March 18, 2022
On this week’s episode, Dr. Gabi Hester explores how to diagnose and manage headaches in children with Dr. Meghan Candee, associate professor of pediatric neurology and director of the Comprehensive Pediatric Headache Clinic at the University of Utah.
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota. Home to the kid experts, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric healthcare information as we partner with you in the care of your patients. Our guest, data, ideas and practical tips will surprise, challenge, and perhaps change how you care for kids. Welcome to Talking Pediatrics, I’m your host, Dr. Angela Kade Goepferd.
We have all taken care of kids with headaches, and surprisingly, migraine headaches are relatively common. About 10% of kids ages five to 15, and up to 30% of teenagers get them. On this week’s episode of Guidelines with Gabi, Dr. Gabi Hester explores how to diagnose and manage headaches in kids with Dr. Meghan Candee, associate professor of pediatric neurology and director of the Comprehensive Pediatric Headache Clinic at the University of Utah.
Welcome to Guidelines with Gabi.
Dr. Gabi Hester: Data would suggest that almost all of you listening to this podcast have had a headache in your life. By age 18, more than 90% of adults will report having had a headache, and about one in five kids four to 18 years of age, will have recurrent headaches each year. Headache is one of the most common contributors to days missed from school, work or activities. And symptoms can range from mild discomfort to full on laying on the floor in a dark office with the trash can by your head, hypothetically speaking of course.
So what actually causes headaches, and how can we help kids to minimize the impact they have on their lives? Today, I’ll be joined by Dr. Meghan Candee, associate professor of pediatric neurology and the director of the Comprehensive Pediatric Headache Clinic at the University of Utah. So Meghan, my first question for you is why? Why do humans go through these episodes where it feels like your brain is being squeezed in a vice? What is a headache, and what’s going on in there?
Dr. Meghan Candee: A headache is more than just pain in your head. It’s really the entire experience. Everything from the symptoms you have before the pain in your head starts, to the associated symptoms that you also have. Especially in children, the majority of headaches are migraine or tension headaches. And so by nature, there are many associated symptoms that we think of when we think of migraine.
Dr. Gabi Hester: Walk me through some of those symptoms, especially in kids. What are some of the other symptoms beyond the head pain that you might be seeing in your patients?
Dr. Meghan Candee: Things like nausea, vomiting, sensitivity to light and noise. And those are things that kids can’t always put into words. So those are things we infer by noticing when they go into the dark, or want everyone around them to be quiet, not always easy when there’s a busy family environment.
Dr. Gabi Hester: And when you’re meeting with families at your headache clinic and kind of talking through that with them about what a headache is, how do you explain it to a family that’s in front of you?
Dr. Meghan Candee: So I think one of the best ways is to talk about it as a hyperactive brain, so kind of like a highly sensitive smoke alarm that is alerting the person to something not right going on in the rest of the body or in the environment. And that can manifest as throbbing pain in the head, but also as those other associated symptoms we just mentioned.
Dr. Gabi Hester: So the American Academy of Neurology and the American Headache Society published a practice guideline in 2019 for the acute treatment of migraine in children and adolescents. What are some of the primary treatments that you would use, particularly for more severe headaches like migraines in young children?
Dr. Meghan Candee: Yeah, so the best things are those that are readily available, or have the fewest side effects, and are relatively inexpensive. And that largely in children, includes over-the-counter medication. Things like NSAIDs and Tylenol were our first line agents. And for many, that alone is effective when used in proper doses.
Dr. Gabi Hester: Beyond the dosing, is there any counseling that you give to families as far as the timing of those medications? Do they work better if you take them earlier, or take them with something else?
Dr. Meghan Candee: Definitely, the earlier on in the headache experience, the better off you’ll be in terms of getting some relief. I talk about if you see a pot on the stove and see that it’s on fire, do you walk into the next room and come back and check on it later, or do you try to put it out as soon as you can, and before it becomes a big kitchen fire? And I think that helps some families.
The reason for wanting to treat headaches sooner is that there are all these inflammatory chemicals that cascade and set off other chemicals. And so really, your best chance of stopping the headache in its tracks is the earliest on. And so if you can take medicines earlier, many families quickly realize that they have kind of a window of time during which if they treat the headache, they can keep it under control. Whereas, if they get past a certain point of no return, they know how that’s going to play out in terms of vomiting and prolonged discomfort.
