see the same effects. Um, the real clear distinction here though is that if we, uh, stop the medication overuse, the, uh, pathophysiology leading to this, this type of headache is reversible. And so we can get the, uh, complete revers uh reversibility of the, um, medication overuse, um, um, changes that we see. So, Um, sometimes it's important though to educate families that things may get worse before they get better just because they've been using that pain medication and maybe it's having some, um, some partial effects, but we really need to taper off that medication, um, it's a washout period while we're trying to treat the headache. And so things sometimes get worse before they get better, but as long as we can Um, educate patients and kids that that's expected, then, um, then that can be really helpful. In terms of history, so these are, of course, the typical questions we go through. I'm sure you're all very aware of these, um, but this really helps us kind of determine, do we have a primary headache disorder or are we thinking more potentially something like a secondary headache disorder. Um, and so, of course, frequency and duration, um, and, um, determining how long each headache lasts helps us with that criteria, figuring out the location and the quality. With our younger kids, it's oftentimes very hard to get them to really pinpoint the quality of the pain. Um, and so, um, sometimes it's hard to get them to kind of commit to a pulsating or a throbbing type of pain. Um, but, uh, sometimes kids can be quite creative with how they're describing their headaches. So, um, kind of try to infer what they, what they might be meaning if we're trying to get, um, get to that migraine criteria. Um, we always, of course, asked about associated symptoms, not just the typical nausea, vomiting, photophobia, phonophobia. Yeah, but other things like dizziness and those types of vertigo feelings, sometimes people can have um a bit of a vestibular variant of migraine. Um, we, of course, talk about current treatment, making sure we don't have a medication overuse headache, um, and asking, you know, how long are you waiting before you're treating your headache. Um, that can help, uh, moving forward as well. Migraine is really quite heritable, so 50 to 60% of the time, there is a family history we can pick up. And sometimes it'll be the parents say, oh, I just get a stress headache every now and then, um, or, you know, my headaches aren't as bad as my child's. Um, But we, any of that history really is important. Um, so we still, uh, suspect that genetic tendency that they have even with those more mild headaches. Um, and sometimes, uh, headaches can start younger in the following generations than they can in their parents. So parents might say, yeah, my headaches started, you know, when I was in my twenties or teens, but they're starting much younger and my kid, and so, um, that's actually not uncommon to hear that the headaches are starting earlier in the younger generations. Um, I tend to focus more on functional impact of the headaches the child is having versus uh having them focus on a severity scale. So really asking more questions about missing school, missing activities, and there's a questionnaire I'll show you on the next slide of the, um, those standard questions that we can ask. Um, so as you all know, some kids will report, you know, 10 out of 10 headache pain, but they're still going to school, they're still doing their activity. They're probably really in, in true pain. That's uh not disputed. It's just, it's harder um to kind of quantify that as we're moving forward with our treatment plan. Um, so using something more standardized can be more helpful. Um, I don't want kids to focus on the specific number or think about the number too much either. I think it's easy to kind of get focused on something like that and then, um, when it's really more important if you know, do you feel OK enough to go, um, to go to your sports after school or can you stay in school all day, that type of thing. And then we spend a large majority of the visit talking about lifestyle factors and triggers. Um, and so, um, this is really kind of the key, uh, when we're talking about headache in kids is Many adolescents and, uh, and kids aren't maximizing these lifestyle factors for various reasons, um, including, um, stress and dehydration, missing meals, those types of things. But for some families, they'll really pick up on, you know, every spring, they're getting a lot more, uh, you know, they're having a lot more headaches, um, and then, you know, we have allergies or other things. So sometimes we can pick up. On some of those patterns that happen um just based on the time of the year um we tend to see this pattern where things sometimes get better in the summer and then as we get back into the school uh in the fall things might get worse and that's for a lot of reasons I think um not just you know the stress of school but there's loud halls there's bright fluorescent lights those types of things that maybe aren't getting. Um, the typical sleep that we were getting before. So we can really kind of pick up on these, um, patterns over the long term if families start to think about them and start to recognize them. Um, for