Headache Management in Primary Care: A Q&A With Dr. Heidi Blume
February 7, 2024
Dr. Blume will be presenting a one-hour category I CME on February 29 at 6 p.m., Migraine in Pediatrics. Learn more and register.
Please note that many of Dr. Blume’s answers direct PCPs to contact Seattle Children’s Neurology. As we continue to evolve how we support Referring Providers needing consultative services, please visit our Healthcare Professional site for the latest information eConsults and the Provider-to-Provider line.
Q: What are some important things to know about pediatric headaches?
Heidi Blume, MD, MPH, principal investigator, Seattle Children’s: Headaches are very common in pediatrics. One study found that over 10% of school-aged kids and more than 20% of teens had “frequent or severe” headaches in the past year, and about 5% of younger children and 20% of teen girls have migraines.
Headache is a frequent complaint in both primary care and the ED, and many families are afraid that something dangerous, like a tumor or aneurysm, is causing headaches. Fortunately, this is very rare.
Many things can contribute to headaches, including genes (family history of migraine), poor sleep, poor hydration or nutrition, stress/anxiety/depression, other medical problems (e.g., anemia, thyroid abnormalities, rheumatological disorders), dental problems, concussion, pregnancy, drug abuse, musculoskeletal pain (e.g., from slouching over a laptop or other screen for hours) or medications (e.g., stimulants or tetracyclines) so, it is important to consider further workup for other underlying disorders when appropriate in the evaluation of headaches.
The good news is that there are many ways to manage headaches including relatively simple lifestyle changes, supplements, medications, neuromodulation devices, biofeedback and mental health treatment.
Q: When should I refer my patient for headache?
Dr. Blume: It is reasonable to refer children and teens to Seattle Children’s Neurology for evaluation of headaches that:
- Are causing disability despite adequate trials of over-the-counter medications such as ibuprofen or acetaminophen at appropriate doses.
- Have not responded to a trial of adequate sleep, regular diet and good hydration. A reasonable goal is ½ body weight (in pounds) in ounces of fluid per day)
- For an urgent or emergent assessment, please consider contacting Seattle Children’s Neurology directly if you see a child with new headaches and new abnormalities on their neurological exam or papilledema.
Q: When does a child need neuroimaging for headache (or not)?
Dr. Blume: We have strong guidelines from the American Academy of Neurology (AAN) to help identify headaches caused by intracranial lesions; these recommend neuroimaging for a child with:
- Headache AND any abnormalities on neurological exam, i.e.:
- Gait abnormalities
- Asymmetry on neurological exam
- Altered mental status
- Abrupt onset of severe, unremitting headache
- A new severe headache type
- Headaches that frequently wake them from sleep or occur with exertion
- Headaches with cough or Valsalva maneuver
- Headache and an underlying disorder that leads to immunodeficiency or increased risk of thrombus formation or bleeding
We suggest doing a brain MRI (magnetic resonance imaging), if possible, to avoid radiation and to obtain a detailed image, although a CT (computed tomography) scan is useful to rule out hydrocephalus, hemorrhage and fractures and usually will identify significant brain lesions.
Q: Should PCPs order neuroimaging before referring?
Dr. Blume: The short answer is that it depends. If a child has headaches with the problems noted above, PCPs can contact Neurology to discuss how best to obtain imaging and a neurology consult. However, I would expect that neuroimaging for a child with these symptoms would be approved when ordered.
Q: When is neuroimaging not recommended?
Dr. Blume: Neuroimaging isn’t recommended for children with a normal exam and recurrent intermittent headaches that resolve or have a stable pattern over months.
If there is a question about how urgent the need is for neuroimaging vs. urgent neurology evaluation, community practitioners can reach out to Seattle Children’s Neurology to review the case. We would much rather know about kids with worrisome symptoms early on and get them to the correct treatment as soon as possible.
Q: What is the wait time for a patient referred for headache?
Dr. Blume: Unfortunately, it can be several months for a child to be seen in the Neurology Clinic at Seattle Children’s if they have a nonurgent complaint or recurrent headache and a normal exam. We know this can be frustrating for families and referring providers. Seattle Children’s Neurology receives over 3,000 referrals/year to see new patients for evaluation of headaches. To reduce wait times, our aim is to partner with our colleagues in the community to get kids the care they need.
Patients with an urgent complaint or abnormal exam are triaged and will be seen in a clinically appropriate timeframe or possibly directed to the ED if there is an emergent concern. Please contact Seattle Children’s Neurology if you have urgent clinical concerns.
Q: What information can PCPs send with a referral?
Dr. Blume: When PCPs refer a child to Seattle Children’s Neurology for evaluation of headaches, we ask that they include:
- Particular concerns and the consult question/s.
- Copies of recent clinic notes, growth charts, labs results, imaging reports and relevant consult notes from previous providers (such as ophthalmology or a prior neurologist).
