Acute and Chronic Headache Management in Children and Teens

When child and adolescent patients complain to their parents about a headache, it can be anything from a plea to stay home from school in hopes of avoiding a test, to a sign of something more serious. Dr. Sharief Taraman, a pediatric neurologist at CHOC Children’s, offers advice to the referring community on acute and chronic headache management in children and teens, including headache hygiene, non-medical intervention options, and referral guidelines.

Dr. Sharief Taraman, a pediatric neurologist at CHOC Children’s

Types of headaches often seen in children and adolescents

Migraine symptoms in kids

  • At least 5 attacks that meet the following criteria:
  • Headache lasting 1 – 72 hours
  • Headache has at least two of the following features:
    • Pain on both side or one side of the head
    • Pain is pulsating
    • Moderate to severe intensity
    • Aggravated by routine physical activities
  • At least one of the following:
    • Nausea and/or vomiting
    • Sensitivity to light or noise
  • Chronic migraines are indicated by 15 headache days per month over a three-month period, and at least half of those are migraines.
  • About 1 out of every 20 kids, or about 8 million children in the United States, gets migraines. Before age 10, an equal number of boys and girls get migraines. But after age 12, during and after puberty, migraines affect girls three times more often than boys.

Tension headache symptoms in kids

  • Headache lasting from 30 minutes to seven days
  • Headache has at least two of the following characteristics:
    • Pain in two locations
    • Pressing or tightening feeling (not a pulsing pain)
    • Mild to moderate intensity
    • Not aggravated by routine physical activity such as walking or climbing stairs
  • No nausea or vomiting – many children experience a loss of appetite
  • Either sensitivity to light or sensitivity to sound
  • Tension headaches occur most often in children ages 9-12

Cluster headache symptoms in kids

  • At least five headaches that meet the following criteria:
    • Severe pain in one location: within the eye, above the eyebrow, or on the forehead, that lasts from 15 minutes to three hours when left untreated
  • Headache is accompanied by at least one of the following symptoms on the same side of the body as their headache:
    • Conjunctival injection and/or lacrimation
    • Nasal congestion and/or excess mucus in the nose
    • Eyelid swelling
    • Forehead and facial swelling
    • Droopy eyelid and/or small pupil
    • A restlessness or agitation
    • Cluster headaches usually start in children at around 10 years old

Post traumatic headache symptoms in kids

  • Acute post traumatic headache: lasts less than three months and caused by a traumatic injury to the head
  • Persistent post traumatic headache: lasts more than three months and caused by a traumatic injury to the head
  • Both acute and persistent headaches develop within one week of: the injury to the head, regaining of consciousness following injury to the head, or discontinuing medicine that impairs the ability to sense a headache following a head injury
  • Extended recovery risk factors:
    • Prolonged loss of consciousness or amnesia
    • Females
    • Initial symptom severity
    • Premorbid history of ADHD, mood disorders, and migraines

Sleep apnea headache symptoms in kids

  • Typically a morning headache
  • Pain is present on both sides of the head
  • Lasts more than four hours
  • Not accompanied by nausea, nor sensitivity to light or sound

Medication overuse headache symptoms in kids

  • Headaches on 15 or more days per month
  • Takes over-the-counter medication for headaches more than three times per week over a three-month period
  • Headache has developed or gotten worse during medication overuse
  • Pattern of headaches resolves or improves within two months after discontinuing the overused medication.

Remind parents of headache hygiene tips

There are a number of things parents can do to prevent headaches, says Dr. Taraman. Remind parents to practice headache hygiene:

Non-medical interventions

A variety of non-medical interventions can be helpful for children who are suffering from headaches, including ice packs; warm baths; taking a nap in a cool, dark room; neck and back massage; and taking a walk.

Medication as treatment for headaches in children

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, should be limited to no more than three days per week, with no more than two doses per day, in order to avoid medication overuse headaches.

