Treating Chronic Daily Headache

Q. My child has missed so many days of school due to headaches that it's affecting her grades and she's missing out on after-school activities. I'm starting to really worry. What should we do?

A. Headaches are common in children and adolescents and can usually be managed at home, but it's particularly concerning when headaches become chronic. Chronic daily headache (CDH) is defined as having more than 15 headache days per month. It can refer to very frequent tension-type headaches, transformed migraine (migraine that has gone from being episodic to chronic), or a mixture of migraine and tension-type headache. It occurs in 4% of the adult population and up to 30% of adolescents seen in pediatric headache clinics.

The disability seen with CDH is considerable, not only from the pain of headache, but from missing school and other activities. Typically, kids with CDH have frequent school absences and are overusing analgesic medications to treat their headaches. As kids learn to take medications on their own, they often use more and more, which actually increases the likelihood of developing chronic headache. In fact, overusing medicines or missing lots of school because of headaches raises a red flag for healthcare providers.

The medical model to evaluate CDH calls for a thorough history and examination to make sure no underlying medical or neurological disorders are present. In most patients, the work-up, including laboratory tests and imaging, is negative. A psychosocial evaluation often reveals stress at school, at home or with friends. In addition, excessive extracurricular activities, lack of sleep and dietary irregularities can contribute to the problem.

Treatment with medication alone is often unsuccessful. Amitriptyline and topiramate are used most often, but they are usually unsuccessful unless combined with lifestyle changes. These include improved sleep hygiene, nutritional counseling, exercise, discontinuation of overuse of analgesics, return to school, weight loss in obese patients, and counseling. In the most difficult cases, inpatient rehabilitation may be helpful.

Inpatient treatment typically lasts around three weeks and combines intense physical, occupational and psychological therapies. Daily activities may include school reintegration, physical reconditioning, exercise, relaxation skills, group and individual counseling, and parent counseling.

--A. David Rothner, MD, Director of the Pediatric Headache Clinic and Director Emeritus of Child Neurology at the Cleveland Clinic in Cleveland, Ohio

A. When a child is hospitalized due to a severe headache, it is not uncommon for a psychologist to conduct an inpatient consultation. The consultation may consist of a single session or multiple visits during the hospitalization. Based on the psychologist's findings, inpatient headache treatment can range from relaxation training to assisting the family with planning for treatment once the patient is discharged.

During the hospital stay, children are taught behavioral strategies to help relax their muscles and relieve pain. The most common relaxation skills are deep breathing, progressive muscle relaxation and pleasant imagery. Massage therapy can also be a helpful relaxation technique.

Positive thoughts and other active coping skills are an important part of behavioral treatment. Negative thoughts about headaches often lead to sadness and anxiety, which can, in turn, cause an increase in pain and impact a child's quality of life. Teaching children to think positively about headaches encourages active coping and can prevent a worsening of headache pain. Skills emphasizing active coping are strategies that children can practice at home and use when they have headaches anywhere.

Psychologists also address lifestyle factors related to liquid intake, nutrition, sleep and exercise that may serve as triggers for a child's headaches. They work with families to identify and problem-solve around barriers to following medical recommendations about headache care. Families often need assistance with ways to help their child return to regular daily activities such as school and after-school activities. Children with recurrent headaches and/or significant headache disability can benefit from additional training in behavioral pain coping skills and are often referred for additional outpatient behavioral therapy.

--Shalonda Slater, PhD, Megan Crawford, and Scott W. Powers, PhD, ABPP, Headache Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio