BOSTON—Chronic daily headache is one of the biggest challenges for pediatric neurologists, in terms of diagnosis and treatment, according to Bruce Masek, PhD. Often, the expertise of a child and adolescent psychiatrist proves beneficial in managing comorbid anxiety and depression.

HEADACHE CLASSIFICATION

At the 54th Annual Meeting of the American Academy of Child and Adolescent Psychiatry, Dr. Masek reported that part of the problem with diagnosing headache in pediatric patients is that children may find it difficult to accurately describe their symptoms. “You can waste a lot of time in a 45-minute session trying to get them to pinpoint what is the peak intensity and what is the average intensity,” said Dr. Masek, Clinical Director of Outpatient Child and Adolescent Psychiatry at Massachusetts General Hospital in Boston and Associate Professor of Psychology at Harvard Medical School. “Trying to associate when they take nonprescription pain medicine is even more difficult.” In addition, he noted that ascertaining a three-month headache history often yields unsatisfactory and vague descriptions, even with the help of a parent’s report.

Few studies have investigated pediatric headache, and prevalence rates are based largely on studies involving adults, some of which may have a subpopulation of adolescents. Dr. Masek reported that migraine with aura is the most common type of headache that he has seen in pediatric patients during the last three decades. Migraine with aura lasts two to three days, can be unilateral or bilateral, can have a pulsating quality, and can be aggravated by routine activity such as exercise or any increase in activity level. It is also characterized by nausea and/or vomiting and photophobia or phonophobia.

Tension-type headache is characterized by diffuse bilateral pain, band-like tightening, and viselike pain, according to Dr. Masek. It often involves the posterior of the head; however, he noted that it is less common in children, compared with adolescents.

Although Dr. Masek has never had a patient with daily persistent headache referred from a pediatric neurologist, he noted that the condition is distinguished by rapid-onset, continuous pain. Hemicrania continua is characterized by fluctuating intensity, continuous pain—more continuous than chronic daily headache—and unilateral photophobia, phonophobia, nausea, and tearing.

RECOMMENDED TREATMENT

Current recommendations for the acute treatment of pediatric patients with migraine include the use of ibuprofen and sumatriptan nasal spray. Both are thought to be effective and well tolerated. “These are the two most useful drugs for migraine, particularly for the most classic type of migraine,” said Dr. Masek.

In his own clinical experience, he has found amitriptyline, propranolol, and cyproheptadine to be effective as preventive therapy, although he noted that there is not enough evidence supporting their use.

According to Dr. Masek, opinion on the effectiveness of biobehavioral treatment—such as relaxation therapy, biofeedback, cognitive behavioral stress management, and lifestyle modification—for children and adolescents with chronic headache is divided. However, he said that it is not at all uncommon for a pediatric neurologist to first recommend biobehavioral therapy paired with the use of OTC pain medications. If symptoms are severe, or if the patient is experiencing more of a classic-type migraine, the pediatric neurologist might recommend sumatriptan along with lifestyle modifications, such as healthy eating and sleeping habits.

PSYCHOSOCIAL FUNCTIONING AND QUALITY OF LIFE

Most of the patients referred to Dr. Masek are female, with two or three years of prior headache history. At first examination, these patients typically do not present with any comorbid neurologic, psychiatric, or medical conditions; however, he stressed that they are being referred to him because they are starting to miss school or their school performance is declining due to their headache.

Among children and adolescents with episodic migraine or tension-type headache, there is a higher incidence of somatic complaints, such as fatigue and stomachache. In addition, conflict is sometimes observed in families with children who have migraine or tension-type headache, although the cause of this conflict is unknown. However, he noted that daily functioning is minimally affected in these patients.

Dr. Masek pointed out that chronic daily headache is associated with significantly lower social, emotional, physical, and school functioning. “Some of these kids wind up having to drop out of school and then having to go for a GED,” he said. “It almost makes me wonder if, for chronic daily headache, we should have a more multidisciplinary team with an educational consultant,” he said.

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