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Headache in Children

Chronic or recurrent headaches occur 75% of children by 15 years. The neurogenic hypothesis proposes that cortical neuronal depression is followed by dilation and inflammation.

Clinical evaluation

Headaches are characterized as isolated acute, recurrent acute, chronic nonprogressive, or chronic progressive. History should exclude renal, cardiac, sinus, or dental disease or previous head trauma.

Migraine

Migraines may be associated with a preceding aura, which usually involves visual phenomena. The headache is usually unilateral or bilateral, recurrent, throbbing, and associated with nausea or vomiting. Photophobia or phonophobia is common. Characteristically, the headache is relieved by sleep.

Management of acute episodes

Oral promethazine ( Phenergan), 1 mg/kg up to 25 mg, often results in sleep and is generally effective. Intramuscular chlorpromazine (Compazine),1 mg/kg, can be used for severe attacks.

Simple analgesics, such as acetaminophen, ibuprofen, or naproxen.

Sumatriptan (Imitrex), a selective 5-HT agonist, is an effective treatment for migraine. The subcutaneous dose of 6 mg is effective and safe in school-age children. Oral and intranasal sumatriptan spray.

Intravenous dihydroergotamine mesylate (DHE) is often effective when used with metoclopramide.

Treatment of Acute Migraine Episodes
Simple analgesics
Acetaminophen	Initial dose of 20 mg/kg PO, followed by 10 to 15 mg/kg q 4 h up to a maximum dose of 65 mg/kg per day (maximum, 3,000 mg/day)
Ibuprofen	1 to 12 years: 10 mg/kg PO q 4 to 6 h More than 12 years: 200 to 400 mg PO q 4 h; maximum dose 1,200 mg/day
Naproxen	5 mg/kg PO q 12 h; maximum dose 750 mg/day
Antiemetics
Promethazine	Initial dose of 1 mg/kg PO (maximum, 25 mg); can be repeated at doses of 0.25 to 1 mg/kg q 4 to 6 h
Metoclopramide	0.1 to 0.2 mg/kg PO (maximum, 10 mg)
Chlorpromazine	1 mg/kg IM for severe attacks
Other Drugs
Sumatriptan (Imitrex)	6 mg SC; may repeat in 1-2 hours; max 12 mg/day Oral: 25-50 mg PO once; may repeat in 2 hours Intranasal: 5, 10, or 20 mg in one nostril; may repeat after 2 hours
Dihydroergotamine mesylate	0.5 to 1 mg IV over 3 min in children >10 y. Can be repeated q8h. Used with metoclopramide.

Migraine prophylaxis. Migraine may be precipitated by stress, certain foods, lack of sleep, hormonal changes during the menstrual cycle, alcohol, and oral contraceptives. Elimination of these factors may reduce.