women, we of course always ask about, um, the menstrual cycle. There can be really clear correlations with hormonal changes, um, and so getting them to recognize some of those, uh, some of those triggers can be helpful as we're treating too. Um, so this is the PD Moss scale. This is the pediatric migraine disability assessment, and this is validated for kids 4 to 18, um, to measure how much migraines are really impacting daily lives and school performance, and they think about these questions over the course of the previous 3 months. And again, this is just to help to kind of guide and monitor treatment, um, as we're starting a treatment, um, if we're able to ask these questions again and see that the score has changed, it's often helpful. Um, and so basically we go through all of these questions and it's just a sum total of the number of days impacted, um, and so, um, We do this at an initial evaluation and then after treatment, the follow-up, we can do this again and we can actually see has there been any real, have we moved the needle at all? Is there any clear change um that we can see. Um, sometimes this, of course, changes too in the summer when we're not in school, but we still try to, um, try to get some sort of a, um, kind of a number that we can use to, to help guide treatment. Um, of course, the red flag questions, we have this pneumonic Snoop 4, and again, these are, these are things we all try, we try to tease out, um, as we're going through our history, um, making sure that we don't have systemic symptoms. We wanna make sure they haven't noticed any focal deficits between headaches, um, the onset pattern, if it is very sudden or abrupt, um, sometimes that, um, that is more concerning. Um, onset under age 5. This is a little bit debatable, you know, some people, my threshold is typically about age 5, but, um, but this can be a little bit variable for people. And then is there a positional change, a pattern change? Does it get worse with Valsalva, um, or is it worse with lying flat, um, those types of things. And when we have positives on these questions, then sometimes we're thinking or considering mirror imaging or other workup. Um, and so that brings us to when do we actually get imaging. So for the vast majority of kids, they don't need neuroimaging. And those are the kids that have a normal exam. They meet clear criteria for migraine or tension type headache, and they have a stable pattern. They don't have any of those red flag features. Um, if we have something on our neurological exam that's abnormal, if we're consistently having nighttime symptoms waking us up from sleep, and I ask these questions to kids, to quit kids, and sometimes they'll say, yeah, I have headaches that wake me from sleep. You know, once or twice here and there. That's really not the pattern we're looking for. We're looking for consistency. Um, so I don't get as excited about a couple of times or a couple of morning headaches, um, but it really, if it's the pattern over, over time, makes more, much more, uh, it's much more concerning. Um, my threshold again, like I said, is I typically image kids if they're around 5, if they're starting to have headaches, um, if they're less than 5, certainly imaging them. And then if there's anything in their history that suggests um a uh neurocutaneous disorder or a vascular issue, um, then we think about imaging too. But both the American Academy of Neurology and the Child Neurology Society have a practice parameter out regarding um the, uh, the use of getting imaging. And typically, it's not recommended unless we have one of those uh abnormal findings. And when we do imaging, we wanna get an MRI first, we're trying to avoid radiation. Um, we are able to do a focused MRI. So, um, you know, one of the hangups is always do we get an MRI because now we have to sedate the child if they can't lie still. Um, but we do have a protocol to get a focused scan, so it's much shorter. It's about 10 minutes or so, um, where we can just get a few sequences. It's not highly detailed, but we're able to rule out things like tumors or hydrocephalus, those types of things. So we can do it pretty quickly. Um, so if we end up needing an MRI, then we get this focus scan most of the time. But for the far majority of people, we don't need to get a scan. But we often have parents who come in, their child's now having headaches, and they're very, very worried about a brain tumor. Um, and so most children with a brain tumor have an abnormal exam at diagnosis. Having just the headache alone is not as common. So 88% of the time there is an abnormal neurological exam finding. Um, and typically we're talking about progressive symptoms over time, of course. So, um, you know, the headaches start and now seems, um, over the course of weeks to months have gotten much, much worse. Um, the most common abnormal finding on exam are cranial neuropathies or cerebellar signs, papilledema, or long track signs like increased reflexes and those types of things. Um, so, um, when we tend to have a, a brain tumor and we're having headache symptoms, they don't tend to have the nausea or the vomiting, um, the nausea or the photophobia or phonophobia that we see with migraine. Um, and their vomiting tends to be