- Email: [email protected]
Pediatric Headache: A Case Study
ARTICLE IN PRESS
Department
Case Study
Pediatric Headache: A Case Study Emily Schumacher, BSN, RN KEY WORDS Headache, pediatric primary care, tension-type headache
Headaches are the most common neurologic issue in pediatrics, affecting up to 88% of children and adolescents, and are one of the most common reasons that children seek medical care (Langdon & DiSabella, 2017). Furthermore, headaches can significantly affect quality of life and cause children to miss school and extracurricular activities (Langdon & DiSabella, 2017). Knowing how to manage headaches and differentiate between types of headaches and understand symptoms of a potential serious underlying condition are important skills for the pediatric nurse practitioner. Most headaches in children are caused by a primary headache disorder; however, they can also be a sign of a serious underlying condition (Blume, 2012). It can be difficult for young children to verbally describe their symptoms, creating a challenge for the provider in identifying headache causes and classification, and developing an appropriate management plan (Langdon & DiSabella, 2017). This case presentation describes a school-age boy who is following up for headaches after his vision test from his last appointment showed that he needed prescription glasses. CASE PRESENTATION Chief Complaint and History of Present Illness A 9-year-old Hispanic boy presented for follow-up at his primary care provider’s clinic with a chief complaint of intermittent headache with dizziness for 3
Emily Schumacher, Doctorate of Nursing Practice Student, University of Wisconsin–Madison School of Nursing, Sun Prairie, WI. Conflicts of interest: None to report. Correspondence: Emily Schumacher, RN, BSN, University of Wisconsin–Madison School of Nursing, 6339 Arrowhead Trail, Sun Prairie, WI 53590; e-mail: [email protected] 0891-5245/$36.00 Copyright © 2017 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.pedhc.2017.08.007
www.jpedhc.org
months. He was seen 1 month earlier for headaches with dizziness by the same provider, and his Snellen vision test indicated that he needed prescription glasses, with each eye measuring 20/35. He was referred to an ophthalmologist, bought glasses, and returned to clinic for follow-up after wearing his new glasses for 2 weeks. During this follow-up appointment, he reported that his headaches improved since wearing his new glasses but that he was still experiencing intermittent headaches. His headaches occur twice per week and last approximately 1 hour. The patient’s mother, however, stated that his headaches occur daily and last longer than 1 hour. This practitioner focused mostly on the answers that the patient provided and interviewed him first. The patient described his headache as bilateral frontal forehead pain and denied any trauma to the head. He denied other locations of pain and denied headache at the time of examination. He said that when he has a headache, he would rate the pain as 5 out of 10 on the typical numeric rating scale for pain. The patient described the pain as “my forehead feels tight.” He said that he did not know if the pain has a pulsing quality. He reported that he was dizzy when he had a headache but denied losing balance, falling, confusion, vision changes, photophobia, phonophobia, nausea, vomiting, or auras. The child denied any recent or current illness or fever. He also denied history of headaches earlier in childhood. The headaches occurred at school and home; he had not missed school because of the headaches. The boy eats three meals per day and one midmorning snack, and he reports being hungry when he gets home after school. His mother said that he had a headache almost every day after school. He drinks water mostly but does have four cans of caffeinated soda per week, with no more than one can per day. He sleeps well through the night and never wakes up with a headache. He is not tired during the day. His headaches are relieved if he puts his head down on his desk at school or lies down at home; he has never gone to the school nurse. He takes ibuprofen 4 to 5 times per week, which he did not think helped improve his headache. His mother thought the ibuprofen did ■■ 2017
1
ARTICLE IN PRESS BOX. PedMIDAS questionnaire and key
Sources: Cincinnati Children’s (2001), Hershey et al. (2001).
