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.

 

Return to Learn Concussion Guidelines Every Medical Provider Should Know

While most medical providers are familiar with Return to Play laws – a step-wise progression addressing when student athletes with concussions should return to sports/physical activity – there is no similar legal process for “Return to Learn” guidelines addressing when students with concussions should return to school.

Further, a study in the December 2016 Pediatrics found that only a few states have Return to Learn concussion laws, and these varied in delineation of responsibility. Some of the laws were restricted to student athletes, excluding students who sustained non-sport related concussions.

Dr. Chris Koutures, pediatrician and sports medicine specialist at CHOC Children’s.

When returning a student to the classroom after a concussion, we try to balance stimulation levels and worsening of symptoms, explains Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC Children’s.  While too much cognitive exertion can lead to headaches, problems concentrating, fatigue and trouble with emotional control, over restriction from classroom and academic activities can result in social isolation and anxiety about falling behind or lower grades that can also slow the recovery process.

“Returning to the classroom after a concussion optimally takes a team approach including the student, family, medical and education teams,” Dr. Koutures says. “Flexibility and creativity in paying attention to individual student needs and concerns can make this process more rewarding for all parties.”

Dr. Koutures advises the patient’s care team to follow CHOC’s recommended six stages for returning a student to school after a concussion, including the following added guidelines:

Step-wise Return to Learn Progression

Step 1: No formal academic activity

  • Recent studies suggest that full or prolonged limitations in cognitive activity may actually delay recovery
  • In first few days after concussion, allow 15-20 minute intervals of single-task activities that do not provoke symptoms and are not excessively taxing
    • Listen to light music
    • Draw or color
    • Journal writing
    • Audiobooks
    • Passive television or movies (at home), larger screen preferred, lower volume
    • Some texting, smartphone use; want to balance maintaining key social contacts with not having symptom-flare
    • Conversations with 1-2 other people
  • Separate the 15-20 minute bursts of activity by 30-40 minutes minimum of non-cognitive activity
  • If symptoms flare before 15-20 minute limit, stop activity and try again later
  • If patient can handle 2-3 periods of 15-20 minute activity over the course of day, can consider advancing toward partial return to school

Step 2: Light academic activity

  • Attend 1-2 periods or 1-2 hours of school
  • Select consecutive classes; have child help make decision
  • No physical education or other activity classes
    • Caution with more noisy classes such as woodshop, music/band, chorus
  • Tend to avoid first class in morning to allow more sleep and arrival at school without busy parking lot and hallways
  • Main goal: be in class; no responsibility for note-taking, participating in class /responding to teacher, in-class work, homework or testing
    • Audible learning (most kids handle this better than visual learning after a concussion)
    • Should have pre-printed notes for reference or have others take notes and share
  • Sit away from louder students, windows, projectors, or other light/noise stimulation
  • Sit close to teacher
  • Allow to wear earplugs and sunglasses as needed
  • May allow brief 1-2 minute periods of putting head on desk for rest
  • May leave class early to avoid the noise and commotion of hallways during passing periods

Step 3: Increased academic activity

  • Expand day to 3-4 periods or hours per day
  • Incorporate break periods (nutrition break, lunch)
    • Have quiet place to rest
  • Recommend against assemblies or rallies due to noise stimulation
  • Continue to avoid physical education or activity classes
  • Main goal is to be in class and handle longer day; still not responsible for note-taking, participating in class/responding to teacher, in-class work or homework

Step 4: Full-time attendance

  • Full-day attendance without activity or other higher-stimulation classes
  • May expect some increased fatigue at end of school day
    • If student wants to nap after school, limit to no more than one hour
  • May start to take own notes, though helpful to have pre-printed teacher’s notes or other student notes
  • Incorporate “to do” lists with short-block (10-15 minute) work periods followed by short (5 minute) breaks
  • Break period and breaks in class (especially if block schedule) may still be needed
  • If possible, move most challenging courses to time of day when student feels the best