Dr. Gabi Hester: Beyond the pain management, as you mentioned with acetaminophen or NSAIDs, are there any other supportive medications or treatments that you would recommend for some of those other symptoms, like the nausea and vomiting?
Dr. Meghan Candee: Kids are great, in that they’re really distractible too. And so some of the things that parents naturally use and have access to, things like hot or cold packs, not necessarily applied to the head, but applied to any part of your body to kind of distract you from pain, a great place to start. Antiemetics, things like Zofran are also really important and helpful.
Sometimes families will shy away from them thinking, “Oh, well, vomiting or nausea. They don’t really mention that, that’s not a big part of the experience.” But I do think that for some patients, if they take antiemetics early on, even sometimes before the ibuprofen, that they seem to perhaps absorb the other over-the-counter medicines better, and have better relief.
Dr. Gabi Hester: Now, what if some of those treatments don’t work, and that pain is really progressive and disabling for a patient, or their family, and their activities, what are some next steps that might happen?
Dr. Meghan Candee: So many parents I’ve found, have this notion that the only thing that will help them is if they go to the hospital, if they go to the emergency room. “My mother always got a shot for her migraine, or this is what we had to do.” And I think the hospital or even the doctor’s office is probably the last place you’d want to be if you had a headache or a migraine.
And so, really empowering families to treat headaches at home, and especially migraine at home is important, having a really good plan. So if you find that the first line agents, like the medicines we mentioned, ibuprofen and acetaminophen are not adequate to get a full response of a headache relief. Then the next thing we talk about most often are triptans. And those are things that can be prescribed by primary care doctors as well, once they’ve made the diagnosis of migraine and feel confident about it.
Like the over-the-counter medications, triptans also should not be used frequently. So all of the medicines, whether you’re using them in combination or not, should not be used more than two or three days a week. If you’re using them more often, then you might get into the cycle of medication overuse headache, where your body’s actually giving you a headache to remind you to take those medicines again.
Dr. Gabi Hester: Can you tell me a little bit more about triptans? How do they work, and what are some of the potential side effects that we’d want to watch out for?
Dr. Meghan Candee: Like all of the rescue medicines in headache, the full mechanism for how they work has probably not been fully elucidated. But we think it has to do with reducing that inflammatory cascade and reducing the inflammation, and the effect of inflammation in blood vessels and nerves on the trigeminal system, in terms of how we feel pain in our heads, that trigeminal vascular system or complex.
Dr. Gabi Hester: Meghan, when would you consider adding triptans into a medication regimen for a patient who’s having headaches?
Dr. Meghan Candee: I think about triptan use when over-the-counter medications have failed. I don’t think they’re helpful in people who have chronic daily headaches, so I don’t think it’s going to help break up a daily habit of headache. But I think when you’re a person who has episodic headaches, not more than a couple of times a week, that triptans can be really effective.
We’re fortunate in that some triptans are approved down to age six. So that one will include Rizatriptan. There’s an oral form and a melting tablet. I think a lot of people aren’t even aware that triptans are available for kids that young. And then there are many more, once you get to age 12 and up, when they come in all different forms, oral, melting, dissolvable, nasal sprays, injections. So depending on the associated symptoms that a patient experiences, oftentimes, we can find a triptan that won’t work for them.
If patients don’t have benefit from one triptan, it doesn’t necessarily mean that they’re not going to have benefit from another. So sometimes there is a bit of trial and error. Many parents feel as though because they have a triptan that they have found most effective, that, that’s going to be the same for their child. And so often we’ll try that, but it doesn’t always prove to be the case.
Dr. Gabi Hester: So Meghan, we talked a little bit about how triptans work, what would your sort of spiel or explanation be to a family as you’re initiating triptans?
Dr. Meghan Candee: So when over-the-counter medications like ibuprofen and acetaminophen are not effective, the next line of medicines that we think about that are specific for migraine is the category of medicines called triptans. Many families have heard of them because migraine is a genetic disorder, so many parents, or grandparents, or aunts and uncles have already experienced this, and have tried various triptans. So we’ll talk about that as the next layer or the next thing that we can try.