help, which is why she encourages him to take the medication. The PedMIDAS tool (see Box) was completed by the child and his mother. Although the patient’s and mother’s answers differed somewhat, the patient fell into the little to none disability grade based on their scores. Past Medical History This patient is a healthy, developmentally appropriate child who is well known to this primary care clinic. His last well-child examination was 13 months ago, and results were unremarkable. His immunizations are up to date. He sees a dentist every 6 months and was last seen 3 months ago. He takes no medications other than ibuprofen. He has no known allergies. 2
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Family History The child’s mother and father have no significant medical issues. The child’s maternal grandfather has hypertension. Other family members have no significant medical issues. There is no known family history of migraine headaches. Personal, Social, and Developmental History This child lives at home with his mother, father, and 5-year-old sister. His father is employed outside the home, and his mother is a homemaker. There are no pets in the home and no secondhand smoke exposure. He has met all developmental milestones at the expected ages and does well in school. This child attends fourth grade and says he likes school, especially gym and math class. He likes to play football and soccer Journal of Pediatric Health Care
ARTICLE IN PRESS with his friends. He feels safe at school and at home. He has a best friend at school and denies getting teased or bullied. Review of Systems A 12-point review of systems was performed, and results were negative. Pertinent Physical Examination Findings This child was well-appearing, alert, and interactive. He was cooperative during the examination and answered questions appropriately. Vital signs were within normal limits for his age group. His weight and height were in the 50th percentile. A thorough neurologic examination was completed, during which the practitioner looked for abnormalities in mental status, vision, eye movements, speech, sensation, strength, reflexes, gait, or coordination, particularly noting any focal abnormalities, significant asymmetries, or cranial nerve palsies. A funduscopic examination looking for evidence of papilledema, optic atrophy, or other abnormalities was also completed, and results were unremarkable. Diagnostic Studies No diagnostic studies were completed. The American Academy of Neurology and Child Neurology Society recommends against routine laboratory studies, lumbar puncture, electroencephalogram (EEG), or neuroimaging when there are no red flags on history and a normal neurologic examination result (Lewis et al, 2002). DISCUSSION Differential Diagnoses Headache classification The differential diagThe differential noses for headaches are diagnoses for vast. Based on the inheadaches are formation that the child provided and his prevast. sentation, his headaches are classified as episodic recurrent headaches and are most likely related to a primary headache disorder, such as tension-type or migraine headache (Blume, 2012). Because his headaches are not severe and acute, or chronic and progressive, many serious causes can be eliminated, such as meningitis or encephalitis, intracranial hemorrhage, tumor, stroke, malignant hypertensions, vascular malformations, infection, elevated intracranial pressure, Chiari malformation, and thyroid disease. Tension-type headache In this case, the most likely diagnosis is tension-type headache, which is the most common type of headache in childhood (Blume, 2012). Tension-type headaches are typically less disabling than migraine www.jpedhc.org
headaches and involve mild to moderate pain that does not disable someone from routine physical activity or tasks (Blume, 2012). Langdon and DiSabella (2017) state that the emphasis of the interview should be placed on having the child report the headache history, with parents adding their comments only after the child’s account has been taken. The PedMIDAS tool (see Box) was completed by the child and his mother; this tool is a validated questionnaire to assess migraine disability in pediatric patients and to evaluate how headaches are affecting his daily life, regardless of a migraine diagnosis (Langdon & DiSabella, 2017). According to this child’s PedMIDAS score, he experiences little to no disability from his headaches (Hershey et al., 2001). The boy’s pain usually lasted for about 1 hour, occurred less than 15 days per month, and was described as tightness and as located bilaterally, which is consistent with tension-type headaches (Langdon & DiSabella, 2017). Triggers for tension-type headaches include stress, fatigue, depression, poor hydration, overuse of nonsteroidal anti-inflammatory drugs (e.g., naproxen, ibuprofen), inadequate sleep, inadequate or inappropriate food or caffeine intake, inadequate exercise, or anxiety. Identifiable triggers for this patient were caffeine intake, taking ibuprofen frequently, and not eating after school when he is hungry and often has a headache. Caffeine intake on more than 2 to 3 days per week or taking ibuprofen more than 15 days per month may cause rebound headaches (Langdon & DiSabella, 2017). Headaches associated with fasting typically improve with eating and are typically diffuse