Step 5: Return to Majority of Academic Activities

  • Once handling full day attendance, can resume taking notes in class, verbal responses to teacher, and in-class work
  • May begin homework starting with limits to 30-60 minutes a night and priority on essential concepts that are needed for eventual testing or continuity of learning
    • Waive any projects, papers, essays or other assignments that are not required for future learning needs
    • Try to limit burden of make-up work; focus should be on those assignments that are necessary for future learning
      • Sequential classes (math, foreign languages, science) tend to be the most challenging for make-up work
    • No tests or quizzes at this stage
    • Audible learning – listen/speak responses vs. writing, dictating work, audiobooks may be more favorable at this point

Step 6: Return to Full Academic Activity

  • Full-day attendance without symptoms, fulfilling all in-class duties and completing usual homework assignments
  • Can resume tests and quizzes
    • Strongly consider waiving missed tests or quizzes
    • Combine missed tests or quizzes to allow more quick completion of make-up work
    • Allow student to take missed tests/quizzes to gain exposure/mastery of material without being graded, or only receive grade if results are in usual level of achievement
    • Assign grades at end of grading period based on level of work prior to concussion
  • May need more time for test completion
  • May need individual room placement for testing
  • May limit testing/make-up testing to one test per day
  • May allow open book, use of notes, word banks or home-based testing
  • Consider alternate forms of testing such as spoken test, or multiple choice vs. longer essay responses that might be more taxing for the student
  • Students may still benefit from more audio learning
  • Can resume physical education (with physician release) and activity courses.

To contact Dr. Chris Koutures, please call 714-974-2220.

Learn more about CHOC’s concussion program.

Infantile Spasms: What Pediatricians Should Know

Though seizures in children are always worrisome, pediatricians should be especially watchful for infantile spasms, a type of epilepsy that occurs in young infants typically between ages 3 and 8 months, a CHOC Children’s neurologist says.

These seizures should be considered a medical emergency due to the potentially devastating consequences on the developing brain, Dr. Mary Zupanc says. Many children with infantile spasms go on to develop other forms of epilepsy because a developing brain undergoing an epileptic storm essentially becomes programmed for ongoing seizures and cognitive/motor delays.

To that end, here’s what pediatricians should look for:

  • Infantile spasms often occur in clusters, with each spasm occurring every five to 10 seconds over a period of minutes ranging from three to 10 minutes or longer.
  • Though there is almost always a cluster of spasms in the morning when the child awakens from sleep, infantile spasms can occur at any time during the day or night.

Infantile spasms can be easily missed because they can mimic common symptoms and conditions such as sleep disturbances, gastroesophageal reflux, startle and shuddering attacks.

Diagnosis, treatment

If infantile spasms are suspected, a pediatrician should quickly refer the child to a pediatric neurologist. CHOC neurologists admit these children urgently for long-term video electroencephalogram (EEG) monitoring to confirm the diagnosis.

Infantile spasms are diagnosed on the basis of clinical spasms, in association with a markedly abnormal EEG showing a hypsarrhythmia pattern. A hypsarrhythmia pattern is characterized by very high amplitude electrical activity and multifocal areas of the brain demonstrating epileptic discharges.

High-dose adrenocorticotropic hormone, or ACTH, is CHOC neurologists’ first line of treatment for infantile spasms, per the American Academy of Neurology’s 2004 practice parameter. Vigabatrin (Sabril), the parameter states, is probably effective in the treatment of infantile spasms, especially in children with tuberous sclerosis and infantile spasms.

If started within four to six weeks of seizure onset therapy has better success at stopping spasms, eliminating the hypsarrhythmia pattern and improving developmental outcomes regardless of etiology.

The course of treatment is approximately six weeks. During this time, and for two to three months after the ACTH course, immunizations should not be administered. The effectiveness of ACTH may be as high as 85 percent, though a recent published study placed the efficacy at a slightly lower percentage, regardless of etiology.

Side effects, causes

Side effects of ACTH, a steroid, include high blood pressure, increased appetite and weight gain, increased sugar in the blood, temporary suppression of the immune system, and sometimes gastritis. All side effects are monitored during the time of the ACTH, and they disappear after the course of treatment.

Successful therapy is marked by two achievements: the cessation of the infantile spasms and the elimination of the hypsarrhythmia pattern. But because clinical spasms can be very subtle and the hypsarrhythmia pattern may sometimes only be seen during deep sleep, therapy’s success can only be confirmed through objective long-term video EEG monitoring.

