Pediatric neurologist Hannah Johnson Shapiro, MD, who specializes in care for children and adolescents with headache disorders, presents this practical guide to arriving at the correct diagnosis – primary condition? tension or migraine? – and savvy use of the numerous medications and other tools available to address frequent or severe headaches in the young. Here's help with ruling out serious underlying conditions, getting kids to describe their symptoms, selecting appropriate triptans, and incorporating effective non-pharmacological interventions. Shapiro also explains a stratified approach to care that accounts for the severity of an attack.
So, um, I am going to talk with you about pediatric headache disorders today. Um, I would like to start with these little drawings. So these drawings are actually from a manuscript that was published in pediatrics that asked children to draw what it feels like when they have a headache. And I think that this just shows how insightful kids are into their headache. And if you ask them the right questions, they really can give you good information about how they're feeling. I have no disclosures At the conclusion of this talk, learners should be able to diagnose common pediatric headache disorders, counsel effectively on lifestyle interventions, Help patients optimize their acute medications. Understand when and how to use preventive medications. And incorporate non-pharmacological interventions into a headache treatment plan. So why is this important? Headache is one of the most prevalent and disabling medical conditions, and migraines specifically affects 1 in 11 children. Headache contributes to missed school days, impaired school performance, and impaired quality of life. However, it's not all doom and gloom. About 2/3 of children will respond to the currently available therapies. And for primary care specifically, it's very important, uh, because primary care is often the first point of contact, and primary care can really influence outcomes. We know that patients who receive effective headache treatment earlier on tend to have better outcomes. So this is really um an area where you can make a big difference. For the remainder of the talk, I'm going to lay out a practical approach. So how do you approach a patient who comes to your clinic with the complaint of headache? So the first thing is to rule out secondary causes of headache. Then make a specific headache diagnosis. Then you'll formulate your headache treatment plan, which first starts with counseling on lifestyle interventions, prescribing acute treatment. Considering preventive treatment. And then finally to discuss non-pharmacological treatments. So now I'm going to go into each of these steps in much more detail. So the first is rule out secondary causes of headache. It's really important to ask about red and yellow flag symptoms when you're taking a headache history, and also to perform a good and thorough neurological exam, which includes a fundoscopic exam. So when you're taking the clinical history, if you identify these red flags, this would be, these would be reasons to send the patient to the emergency department. So if the patient describes a thunderclap headache, so that's a headache that goes from having no headache to very severe headache in less than 60 seconds, that can be a sign of subarachnoid hemorrhage or other secondary headache and would be a reason to send them to the ED if they have new onset intractable vomiting upon a. Awakening that can be a sign of increased intracranial pressure. If they have an abnormal neurological exam, so perhaps they have focality on exam, um, or if they have optic disc blurring on exam, on fundoscopic exam, those could be signs of increased intracranial pressure or other secondary causes of headache. And then, of course, if you're concerned for any other reason, so say they have other systemic Um, illnesses, say they are immunocompromised, um, or potentially have a history of cancer, those would be other reasons to, um, consider sending them to the emergency department. And then there's yellow flags. So these are things where you should consider getting imaging or consider referring to a specialist. So if the patient is younger than 6, oftentimes they have trouble describing their symptoms or aren't as reliable as, as historians. So consider imaging in those um patients. If there's new onset or change in the headache pattern, that can be concerning. So, say you have a patient who's never had any headache, and then they wake up and they have a headache that day, that's daily and continuous from onset, um, that can be a sign of new daily persistent headache or another secondary headache disorder, or if there's a change in pattern, so say they went from having, you know, a headache a couple of times a month, and it's got, it's getting progressively worse, and now it's daily, that can be a sign that something else is going on. If the headache is strictly sidelocked, so oftentimes in headache disorders, it'll switch between sides. So even if it's unilateral, it'll sometimes be on the right, sometimes be on the left. But if a patient tells you that it's always on the, on the same side, it's never been anywhere else, that can sometimes be a sign of