PEDIATRIC HEADACHE

Introduction: Treatments for headache in children have been selected on the results of a few good quality comparative studies, but also by inference from case studies, etiological studies, and studies on chronic pain in children, and headache in adults. Methods: A literature search was carried out for all articles written in English from January 1999 to August 2004 detailing headache and migraine in children aged 0‐18 years. Results: Overall, the search revealed: Psychotherapy. Meta‐analysis shows psychotherapy to be efficacious for tension‐type headache and migraine. Refractive errors. Seven percent of adults with refractive errors have headache that is related to the refractive error. Children with chronic headache may benefit from spectacles. Diet. There is no clear relation between food substances and migraine in adults; extrapolating this finding to children seems logical. Caffeine. Caffeine in high quantities cause chronic daily headache in children. Caffeine‐withdrawal headache is mild and rare in adults. Caffeine in association with minor analgesics is more effective for the treatment of headache than analgesics alone. Sleep. Addressing poor sleep through routine improves migraine in children considerably. Medication‐dependent headache. About 1% of children have chronic daily headache associated with daily use of analgesics. No intervention trials were found. Cervical problems. Evidence for cervicogenic headache is minimal in adults and absent in children. Vertebral column trauma in childhood may be related to tension‐type headache in young adulthood. Prophylactic medication. β‐Blockers are safe and effective in children with migraine (Cochrane review). Other prophylactic drugs for children are discussed including flunarizine, tizanidine, amitriptyline, and the antiepileptic drugs, valproate and topiramate. Migraine attack medication. Although not extensively studied, NSAIDs and paracetamol appear to be effective for headache in children. Sumatriptan, zolmitriptan, and rizatriptan have been evaluated in clinical trials in 12 to 18 year olds. Evidence for the effectiveness of sumatriptan is robust; other triptans are not expected to be ineffective. In children aged less than 12 years, sumatriptan nasal spray is safe and effective. β‐Blockers, nonsteroidal anti‐inflammatory drug, paracetamol, and triptan nasal spray are believed to be the safe options for the primary care physician in children of 12 years or more. Conclusion: Evidence for the treatment of headache in children is weak. There is more emphasis on nonpharmacological treatment than on drugs, although both options appear to be applicable to children. Comments: A lot controversial here, but a well‐researched article, and so worthy of perusal and consideration.—Stewart J. Tepper, MD No mention here of acupuncture or electroacupuncture (ie, without needles). I am not aware of any published reviews of acupuncture relating to children. Might this be a fruitful area of inquiry in children?—David S. Millson, MD