Sunday, February 14, 2016

Treatment of pediatric post-traumatic headaches

Kacperski J, Arthur T. Management of post-traumatic headaches in children and
adolescents. Headache. 2016 Jan;56(1):36-48.


Traumatic brain injuries (TBI) occur in an estimated 475,000 children aged 0-14 each year. Worldwide, mild traumatic brain injuries (mTBI) represent around 75-90% of all hospital admissions for TBI. mTBI are a common occurrence in children and adolescents, particularly in those involved in athletic activities. An estimated 1.6-3.8 million sports-related TBIs occur each year, including those for which no medical care is sought. Headache is a common occurrence following TBI, reported in as many as 86% of high school and college athletes who have suffered from head trauma. As most clinicians who manage concussion and post-traumatic headaches (PTHs) can attest, these headaches may be difficult to treat. There are currently no established guidelines for the treatment of PTHs, especially when persistent, and practices can vary widely from one clinician to the next. Making medical management more challenging, there are currently no randomized controlled trials evaluating the efficacy of therapies for PTHs in children and adolescents.

Treatment still consists of identifying the primary headache type that the PTH most closely resembles and using therapies found useful in that primary headache disorder. Headaches developing after head trauma closely resemble primary headache disorders, most commonly tension-type headache and migraine without aura, although some may be difficult to classify. ..

In the acute treatment of headaches, proper hydration (noncaffeinated fluids) is always attempted. Nonsteroidal anti-inflammatory medications are attempted no more than 3 days per week (maximum of 2 doses in the same day to avoid exceeding maximum daily doses and medication-overuse). If this initial attempt fails to abort a headache with migraine qualities, the use of triptans may be warranted. In general, triptans are well tolerated in children and can be used safely. To avoid overuse, triptans should be restricted to less than 9 days per month.

If outpatient therapy fails, initiation of IV therapy may benefit the patient, as suggested by 52% of pediatric patients who presented to an ED within 14 days of injury and had complete resolution of their headache when treated with various combinations of ketorolac alone, ketorolac and metoclopramide or prochlorperazine, or ondansetron only.  Considering a preventive medication is also appropriate if outpatient therapies fail. However, the use of preventives in a previously medication-na├»ve patient complicates the return to contact sports and activities, as the current opinion across several medical societies is that athletes should not be returned to contact activities until off of medications.  It is not clear that this applies to patients on a preventive prior to the injury...

Although headache is reported to be the most common symptom following concussion, there is a paucity of studies regarding the safety and efficacy of headache treatments for persistent PTH.  As most clinicians who manage concussion and PTH can attest, these headaches may be difficult to treat. There are currently no established guidelines for the treatment of PTH, especially when persistent, and practices can vary widely from one clinician to the next. Making medical management more challenging, there are currently no randomized controlled trials evaluating the efficacy of therapies for PTH in children and adolescents. Most algorithms proposed have been extrapolated from the primary headache literature and small noncontrolled trials of PTH..

 Of the 104 adolescent patients referred during the study period, 77 were identified as having persistent PTH. Fifty-four of 77 (70.1%) met criteria for probable medication-overuse headache and only simple analgesics were overused in this group. Thirty-seven patients (68.5%) had resolution of headaches or improvement to preconcussion headache patterns after discontinuing analgesics; 7 (13%) had no change in headaches or worsening of headaches after discontinuing analgesics and 10 (18.5%) did not discontinue analgesics or were lost to follow-up...

Specific treatments may include dopamine antagonists (including prochloperazine, chlorpromazine and metoclopramide) alone or in combination with NSAIDs (ketorolac or naproxen), ergotamines (DHE), antiepileptic agents (sodium valproate), corticosteroids (dexamethasone or methylprednisolone) and triptan medications. Although there have been no studies to date exploring these agents for the treatment of headache related to head trauma in the ED in the pediatric age group, studies have examined their use and efficacy in children presenting with an acute exacerbation of a primary headache...

Kuczynski et al reported on the use of melatonin in children with persistent PTH. Melatonin was started at 3 mg and increased to a maximum of 10 mg. It was found to improve headache frequency significantly in 9 out of 12 children (75%)...

Nonpharmacologic treatments such as behavioral and relaxation therapy, biofeedback and education on appropriate coping skills have demonstrated good evidence in children and adolescents with chronic headaches.   Treatment strategies are directed toward the various symptoms that persist, and may include school and activity modification, sleep regulation, and treatment for mood disorders. Therefore, a multidisciplinary approach is recommended to optimize outcomes.


  1. From the same author as the post:
    Kacperski J, Kabbouche MA, O'Brien HL, Weberding JL. The optimal management of headaches in children and adolescents. Ther Adv Neurol Disord. 2016 Jan;9(1):53-68.


    The recognition of the diagnosis of migraine in children is increasing. Early and aggressive treatment of migraine in this population with the use of over-the-counter medications has proven effective. The off-label use of many migraine-specific medications is often accepted in the absence of sufficient evidenced-based trials. Mild to severe cases of migraine should be treated with nonsteroidal anti-inflammatory drugs, with triptans used in moderate to severe headaches unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine [DHE] should be used for status migrainosus, preferably in the hospital setting. Antiemetics that have antidopaminergic properties can be helpful in patients with associated symptoms of nausea and vomiting through their action on central migraine generation. Furthermore, patients and families should be educated on nonpharmacologic management such as lifestyle modification and avoidance of triggers that can prevent episodic migraine.

  2. From the same author as the post:
    Green A, Kabbouche M, Kacperski J, Hershey A, O'Brien H. Managing Migraine Headaches in Children and Adolescents. Expert Rev Clin Pharmacol. 2016 Jan 29:1-6. [Epub ahead of print]


    The diagnosis and management of migraine headaches can be challenging in children and adolescents. The description of migraine in this population may include symptoms that are not typically described in adults. Treatment options for pediatric migraine is increasing, however remain limited. This article will go through the key components to diagnosing migraine in pediatric patients as well as give options for short and long-term management.