Pediatric Headache Management: Q&A with Dr. Heidi Blume
Dr. Heidi Blume, a neurologist and researcher at Seattle Children’s, addresses questions about pediatric headache management. For more information or to obtain CME credit, see Blume’s article, “Pediatric Headache: A Review” in Pediatrics in Review.
Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek, a member of Children’s medical staff and author of the Seattle Mama Doc blog, for submitting these questions.
Q: Headaches remain a challenging diagnosis for many pediatricians. Besides red flags like vomiting and morning headaches, what symptoms should lead to further investigation?
A: You have to look at each individual because there are so many things that can cause headaches. The patient’s history – medical, family and social – is the single most important factor in evaluating a headache.
Both the patient and the family should be included in discussions about symptoms, how the headache began and whether headaches run in the family. However, a private conversation with an adolescent is often helpful to discuss any sensitive issues related to headaches, such as conflicts with family or friends, physical or sexual abuse, and drugs or alcohol.
There are four basic headache patterns: acute, acute recurrent, chronic progressive and chronic nonprogressive. See the graph on page 2 in “Pediatric Headache: A Review.”
Chronic progressive headaches are the most worrisome and deserve a thorough neurological evaluation – including neuroimaging – if the evaluation reveals abnormalities. If you are concerned about increased intracranial pressure but are unsure whether neuroimaging is necessary, you may want to refer the child to an ophthalmologist to check for papilledema as a first step.
Red flags also include:
- Increased headache with straining, coughing or sneezing
- Systemic symptoms such as fever
- Headaches that awaken the child from sleep
- Weight loss or joint pain
- Sudden onset of severe and debilitating pain (“worst headache of my life”)
- Neurological symptoms such as altered mental state or abnormal eye movements
See Table 4 in “Pediatric Headache: A Review.”
Q: What are the most common mistakes referring pediatricians make in managing headaches?
A: It’s important to make sure children are receiving the right dose of any medications such as acetaminophen or ibuprofen. It’s not uncommon for parents to give them too little or too much.
It’s also important to talk with families and kids about lifestyle factors that are closely associated with headaches such as sleep, diet and exercise. Eating regularly, drinking enough water, managing stress and getting enough rest can make a huge difference.
Teens in particular often don’t get enough sleep. It’s best to remove electronics from the bedroom one or two hours before a child expects to go to sleep.
Watch for signs of anxiety and depression, which are often associated with chronic headaches. It’s hard to treat the headache if those issues are not treated as well.
It may be helpful to provide families with handouts such as How to Help with Headaches (PDF) and Headache Log (PDF). The SMART (Sleep Meals Activity Relaxation Trigger avoidance) headache management plan is another helpful tool. See Table 6 in “Pediatric Headache: A Review.”
Q: What are the most current recommendations for first-line medical treatment of headache in school-age children and teens?
A: The American Academy of Neurology has recently reaffirmed its 2002 Guideline on Evaluation of Children and Adolescents with Recurrent Headaches and published a guideline in 2004 called “Pharmacological Treatment of Migraine Headache in Children and Adolescents.” Many children can effectively manage their headaches using ibuprofen or acetaminophen, lifestyle changes and supplements.
The most significant change since 2004 is the approval of rizatriptan for children age 6 and older, and almotriptan for children age 12 and up for the acute treatment of migraine. Seattle Children’s is participating in the first multicenter National Institutes of Health study for preventive treatment of migraine in children. We’re comparing the effectiveness of topiramate and amitriptyline versus placebo in children ages 8 to 17.
Q: How often should patients with chronic headaches return for follow-up?
A: They should be seen every one or two months to monitor possible medication side effects and efficacy and to track what’s going on in their life. It’s important to encourage and support lifestyle changes.
It usually takes 8 to 12 weeks to see a change in headaches after starting preventive medications, so remind the family to be patient. Changing preventive medications frequently is counterproductive unless the patient can’t tolerate the treatment.
Q: What nonpharmaceutical interventions work best?
