Headaches

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Updated on: 10/2021

Co-management guidelines

To support collaborative care, the Jane B. Pettit Pain and Headache Center has developed guidelines for our community providers to utilize when managing and referring patients with headaches. These guidelines provide protocols to allow joint management of patient cases between community providers and our pediatric headache specialists.

Summary of International Classification of Headache Disorders (ICHD-3)

Primary

Disorder by themselves. Caused by independent pathomechanisms and NOT by other disorders.

  • Migraines
  • Tension-type
  • Trigeminal autonomic cephalalgia (TACs)

Secondary

Developed as a secondary symptom due to another disorder that is known to cause headaches.

  • Trauma / Injury
  • Cranial / Vascular
  • Pseudotumor –idiopathic intracranial hypertension
  • Medication over-use
  • Infection
  • Homoeostasis
  • Cranium/neck/eye/ears/nose/sinus/teeth/mouth
  • Psychiatric

Other

Caused by a lesion or disease of the somatosensory nervous system. Characterized by pain in the distribution of a nerve or nerves.

  • Trigeminal neuralgia
  • Other

Most common in Primary Care setting for children:

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

Referring provider’s initial evaluation and management:

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 to initiate referral/consider refer to Pain & Headache Center:

  • 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

What information to send to Pain & Headache Center?

  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

Specialist’s workup will likely include:

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.

Medication table

BREAK-THROUGH

Medication class / Medication name

Acetaminophen

Dosing

10 - 15 mg/kg
q4-6h PRN

Medication class / Medication name

Acetaminophen + Caffeine (Excedrin Tension)

Dosing

25 kg 1 tab
50 kg 1.5 tab
>70 kg 2 tab
q6 PRN

Dosing forms

500 mg-65 mg per tab = 1cup coffee

Notes

NO ASPIRIN:
Do not give Excedrin Migraine (contains aspirin) or Fioricet (contains butalbital)


Prescription NSAIDS

The following is the same for all medications in Prescription NSAIDS

Common side effects

  • GI upset
  • Bruising
  • Itching
  • Ringing in ears
  • Dark urine
  • Jaundice
  • Insomnia
  • Nervous/irritated

Notes

Can decrease GI side effects if taken with food

Medication Class / Medication Name

Diclofenac

Dosing

2 - 4 mg/kg
divided q8-12h PRN
Max 200 mg/day

Medication Class / Medication Name

Ibuprofen

Dosing

10 mg/kg q6h PRN

Dosing Forms

200 mg, 400 mg, 600 mg, 800 mg
100 mg/5 ml

Medication Class / Medication Name

Naproxen

Dosing

5-10 mg/kg q8-12h PRN

Dosing Forms

250 mg, 375 mg, 500 mg
125 mg/5 ml

Medication Class / Medication Name

Ketorolac (Toradol)

Dosing

10 mg q6h PRN

Medication Class / Medication Name

Meloxicam

Dosing

30 kg 3.75 mg
60 kg 7.5 mg
>60 kg max 15 mg

Dosing Forms

QD prn


Triptans- Migraine only

Medication class / Medication name

Rizatriptan (Maxalt)

Dosing

<40 kg: give 5 mg once
>40 kg: give 10 mg once
If >12yrs old, may repeat in 2h if pain continues

Common side effects

  • Palpitations, increased heart rate
  • throat or chest tightness
  • tingling hands/feet
  • anxiety
  • drowsiness

Notes

  • FDA-approved for kids aged 6 years and older
  • must take at first sign of migraine

CAUTION:
Do not use in patients with cardiac history, cerebrovascular syndromes, peripheral vascular disease, or complex migraines

Medication class / Medication name

Sumitriptan (Imitrex)

Dosing

Tablet:
25 mg, 50 mg or 100 mg
If >12yrs old, may repeat in 2h if pain continues

Nasal:
<38 kgs: 10 mg
>38 kgs: 20 mg

Injection:
3 – 6 mg

Common side effects

  • Palpitations, increased heart rate
  • throat or chest tightness
  • tingling hands/feet
  • anxiety
  • drowsiness

