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-thecounter 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 tensiontype 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, Benedryl ®( 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( see page 30). 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. HW
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.
www. headaches. org | National Headache Foundation 17