projectile, but they really don't have that nausea component that we see with, with migraine. Um, oftentimes it is early in the morning, but there's no clear trigger and it doesn't get better with rest or sleep. So when we have those features, um, we are thinking about imaging, of course. Um, I like to tell parents, you know, we don't, we're not hearing any of these red flag symptoms. We've had a pretty stable, uh, history of headaches over the long term, but things can always change. And so we always have the option to get imaging, but let's see what the next few months bring. If Things don't get worse and we don't develop other neurological symptoms or focal deficits, then that's much more reassuring. Um, so I think sometimes parents come with the expectation that they're coming, they're gonna get a scan to make sure there's not a tumor, but the majority of the time we don't need to do that. Um, so a little bit of reassurance can go a long way. Just knowing also that we can of course scan if something changes because things do change. Um, but most kids who have brain tumors get Get diagnosed within the first few months to a year, up to 1 year. So, um, if they come in and they have had headaches for 4 years and now things are a little bit worse, um, that's not quite as exciting as, um, somebody who just started having headaches a month ago and now they're having trouble with walking or their, um, eye movements are off or something like that. So, a lot of reassurance, but we image if we need to. Um, you all know how to do a neurological exam, of course, so there's some things that we focus on, um, really again, to, to look for secondary, uh, causes of headaches. Um, when we're thinking about, um, things like, uh, increased idiopathic hyper, uh, um, um, elevated, um, pressure, so, um, idiopathic hypertension. We think about obesity, so we look at the weight. In our little kids, we Uh, measure head size, make sure we're not having rapid head growth. Um, blood pressure is a, a common one. So everybody who comes in with a headache complaint gets a blood pressure, can be kind of a silent marker, um, and can be causative of headaches, of course. We do a fundoscopic exam. Sometimes it's more challenging than others in our, our younger kids. Uh, we do a good skin exam. We do some range of motion, movements with the neck, and then, of course, your complete exam. Um I don't tend to do a lot of testing when it comes, when kids come in with headache or migraine unless there's uh some of those other more concerning features, but some people could consider some testing. Um, I think vitamin D is a common one. We know that vitamin D tends to be low in everybody. It's also low in people with migraines. Um, so I don't tend to do a lot of, um, lab work. If we have um features um that suggest um increased intracranial hypertension, then we consider lumbar puncture if they have a if they have papilledema on exam. Um, if there is an infectious component, of course, we would consider that, but we're really not typically seeing that in the clinic. Um, if we can't get a good eye exam in the clinic, then we send for an ophthalmology evaluation as well. And so this is really the framework we use in terms of management. You've, you've seen the kid, you've diagnosed migraines or tension type headaches. Now, what are we gonna do about it? Um, so, the vast majority of time, like I mentioned, is spent on lifestyle and behavioral modifications. Um, and so, I really tend to like, I think, uh, about migraine as kind of, um, a disorder of brain homeostasis. The brain won't Things to be very stable over time. And so I try to reiterate that with parents and with kids, but we talk about lifestyle at every single visit. Again, I spend the majority of the visit talking about these things. Um, and Um, and so that's where we'll start. We know that lifestyle factors are low risk, they're low cost, they can really empower patients and families, and they can improve the effectiveness of our medications. So, um, I, I like to tell families one pill alone isn't gonna fix your headaches or your migraines. All of these other, um, uh, factors make a Big, uh, play a big role. Um, and so, um, the other issue with this is, of course, we don't wanna really frame this discussion as you're doing all these things wrong, you're causing your own headaches. Um, so we really try to frame this as kind of more of a comprehensive approach rather than implying that, you know, we're not doing these things well enough and, and, and something's the patient's fault or the parents' fault. Um. But, um, but the migraine brain really prefers consistency. Um, and so, um, this is where we spend, uh, a majority of our time focusing on. So we'll go through some of this. Um, stress is the most common reported trigger. So I ask every, every child, you know, do you feel like stress makes your headaches worse, what things are stressful? Do you know what stress is? Um, and so this is by far the most commonly reported trigger, and school is always the number one stressor for, uh, that, that I tend to see. Um, and stress can cause, um, migraines in several different ways. There can be, uh, high stress directly triggering attacks. We've had a really stressful emotional day, and then I get