Headaches

Pediatric migraine: ICHD – II

1. At least five attacks fulfilling criteria B – D
2. Headache attacks last 2 – 72 hours (untreated or unsuccessfully treated)
3. Headache has at least two of the following four characteristics:
   • Unilateral location (often bilateral in pediatrics)
   • Pulsating, throbbing, pain
   • Moderate to severe pain intensity
   • Aggravation by or causing avoidance of routine physical activity
4. During headache at least one of the following:
   • Nausea and/or vomiting
   • Photophobia and phonophobia
5. Not better accounted for by another diagnosis

Migraine with aura

1. Fully reversible sensory disturbances occurring up to 60 minutes before headache pain
2. Includes visual (e.g., wavy lines, blind spots, flashes of light), auditory (ringing in the ears), motor weakness, paresthesias of the hand, face, lips, tongue, difficulty speaking

Tension-type headache: ICHD – II

1. < 15 days/month and fulfilling criteria B – D
2. Headache lasting from 30 minutes to 7 days
3. Headache has at least two of the following characteristics:
   • Bilateral location
   • Pressing/tightening pain (non-pulsating)
   • Mild or moderate pain intensity
   • Not aggravated by routine physical activity
4. Both of the following:
   • No nausea or vomiting (anorexia may occur)
   • No more than one of photophobia or phonophobia
   • Not attributed to another disorder

Medication overuse headache: ICHD – VIII

1. > 15 days/month and fulfilling criteria B-C
2. Regular overuse of >3 months of one or more acute/symptomatic treatment drugs
   • Ergotamine, triptans, opioids, or combination analgesic medications > 10 days/month on regular basis for >3 months
   • Simple analgesics or any combination of ergotamine, triptans, analgesic opioids on >15 days/month on regular basis for >3 months without overuse of any single class alone
3. Developed or markedly worsened during medication overuse

S.M.A.R.T. Lifestyle modifications:

S – Sleep

• Get 8 – 10 hours of sleep a night.
• Keep consistent bedtimes and wake times (no more than 1 – 2 hours variation).
• Avoid daytime naps, which disrupt the sleep cycle.
• Avoid electronics/screens in bed.

M -- Meals / drink / caffeine

• Eat 3 meals a day plus snacks; do not skip meals.
• Make sure each meal is protein-rich (e.g., eggs, cottage cheese, Greek yogurt, peanut butter, etc.).
• Drink 64 – 100 oz of water a day – an ounce for every kg of weight.
• Avoid caffeine and artificial sweeteners.

A – Activity / exercise

• Exercise 30 – 60 minutes a day for 3 – 4 days a week.

R – Relaxation / CBT / biofeedback

• Use good stress management: identify parts of stressful circumstances you can control and make changes, make time for activities you enjoy (exercise, hobbies, etc.), talk with others, journal, and/or engage in relaxing activities (listening to soothing music, yoga, massage, meditation).
• Find a quiet activity to try to distract from the pain.
• Rest in a quiet, dark room until pain is more manageable.
• Put a cool washcloth or ice pack where it hurts.
• Relaxation apps for home use: Calm, MyLife

T – Trigger avoidance

• Identify stress-related triggers
• Limit medication to no more than 2 out of 7 days per week
• Wear glasses as prescribed
• AVOID trigger food – nitrates, hard cheese, caffeine, MSG
• AVOID/REDUCE stress – good/bad, happy/sad, physical/emotional
• Maintain a headache diary tracking symptoms, possible triggers, frequency, and alleviating factors

Basic school accommodations

1. Encourage regular attendance
2. Eating and drinking
   • Allow use of a water bottle to stay hydrated
   • Allow the student to use the restroom as needed
   • Allow student to eat snacks during the day to help blood sugar
3. Rest to reduce stress
   • Provide a quiet resting place during pain
   • Allow student to leave class without drawing attention
   • Give student short breaks of 10 to 20 minutes, then expect them to return to class
4. Medicine
   • Allow the student quick access to medicines to help control pain
   • Follow dosing as written by medical staff
   • Keep extra doses at school
5. Academic help and support
   • Headaches can make concentration and learning hard. Some students may need:
   • Extra school support or other accommodations
   • A Health Plan or 504 Plan to address a health concern
   • Individual Education Plan (IEP) to address learning difficulties.

Screening Tools

1. Labs:
   • Baseline -- CBC, Ferritin, TSH reflex Free T4, Vitamin D
   • Additional –
     • B12, Folate – if concerns not eating red meats &/or green leafy vegetables
     • PT, PTT – if concerns of easy bruising, females with heavy menstrual cycles >> in turn can effect iron
2. Image IF:
   • New onset, severe headache
   • "Worst headache ever"
   • Child is <6 years old
   • Occipital headache
   • Abnormal neurological exam
   • Headache with systemic disease or symptoms, neurological signs or symptoms, worsening acutely/progressive symptoms, nocturnal awakening, early morning vomiting, history of trauma, papilledema or diplopia, and/or exertional or positional aspects

• When headaches are unable to be managed with break-through medications
• When considering daily preventative medication for headache management
• Headaches get worse
• New symptoms develop
• Child or family preference
• Frequently missing school due to headaches
• The child or adolescent appears to have difficulty managing stress, worry, or pain

1. Using Epic referral form, please complete:
   • Urgency of the referral
   • What is the patient's chief complaint?
   • Describe details
   • Pertinent past medical history
   • Abnormal lab or imaging findings
   • What is the key question you want addressed?
   • Does patient have psychosocial stressors or mental health concerns?
2. In addition, please include the following in your note when you recommend an appointment to our clinic
   • List of failed headache medications
   • Whether or not the patient has had a recent eye exam
   • Whether or the patient has a therapist
   • Number of school absences due to headache
3. Not using Epic referral form -- please fax (414- 266- 1761) the above information and include:
   • Chief complaint, onset, frequency
   • Recent progress notes
   • Labs and imaging results
   • Other diagnoses

After referral to Headache Clinic:

• Evaluation by a physician or nurse practitioner, and possibly a psychologist
• Brief psychosocial assessment of the child or adolescent's school, home, social, and emotional functioning.
• We may recommend more targeted mental health services within our clinic or the community.
• Recommendations for lifestyle modifications.
• Possible further work-up which MAY include labs, imaging (if indicated), referrals
• Please note we do not image all patients referred to our clinic.
• Recommendations for medication management
• Anticipated follow up with medical provider and/or psychologist

Medication

• Medication – Please see table below

1. Avoid medication overuse. Do not use breakthrough medications more than TWO TREATMENT days/week
2. Use breakthrough medication at first sign of pain.
3. NO opioids, except low dose tramadol, if refractory migraines.
4. Preventive medications may be introduced when the child or adolescent is experiencing more than two headaches weekly IF:
   • Maintaining all expected life style changes (as noted above)
   • No causes found for headaches during work up process
   • Not overusing break-through medications (per guidelines listed above)
5. The goal of a preventive medication is to reduce the frequency, intensity, and/or duration of a headache by 50%, improve the child's response to breakthrough medications, and/or eliminate medication overuse headaches. Preventive medications typically take 6-8 weeks at the correct dose before they provide benefit.