other headache disorders like hemicrania continua, but it can also be a sign of um secondary headache disorders like mass lesion, um, in that area. If the headache is consistently waking a patient up from sleep, that can be a sign of increased intracranial pressure. It's important to ask them if the, it's the headache that's waking them from sleep or if it's just they're waking up overnight and then they realize they have a headache. It's more so if the headache itself is what's actually waking them up. Um, and then Valsalva-induced or positional headache can also be, um, signs of secondary headache disorders. So, Those would be reasons to consider getting imaging or considering referring to a child neurologist or headache specialist. So just a comment about imaging, most headaches in children are going to be benign. And in children who have brain tumors, less than 1% had headache as their only symptom. So most often, there's going to be an abnormal neurological exam. The American Headache Society came out with a statement that routine diagnostic studies are not indicated when the clinical history has no associated risk factors and the child's exam is normal. However, if you do identify those red or yellow flags in your history, the best test in most cases is going to be a brain MRI. OK. So once you've ruled out secondary causes of headache, the next thing to do is to make a specific headache diagnosis. So, when you think about headache, there's primary headache syndromes, and then there's secondary headache syndromes. So the secondary things are something else is causing the headache, brain tumor, increased pressure, other um things like that versus primary headache syndromes. There's nothing else is going on. It's just the way that the patient is. They have a primary headache disorder. Um, so the two that you're going to see most commonly in primary care clinic will be tension-type headache and migraine, and it's important to distinguish between these two because it does influence what treatments you'll use. There are some diagnostic challenges in distinguishing between these two primary headache disorders. The first is that you really do need to take a good headache history. Oftentimes, um, kids won't just offer up the information, you really have to ask them about specifics. And especially in migraine, the symptoms of migraine are actually a little bit different than what's in adults, and it, the symptoms can be a little bit less clear-cut. So, um, it's important to really ask a lot of the specific questions about what the headache feels like and what associated symptoms there are in order to distinguish between these two primary headache disorders. So the International Headache Society came out with something called the International Classification of Headache Disorders. This is an, it, it's available online, um, and it goes through diagnostic criteria for a number of different headache disorders. So these are the criteria for tension type headache. The duration can be between 30 minutes to 7 days. At least two of the following 4 characteristics are present. It's bilateral in location. There's a pressing or tightening quality to the headache. It's mild or moderate in intensity, not aggravated by routine physical activities such as walking or climbing stairs, and then both of the following, no nausea or vomiting, and no more than one of photophobia or phonophobia. And what you'll notice is that these criteria are pretty much the opposite of the criteria for migraines, so they're really designed to be able to distinguish between the two different types of headache disorders. So for migraine without aura, the ICHD diagnostic criteria are headache attacks lasting between 4 and 72 hours. Headache has at least two of the following four, unilateral in location, a pulsating quality, moderate or severe pain intensity, aggravation by or causing avoidance of routine physical activity, and then during the headache, at least one of the following associated symptoms, nausea and or vomiting, or photo and phonophobia. However, these criteria are designed for adults, so there are some important differences for your younger patients and your pediatric patients. So the duration tends to be shorter in kids, it can be um as little as 2 hours. And then the location is more often bilateral in kids. And oftentimes, you, the kids won't actually tell you about their associated symptoms, um, but you can infer it from their behavior. So they might not tell you that they feel nauseated, but they, you know, don't wanna eat when they have a headache, or they might not tell you they have photophobia, but they're always wearing their sunglasses when they have a headache. They might not tell you they have phonophobia, but they're always asking you to turn down the volume on the TV, things like that. And then migraine with aura. The aura tends to last between 5 and 60 minutes, and it's a very gradual onset, um, so it usually is, um, over like 5 minutes is the onset versus in some other neurological problems such as like seizure or stroke, the onset is very acute. Or it may occur before or during a headache, but it can also occur without headache. Visual aura is by far the most common, but may a kid may also have sensory