and mild; these are common in children because of picky eating habits and irregular meal schedules due to school and activities (Langdon & DiSabella, 2017). The boy’s headaches do not fulfill the migraine without aura criteria because he does not experience nausea, vomiting, photophobia, or phonophobia. Eliminating serious causes and conditions For the cause of episodic recurrent headaches, differential diagnoses include migraine with or without aura, tension-type headache, fasting or eating disorder, recurrent toxic exposure (alcohol, toxins, illicit drugs, medications), recurrent sinus disease, seizure-associated headache, mitochondrial disease, and trigeminal autonomic cephalalgias, dental disease, or psychosocial issues (Blume, 2012). Migraine with aura was eliminated because of the lack of aura according to the Pediatric Migraine Criteria (Blume, 2012). The provided health history eliminated fasting or eating disorder, recurrent toxic exposure, recurrent sinus disease, seizures, dental disease, or psychosocial issues as the cause of his headaches. There is no known family history of migraine headaches; it is important to obtain this information because there is an associated genetic risk (Langdon & DiSabella, 2017). Bullied children and adolescents have a significantly higher risk for headaches ■■ 2017
3
ARTICLE IN PRESS compared with non-bullied peers, but the boy denied being the victim of bullying (Gini, Pozzoli, Lenzi, & Vieno, 2014). He also did not show signs of depression or anxiety, which also have a correlation with increased headaches (Langdon & DiSabella, 2017). Trigeminal autonomic cephalalgias are rare in children and can be eliminated for this patient because of lack of severe stabbing pain and lack of autonomic symptoms, such as ipsilateral eye redness, tearing, nasal congestion, ptosis, facial sweating, and eyelid swelling (Blume, 2012). Mitochondrial disease can be eliminated because of lack of problems with other organ systems or other neurologic symptoms (Blume, 2012). Important considerations This patient had difficulty describing his headaches, including how often they occur, what they feel like, and how long they last. He was unsure of some answers to examiner questions, and his mother’s report was not consistent with information provided by the patient. Langdon and DiSabella (2017) state that headache drawings may aid in the clinical diagnosis of headache type, but they need to be interpreted by someone who is trained. This patient did not complete a headache drawing, and no one in this clinic was trained to interpret such a drawing. If this patient is having headaches as frequently as his mother said, then his headaches could be considered chronic daily headaches because they are occurring more than 15 days per month and could possibly warrant a work-up for migraines as well (Blume, 2012). Chronic tensiontype headaches may share similarities with chronic migraines if the headaches occur daily, and it can be difficult to classify daily headaches as tension or migraine (Blume, 2012). Also, many children suffer from multiple headache types, and tension-type headaches often coexist with migraine headaches (Gofshteyn & Stephenson, 2016). Pathophysiology The pathophysiology of The tension-type headaches pathophysiology of suggests a muscletension-type based source. Painful nociceptor input from headaches cranial and cervical suggests a musclemyofascial components based source. can trigger these headaches initially. If this painful input is sustained, it can cause an individual to become more sensitive to these impulses. This can result in the development of recurrent headaches that may extend to the neck and shoulders (Blume, 2012; Langdon & DiSabella, 2017). Management Education was provided about primary headaches to the patient and mother to reassure them that there is 4
Volume ■■ • Number ■■
no underlying disorder or problem (Blume, 2012). Lifestyle choices that could be potential headache triggers, such as inadequate or irregular sleep, stress, inadequate or inappropriate food or caffeine intake, inadequate exercise, and poor hydration, were discussed thoroughly. Regular aerobic exercise is an important part of a headache management plan, as is elimination of caffeine, stress management, adequate uninterrupted sleep, and staying well hydrated (Blume, 2012; Langdon & DiSabella, 2017). Goals were developed between the provider, mother, and patient using motivational interviewing techniques and were as follows: drink at least three bottles of water per day, exercise at least 30 minutes per day four times per week, sleep 8-10 hours per night, drink two or fewer caffeinated beverages per week, eat three meals per day with at least one fruit and one vegetable at each meal, eat a healthy snack after school, remove electronics from his bedroom, less than 2 hours of screen time per day, and keep a headache journal that the mother and child will fill out daily. Keeping a headache journal can help identify headache timeline details and potential triggers (Gofshteyn & Stephenson, 2016; Langdon & DiSabella, 2017). Significant stressors at home and school were not identified, nor were concerns for depression, abuse, or anxiety; referral to a counselor was not made at this time but was discussed as a future option (Blume, 2012; Langdon & DiSabella, 2017). Complementary