For many patients and family members, they notice that there are certain headaches for which they really need to use the triptan, and others that they can and keep at bay with an over-the-counter medicine. So over time, I really try to empower families to kind of figure out early on, can they tell if it’s going to be a milder headache or a tension headache, versus is this a migraine? Are you having all the other associate symptoms? And kind of talking about… So you might use a different rescue plan depending on the type of headache you’re experiencing at that time.
Parents are often much more inclined to use over-the-counter medicines, they’re wary of prescription medications for their child. But I think once they’ve given it a trial and see that perhaps their child’s headache is shorter or less severe, that they’re much more open to trying it.
Dr. Gabi Hester: It sounds like we have a lot of tools in our toolkit these days, which is great. To have some options, to be able to individualize, and sort of tailor to specific headaches for specific kids in a different situation. Are there any patients where we should avoid using triptans?
Dr. Meghan Candee: Fortunately in children, they have fewer complications most of the time, a shorter past medical history list. But certainly anyone who has coronary artery disease, cardiovascular disease, arrhythmias, those medicines, triptan should be avoided. And triptan specifically, most insurance companies will not give you more than eight or nine per month, which is kind of nice. So they really do help us to reduce the likelihood of medication overuse.
Dr. Gabi Hester: A few years ago, I noticed a really strange personal association where if I ate Brussels sprout, I would develop a horrific migraine, my N of 1. And Brussels sprouts are actually quite delicious when you cover them in oil. What is the deal with weird migraine triggers? Is this real, or is this just all in my head? Do people find specific triggers that can lead to migraines or headaches in them?
Dr. Meghan Candee: I think that’s another one of those old wives’ tales that everyone has the same trigger, or that everyone has an identifiable trigger. I think if people are fortunate enough to identify a trigger like you have, that’s great, because that you can avoid. And we encourage families and patients to try to identify those, to keep a headache diary. I think especially when headaches are infrequent, that can be valuable. So if you see that over time, they’re happening maybe once a quarter, and you notice that’s the day that you go to this one place, or eat this one food, then that’s really helpful.
Dr. Gabi Hester: Or eat your Brussels sprouts, yeah.
Dr. Meghan Candee: But like I said, with a lot of my patients, if you’re eating Rice Krispies every day, but you get a migraine once a quarter, it’s probably not the Rice Krispies, but it could be something else. So for some kids, if they can identify whether it’s a certain pizza sauce at a restaurant, or a certain candle at grandma’s house, or a certain smell, that’s great.
I would say a lot of people put pressure on themselves, or really feel that they haven’t done their due diligence if they haven’t identified their triggers. And I think that the majority of patients are not able to identify clear triggers. Migraine has a genetic ideology. It’s not something that we’re going to cure, but it’s something that we can certainly treat and manage.
Dr. Gabi Hester: What are your goals for treatment of people who suffer from recurrent migraines? Do you identify individual goals with each patient family, or how do you approach that?
Dr. Meghan Candee: My goal in our headache clinic, which is a comprehensive care clinic where we have behavioral health, and we have nurse educators, and I’m so fortunate to work in that setting. But our goals are to educate families about some of the things we’re talking about today. Things like this being a genetic diagnosis, that this is treatable. I aim to provide reassurance that there’s not something else scary going on, that this isn’t a secondary headache due to something else.
Reassuring that for the most part, imaging is not indicated, and we order very few imaging studies in our clinic. And then having clear plans for reducing the frequency of headache for the majority of patients, because unfortunately, many children suffer from chronic daily headache, or chronic migraine, or chronic tension headache. And then having a really good plan for when an episode occurs.
And I think being really proactive and empowering kids to know what they’re going to do when the next episode happens, and parents too, because many parents feel really helpless in that moment, that’s the key part. And so making sure families understand the plan when they leave.
Dr. Gabi Hester: You mentioned head imaging, and I know a lot of families might feel stressed or worried, could something else be going on when their child, particularly younger children get a headache? How do you go about that process of deciding who does need head imaging? And what recommendations would you have for outpatient providers of red flags to look out for?