aura, speech or language aura, or motor aura. Generalized blurry vision is actually quite common in migraine and does not always mean that it's aura. Oftentimes for visual aura, what kids will describe is, you know, in one half of the visual field, they'll notice a dark spot in their vision that kind of slowly expands over the course of 5 minutes. Um, and sometimes it can even expand over kind of a very large portion of the visual field. There's often uh flickering lights associated with visual aura or kind of jagged or zigzag lines associated with aura. And then the important thing to know about migraine with aura is that there is a slight increase in risk for ischemic stroke in um young women who have migraine with aura, so it is important to counsel on that. The main thing or the main time this comes up is when a patient is thinking about going on combined hormonal contraception, and they also have migraine with aura. So there's a couple of different recommendations. ACOG recommends um that, you know, you should not use combined hormonal contraception in young patients who have migraine with aura. The International Headache Society says that you can use low-dose estrogen in migraine with simple visual aura. So there's kind of two. Um, recommendations on that. In general, uh, when a patient is going to start on contraception, um, and they have migraine with aura, the general goal is that you wanna limit their stroke risk. So your best options will be non-hormonal IUD or a progestin-only form of contraception. If you have a patient who you have started on um an estrogen-containing um contraception, and they have new onset aura or their headache pattern dramatically changes, those would be reasons to stop the estrogen. So when you're trying to make these diagnoses of primary headache disorders, if there's ever an atypical or really unusual presentation, or if the diagnosis just is not clear, those would be reasons to refer to a child neurologist or headache specialist. OK. So, after you've made the diagnosis, the next thing to do is formulate your headache treatment plan. And so the first step in that is, no matter what the diagnosis is, will be to counsel on lifestyle interventions. From the, these next steps, these are for both tension headache and for migraine. And I'll highlight just a few differences where um the migraine treatment is a little bit different from tension um type headache treatment. OK. So for any type of um headache disorder, the first thing is the lifestyle interventions. We talk about SMART habits, which stands for sleep, meals, activity, relaxation, and trigger avoidance. So for sleep, you want to counsel on having a consistent bedtime, give the patient specific sleep duration goals based on their age, and to limit naps during the day. For meals, counsel on having regular meals, 3 meals plus a snack, and give them specific hydration goals. A good rule of thumb is whatever their weight is in kilograms, they should be drinking that amount of water in ounces. So if the patient weighs 40 kg, they should be drinking at least 40 ounces of water in a day. For activity, we recommend 30 minutes of aerobic exercise at least 4 days per week. We counsel them on maintaining a healthy weight. We know that being overweight or obese um can contribute to headache worsening and chronic headache, um, and then limit screen time. We always encourage relaxation techniques and encourage stress reduction strategies. And then trigger avoidance, if there are clear triggers, then of course, trying to limit those, and then using a headache diary to try to track some of the triggers can also be helpful. I like to give my patients this website, headache reliefguide.com, just gives a little bit more information um about the lifestyle recommendations for migraine and headache. So after you have talked to your patient about lifestyle interventions, the next thing to do is to prescribe acute treatment. So acute treatment is what you take when you get a headache. So, acute treatment for tension type headache is just going to be simple analgesics, whereas acute treatment for migraine is going to fall into these three categories, simple analgesics, triptans, and antiemetics. Triptans are migraine-specific, so we don't tend to use them in um tension headache. And then antiemetics, there is not nausea or vomiting associated with tension headaches, so we don't tend to use antiemetics for tension headache. Um, so, for simple analgesics, The first line is ibuprofen, so you can also use Tylenol and naproxen. I like to use naproxen in kids who either have to repeat their ibuprofen dose throughout the day or their headache recurs just because of the long half-life with naproxen. So for triptans, the American Academy of Neurology and the American Headache Society came out with guidelines on which triptans to use in pediatric patients. So these are the ones that they recommend in their guidelines. Um, so rizatriptan is the only one that's approved down to age 6. So if you have, um, a very young patient, I often will use rizatriptan. And then just they also recommend amitriptan, zolmatriptan, the the sumatriptan naproxen combo tab, and then sumatriptan nasal spray. Even though it's technically not FDA approved for