Triptans are often used to treat moderate to severe migraines or cluster headaches, but should not be prescribed to patients with cardiovascular disease, uncontrolled hypertension, basilar migraine or hemiplegic migraine.

Encourage patients to keep a headache diary

Encourage your patients to keep a journal of their headaches so you can identify a pattern. Patients should keep track of:

  • Headache start date and time
  • What happened just before the headache?
  • How much did your head hurt, on a 0-10 pain scale?
  • Where did your head hurt?
  • What did you feel just before and during the headache?
  • What did you do to make yourself feel better?
  • Did you feel better, on a 0-10 pain scale?
  • Headache end date and time

When to refer cases of headaches to pediatric neurologists

Dr. Taraman offers the following guidelines on when to refer headaches to a pediatric neurologist for imaging:

  • Diagnosis of neurofibromatosis of tuberous sclerosis
  • Immunosuppressed child
  • If the child is awoken on a regular basis by headache pain or vomiting
  • Headaches beginning shortly after arising from bed in the morning (i.e., positional headache)
  • Syncope
  • Chronic progressive headaches
  • Persistently posterior headaches
  • Chronic headaches in patients less than 3-5 years old

When patients have a history of the following symptoms during headaches, Dr. Taraman offers the following guidelines on when to refer headaches for imaging and possible neurology consultation:

  • Double vision
  • Abnormal eye movements and/or nystagmus
  • Unilateral ptosis or complete 3rd nerve palsy
  • Motor or gait dysfunction or hemiplegia
  • Hemisensory disturbance
  • Confusion
  • Vertigo

CHOC is the only specialized imaging facility in Orange County just for children, and we only use board-certified pediatric radiologists and specially trained pediatric radiology technologists, nurses and child life specialists.

Parents should immediately be sent to the emergency room for headaches when:

There are some clear instances of severe headaches that warrant an immediate trip to the emergency room, says Dr. Taraman. These include:

  • Thunderclap headache: severe, sudden onset of pain that occurs anywhere in the head, and grabs your attention like a clap of thunder. Pain usually peaks within 60 seconds to a few minutes.
  • Any headache that comes with acute focal neurologic deficit.
  • Changes in vision due to papilledema, which can include blurred or double vision, flickering, or complete loss of vision.
  • If the child had a shunt placed for a condition such as hydrocephalus, and it becomes obstructed or infected, they can show symptoms of untreated hydrocephalus.

Learn more about the Neuroscience Institute at CHOC Children’s.

 

Longtime CHOC Pediatrician Retires

Dr. Michael Shannon can’t walk through the lobby of Sea View Pediatrics without at least one parent coming in for a hug.

After nearly 45 years in pediatric health care in Orange County, he’s earned more than a few fans – and the respect is mutual.

“Much of what a pediatrician learns is after training,” Dr. Shannon says.

Bring on the hugs though: At the end of this month, the 73-year-old will retire, completing a career that has spanned more than four decades and thousands of patients.

Born in Kansas, Dr. Shannon crisscrossed the country as a youth and young adult before ultimately attending medical school at Northwestern University in Illinois.

Dr. Shannon pursued a career in medicine following a childhood with frequent visits to doctor’s offices.

“I had bad allergies as a kid, an early tonsillectomy, a hernia at 7, appendicitis and asthma,” he says. “I was in the doctor’s office quite a bit. My parents seemed to like him, so I thought that would be a good thing to do.”

When it came to choosing his specialty, Dr. Shannon settled on pediatrics because he enjoyed children’s innocent natures.

“I always liked kids. Children don’t judge you, and their charts were really thin,” he says with a laugh.

When it came time to a residency and internship, Dr. Shannon and his wife, who’d long grown tired of cold Midwestern winters, headed west to California.

Ultimately, the pair settled in Orange County, where Dr. Shannon began a private pediatrics practice in July 1973. He practiced near Mission Hospital until 1995, when he joined Sea View Pediatrics, now a part of the CHOC Children’s Network.