The etiologies for infantile spasms can include:  tuberous sclerosis; cortical dysplasias; stroke; infection including meningitis and encephalitis; hypoxic-ischemic injury; trauma; or genetic conditions such as Down syndrome and metabolic disorders.

 

ROSA Robot Assists in CHOC Patient’s Successful Epilepsy Surgery

Five-year-old Ian Higginbotham recently enjoyed his best summer yet.  He experienced his first family vacation. He learned to swim and ride a bike. He got himself ready for kindergarten.  These are milestones most kids and parents, alike, eagerly welcome.  But there was a time when Ian’s parents weren’t certain their son, who was born seemingly healthy, would enjoy such happy pastimes.

Ian began talking and walking in his sleep as a toddler.  When the episodes, including night terrors, increased in frequency and severity, his mom Lisa made an appointment with the pediatrician.  One day, Lisa knew something just wasn’t right and didn’t want to wait for the appointment to get Ian checked out.  She and her husband Derek took him to the Julia and George Argyros Emergency Department at CHOC Children’s Hospital.  To her surprise, doctors diagnosed her son with epilepsy.    Ian’s “sleepwalking” and “night terrors” were actually seizures.

The family was referred to CHOC’s comprehensive epilepsy program.  A national leader in pediatric epilepsy care, CHOC’s comprehensive epilepsy program offers cutting-edge diagnostics, innovative medical approaches and advanced surgical interventions.  CHOC was the first children’s hospital in the state to be named a Level 4 epilepsy center by the National Association of Epilepsy Centers, signifying the highest-level medical and surgical evaluation and treatment for patients with complex epilepsy.

CHOC Children's

Ian’s neurologist Dr. Andrew Mower suspected he was experiencing complex partial seizures, which was confirmed by video EEG monitoring.  Complex partial seizures start in a small area of the temporal or frontal lobe of the brain, and quickly involve the areas of the brain affecting alertness and awareness.  The pattern of Ian’s seizures suggested they were originating from the right frontal lobe.  Dr. Mower knew Ian and his family were in for a tough journey.

“I really don’t think the general public understands the impact epilepsy has on a child and his family.  Its effects are multifaceted and extensive.  Our team’s goal is to reduce or eliminate our patients’ seizures, helping improve their quality of life,” explains Dr. Mower, who placed Ian on a series of medications.

The medications reduced Ian’s seizures, but did not control them.  Dr. Mower was concerned about the seizures affecting Ian’s development, and presented his case to the epilepsy team.   The multidisciplinary team agreed Ian was a candidate for epilepsy surgery.  For children who fail at least two medications, surgery may be considered early in treatment versus as a last resort.  Surgery can result in an improvement in seizure control, quality of life, and prevent permanent brain damage.  Ian’s surgery was going to be performed by CHOC neurosurgeon Dr. Joffre Olaya.

While the thought of surgery was frightening to Lisa and her husband, they were confident in the team and comforted to know their son was going to benefit from innovative technology, like the ROSA™ Robot. Considered one of the most advanced robotized surgical assistants, ROSA includes a computer system and a robotic arm.  The computer system offers 3D brain mapping to aid surgeons in locating the exact areas they need to reach and planning the best surgical paths.  The robotic arm is a minimally invasive surgical tool that improves accuracy and significantly reduces surgery/anesthesia time.

Dr. Olaya used ROSA to accurately place electrodes in the area of Ian’s brain suspected to be the source of his seizures.  By using the robot, Dr. Olaya avoided performing a craniotomy.

“ROSA is an amazing tool that yields many benefits for our patients, including less time under anesthesia in the operating room.  It reduces blood loss and risk of infections.  Patients tend to recover faster than they would if they had craniotomy,” says Dr. Olaya.

Lisa was amazed at the outcome. “I couldn’t believe how great Ian looked after the placements of the electrodes with ROSA.  He wasn’t in any pain, there was no swelling.  It was wonderful!”

She and her husband were also amazed at how well Ian did following his epilepsy surgery.

“We got our boy back,” says Lisa. “There were no more side effects from medication and, more importantly, no more seizures!  He started developing again and doing all the things a child his age should do.”