a migraine, um, during that, that, uh, emotional time. Um, there is also a letdown phenomenon, so where we have this sudden decrease from a high stress to low stress situations that lowers our migraine threshold. Um, these are the people that, you know, they've had a hard week, and then on the weekend when they're supposed to be relaxing, they get the migraine. Um, we think this is possibly due to withdrawal of, uh, glucocorticoid mediated anti-inflammatory effects and some anti-nociceptive effects of that. Um, so sometimes we see that pattern, and then for some people, there's not really a clear discernible relationship between the stress or the lack of stress and migraine. Um, but we know that most individuals will have some, um, episodes across these multiple different pattern types for stress. When we treat stress, we know that it decreases sympathetic activation and reduces central, central sensitization. Um, and so, uh, we can see those effects, um. On, um, with testing. Um, I've added in here the, uh, psychiatric comorbidities. We know that children and adolescents with migraines have significantly higher rates of both anxiety and depression. Um, and we know that there's really a complex bidirectional relationship with environmental factors and genetic factors, of course. Um, kids with adverse childhood experiences showed dose response relationship with primary headache disorders as well. So those are all things to keep in mind. Um, and so what do we do about stress? Well, the main things that we can do, um, are cognitive behavioral therapy. So this is really, um, the, the tool that we have the strongest evidence among our stress-oriented interventions. And developing coping skills can help change unhelpful thinking or patterns of behavior. If we can manage our stress more effectively, we address behaviors that worsen disability like not wanting to go to school or missing our activities, and we try to establish healthy routines with cognitive behavioral therapy. And then biofeedback is more of a physiologic self-regulation. It is, um, where kids will, um, will they'll learn, uh, to regulate body functions that usually have an automatic, um, um, function. Things like, um, tensing our muscles or slowing our breathing, those types of things. So it's really kind of learning to relax those functions or, or get more cognizant of them, um, and work on some of those techniques to kind of improve that autonomic nervous system balance. Um, and then if we do have those other comorbid conditions like anxiety, anxiety or depression, treating those, um, of course, is very helpful, so we refer out for that. Sleep is another huge factor, huge trigger. Um, and this is the one that we actually have the strongest supporting data among all, all of our lifestyle factors for. So if we were trying to focus on just one thing, sleep would be a big one, to focus on. We know that, uh, sleep, uh, decreases in sleep increase migraines. There's a bidirectional, um, uh, pattern that we see. And then there is some evidence that actually having migraine itself can change the quality of the sleep. So, you know, just having the migraine may make your sleep um much worse and um not by anything the child is doing, but that's just the, um the underlying um changes that we can see. So, Um, the, the night owl pattern tends to worsen headaches, and if we can get good sleep, cons consistent sleep, um, this can help stabilize our hypothalamic function and circadian rhythms. Other sleep things that we think about, of course, sleep apnea, are we grinding our teeth, um, those types of things. So, um, so other things to kind of, uh, screen for, um, as we're going through, um, our questions. Um, and we try to get kids to understand consistent sleep times and wake times, um, a cool dark place, avoiding making ketchup, getting enough sleep, uh, limiting naps, and having no screens in bed. Um, there was a practice parameter that came out, uh, from the AEP this year talking about, um, digital media and sleep disruption. And so, there's a few different mechanisms. We know that blue light can suppress melatonin and shift our circadian phase. Um, there can be just a cognitive and physiological arousal from looking at something stimulating on the phone. Um, and then we also know that the notifications and the, the screen lighting up can also disrupt sleep. So we try to limit screen time in bed, of course, um, as, um, As part of a good kind of sleep hygiene um plan. Dietary factors are um a huge part of this as well. I'm sure you all have heard this several times, kids don't wanna eat their breakfast, they don't wanna eat lunch at school for whatever reasons. Whatever reason it is. Um, but, um, we really try to focus on consistent meals, uh, avoiding hypoglycemia, um, and really increasing our hydration status. Um, there are several foods that we know can be triggers for migraines, things like chocolates and aged cheeses. We don't try to, um, eliminate those things from the diet unless we've established that there's a clear link between them. So I'll have parents come in and say, what kind of diet can we use? And really, it's just about a healthy, nutritious diet for age of Processed foods, those types of things. Um, we don't have a specific diet, but sometimes whole, whole diets, um, that, uh, um, have some of our, um, matraceuticals, um, in them can be helpful too. Things high in magnesium or riboflavin, those types of things. Um, but really just focusing on a good healthy diet for age. Um, and, um, hydration is also really important. So, um, most kids think they're drinking enough water, majority of them aren't. Um, and so, fortunately now, I'm hearing a lot more that schools are letting kids bring, uh, water bottles to school. They can go to the bathroom. It's not as big of a deal as it was before, um, but I'm still have some issues getting kids to, um, bring water to school. And I'll just make one comment. So, um, we know that kids who are overweight or obese have increased headaches and actually just losing 10% of the body weight can also um improve our headache pattern. So again, just more overall healthy dietary uh lifestyle. Um, in terms of caffeine, this is, um, a little bit of a paradoxical relationship between caffeine and migraine. So we know that acute and excessive intake can trigger a migraine, but for some people, it can help acutely by causing some cerebral vasoconstriction and kind of modulating some of that pain signal. Um, but then we know if we're drinking too much caffeine consistently and then we stop, we can have a caffeine withdrawal headache. So I tend to try to, um, recommend that we're not drinking caffeine, especially in kids, um, just to kind of get this out of the, uh, out of the picture, so not something that's muddying the waters. Um, and so, um, so that's typically what I'll recommend. And then physical activity, we have had multiple large population-based studies linking low physical activity to increased headache frequency in, in kids. Um, and so we know that there's several mechanisms that, that help with people with headaches and migraines and other pain symptoms, um, not just, uh, things like increasing endorphin and anti-inflammatory effects, but we know that there's important psychological benefits to exercise as well. And so even just exercising 3 times a week for 30 to 60 minutes can make a huge impact on headache frequency. Um, there are some kids that will report exertional headaches or headaches that happen after they've exercised. Sometimes when we're running, kind of that pounding movement of the head for some kids can be a trigger, but generally encourage encouraging a warm-up phase, um, and then appropriate rest periods. Um, we can help combat that if that is an issue. Um, and so again, all of these things just more of a comprehensive approach to our headache management, um, uh, again, um, before we're thinking about other, other things. Um, so moving up our treatment ladder to the acute treatment. So we talked about all these lifestyle factors. If they're still gonna get headaches and they're still gonna have migraines. So what do we do? So acute, uh, acute treatment really, uh, the most important thing we can do is treat early. So as soon as we recognize we're starting to have a migraine, we try to change our environment, dark, quiet place if we can, we drink some water if we can. And then we use something over the counter, uh, whether it be acetaminophen or ibuprofen or naproxen. Uh, we treat it as early as we can. If nausea is a big component early on, we can add an anti-emetic to that. And if we find that that's not helpful, then we can add on the triptan. Um, I hear a lot of kids who say, yeah, I get a headache at school, and then, you know, they'll wait all day, they won't tell anybody, they won't go to the nurse, and then they get home from school, and then they just have to go to sleep because their headache is so bad. Um, so we try to encourage kids to take something early, um, providing school notes, of course, for kids to take ibuprofen or, uh, acetaminophen at school. Some parents will want them to take the triptan at school. Um, so, of course, having, um, that conversation, um, early on before the school year is important. Um, and, um, if the, uh, first line over the counter medication doesn't work, then we try something else. If all they've ever tried is, uh, is acetaminophen, then we try ibuprofen or naproxen. Um, we have a little bit more data that, um, that, um, uh, things like NSAIDs work more effectively than acetaminophen, but I've had several parents and kids tell me that, you know, acetaminophen just works better. So, unfortunately, it's a little bit of trial and error. Um, but if it doesn't work, we, of course, have to make sure that they're on the right dose. Um, I hear a lot, this a lot where parents don't wanna give too much. They're worried about the dose. Um, and you all know the doses, of course, for the over the counter medications here, but really encouraging them to give a full dose. Um, I have some kids who weigh 60 kg and they'll take one ibuprofen, and then, of course, their headache doesn't get any better. Um, because, um, parents are a little bit worried about the GI effects or other things, so we try to encourage, um, A good dose for weight because for many people hitting it early with a good dose of an over the counter medication will kind of stop that migraine cascade before it snowballs and then it's harder to get rid of after that point. Um, in terms of the triptans, so, uh, our triptans work on serotonin, and, um, there's several mechanisms in which they can be helpful. Um, there are 4 that are FDA approved in kids, um, rizatriptan being one that comes in a dissolvable form, and so we can give this to kids as young as 6 years old, um, with weight-based dosing. If they're more than 40 kg, it's 10. If they're less, it's 5. and so oftentimes I'll start with rizatriptan. Um, and then, um, if one triptan doesn't work, however, we move on to another one. For some people, one triptan won't work, the other 1 may work, or we try a different formulation or, or administration. So, uh, zolmatriptan is a nasal spray. Sumatriptan also comes as a nasal spray. Um, it also comes sub Q. Never had any kid who chose that option, but, um, but sometimes changing the way that it's given can be helpful as well. Um, so usually we'll try at least 2 or 3 of these. Um, and we know that the triptans actually tend to work better if they're given with an NSAID. So, um, I'll have, um, if kids fail just the over the counter medication alone, I'll have them take, um, their triptan with something over the counter at the same time. Um, sometimes we'll add in that anti-emetic like, uh, um, ondansetron or, uh, prochlorperazine, um, as almost a little bit of a migraine cocktail. Um, we know that, um, uh, prochlorperazine also has an independent anti-migraine effect, so it may work slightly better for the, the migraine cascade than ondansetron, but, um, uh, just given the, that we can give ondansetron as a, a dissolvable or liquid is, uh, tends to be used more frequently. Um, and then in the past there was this theoretical risk about giving a triptan with an SSRI. As I said, many of our kids have comorbid anxiety or depression. Um, and so in the past there was a fear about using tryptans with SSRIs, but we know that the risk for serotonin syndrome is almost zero, and so there is no contraindication between giving tryptans and SSRIs at the same time. Um, in terms of side effects of the triptans, um, you can have this kind of triptan sensation that can happen where you get a little bit of tingling or paresthesias or just kind of some, a warmth sensation or, um, kind of a flushing feeling that can happen. For some kids, it makes their nausea worse. Um, I've had somebody, uh, recently tell me that it just made their migraines so much worse. So, Unfortunately, it's a little bit of trial and error to find out what's gonna work best for kids. Um, and if there is a family history, I'll often ask mom and dad what they've tried, what they've been on, did something work for them, and then we'll utilize that as well. And then of course, reminding families that medication overuse headaches are real, so we're limiting this. Usually I'd say 3 times a week or less. If we're needing something more than that, then we move up to our preventative therapy. So, um, When do we really start this? This is always a discussion with families. Um, oftentimes I'll say, you know, are you at the point where you want your child to take something every single day to try to decrease the number of headaches that we're having or make the severity less intense. Um, and for many, many families, they don't want their kid on medication. Um, they're not ready for that. They don't want the side effects, which is very understandable and reasonable. Um, but I try to, uh, encourage them when we're having more than 4 migraine days a month or we're having chronic migraines more than 15 days a month, if we're using that acute treatment more than 3 times a week. Um, or if they're missing school, they're missing activities, those types of things, so, um, Really, the, the goal is to keep kids functional, um, keep them doing the things that they wanna do, not missing school or activities, um, and, um, so while many parents don't want them on a prescription medication, we have the, the nutraceuticals which we'll talk about here next. Um, but really the goal is meaningful reduction in the frequency and severity. We're not trying to totally eliminate headaches or migraines. Um, that'd be great if that's what we could do every time, but we have to really set the expectations that, you know, even if we get a 50% reduction in migraines, that is an excellent, um, outcome. Um, the other part of this is none of our preventative therapies work quickly. It's an 8 to 12-week trial for any of them, whether we do a nutraceutical or a prescription medication. And so making sure that the child and the parent is gonna commit to taking it, uh, for 8 to 12 weeks is also, uh, important. Uh, if we're not gonna take it every day, then, you know, it's not likely to have as much benefit, so. Um, like I said, the nutraceuticals are oftentimes more, uh, um, More, parents are more open to these. Their side effect profile is pretty minimal, they're low cost. Um, and so oftentimes, you know, are the first line treatment. I'll give parents the option and say, you know, we have these nutraceuticals, we also have prescription medications. Um, we don't really have any data that one is better than the other. Again, trial and error. And so usually we start with the nutraceuticals just because of the, the safety profile and the cost. Um, some of these can be