Pediatric Primary Headache From A to Z

William T. Basco, Jr., MD, MS


June 24, 2015

In This Article

Treatment of Headache in Children

An important element in the management of pediatric headache is to demystify headaches. Children are not too young to have chronic headaches, and most headaches are not caused by a brain tumor, a patent foramen ovale, or video game-playing.

It is helpful to provide parents with some clear criteria for when they should seek urgent care, to prevent excessive urgent or emergency care use. The focus should be on functional impairment caused by the headache and not the reported pain level of headache.

Parents and patients must be given hope, and a therapeutic alliance should be formed. This can be done by using the in-office visits to frame the goals of therapy and help the patients and parents accept realistic goals, such as reducing the frequency of headache vs achieving a complete absence of headache.

Dr Gary Nelson prefaced his talk on the treatment of migraine by emphasizing that much of the research involves off-label use of medications for migraine, and the data for children are limited. A study by Lewis and colleagues[8] published in the journal Headache demonstrated a significant placebo response in the treatment of migraine in children—in the range of 50%-60% in many studies. These rates of placebo response are higher than those found in adult studies.

Home setting. Studies show that NSAIDs have a better response rate than acetaminophen,[9] but both acetaminophen and NSAIDs are appropriate for first-line treatment in the home setting. Appropriate second-line therapy in the home includes the triptans, two of which have pediatric approval (rizatriptan [Maxalt®] and almotriptan [Axert®]).

It is important to focus on adjunct treatments of migraine, particularly antiemetics, such as metoclopramide, ondansetron, or prochlorperazine. Not only do the antiemetics appear to treat nausea, but they may also mitigate other headache pathways.

Adjunct treatment with antihistamines can also be helpful; diphenhydramine has the most pediatric data. Although the data on antihistamines for migraine prevention or acute treatment are mixed,[10] Dr Nelson recommended antihistamines for both their antinausea effects and the potential that histamines may play a role in headache.

Emergency department setting. In the emergency department (ED), all three approaches can be used simultaneously (NSAIDs, antiemetics, and antihistamines), especially if the patient has not already tried combining all three approaches to break the headache episode. Intravenous hydration as an adjunct is highly recommended, and antiemetic treatment during acute migraine is important. Research shows that antiemetics alone are more effective than ketorolac.[11,12]

Combination therapy can affect multiple headache pathways, so combining all three approaches can help in the acute setting. The goal for the ED setting is to improve the patient's pain enough so that he or she can go home and sleep off the headache.

Hospital inpatient setting. If hospitalization is needed, the use of dihydroergotamine (DHE) is recommended.[13] Administration of this drug should be by protocol, accompanied by aggressive intravenous hydration. Typically, the drug is started with a test dose of 0.01 mg/kg, with a target dose of 0.02 mg/kg/dose (maximum dose 1 mg), given every 8 hours, for up to 20 doses.

Studies suggest administering DHE for five or six doses before deciding whether the patient has had a response. However, if the patient has not demonstrated a response by the fifth or sixth dose, DHE is less likely to work. Up to 75% of patients will eventually respond to this aggressive intravenous approach.[14]


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.