Headache is common among the pediatric population—so common that it affects up to 51 percent of children during their elementary school years.1 The more frequent or serious headaches only affect 17 percent of children, but these can impede a child’s daily activities and a family’s function. Among the more severe headache types is chronic daily headache (CDH), which affects 2 percent of children.
CDH is a daily or near-daily headache in which the headache is present for three months or longer, occurs at least 15 days a month, and lasts at least four hours per day. The more severe form occurs 24 hours a day, every day of the month. Girls tend to experience chronic headache more than boys, and it seems to increase with age.2
While it would be simpler to put a singular face on the condition, CDH comes in many forms. Holistic treatment that involves both traditional medications as well as lifestyle and dietary changes is necessary to keep a child in school and away from over-the-counter medications that can exacerbate the situation.
Characteristics of Chronic Daily Headache
CDH occurs in primarily four varieties:
- CDH can be a tension-type headache that’s evolved into a daily or near-daily problem, where migraine is not present.
- CDH can start as migraine and evolve into daily or near-daily tension-type headache accompanied by a few migraines a month. This is sometimes called CDH with episodic superimposed migraine, trans- formed migraine or mixed headache.
- One form of CDH is New Daily Persistent Headache, in which an infection or other trigger causes a child to awaken with their first headache one day and continue to experience that headache from that day forward.
- Post-concussion headache can turn into a chronic issue among children who had few or no headaches prior to the concussion.
For some children, CDH can be traced to an event such as a concussion or an infection. However, for most children, the reason for the new onset or long-time occurrence is still unknown.2
We do know that stress, inadequate sleep or diet, and medication overuse can play a role in exacerbating a headache condition. When a child with CDH misses an excessive amount of school (some have missed years of school) or overuses over-the-counter medications, this complicates the condition and diminishes the quality of life for both the children and their families. For one, overuse of over-the-counter medications can exacerbate a headache condition, turning a headache condition that might otherwise have been treatable into a chronic condition. With schooling, children may miss school because they are anxious or because parents are afraid to send their children to school with headaches. Unfortunately, this merely keeps children from their daily activities and does not address the root of the problem (the headaches or any underlying stress). It is best to keep children in their normal environments, keep them working on school-related activities and prepare them to manage their headaches in the real world. Headache specialists cannot truly help children with CDH unless the patient stops overusing over-the-counter medications and moves forward with school and daily activities.
Treating all Aspects of the Child’s Life
The treatment program for CDH should involve a holistic approach, addressing everything from lifestyle to diet. Medication is only part of the equation.
First, it should be noted that all teens have stress, and this might be especially prevalent among teens who put pressure on themselves to be straight-A students or the best in their activity. Many children also encounter stress at home or bullying from their peers. Because stress can trigger headache, it should be managed; a stress management program might incorporate cognitive behavioral therapy or biofeedback.
Other aspects of the child’s lifestyle should also be addressed. This includes ensuring the child receives eight hours of sleep each night, drinks six to eight glasses of water per day, has a routine eating schedule with no skipped meals, reduces over-the-counter medication usage to no more than two days per week, does cardio exercise three times a week for an hour each time, and returns to school. A specific diet may also be helpful. This should exclude food additives, caffeine, chocolate, lunch meat, aged cheese and MSG (which can be found in everything from Ramen noodles to Doritos).
Medication, Only Part of the Equation
Headache specialists typically prescribe both rescue medications and preventive treatments. Rescue medications can help the child abort a particularly severe headache or migraine. For CDH patients with tension- type headache and migraine, a headache specialist may advise the use of Zofran® (ondansetron), used for the treatment of nausea and vomiting. To help the child abort a severe attack, the medication can be combined with a cold compress, a quiet place to rest, Benadryl (diphenhydramine) to help the child sleep, and Aleve® (naproxen) to help with the pain (the dosage will depend on the child’s weight). This approach should not be used more than two days a week, to avoid medication overuse headache.
Preventive medication can also effectively reduce the number of headaches and can be prescribed based on comorbidities. For example, for anxious or depressed patients, Elavil® (amitriptyline) may be prescribed; for thin patients who have trouble sleeping, Periactin® (cyproheptadine) can be effective as it improves sleep and increases appetite; and for obese or overweight patients, Topamax® (topiramate) can both reduce the headaches and decrease appetite. Many physicians start treatment with a low dose and increase the dose slowly to avoid side effects and to find the lowest dose possible that benefits the child. Regardless of the dose, the child will probably need to use the medication for 6-8 weeks in order to see improvement.
Medications like propranolol (e.g., Inderal®) are used less frequently. Propranolol can cause depression or lower heart rates in teens, thereby reducing the teen’s ability to increase their heart rate to the level needed for competitive sports.
Complementary therapies can be effective in CDH patients, in addition to traditional treatments. Complementary therapies include biofeedback, cognitive behavioral therapy, acupuncture, yoga, and vitamins and minerals (e.g., magnesium, riboflavin, butterbur and coenzyme Q10). An inpatient rehabilitation program can also be beneficial for children who are missing excessive amounts of school and are overusing medication. Inpatient programs focus on treatment as well as teaching the child to cope with headaches and lead a normal life.
Today’s children are tomorrow’s adults. Preparing them now to manage daily headaches amid their circumstances and within their everyday environment will empower children to become productive adults who can advocate for their own health.
A. David Rothner, MD, is director of the Pediatric/ Adolescent Headache Program, chairman emeritus of Child Neurology at the Cleveland Clinic in Cleveland, and a member of the Head Wise editorial board.
References:
1. Lopez et al. “Pediatric Headache.” Medscape Reference. May 14, 2012.
2. Gladstein et al. “Chronic Daily Headache in Children and Adolescents.” Seminars in Pediatric Neurology. 2010;17(2):88-92.