Over more than four decades of practice, Dr. Shannon has treated thousands of Orange County children.

Steve Concialdi and Dr. Shannon

“I remember him being a cool doctor,” says Steve Concialdi, a patient of Dr. Shannon’s as a child and who is now a captain with the Orange County Fire Authority. “He was hip and he was fun.”

The doctor reached an icon status for a young Steve when he was about 10. He’d been battling a cold and his mother thought he should skip a school whale watching trip. After hearing Dr. Shannon’s opinion, mom Bonnie was swayed and Steve went on the trip.

“I went and I had a blast,” he says. “I ended up throwing up, but that’s because I got sea sick. But I just remember as little boy, what a cool doctor he was. We saw Dr. Shannon for years.”

And so, when Steve and his sister, Carrie, started their own families, Dr. Shannon was a clear choice for their children’s pediatrician – and Bonnie agreed.

“I told them, you’ve got to go to Dr. Shannon,” she said. “I wouldn’t stand for anyone else. I went to their first appointments too. I wanted to see Dr. Shannon because I missed him.”

The Concialdis are just one of many families in Orange County that have had generations of children see Dr. Shannon. The phenomenon is a testimony to Dr. Shannon’s long career and strong relationships with his patients and families.

Dr. Shannon with Gracie Concialdi at her first appointment; her father, Steve Concialdi; grandmother, Bonnie; and her brother, Andy Concialdi.

And that bond was never more evident than in March 2011, when he was seriously injured in a car accident. His patients and families – past and present – showed an outpouring of concern for him during a long recovery period.

The swell of support clarified for Dr. Shannon the impact his career had made on patients and families.

“The accident made me feel even more than ever before that I didn’t want anything happening to my babies,” he says of his patients.

And now, nearly seven years later, Dr. Shannon says he’s ready to hang up his stethoscope and entrust the care of his babies to the other Seaview physicians.

Dr. Shannon plans to spend his retirement traveling and focusing on his grandchildren. His future trips include travel to Louisville, Ky., to visit his daughter, Vanessa, and Ireland and Spain in 2018.

 

Dr. Heidi Stephany Joins CHOC Children’s Urology Team

CHOC Children’s urology program, ranked one of the nation’s best by U.S. News & World Report, has grown with the addition of Dr. Heidi Stephany.   A fellowship- trained pediatric specialist Dr. Stephany most recently served as assistant clinical director for the division of pediatric urology at Children’s Hospital of Pittsburgh of UPMC (University of Pittsburgh Medical Center), where she was also an assistant professor.

Dr. Heidi Stephany, pediatric urologist
Dr. Heidi Stephany

“The pediatric program at CHOC is a distinguished specialty with a solid reputation. I was drawn to work alongside such remarkable physicians, including Dr. Antoine Khoury, who is world-renowned in the field of pediatric urology,” says Dr. Stephany. “I was also attracted to the opportunity to help educate and train residents and fellows, in addition to working on challenging patient cases.”

Dr. Stephany’s clinical interests include complex reconstructive surgery, specifically hypospadias and disorders of sexual differentiation. Her clinical outcomes research is focused on voiding dysfunction.  She hopes to develop a combined urology/gastroenterology clinic for patients suffering from the condition.

A desire to solve problems and help others sparked, during her high school years, Dr. Stephany’s interest in surgery. After shadowing a urologist at the start of medical school, she knew urology—offering the perfect mix of medicine and surgery— was the specialty for her. She was intrigued by the wide array of complex issues and procedures within the specialty.

Working with children is particularly fulfilling for Dr. Stephany.

“In pediatrics, we have the opportunity to identify, address and achieve positive outcomes that will have a lasting impact on our patients’ lives,” she explains.

Since joining CHOC, Dr. Stephany has enjoyed immediate camaraderie with her colleagues and the team approach to care, which she says extends beyond her specialty and benefits patients. “It makes working here a truly fulfilling experience,” she adds.