use in pediatric patients, we do use uh sumatriptan quite frequently. There's also other formulations of these triptans that aren't in the guidelines that we use. So, the zolmatriptan also comes in an oral tablet. Sumatriptan also comes in an oral tablet and a subcutaneous injection. And then there's also naratriptan, frovatriptan, and alatriptan. So in pediatric headache, we actually use all of these triptans. And how do you actually choose between them? So the first is insurance coverage. Oftentimes insurance, insurances will want you to try sumatriptan first. So, um, I usually start with sumatriptan. Depends on what formulation. So some of the triptans, um, are nasal sprays or dissolvable tabs. So if the patient can't swallow pills, those are, um, good alternatives. And then it depends on the onset and duration of the specific medication. So the triptans have different characteristics. Some of them are fast onset, some of them are slower onset, some of them have longer half-lives than others. So when you're comparing the different triptans, those with faster onset will be the subcutaneous injections, the nasal sprays, and dissolving tabs. Those with a slower onset with a long half-life are naratriptan and frovatriptan. So those are good triptans um to use in uh menstrual migraine. And then the ones that tend to have the uh fewest side effects are amitriptan, naratriptan, and frovatriptan. So if you've had a patient have a lot of side effects to one of the other triptans, oftentimes switching to one of these can be um useful. So here's just a couple of situations, um, how to use triptans. So if you have rapid escalation of pain or significant nausea with the migraine, I like to use a nasal triptan. If the child is unable to swallow pills using dissolvable tabs or nasal sprays, if the headache recurs, use frovatriptan or naratriptan given their long half-life. And if the one triptan is not effective, you can try a different triptan because just because you didn't respond to one doesn't necessarily mean they won't respond to another, or have them pair it with an NSAID. If you do triptan plus an NSAID, you can get um a synergistic effect. A few tips on triptans. Counsel the patient to take their triptan when their headache starts. They're more effective when the head pain is still mild. They can repeat the dose in 2 hours if they either still have a headache or if their headache recurs. And it's important to counsel on side effects. Um, you, they can get tightness in their chest, neck, face, a feeling of hot, feeling hot or tingling, dizziness, nausea, fatigue. I usually tell my patients that, you know, if these things happen, it's not dangerous, but it is uncomfortable, it should go away in 10 to 20 minutes and to let me know so that we can switch their triptan to something um else. There are a few triptan contraindications. Most of these are more relevant in your adult patients. Um, but if there's significant cardiac disease, if there's uncontrolled hypertension, cerebrovascular disease, or in some of the more rare migraine subtypes such as hemiplegic migraine and migraine with brain stem aura, um, those are contraindications to using triptans. The American Headache Society came out with this position statement that talks about triptans and serotonin toxicity. So they say that the currently available evidence does not support limiting the use of triptans with SSRIs or SNRIs. So you can safely prescribe triptans in patients who are on those medications. OK. So, uh, the next class of acute medications is antiemetics. So this also, um, will be used for patients who have migraines. These are your options. Uh, prochlorperazine and metoclopramide are both dopamine antagonists. These are good for both headache. They have anti-headache and anti-migraine properties to them as well as nausea and vomiting. Um, and then ondansetron is good for nausea but doesn't have any impact on the head pain. Um, but it is very well tolerated without a lot of side effects, so it's another good option. Um, if I'm using prochlorperazine or metoclopramide, I do, uh, counsel on akesthesia as a side effect or the feeling of restlessness, um, as well as the possibility of a dystonic reaction, um, which is like tightness in the neck. And I will often prescribe, uh, diphenhydramine for the patient to take with, uh, chlorprazine or metoclopramide to, uh, try to minimize the risk of a dystonic reaction. Just a quick note on narcotics and barbiturates. These are not indicated for primary headache disorders. The ones that I see being prescribed most often are tramadol or butalbital, acetaminophen, caffeine combination pill, which is Fioricet. These are not superior to triptans or NSAIDs, and there's an increased risk of pain chronification as well as a risk of dependency. They also can contribute to medication overuse headache. So, we have other options. I would just avoid using the narcotic and barbiturate classes. So some uh tips on using acute treatment, treat the headache early in the, in the headache attack. Make sure you optimize the dose. So if a patient starts on sumatriptan 25 and they don't respond, bump them up to 50, bump them up to 100. Combine medications. So use NSAIDs with triptans or NSAIDs with um antiemetics, and