found in gummy formulation, some are in powders. Um, you try to send them to the pres uh, sometimes try to prescribe them. Oftentimes you can't get them or, uh, from the pharmacy, you gotta buy them over the counter. So sometimes that's a, a limiting factor. Families won't end up getting it over the counter. Um, so sometimes there are challenges, you know, versus them just being able to go pick up a prescription from the pharmacy, um, but these tend to be, um, uh, where I'd start. And so riboflavin or vitamin B2 is often recommended first line because we have the most evidence um that it can be helpful. Um, and so we think that riboflavin works as a, a co-factor to mitochondrial complexes and, um, and increasing ATP production and reducing oxidative stress. We really don't fully understand how this helps with migraine, any of these nutraceuticals or, um, for several of our prescription medications, but, um, but we have ideas about why it might be helpful. Um, and so, Dosing for this is 22 to 400 mg um once a day. So in the older kids, it's 400 mg, and the younger kids, it's 200. And there really aren't significant side effects. I always make sure that the families know that this can cause the urine to look a little bit more bright or a little bit more orange colored. Um, it's a water-soluble vitamin and the excess gets excreted in the kidneys and so some of that's part of it and it's just the The property of the the um The riboflavin structure. Um, so it's not a true side effect, it's just something that can be disturbing if uh families see it. Um, magnesium is the next one, so we don't have as much trial evidence, um, but it seems mechanistically like there would be a decent rationale for you. So, um, there are, um, we think that it could potentially help with cortical sweating depression, relax with muscle, and stabilizing neural membrane excitability, so. We don't have the clear data, but we think maybe it would uh maybe theoretically, it, it seems like it could make sense. Um, there's various forms out there. Oxide is actually the most studied form. Um, mag oxide tends to have higher elemental magnesium content, but it's less bioavailable than citrate. Um, citrate can cause more GI side effects. Glycinate might be better tolerated, but we really don't have any data at all for that form. So oftentimes I'll, I'll start with mag oxide. Um, and, um, Main side effects for this GI side effects, if those kids are constipated, sometimes it helps with this, but usually talking about 250 to 500 mg once a day. Um, when kids have other issues with sleep or they're kind of having aches and pains, and oftentimes I'll start magnesium, um, over riboflavin. Um, but, um, but these are, parents are starting to hear more and more about these. So when I say magnesium or riboflavin, they, they're often uh more interested in, in trying these. And then CoQ10 is the, the other uh nutraceutical that we have. I don't tend to use this one as much. Um, I don't often need to get to this one, but, um, there was some data showing that it may be more beneficial in kids with low CoQ10 levels. We don't test CoQ10 levels obviously in clinic, but, um, but this is another one that we could potentially use again, working with mitochondrial complexes, reducing oxidative stress, kind of a similar mechanism to riboflavin or what we think, uh, what we think it does. Um, and this is 200 mg a day. This one can potentially cause some sleep issues, so we try to give it in the morning versus at night just to make sure that there's no, um, no interaction there. Um, and then we get to our prescription medication options and, um, usually what's happened is they'll, they'll have tried uh nutraceutical, um, and then, um, we're not finding that we're making progress and then we'll move on to a prescription medication. And we typically pick kind of based on what side effects could we potentially tolerate. Um, all of these medications work in different ways. Um, amitriptyline, topiramate, and propranolol, they were all, of course, they're all used for different things. Um, and we just happen to find People who took these also reported improvement in their headache and their migraines. Um, so, um, they're definitely not specific, but, um, but I tend to start or think about amitriptyline as a first line one just with the neuropathic pain properties that blocks serotonin and norepinephrine reuptake. Um, and so if, uh, the main side effects with this one being it could potentially cause some weight gain, some dry mouth. Um, the cardiac, uh, risks, um, but it can also be sedating and so if kids are already having some additional trouble with sleeping, then oftentimes we'll use amitriptyline. Um, there is also nortriptyline which comes in a liquid, um, and so we use them interchangeably, um, for, for younger kids who can't take pills. Um, nortriptyline might be slightly better tolerated based on side effect profile, so sometimes we'll use that instead. Um, topiramate is an anti-seizure medication. Um, it works in several different ways, but we think that it might help migraines by reducing cortical excitability. Um, there's several different side effects though, the cognitive slowing, paresthesias. It has the potential to cause some weight loss, um, but