Dr. Meghan Candee: Fortunately, there have been some really big studies looking at this. There have even been some studies where they did imaging really only to provide parental reassurance. And the findings were no different. The majority of children who have a normal exam, who have a family history of headache or migraine, and have had long standing headaches or migraine. And unfortunately that’s the case for a lot of people by the time they get to our clinic.
So if you kind of have all three of those criteria being met, imaging is not indicated. The reasons for which we do think about imaging include headache in a child less than three, who probably has been able to tell us much about what they’re experiencing. New changes in exam, so any change in gait, or concern for imbalance or incoordination, other new neurological signs. So changes in their vision, changes on an ophthalmologic exam. If you’re noticing any developmental regression, and certainly probably new seizures.
Sometimes, if there’s a positional or exertional component to the headaches, we’ll more strongly consider imaging, if the type of headache has changed over time, or severity has increased, those would be all the reasons. And so people presenting with those things are really, really rare. We very rarely feel the need to perform imaging.
Dr. Gabi Hester: What are some of the reasons that you would tell families why imaging should be avoided if it’s not indicated?
Dr. Meghan Candee: So for a lot of the young kids, especially eight and under, at where I work, you would need sedation to have the imaging performed. It’s common to find incidental findings on MRIs. So things like small cysts that we weren’t aware of, Chiari malformations, that can be new sources of anxiety, but don’t really change headache management.
And many young kids also have dental braces or other things inside their mouth that make the images not that useful. And also the cost. And you notice availability of access to MRI for patients who need it.
Dr. Gabi Hester: Are there any new treatments that are in the pipeline for headache management?
Dr. Meghan Candee: It is a really exciting time to be, in headache medicine, even in pediatric headache medicine. For the longest time, we really only had medicines that were kind of anecdotally noted to be beneficial for headache. So things like antiseizure medicines like Depakote, or beta blockers like Propranolol or tricyclic antidepressants like amitriptyline. And so we were kind of exploiting their side effects to try to get a benefit for headache.
And so now, we have medicines that are more specifically designed for headache, things like the CGRP modulators. So you’ve probably seen ads for those on TV. A lot of those are injectables given either monthly or quarterly. The downside of practicing headache medicine in pediatrics is that, a lot of the studies have not been done in children. So we’re still inferring a lot of the benefit, but that being said, we are seeing increased access to some of those medicines.
We still have to go through this process with insurance companies, of showing that those medications that I’ve already mentioned that we know are not effective, before we can get access to some of those newer things. Also, Botox injections, which are approved for chronic daily headache in adolescents and adults. So we kind of have to go through that process first before getting access, but we’re finding that we’re increasingly able to get access.
There are also non medicinal therapies available now. So we call those the neuromodulator devices, things like Cefaly, which is a transcutaneous super orbital neuro stimulation device, kind of looks a little bit like She-Ra or Wonder Woman headband, and then other trans magnetic stimulators. And there’s also a new one called Nerivio, that was just approved this year, which is worn on the arm, and is a vagal nerve stimulator operated by a remote. For a lot of families who are very wary of medicine, it’s exciting to have other options to show them. And we try to demonstrate some of those in our clinic.
Dr. Gabi Hester: Are those things that you would use in the midst of an active headache or are they preventative?
Dr. Meghan Candee: Both actually. So we find that if they use them kind of regularly over time, and then they can also be beneficial for rescue.
Dr. Gabi Hester: Do kids tolerate wearing them?
Dr. Meghan Candee: We found that some of our adolescents don’t even want to try them in the clinic because it might mess up their makeup. But for others, it’s really exciting, and they kind of think of it as a game. And I think for some, it’s a nice distraction.
Dr. Gabi Hester: So it sounds like there are some really cool strategies, especially in development of what to do once you get a headache. And some of that you’ve mentioned about preventing headache as far as some cool new technologies. Are there any just basic regular recommendations that you have for families, of how to try to prevent a headache cycle from starting in the first place?
Dr. Meghan Candee: Like most things in healthcare, prevention is the key. In kids and in headache medicine in general, we love this mnemonic called SMART, S-M-A-R-T. So that S is for sleep, M is for meals and hydration, A is for activity, R is for relaxation, and T is for triggers. So identifying triggers and having a good treatment plan.