Ian’s care team isn’t surprised by his recovery.

“Children are resilient, and their brains are no different.  In fact, the plasticity of a young brain allows it to adapt to changes and heal more easily than an adult brain,” explains Dr. Mower.

Learning to ride a bike and swim were among the first of many milestones Ian quickly reached following surgery.  He enjoys playing with his younger brother and his friends.  And, whether inspired by his experience with ROSA or not, Ian loves robots.

Meet Dr. Anjalee Warrier Galion

CHOC Children’s wants its referring physicians to get to know its specialists. Today, meet Dr. Anjalee Galion, a pediatric neurologist and sleep specialist.

CHOC Children's

Q: What is your education and training?
A:  I attended the University of Medicine and Dentistry of New Jersey- New Jersey Medical School, and completed my residency in pediatrics at University of San Francisco, Fresno.  During my academic year, I worked for Walter Reed Army Institute of Research to help identify a vaccine for malaria. My second day was September 11, 2011, and it was an amazing, humbling, and scary experience to be a part of the military for this day. My first fellowship was in pediatric neurology at the University of California, Irvine (UC Irvine), and my second fellowship was in sleep medicine at the University of California Los Angeles- Cedars Sinai Sleep Medicine Fellowship.

Q: What are your administrative appointments?
A: Assistant clinical professor at UC Irvine, assistant program director for the UC Irvine child neurology residency program, chair of the junior faculty leadership council, and co-chair of the sleep workgroup for the National Autism Treatment Network.

Q: What are your special clinical interests?
A: Sleep disorders in children with neurologic diseases such as epilepsy and autism, as well as sleep and cognition.

Q: Are you involved in any current research?

A: Evaluation of efficacy of specific sedative hypnotics in children with Autism spectrum disorder, and Identification of sleep architecture and pathology in children with epilepsy.

Q: How long have you been on staff at CHOC?
A: Four years.

Q: What are some new programs or developments within your specialty?
A: CHOC is one of the few, if only, hospitals in the country doing combined long-term video EEG as well as polysomnography (sleep study).  This allows us a very unique opportunity to look at the brain activity and pathology in sleep. Multidisciplinary sleep clinics involving psychology and pulmonology are also unique. Also, identification and treatment of a variety of pediatric sleep disorders including all types of insomnia, narcolepsy and parasomnias, such as sleepwalking/sleep talking/night terrors.

Q: What are your most common diagnoses?
A: Insomnia, narcolepsy, sleepwalking (or somnambulism).

Q: What would you most like community/referring providers to know about you or your division at CHOC?
A: We treat all types of sleep-related disorders and are providing state-of-the-art care for children with sleep disorders. It is estimated that more than 30 percent of children have sleep-related disorders, and improvement in sleep is essential for learning and cognition. Research suggests improved sleep supports optimal athletic performance as well. If there is any concern for a sleep-related disorder we are happy to help evaluate these children.

Q:  What inspires you most about the care being delivered here at CHOC?
A: We treat every child with the highest level of care and the physicians genuinely care for the patients and our community.

Q: Why did you decide to become a doctor?
A: I had been interested in neuroscience since I was a Howard Hughes fellow at the University of Maryland, having done work in spinal cord regeneration. I heard a talk in my first year of medical school about pediatric neurology and haven’t looked back since.

Q: If you weren’t a physician, what would you be and why?
A: If I was not a physician I would mostly likely be a PhD working in the field of neurobiology and sleep medicine. Both my parents were PhDs and I grew up hearing about fascinating advances in the world of science, so I have been drawn to science and research from a young age. For quite a few years I was strongly considering becoming a professional flute player. I was fortunate enough to travel through Italy with my youth symphony and performed around the country in orchestras, but science drew me in by the time I was in college.

Q: What are your hobbies/interests outside of work?
A: I enjoy hosting parties and events for family and friends. Our family enjoys traveling and spending time together.

Q: What have you learned from your patients?
A: The best part about working with pediatric patients is that you are constantly reminded to enjoy life and be grateful for every day. The smallest things can make a child happy, like playing with a light-up toy or seeing bubbles, and it is a great reminder to take pleasure in all the simple things around us every day.