kids have to stay really hydrated. It can cause kidney stones. Um, so, um, if weight is an issue, then sometimes we'll go with this one, if parents choose that. And then propranolol, Um, reduces cortical excitability and stabilizes cerebrovascular tone. Of course, we don't use this, uh, with kids with asthma, but, um, we can use metoprolol, um, and some kids, uh, who end up wanting to choose this one. so really, I kind of go through these medi prescription medications, and I tell them the side effects and, uh, what we might need to watch for, and we kind of decide together what might be a good option. Um, then there are the newer CGRP, uh, monoclonal antibodies. Um, the, the newest one, or the only one that we have that's FDA approved for kids is the framinizumab. So this got FDA approved in August 2025, but really this is finally starting to target the underlying pathophysiology of migraine. Um, so this is really exciting. There are several that are out for adults, and there are several other ones that are in. Um, in the pipeline being studied for use in kids. But really, we're, um, we're, we're trying to, um, block the CGRP release, which is one of those neuropeptides that goes on to, um, propagate the signaling to the trigeminal vascular, um, network that we have. So, um, these, unfortunately are, um, injections and so, uh, usually, um, with our older kids, it's not as much of a problem. Um In terms of getting these covered, most insurances require, require you to fail a few of our other preventative options. Um, so we usually can't jump straight to this, um, from an insurance perspective, but they tend to be pretty well tolerated, and I've had kids have improvement within a couple of months of, of using these. So the main side effect is injection site erythema with some of the other formulation, there's some constipation, but with this formulation, it's, it's mainly just the injection itself. And then we track and monitor migraine frequency when we start a preventative medication, so really having them take, uh, take notes, make a migraine diary is really helpful, um. Most kids don't want to do that, but they, uh, when they come back in and I ask them 3 months later, you know, how have your headaches been, it's always really hard to, uh, to remember for 3, you know, the last 3 months if we're not keeping track. And that way we know if we're actually making any, uh, if we're making any progress, um, with our treatment. Um, if after 8 to 12 weeks, they don't think they've had any improvement at all, I switch them off one of those nitraceuticals and add a different one. If they think, yeah, maybe it's helped a little bit, then I add on an additional supplement. Um, there are some, uh, formulations that, uh, combine supplements, but I generally try to take the approach of starting one at a time cause one might do it. Um, if we start, um, a combination supplement like Migrelief, then we don't always know what is, um, which, what part of it is helping. Um, and then parents always wanna know, of course, what's the future gonna hold, what, uh, what is their, um, are they gonna have migraines forever? Is this something that they'll always have to deal with? So there have been several, uh, studies that actually have looked at long term, long term outcomes of kids with migraine, and so these charts are organized by study duration, so up to 7 years, 10 years, 10 years, and this is much longer. So, um, now 16 year follow-up or 40 year follow up, and so. A little bit varied, but, um, but generally, around 40 to 60% of kids will continue to have migraines. Um, around 20 to 38% here will have, um, remission. Um, and then there are some people who will go on to develop other headache types. So most commonly transitioning from migraine to tension type headache. Um, there is a pretty strong difference, um, in, um, males versus females with this. So males are much more likely to achieve remission than, um, than females. But family history tends to be the strongest predictor of continued, uh, childhood, uh, childhood migraines. So if they do have that family history, they're much more likely you need to have it. Um, as we get much, much older in terms of, um, you know, we're 25, um, Uh, 50 even, um, you know, things might, uh, might get a little better at that age, but, um, but it's really hard, hard to predict. So in summary, um, we try to define the headache type. We uh look for those red flag features. We do a neurological exam. We really emphasize lifestyle factors. Treat them early, treat them adequately, and make sure they're taking a good dose, and then start a nutraceutical. Um, we try to encourage them to take, keep a headache journal to determine efficacy. You can refer to neurology at any point. We're happy to see these kids. Um, I see kids who've had one headache and I see kids who've had a headache for 5 years for the first time referral, so referring at any point, we're always happy to take care of them. Um, and I think hopefully I've left a few minutes here for any questions that, uh, that might have come up. Um, but thank you all again for attending and, um, Uh, thanks for everything you do for, for these kids. Created by Related Presenters Keely Fitzgerald DO Pediatric neurologist View full profile