then limit the use of acute medications to prevent medication overuse headache. This is most important for the triptan class, so limit them to no more than 9 days of triptan use in a month. Um, It's OK if they have a bad month and they, you know, use it 10 or 11 times. It's more, the risk is more if you're continually using it, you know, over 10 days in a month for many months in a row. And then NSAIDs and um acetaminophen, the risk of medication overuse is much lower. Um, the general recommendation is to try to limit them to no more than 15 days per month. But again, it's really the consistent use of that, that it becomes an issue. So if there's like a bad month and they need to use it 20 days, I think it's OK. It's really important to have good acute treatments because we know that treating acute attacks can prevent headache progression and chronification. So it's worth going through many different um acute treatment options to find the regimen that works best for your patient. It also allows them to get back to whatever their activities are that they wanna do, whether it's school or sports or other after-school activities. If they have something that reliably works, it really decreases the amount of disability associated with headache and migraine. So, when we think about how you treat an individual headache attack, there's kind of these two different ways to think about it. One is called stepwise care, and the other is stratified care. In stepwise care, it doesn't matter what the headache intensity is, no matter what the patient starts by taking an NSAID, and if they still have a headache. After an hour, then they take their triptan. If they still have a headache after an hour, then they take their antiemetic. However, that delays treatment. So the idea of stratified care is you tailor your treatment to what the individual attack is. So, for example, if you have a more mild headache attack, then they take their NSAID. If they have a moderate headache, um, or migraine attack, they take their triptan plus their NSAID, and if it's severe, they take their triptan plus their NSAID plus their antiemetic right from the beginning. And this allows them to get their acute medications, um, in much faster than if they were to kind of wait and do it more stepwise. It's important to work with the schools to ensure they have access to their medications and they can treat their headaches while they're at school. So this is called the migraine action plan. It's similar to what you might use for like an asthma action plan. It's broken down into these three zones, green, yellow, and red. Green is you're feeling good, um, you're doing all of your lifestyle interventions for headache, and then yellow is when you're starting to get a headache, and you can fill out what you want your patient to have access to, uh, when they're at school. Just a quick side note on migraine at school and really headache in general at school, we really encourage regular school attendance if at all possible. This allows for them to have social opportunities, um, as well as regularity in their schedule, which is super important for kids who have headache and migraine. However, they might need some accommodation, so we often will write letters um to the school just recommending um different accommodations that might be helpful. Some of the most common ones that we recommend are extra time for tests or assignments if they were to get a headache or migraine. When they are either taking the test or when their assignments are due, and also having access to their medications at school as well as access to a dark room where they can rest after they take their medication. And then the ideal is that they take their medication rest, and then they're able to return back to the classroom. OK. So now we're going to talk about when to consider preventive treatment. So preventive treatment you can use for both tension headache or for migraine. The data is pretty much all for migraine, and then we just extrapolate that and use it in tension headache if tension headache is um becoming more intense or they have a lot of disability associated with it. Um, so the principles on when to start preventive treatment is the same for both tension headache and migraine. So if the headache is impacting daily function or there's significant disability, if in general, there's 1-2 headaches per week, if their acute medication is ineffective, or if their acute medication is overused, those would all be reasons to consider starting preventive medication. Um, and that, of course, if the patient has a strong preference to start preventive medication, that's another indication. So how do you actually assess disability in your pediatric patients? I'd like to ask a series of questions. The first is how often do you miss school due to headache? I then always follow it up by asking how often do they miss activities that they really enjoy doing because of headache. So if somebody is a high-level hockey player and they're missing hockey practice multiple times a week, that gives me a lot more information than if they're just missing school, because there can be school avoidance for a lot of other reasons. And then similarly, I also ask if they get headaches on the