Notes

Not FDA approved in kids (for < 12 years)

  • must take at first sign of migraine

CAUTION:
Do not use in patients with cardiac history, cerebrovascular syndromes, peripheral vascular disease, or complex migraines

Preventive

Antidepressant: SSRI

Medication class / Medication name

Sertraline (Zoloft)

Administration dosing

A: Morning
D:12.5-50 mg

Dosing range

12.5-50 mg

Titration

Wean schedule:
½ dose daily for 7days then full dose

Common side effects

  • Sedation
  • weight gain
  • dry mouth
  • constipation
  • increased suicidal ideation

Tricyclic antidepressants

Medication class / Medication name

Amitriptyline (Elavil)

Administration dosing

A: 1 - 2 hours before bedtime

D: 0.5 - 1 mg/kg

Dosing range

10 - 100mg

Common side effects

  • Sedation
  • weight gain
  • dry mouth
  • constipation
  • increased suicidal ideation

Notes

  • Get baseline ECG to check QTc – if <450 ok to use
  • Helpful with insomnia, trouble with sleep onset

CAUTION:
overweight/obese patients when used with SSRIs can be fatal. If overdose, do not use with complex cardiac issues, seizures, diabetes

Medication class / Medication name

Nortriptyline (Pamelor)

Administration dosing

A: 1 - 2 hours before bedtime

D: 0.5 - 1 mg/kg

Dosing range

10 - 100mg

Common side effects

  • Sedation
  • weight gain
  • dry mouth
  • constipation
  • increased suicidal ideation

Notes

  • Get baseline ECG to check QTc – if <450 ok to use
  • Helpful with insomnia, trouble with sleep onset

CAUTION:
overweight/obese patients when used with SSRIs can be fatal. If overdose, do not use with complex cardiac issues, seizures, diabetes


Beta blockers

Medication class / Medication name

Propranolol (Inderal)

Administration dosing

A: Morning or evening

D: 1-3 mg/kg/day given q8 or as a single LA/ER dose

Dosing range

60-240 mg LA/ER

Common side effects

  • Fatigue
  • Dizziness
  • Bradycardia
  • Hypotension
  • exercise intolerance
  • exacerbation of asthma
  • depression
  • diabetes

Notes

  • Helpful for decreasing anger or physical symptoms of anxiety (e.g., tachycardia, sweating)

CAUTION:
patients with asthma, depression, diabetes, elite athletes, Raynauds


Bantiepilepics

Medication class / Medication name

Topiramate (Topamax)

Administration dosing

A: Morning & evening

1-3 mg/kg/day QD or give BID divided

Dosing range

25-200 mg

Tiration

Wean schedule:
25 mg QD x 3 days,
25 mg BID x 3 days,
25 mg qam/50 mg qpm x 3 days,
50 mg BID

Common side effects

  • Weight loss
  • decreased appetite
  • sedation
  • parethesias
  • cognitive slowing
  • blurred vision
  • eye pain
  • May reduce efficacy of oral contraceptives

Notes

  • FDA-approved for migraine prevention in children 12 years and older
  • helpful with overweight/obese patients
     

CAUTION:

  • avoid in patients with eating disorders
  • avoid in patients with significant attention/learning difficulties
     

Medication class / Medication name

Divalproex (Depakote)

Administration dosing

ER QD

Dosing range

6125 - 1000mg

Common side effects

  • Drowsiness
  • Nausea
  • weight gain
  • cognitive slowing
  • liver toxicity
  • possible increase hair growth

Notes

  • Requires labs (platelets, AST, ALT at initiation, each dose increase, and at least q6 months

NOT PREFERRED FIRST LINE TREATMENT

CAUTION:

  • avoid in patients of childbearing age due to associated birth defects
  • avoid in patients with PCOS, liver disease