Dr. Stephany is dedicated to treating patients like her own family members, and communicating complex issues in a compassionate way that is easily understood. She looks forward to becoming an integral part of the medical community in Southern California.

“I am excited to be here and want to be a resource for serving children in the area who need our care. I pride myself on being approachable and am eager to work collaboratively with local pediatricians,” says Dr. Stephany.

For physician referrals to Dr. Stephany, call 888-770-2462.

Five Tips to Help Doctors De-Stress

By Dr. Carla Weis

 As physicians, we put the health and well-being of others before our own.   The passion to help others is what inspired us to pursue the journey into modern medicine. Noble work? Absolutely. Work that justifies destroying our own physical health and perhaps soul? No.

Dr. Carla Weis, board-certified neonatologist and member of CHOC Children’s Specialists.

How can we truly serve others, if we don’t take care of ourselves? Put your own oxygen mask on first, right? For most healthcare professionals, this is easier said than done. But I ask you, how can we be fully present for our patients’ healing and provide them with the best possible outcomes, if we ignore our own spirit and soul?

The answer is quite simple: “Physician, health thyself.” How? First, examine yourself and how you live. It’s hard to take this first step, however, when we feel so much stress. In fact, we often accept stress as a way of life. It doesn’t have to be that way. Here are a few tips to find relief from stress.

  1. De-clutter

De-cluttering is often touted as an important step in de-stressing, and in fact, it is a huge part of facilitating a greater sense of inner peace. Make a commitment to yourself that over the course of several months you will get rid of all that stuff in your home that doesn’t add joy to your life.  Consider renting a large bin or dumpster, have it delivered to your driveway or the front of your house, and just start tossing stuff.  You’ll be amazed at how fast it fills up and how much of a difference there is in your sense of calmness and inner peace.  A good rule of thumb is to keep only what you need or love.  We keep so many things that are simply carrying an emotional attachment for us, but are unnecessary and drag us down on many levels.

I highly recommend reading The Life-Changing Magic of Tidying Up by Marie Kondo.

2.  Meditation

Meditation is one of those things we know would be good to do, and maybe even recommend it to our patients, but it will always hold the lowest position on our list of priorities. Why is that?  Well, we just don’t have the time, of course.  That’s the funny thing about meditating.  It takes time and that’s exactly what we don’t have enough of!

Years ago, I joined a gym and took advantage of the free consultation with a personal trainer. She asked me what my fitness goals were. I thought about how uncomfortable it was to do cardio and I wanted to be more comfortable with cardio.   I said, “I’d like to be more fit on a cardiovascular level.” She said, “Ok, add 20 minutes of cardio training to every workout.”

I was silently aghast. I didn’t say I wanted to do more cardio.  I just wanted to be better at it.  And so, I learned a very poignant lesson. The only way to become better or more comfortable at doing something is to do more of it.  If you would like to have more inner peace in your life, more quiet time, guess what? You must bring more inner peace and quiet time into your life.

Start with just five or 10 minutes a day. Find a time that works best for you.  For me, it’s first thing in the morning before I’m even really awake.  For others, it’s at night before sleep.  And for some, it’s both.  You choose.  Just set the timer on your phone and sit quietly with your eyes closed, focusing on your breath and relaxing your body with each breath.  Bring your attention to your body inwardly.  It’s useful to simply practice the art of noticing any distracting thoughts as they come in and then bringing your attention back to your breath and the present.  You may find that this is the best part of your day!

3. Love yourself more

We take care of others, but how good are we at taking care of ourselves? Pay attention to the inner dialogue within your mind as you go about your day.  Do you talk nicely to yourself?  Often, we speak quite harshly to ourselves and aren’t even aware of it.  Take moments during the day to be aware of your inner dialogue and then redirect the way you speak to yourself in your mind.  Re-train yourself to talk lovingly to and supportive of yourself.  Realize that the most important person to give and show your love to, is yourself.  From there, you will have so much more love to share with others. “Physician, heal thyself!”

4. Invest in a stress -reduction program

Invest in a stress reduction program. I highly recommend receiving a stress-reducing modality called a Life Activation, where you will receive a greater connection to your spirit within.

5. Bring spirituality into your life

What does this really mean? Are we talking about God?  Religion? A higher power?  Don’t we often think of spirituality as something for mystics and philosophy buffs to ponder?

Spirituality gets lumped into those areas of our lives that we’d love to pay more attention to at some point — when we have more time. When is that?  No doubt, life is busy.  But the truth about spirituality is that it’s part of who we are.  It’s not about worshipping a God in the sky or giving our power away to any religious figure.   Maybe it’s something we’ve allocated only to one day a week.  And, of course, as physicians, we often work on that day, so we get a pass from spirituality, right?

I suggest starting to explore what spirituality means to you. There’s no right answer and in fact, the answers are infinite!  Because we are infinite!

Dr. Carla Weis is a board-certified neonatologist and member of CHOC Children’s Specialists. She practices primarily in the neonatal intensive care unit at Hoag Hospital Newport Beach.  She received her medical degree from Temple University in Philadelphia, and completed her fellowship in neonatal-perinatal medicine at Children’s Hospital of Philadelphia (CHOP).  Her metaphysical/spiritual training has been with the Modern Mystery School, International.  Her primary focus is supporting healthcare workers to find balance in their lives, and guiding others to explore life concepts including and beyond the physical. 

Continue to follow the blog for more helpful tips from Dr. Weis.

Join Us for CHOC’s Inaugural Complex Feeding Disorders Conference, Jan. 19-20

Disordered feeding among children with food allergies and eosinophilic esophagitis; avoidant/restrictive food intake disorder; and motivational interviewing to improve parental learning are just some of the topics being covered at “Optimizing Feeding Outcomes – An Advanced Course in Managing Complex Pediatric Feeding Disorders,” hosted by CHOC Children’s on January 19-20, 2018, at the Newport Beach Marriott Resort.

The anticipated event, featuring CHOC’s multidisciplinary faculty and nationally recognized leaders, including Mitchell Katz, medical director, gastroenterology and CHOC’s Multidisciplinary Feeding Program, and keynote speaker Evan Kleiman, radio host of Good Food, is open to pediatricians, gastroenterologists, family practice physicians, nurse practitioners, nurses, occupational therapists, speech-language pathologists, clinical psychologists, licensed clinical social workers, registered dieticians, and others who care for children with feeding challenges.

CHOC Children's Multidisciplinary Feeding Program

“The conference is a great opportunity for us to share nationally and internationally our experience in assessing and treating children with complex feeding disorders,” Dr. Katz says. “We have a responsibility to our community to be educators, in addition to our roles as medical providers.”

CHOC’s Multidisciplinary Feeding Program — the only one of its kind on the West Coast — offers a positive, holistic approach to feeding disorders and receives referrals from throughout the country.

After the conference participants will be able to:

  • Follow suggested best practice model for treatment of pediatric feeding disorders and gastrostomy tube weaning.
  • Advocate for developing an effective multidisciplinary team to improve outcomes for children with feeding difficulties and gastrostomy tube dependence.
  • Apply specific behavioral feeding strategies to improve a child’s interaction with and intake of food.
  • Follow nutritional intervention strategies to improve nutrient balance, increase caloric intake and optimize growth and development of children with restrictive diets.
  • Coach parents on strategies and techniques to improve the parent‐child feeding relationship.

To register for Optimizing Feeding Outcomes – An Advanced Course in Managing Complex Pediatric Feeding Disorders visit CHOC’s website. Early bird fee registration deadline is Dec. 15.

This activity has been approved AMA PRA Category 1 Credit TM