weekends. So if they're frequently missing out on hanging out with their friends on the weekends because of their headaches, that also gives me a lot of information um beyond just the school question. This is a really important clinical trial that was published in the New England Journal of Medicine back in 2017. It's called the Childhood and Adolescent Migraine Prevention Trial or the CHAMP trial. It was a clinical trial that divided patients into three groups. The first group received amitriptyline for migraine prevention, the second group received topiramate for migraine prevention, and then the third group was a placebo group. And then this, um, the primary endpoint was at least a 50% reduction in headache days from baseline. Um, and so on this graph is showing you on the Y axis is the percent of patients who met that primary endpoint, and on the X axis are the three treatment groups, so amitriptyline, topiramate, and placebo. And what you can see from this graph is that there was no difference between the three treatment groups. Um, so, the number of patients who met the primary endpoint was the same. It didn't matter if they got amitriptyline, topiramate, or placebo. But it wasn't that nobody responded, it was actually that the placebo rate was really high. So over 60% of patients in the placebo arm um had at least a 50% reduction in their headache days. So, since this study was published, there's been a lot of um kind of thought about why there was no difference from placebo. And so there's a few kind of thoughts. One is that there were co-interventions present in this study. Um, so at every visit, there was headache education. There was avoidance of medication overuse, and there was optimization of acute medication types and dosings. Um, so what we now know from this trial is that with pill-taking behavior and headache education and optimization of acute medications, about 60% of your patients are going to get better. So does this change what we do? I would say yes. We definitely emphasize lifestyle interventions, um, we emphasize non-pharmacological interventions, um, as well, and we'll often try nutraceuticals first. So nutraceuticals are great. Um, they allow the patient to have that pill-taking behavior, and then there's a handful that do have evidence, um, in pediatric migraine. So, The one, here's a kind of list of the ones that we use most commonly, um, riboflavin, Extremely well tolerated, can change the urine to be a little bit of a brighter yellow, so I do talk to my patients about that. Magnesium is great. Um, it has some anti-headache properties, um, also well tolerated. Some of the forms can cause a little bit of diarrhea, so I usually switch them to a chelated form if they do have GI side effects. I like magnesium glycinate. Um, coenzyme Q10 doesn't really have any side effects, it's a little bit more expensive. And then melatonin, in addition to helping with sleep initiation, it actually also has some, um, anti-headache and anti-migraine properties as well. Um, so if the patient has, um, sleep issues, I often will do melatonin as my first nutraceutical. Um, if they don't have sleep problems, then I usually will go with one of the other ones like, uh, magnesium, for example. But all of these are Uh, good options, something that you can easily do in primary care, um, and they can really make a big difference. So if the patient um doesn't get enough benefit using nutraceutical medication, I then will step them up to prescription preventive medication. So, um, I use amitriptyline often. It can cause some drowsiness, dry eyes, dry mouth, constipation. Um, I counsel them to take it about 2 hours before bedtime. Topiramate tend to have a few more side effects. They can get paresthesias, decreased appetite, weight loss, some cognitive slowing, especially at the higher doses, and, uh, renal stones. Um, you also have to counsel on the reproductive risk. Propranolol is another medication we use, can cause some lightheadedness. It's relatively contraindicated um in asthma because of the risk of bronchospasm, um, as well as diabetes because it can mask hypoglycemia. And then cyproheptadine um can cause a little bit of drowsiness, increased appetite or weight gain, and it's going to be most useful in your younger patients, and I also give this one at least 2 hours before bedtime. So a few tips on prevention. It's important to set your expectations. So the goals are to decrease headache frequency, improve their response to acute medications, and an adequate trial is 6 to 8 weeks. So they really have to stay on the medication for it to work. And then prevention is not forever. Once you've received, once they've achieved good headache control for 3 to 6 months, you should start to wean the medications. And then in, in order to mitigate side effects, start at a really low dose and then titrate up. So how do you choose between these different options? The first is age, so if they are less than 10 years old, I often will do cyproheptadine. I also like to take advantage of side effects. So if a patient has poor sleep, I will often use amitriptyline. If they're anxious, I'll use propranolol. If they're overweight, I'll use topiramate. And then I have them keep a headache diary. Um, I like to have