Headache Program

Provider’s initial evaluation may include:

• Asking about common symptoms seen in primary headaches:
• Tension headaches are diffuse, non-throbbing, mild to moderate severity headaches without significant worsening with activity, light or sounds sensitivity, or nausea
• Migraine headaches are bifrontal or unilateral moderate to severe intensity headaches associated with a throbbing quality, worsening with activity, and light or sound sensitivity, nausea and/or vomiting
• Migraine aura may occur before or during headaches lasting 5-60minutes and include sensations of visual changes (dark or bright spots or lines), sensory changes (tingling, numbness), or speech changes
• Considering other common causes of headache:
• Sinus headache
• Post traumatic/concussive headache
• Allergic rhinitis
• Ophthalmologic problems
• Depression

Provider should instruct family on basic first line treatment for headaches including:

• Lifestyle modification for prevention of headaches including:
• Hydration – goal ounces per day = weight in pounds to a max of 100 oz per day, none with caffeine or artificial sweeteners
• Exercise at least 3 days per week for 30 minutes
• Sleep per AAP guidelines with no more than two hours of variability in sleep or wake timing
• Eat 3 healthy well balanced meals per day
• Abortive therapy when child gets a headache includes:
• Ibuprofen 10mg/kg per dose up to three days per week
• 8-12oz fluid bolus with medication, sports drinks preferable in those without contraindications (obesity, diabetes)
• Triptans may be considered up to twice weekly if no contraindication
• Preventative therapy may be considered in those with frequent headaches and include cyproheptadine (max 0.25mg/kg/day) and amitriptyline (max 1mg/kg QHS)

Provider may consider testing in patients who:

• Patients with recurrent headache and a normal neurologic exam generally do not require additional testing.
• Brain imaging studies are suggested for patients who have:
  • Headaches for less than 6 months duration not responding to lifestyle changes and first line treatment (ibuprofen, triptans, cyproheptadine),
  • Headaches associated with abnormal neurologic exam findings, especially papilledema, nystagmus, gait or motor changes
  • Absent family history of headache
  • Headaches associated with substantial confusion or emesis
  • Headaches that awaken a child from sleep repeatedly
  • A family history or disorders that predispose child to central nervous system lesions such as brain tumors or cerebral aneurysms
• Specific testing for children with other systemic complaints including arthralgias, rash, sleep complaints

Providers may consider initiating referral to child neurology when:

• Patients with a new severe headache of acute onset, headache with focal neurologic deficit or papilledema should be referred to the Emergency Department for neuroimaging
• Recurrent headache that has been present for at least six months and is not responding to standard medical treatment including lifestyle modification and acute abortive treatment
• Headache that is resulting in missed school days, worsening of school participation (declining grades, extracurricular activity limitation)

Providers may instruct families to bring the following to the evaluation:

• A headache calendar for at least one month including dates of headaches, location, severity, associated symptoms, time at onset and resolution, activities preceding headaches including diet, and treatment provided
• A complete list of medications used for headache treatment including doses and frequency of use. Include any abortive or preventative medications used.
• Copies of testing done including other referrals, labs, imaging films/CDs (not just reports), and any other additional information that may be helpful.