So we always go back to that SMART and focus on those things. We spend so much of our time, all the providers in our clinic focusing on lifestyle modification. Some families are quite resistant, too, eagerly hoping that there’ll be some other magic pill or something else that they can blame. And we spend a lot of our time talking about decreasing electronics use. That’s been particularly hard in the setting of the pandemic, where many kids spent the entire last school year doing school in their bed, the laptop.
And so talking about even just having little breaks to get up and move around, ergonomics, making sure you’re not sitting in awkward positions for long periods of time. And then getting back into school has been hard for a lot of kids. The majority of the people that we see with chronic headache, have other comorbid issues, whether it’s mood dysregulation, poor sleep, and also learning disabilities that perhaps have not been identified or not being managed well. And so if we can kind of better treat those things, we find that people have a much better experience over time in terms of headache reduction.
Dr. Gabi Hester: Meghan, I know you have this wonderful Comprehensive Headache Management Clinic. And you mentioned having some of those support services as well, wrap around care with education, and nursing. In an environment where a provider might be a little bit more limited in their resources that they have for pediatric specialists. Are there any patients that you would prioritize for referral to a pediatric neurologist or a headache specialist?
Dr. Meghan Candee: I think if any primary care doctor is worried that there could be something else going on, I think that’s always, again, the secondary headache, and they don’t feel like they can confidently make that diagnosis of primary headache of migraine or tension, I think that’s a reasonable time to refer.
That being said, I think most primary care providers are really challenged time wise. And so maybe taking a different approach and saying that, okay, I might not be able to make the diagnosis and get into all of lifestyle modifications that need to be made, but maybe I can set up multiple visits over time, where we can kind of break this down further and look at things that could be contributing to headache perpetuation.
For many families, again, who feel like they’ve already tried different preventive medicines, that they’ve already made changes in their lifestyle, I think we’re able to… In our clinic, because we have multiple voices, and hopefully all bring forth the same information, but I think we present it in different ways.
And so I think families feel really validated, and perhaps the way in which one of us says it makes sense to them. And so over time, I think it’s been really helpful for a lot of families. We also have found that buy-in for cognitive behavioral therapy is much higher than it was before. Before we had this clinic, when we were just referring, we found that 0% of the people to whom we were referring to behavioral health were going. And so now every patient sees behavioral health at their first visit.
Dr. Gabi Hester: Wow.
Dr. Meghan Candee: So they’ve had some exposure to it. They understand that it’s not talking about your deep dark secrets or trudging up trauma, but it’s really about learning life skills. And I think families are much more open to that.
Dr. Gabi Hester: Anything else that you think you would want primary care providers to know about, that we haven’t covered yet today?
Dr. Meghan Candee: Even if you want to refer your patient to a headache clinic, I think setting them up for the things we will be talking about is really a good idea. So letting them know, hey, they might not order imaging either. They might talk about lifestyle modification, so are the things you can start changing now.
Have we optimized the school experience? Have we looked into learning disabilities? Have we made sure that the school’s carrying out the IEP? Or have we looked into a 504 Accommodation Plan for migraines, so that the patient can have access to medicines at school? Or maybe even take breaks to be in a quiet place before going back, so that they can stay at school and not be picked up?
Dr. Gabi Hester: Well, thank you so much, Meghan, for joining me today. I feel like I learned a lot that will help me care for my patients, and also a few tricks I may try myself as well. So thank you so much for your time.
Dr. Meghan Candee: Excellent. Thanks for having me.
Speaker 2: Take home points.
Dr. Gabi Hester: Number one, while routine neuroimaging is not recommended. Some patients may present with red flags, which would require a further workup. These red flags might include age less than three, an abnormal neurological exam, presence of seizures, developmental regression, or increase in severity of the headaches over time. Neuroimaging should also be considered in patients with positional or activity related changes in their headache.
Number two, when thinking about prevention of headache, remember the mnemonic SMART, sleep, meals or hydration, activity, relaxation, and trigger identification. A headache diary can be helpful in identifying some of these potential triggers.
Number three, when a headache occurs taking over-the-counter medications such as nonsteroidal anti-inflammatories or acetaminophen as early as possible, can help alleviate the symptoms for most patients. Number four, in patients who do not experience symptom resolution with over-the-counter medications, triptans should be considered as a next line of therapy, and are available for as young as six years of age.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Lexi Dingman is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.