them keep it all the time, but especially if I'm starting a preventive medication that helps us keep track of if the medication is effective. Um, so this is an example of the headache diary that we use, um, in the UCSF headache program. Um, it allows them to keep track of, track of their headaches as well as what acute medications they're using. OK. So the last piece um of this is discussing non-pharmacological interventions. And again, these can be used for both um tension headache as well as migraine. So, cognitive behavioral therapy is an extremely beneficial therapy and intervention for headache. Um, cognitive behavioral therapy often will incorporate biofeedback and relaxation training, um, into it. It's really well supported by data. It's endorsed by the US Headache Consortium guidelines. Um, CBT has long-lasting benefits. It's effective at all life stages, and you can use it by itself or it can be combined with other therapies. So, this is a study that was published in JAMA, um, almost over 10 years ago now, back in 2013. Uh, this was a study that looked at doing amitriptyline. Um, by itself versus amitriptyline plus cognitive behavioral therapy in pediatric patients with migraine. So on the Y axis is headache frequency in days per month. On the X axis is time. The open circles is the control group. So those are patients who just did amitriptyline. And then treatment group, these dark circles are the patients who did amitriptyline plus cognitive behavioral therapy. So what you can see is that the patients who did CBT plus medication had a greater reduction in their headache frequency. So, it is a very well studied um intervention for pediatric migraine, um, and we extrapolate that again to, um, tension-type headache. So in addition to CBT, You can also recommend mindfulness or meditation, yoga, acupuncture, physical therapy. I really like physical therapy and tension type headache, especially if there's a lot of neck, um, tension, they can do head and neck therapy. Exercise is always um a good option as well. Um, and for exercise, oftentimes I'll recommend doing a graded exercise plan where, um, they slowly are building up their stamina. And then one of the biggest barriers to non-pharmacological interventions in cognitive behavioral therapy is finding a therapist who can do CBT um in children and adolescents, um, and also somebody, ideally somebody who's trained in doing pain. Um, so, I often will recommend patients use some apps just on their phone while they're waiting to identify a therapist. So a few um conclusions about treatment. The majority of patients will respond to lifestyle interventions, nutraceuticals, and aggressive acute treatment. I recommend picking 2 triptans, 2 nutraceuticals, and 1 prescription preventive medication that you feel comfortable prescribing. And of course, if a patient does not respond, refer to a specialist. So, a couple of comments on additional options with the specialist. So, you can refer to a general child neurologist who will be comfortable doing um additional oral preventive medications or other prescription preventive medications, and then some will be comfortable doing some of the more specialized treatments. A headache specialist, so if you refer to the headache center, um, we use novel therapeutics and procedures for our patients with headache. So CGRP stands for calcitonin gene-related peptide, and there's a new class of medications that were, um, approved, FDA approved for use in adults. The um CGRP pathway antagonist medications, there are both acute medications as well as preventive medications that target um CGRP and are used in migraine. So we've been using these off-label in the pediatric population, and they can be very, very effective. We also use on a botulinum toxin injections for chronic migraines. So it's a series of 31 injections um over the head, neck, and shoulders that can reduce migraine. We do nerve blocks which um over the greater occipital nerves in the back of the head, um, for different headache disorders, and then we also have access to different research studies. We also use neuromodulation devices. There are two big classes that are approved for use in adolescents. One is a remote electrical neuromodulation device, which looks like an armband, and it stimulates the pain fibers in the arm and competes with the pain signaling in the brain. It's a great non-medication, um, intervention for headache. And then there's also a non-invasive vagus nerve stimulator, um, that the, that patients can use for treating individual migraine attacks or for migraine prevention as well. All right, so just some take home points. Accurate diagnosis is key. This will help direct which treatments to use. You don't necessarily need to get neuroimaging in every headache. Always counsel on lifestyle, healthy lifestyle, and non-medication interventions. Use triptans, they're very, very effective. Try nutraceuticals for prevention. The majority of patients will respond and you can always refer if there's an unusual presentation, an unclear diagnosis, an abnormal exam, or imaging or concern for a secondary headache. My references and thank you for your attention, and I'll be happy to answer any questions if you want to put them into the Q&A.