A: Although there have been few randomized controlled trials, several types of supplements may be effective and are unlikely to cause any harm. The most commonly used are riboflavin, magnesium and butterbur. Coenzyme Q10 and melatonin may also be helpful. See Table 9 in “Pediatric Headache: A Review.”
Q: How often are children treated with biofeedback for headache at Seattle Children’s?
A: We believe biofeedback can be very helpful and we use it frequently. In a study by Seattle Children’s and the University of Washington, 73% of children ages 8 to 18 with episodic headaches reported a positive response to biofeedback, as did 48% of children with chronic headaches.1
Q: What are your opinions about acupuncture for headache?
A: The placebo response is high in children, so it has been difficult to gather conclusive data on the effectiveness of acupuncture. However, it appears to be very helpful for some children.
- Blume HK, Brockman LN, Breuner CC. Biofeedback therapy for pediatric headache: factors associated with response. Headache 2012 Oct;52(9):1377-1386.
Dr. Mark Del Beccaro Appointed Chief Medical Officer
Dr. Mark Del Beccaro has been appointed senior vice president and chief medical officer (CMO). He will succeed Dr. David Fisher, who will retire on Oct. 1, 2014.
“Mark’s leadership and commitment to our patients and families as well as his colleagues will make him an outstanding CMO,” said Dr. Thomas N. Hansen, CEO of Seattle Children’s. “We look forward to seeing what he brings to his new position.”
Del Beccaro trained at the University of Washington School of Medicine and completed his pediatric residency at Seattle Children’s. He joined the faculty of Seattle Children’s Emergency Department in 1989, was appointed pediatrician-in-chief in 2007 and became vice president of Medical Affairs in 2012. In addition to his administrative responsibilities, he continues to see patients in the Emergency Department.
He has made many contributions to Seattle Children’s during his career, leading the first phase of implementation of the electronic medical record, launching the clinical effectiveness initiative and working to ensure all children continue to have access to care at Seattle Children’s.
In his new role, Del Beccaro will build on Fisher’s work in the past seven years, including efforts to improve patient safety. He will partner with community providers on key initiatives, including the expansion of Seattle Children’s electronic medical record to reach community partners and families.
Dr. David Fisher joined Seattle Children’s as chief medical officer in 2007 after a long career as a leader and a critical care physician in trauma and perioperative cardiology.
“David has been dedicated to improving the quality, effectiveness and equity of care at Seattle Children’s,” Hansen said. “He has been a leader and champion in our quest to improve patient safety and eliminate preventable harm. We are fortunate that Mark will carry on his work.”
Overview of Pediatric Dentistry Options with Seattle Children’s Hospital
Seattle Children’s Hospital Department of Dentistry has two dental locations and partners with the University of Washington School of Dentistry to provide care at the Center for Pediatric Dentistry. All three locations accept patients with Medicaid insurance.
Odessa Brown Children’s Clinic
- Patients treated: Children ages 1 to 15 years
- Primary dental care
- Infant and Toddler Dental Program
- Orthodontics (only for orthodontic problems covered by Medicaid/Department of Social and Health Services)
- Dental care for special-needs patients
- Dental emergencies
- Seattle/King County ABCD training site for general and pediatric dentists
- Location: Central District – 2101 E. Yesler Way, Seattle, WA 98122
- No referral required
- Financial assistance available through Seattle Children’s
Seattle Children’s Dental Clinic
- Patients treated: Patients with special healthcare needs seen at Seattle Children’s Craniofacial, Hematology/Oncology, Cardiology, Transplant and other specialty clinics up to age 21
- Dental, orthodontic and facial orthopedic care for children with craniofacial disorders
- Oral and maxillofacial surgery
- Dental care under general anesthesia for medically complex children
- Dental emergencies
- Speech prosthetics
- Location: Seattle Children’s main campus – 4800 Sand Point Way NE, Seattle, WA 98105
- Referral required
- Financial assistance available through Seattle Children’s
Center for Pediatric Dentistry
- Patients treated: Children up to age 18 and children with special needs up to age 21
- Services: Comprehensive dental care, including:
- Interceptive orthodontics
- Third molar extraction
- Root canal treatment
- Treatment under general anesthesia for healthy children
- Location: Magnuson Park, near Seattle Children’s main campus – 6222 NE 74th St., Seattle, WA 98115
- No referral required
- Financial assistance provided through the Center for Pediatric Dentistry (not Seattle Children’s)
The ABCD website can also help you find a dentist in Washington state who will accept Medicaid insurance to provide care for children up to age 6.
