Chronic Daily Headaches in Adolescents Are Major Medical, Family Problem

By A. David Rothner, MD

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Headaches are common in adolescents, with 23 percent reporting weekly headaches. The most common headache types are episodic migraine and episodic tension-type headache. Headaches due to hydrocephalus, tumors and other mass lesions are less common and are associated with symptoms of increased intracranial pressure and an abnormal neurological examination.

Chronic Daily Headache at a Glance

Chronic daily headache (CDH) is diagnosed when headaches occur more than 15 days per month and last at least four hours per day. The frequency of CDH is 4 percent in adults, 2.4 percent in adolescent females and 0.8 percent in adolescent males.

At Cleveland Clinic, 30 percent of new consultations for adolescent headaches are due to CDH. CDH can consist of:

Tension-type headache
A combination of tension-type headache and migraine (also known as chronic migraine/transformed migraine)
New-onset daily persistent headache, in which the patient has not had previous headache and within 24 to 72 hours develops a persistent daily headache

Consultations involve a thorough history, general physical and detailed neurological exam. Common comorbidities are noted in Table 1.

Laboratory tests, MRI and EEG are usually normal. Patients with refractory headache also may be seen by other specialists (Table 2).

Excessive School Absences

Excessive school absences are noted in patients with refractory headache. A red flag is when more than 10 to 15 days of school are missed secondary to headache. Sometimes children who would miss a large number of school days due to headache in traditional settings are home-schooled or cyber-schooled instead; they should still be included in this category.

Medication Overuse, Sleep Disruption

Medication overuse in adults with refractory headache often includes barbiturates and narcotics. In adolescents, overused medications include NSAIDs, acetaminophen and over-the-counter (OTC) combinations containing aspirin and caffeine.

Using medications three days per week for longer than six weeks can cause medication overuse (rebound) headache. Complications of OTC medication overuse can include gastric irritation, GI bleeding, and hepatic and renal dysfunction.

Abnormal sleep hygiene perpetuates CDH. Problems include insomnia, multiple nocturnal awakenings, delayed sleep cycle and snoring with sleep apnea.

Treatment Protocol: Best Practices

Treatment of CDH takes weeks to months. Effective intervention requires a multidisciplinary approach (Table 2), and treatment is multifaceted:

Education of patients and parents/guardians is critical, and handouts are helpful. Patients and parents/guardians need to be reassured that a structural abnormality is not present once that possibility has been ruled out.

The role that stress can play in headaches needs to be discussed. Issues that may need to be addressed include family, friends and school, including extracurricular activities and bullying. The role of counseling should be discussed. The book Conquering Your Child’s Chronic Pain (see Suggested Reading) can serve as an excellent resource to guide parents/guardians in helping children with CDH.

Lifestyle issues follow. Eight hours of restorative sleep are needed. Adequate hydration, consisting of at least four to six 8-ounce glasses of water daily, is critical. Breakfast should not be skipped. An exercise program is initiated, as these patients typically are deconditioned.

Return to school full time is a must. In some patients, this is done gradually. A multidisciplinary approach involves patients, physicians, school personnel, parents/guardians, counselors and other therapists (Table 2). School should not be missed, as school absences perpetuate CDH.

Medication overuse, which occurs in up to 20 percent of patients with CDH, should be addressed. In adolescents, OTC medications are frequently used without parental knowledge.Medication overuse can cause transformation from episodic to chronic headaches. Risks of medication overuse are discussed with patients and parents/guardians. Medications may betapered or stopped “cold turkey.” Bridging this period with rescue and preventive medications is helpful. OTC medications should be used two days per week or less to avoid medication overuse headache.

Therapeutic medication includes rescue and/or prevention. Rescue should be used two days per week or less. At the onset of a “bad” headache, rest and a cold compress are used. Ondansetron, diphenhydramine and 10 mg/kg of an NSAID are given. Two hours later, if symptoms persist, diphenhydramine and 15 mg/kg of acetaminophen are given. If this regimen fails on three occasions, we add a triptan at onset and two hours later. If this fails and/or there are three or more headaches per week, we consider preventive medication (Table 3).

Preventive medications are helpful when patients are experiencing at least three days of headache per week or when rescue medications as described above are not helpful. We try to match the medication with the patient’s individual needs. If patients have trouble falling asleep, for example, we use cyproheptadine or amitriptyline. If patients are normal weight or underweight, we prescribe a medication that may cause some weight gain, such as cyproheptadine or amitriptyline. If patients are obese, we use topiramate, which may help in weight reduction. If anxiety and/or depression are present, amitriptyline may be the most useful. We always begin with very low dosages and increase them very slowly to tolerance and benefit.

The role of diet is controversial, but the parents and children with whom we work have found dietary interventions to be quite valuable (Table 4).

Inpatient Therapy

At Cleveland Clinic, patients with refractory CDH who do not respond to outpatient treatment are referred to our multidisciplinary three-week inpatient Pediatric Pain Rehabilitation Program, which has been accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). This program provides an effective model of care that focuses on independent functioning, improved coping, self-efficacy, and reduction of excessive school absences and medication overuse.

For patients who undergo treatment in Cleveland Clinic’s Pediatric Pain Rehabilitation Program, improvement in real-world indices of functioning have been shown at 24 to 36 months, including significant reductions in school days missed and parental workdays missed (Table 5).

Dr. Rothner is Chairman Emeritus of the Section of Child Neurology at Cleveland Clinic, where he has been a member of the faculty of the Departments of Pediatrics and Neurology since 1973. He is Director of the Pediatric/ Adolescent Headache Program.