This helps us respond at the time of the first visit and begin a plan for evaluation and treatment without having to wait to obtain and review outside records.
Q: What can PCPs and families do for headache before the Neurology Clinic visit?
Dr. Blume: For kids with headache, it is important to do a thorough neurological exam in primary care at the time of referral.
If there are unexpected abnormalities on exam or papilledema, noted by PCP or an eye doctor, that child needs urgent evaluation. If, on exam in a PCP’s office, there is any question about whether the optic discs are sharp or if there are other fundoscopic abnormalities, getting a local eye exam from an ophthalmologist or optometrist is extremely helpful, as their tools are quite advanced and can help us direct that child’s care most appropriately.
While it can be time consuming, it is essential to get the complete history about headache (onset, frequency, characteristics, associated symptoms, aura, triggers, treatments, etc.), family history, medical history, medications, lifestyle factors and stressors.
It is most useful for the Neurology providers to hear that a patient is already working on (or better yet achieved) appropriate sleep, nutrition, hydration, stress management and exercise. In fact, often simply improving these factors will lead to a significant improvement in migraines and tension headaches and may eliminate the need for a Neurology consultation.
Q: What about treatment; what can PCPs do?
Dr. Blume: Reviewing appropriate treatment for acute headache is important; it is crucial to use acute medications like ibuprofen or acetaminophen in the appropriate doses as soon as the child knows it is going to be a severe headache. Waiting to take medications until the headache has been severe for hours or underdosing the medication will reduce the likelihood that the medications will be effective. However, avoidance of medication overuse should also be discussed.
Given how common migraine is in teens, many PCPs are comfortable with a trial of a triptan (such as rizatriptan, which has been approved for abortive therapy of migraine down to age 6 years of age) for teens with episodic migraine and/or a trial of supplements such as vitamin B2 or magnesium or prescription preventive medication for migraine. Any preventive migraine treatment that leads to significant side effects should be discontinued.
A referral for biofeedback may also be a good option. We have found that biofeedback therapy is effective for headache management and can be considered when secondary headaches have been excluded. We are fortunate to have a terrific Biofeedback Program here at Seattle Children’s Department of Adolescent Medicine, with providers in Seattle’s (Springbrook Professional Center) and Everett (North Clinic).
There are online resources from Seattle Children’s and elsewhere that can help patients and providers manage primary headache disorders:
- Patient and Family Education
- Headache Relief Guide for Teens, Parents and Providers
- Seattle Children’s Headache Guide: Headache Help for Your Child or Teen (PDF)
- Miles for Migraine – Finding a Cure for Migraine Begins With You
Q: What are some of the new options for headache management in pediatrics?
Dr. Blume: One change in the last few years is the approval of some neuromodulation devices for migraine treatment for use in adolescents. These are relatively easy to use and quite safe, so I hope that PCPs may begin to feel comfortable considering using these to manage migraines for their patients. Two of the devices we use most commonly in our practices at Seattle Children’s are remote electrical neuromodulation (Nerivio) and external trigeminal neurostimulation (Cefaly). REN has been approved for acute and preventive treatment of migraine for those 12 years old and up, has relatively few side effects and does not interact with other medications. While insurance coverage can be challenging, these are less expensive than many options. (Cefaly has coupon codes and a 90-day return option, Nerivio initial device is < $50 for 18 treatments in most cases.)
There are new migraine-specific medications like Emgality, Aimovig, Ajovy, Nurtec, Ubrelvy and Lasmiditan that have been approved for adults, and your patients have likely seen commercials for these treatments. Research trials of these medications are ongoing in pediatrics, and Seattle Children’s Hospital is a site for studies of lasmiditan (Reyvow), galcanezumab (Emgality) and rimegepant (Nurtec) for migraine management. However, for teens with intractable and disabling migraines, we are sometimes able to use these medications off label in appropriate circumstances.
The headache program at Seattle Children’s Hospital Neurology also has grown. We now have two terrific nurse practitioners, Joyce George, ARNP, at South Clinic and Katherine Slettvet, ARNP, at North Clinic who exclusively see patients with headache. For our established Neurology patients, we now are able to offer Botox treatment for chronic migraine, nerve blocks for acute intractable headaches, and infusion for acute migraine treatment. Dr. Hauser Chatterjee is developing a multidisciplinary specialty clinic with Ophthalmology and Dr. Tarczy-Hornochs for patients with established intracranial hypertension.
- Seattle Children's Headache Assessment (PDF)
- Seattle Children's Headache Algorithm (PDF)
- Seattle Children's Migraine Assessment (PDF)
- AAN Practice Guideline Update: Pharmacologic Treatment for Pediatric Migraine Prevention
- AAN Practice Guideline Update: Acute Treatment of Migraine in Children and Adolescents