For more information on Seattle Children’s Hospital Dentistry, see our web page.
Grand Rounds for August 2014 (CME Credit Available)
Upcoming Grand Rounds
- Physician Blogging: How the Internet Can Help You Reach and Teach, Aug. 14
- HPV Immune Responses and Vaccine Update on Real-Life Outcomes, Aug. 21
- Predictions of Neurodevelopmental Impairment for Critically Ill Neonates: Elucidatory, Elusory or Illusory? Aug. 28
- It’s Back-to-School Time… STDs not ABCs! 2014 STD Treatment Guidelines and Results of eKISS (Electronic Kiosk for Safer Sex), an Interactive Computer-Based Intervention, Sept. 4
- See all upcoming grand rounds.
Watch Past Grand Rounds Online
- Stem Cells and Cancer: Common Pathways
- Eyes Wide Open: The Impact of Industry Interactions on Clinical Practice
- Pushing the Boundaries of Academic Medicine: Translating Metabolites into Clinical Practice
- See all available past grand rounds online.
New Medical Staff and Allied Health Professionals, August 2014
Seth Adams, MD, Seattle Children’s, Hospital Medicine
Emily Berkman, MD, Seattle Children’s, Critical Care Medicine
Sophia Conley, MD, Seattle Children’s, Emergency Medicine
Sarah Dixon, MD, MPH, Seattle Children’s, Hospital Medicine
Mary Farrington, MD, Virginia Mason Medical Center, Allergy
Elena Griego, MD, Seattle Children’s, Hospital Medicine
Divakar Gupta, MD, University of Washington, Ophthalmology
Anna Hedstrom, MD, Seattle Children’s, Neonatology
Joshua Hermsen, MD, University of Washington, Cardiac Surgery
Rafael Hernandez, MD, PhD, University of Washington, Infectious Disease
Kelly Jones, MD, University of Washington, Genetic Medicine
Dane Mejias, MD, Seattle Children’s, Emergency Medicine
Martin Montenovo, MD, University of Washington, Transplant Surgery
Brian Morray, MD, Seattle Children’s, Cardiology
Terra Pearson, MD, University of Washington, Transplant Surgery
Francisco Perez, MD, PhD, Seattle Children’s, Radiology
Richard Robison, MD, University of Washington, Neurosurgery
Jason Rubin, MD, Seattle Children’s, Hospital Medicine
Lori Rutman, MD, MPH, Seattle Children’s, Emergency Medicine
Erin Schoenfelder, PhD, Seattle Children’s, Psychiatry and Behavioral Medicine
Carolyn Schook, MD, Seattle Children’s, Hospital Medicine
Clayton Sontheimer, MD, Seattle Children’s, Rheumatology
Katerina Stursova-Wolff, MD, Seattle Children’s, Hospital Medicine
Christina Tragos, MD, Seattle Children’s, Plastic Surgery
Alpana Waghmare, MD, Seattle Children’s, Infectious Disease
Jesse Wenger, MD, Seattle Children’s, Hospital Medicine
Tara Wenger, MD, PhD, Seattle Children’s, Craniofacial Medicine
Jennifer Wild, MD, Seattle Children’s, Hospital Medicine
Katie Willihnganz-Lawson, MD, Seattle Children's, Urology
Allied Health Professionals
Sarah Benrath, ARNP, MPH, Odessa Brown Children’s Clinic, Pediatrics
Kara Mochan, ARNP, Seattle Children’s, Adolescent Medicine
Jeovana Oshan, ARNP, Seattle Children’s, Psychiatry and Behavioral Medicine