therapies, including biofeedback therapy, relaxation techniques, hypnosis, and acupuncture, can be helpful in the management of recurrent episodic headaches, but may not be very accessible to patients; this child and mother were not interested in these therapies (Blume, 2012). Physical or massage therapy can also be helpful but were not recommended at this time because of lack of patient interest, lack of accessibility, and lack of evidence (Blume, 2012). Early medication intervention is important in the acute treatment of tension-type headaches (Blume, 2012). For tension-type headaches, it is recommended that a nonsteroidal anti-inflammatory drug (e.g., ibuprofen or naproxen) or acetaminophen be taken when symptoms first appear. However, nonsteroidal antiinflammatory drugs should not be used more than 2 to 3 days per week, or more than 15 days per month, to avoid developing medication overuse or rebound headaches. The correct dose for the child’s weight was reviewed with the parent to prevent underdosing or overdosing, as was education regarding not taking ibuprofen and naproxen concurrently (Blume, 2012; Gofshteyn & Stephenson, 2016). Because this patient was potentially experiencing rebound headaches from ibuprofen, it was decided that acetaminophen and naproxen would be used for this patient’s headaches; his mother verbalized understanding of medication overuse headaches and would keep track of how often medications were taken in the headache journal. Journal of Pediatric Health Care
ARTICLE IN PRESS Preventive medication treatment is not indicated because this child was not having four or more days of disabling headache per month (Blume, 2012). Some families may want to try supplements or nutraceuticals for preventive headache management. If a supplement is started for preventive therapy, it is important to educate the patient and family that it takes 8 to 12 weeks to cause a recognizable effect. There are few randomized controlled trials of supplements for the management of headaches in children, but there are options that may be effective and unlikely to cause harm, including riboflavin (50-400 mg per day), magnesium oxide (3 mg/kg given three times per day ), coenzyme Q10 (100 mg/day), and melatonin (1-6 mg before bed; Blume, 2012; Gofshteyn & Stephenson, 2016). The option of using supplements was not discussed at this visit because of lack of evidence and lack of interest from the patient and mother. Follow-Up Eight weeks later, this child and his mother returned to clinic for follow-up to discuss the headache journal and goal progress. Both mother and child thought that he was experiencing fewer headaches; the journal showed that he was having about one headache every 3 weeks and that he had taken acetaminophen and naproxen one time in the past 8 weeks. His mother thought that his recent headaches were from dehydration. He increased his water intake to at least three bottles on most days and decreased his caffeine consumption to one soda per week. His mother has consistently provided him with an afterschool snack, which she thought helped improve his headaches significantly. He is continuing to work toward his goals of eating more fruits and vegetables, sleeping more, and exercising. Electronics are no longer in his bedroom. Both mother and child verbalized that they are satisfied with the current plan and will continue to work on his goals and write in his headache journal. SUMMARY Although tension-type headaches are the most common type of headache in childhood, it is critical to con-
www.jpedhc.org
sider all of the possible Although tensioncauses of new-onset type headaches headaches. Creating a are the most thorough list of differential diagnoses is common type of important for the pediheadache in atric nurse practitioner, childhood, it is because there are many serious causes that critical to consider need to be eliminated all of the possible before such a diagnocauses of newsis can be made. This child did not exhibit onset headaches. any of the red flags that would warrant further work-up, so a conservative management plan was created with input from both the child and his mother. The child and his mother followed through with the plan, while working toward his goals, and were satisfied with the subsequent decreased headaches. REFERENCES Blume, H. K. (2012). Pediatric headache: A review. Pediatrics in Review, 33, 562-576. Cincinnati Children’s. (2001). PedMIDAS tool. Cincinnati, OH: Author. Retrieved from https://www.cincinnatichildrens.org/service/h/ headache-center/pedmidas Gini, G., Pozzoli, T., Lenzi, M., & Vieno, A. (2014). Bullying victimization at school and headache: A meta-analysis of observational studies. Headache, 54, 976-986. Gofshteyn, J. S., & Stephenson, D. J. (2016). Diagnosis and management of childhood headache. Current Problems in Pediatric and Adolescent Health Care, 46, 36-51. Hershey, A. D., Powers, S. W., Vockell, A.-L. B., LeCates, S., Kabbouche, M. A., & Maynard, M. K. (2001). PedMIDAS Development of a questionnaire to assess disability of migraines in children. Neurology, 57(11), 2034-2039. Langdon, R., & DiSabella, M. T. (2017). Pediatric headache: An overview. Current Problems in Pediatric and Adolescent Health Care, 47, 44-65. Lewis, D. W., Ashwal, S., Dahl, G., Dorbad, D., Hirtz, D., Prensky, A., … Practice Committee of the Child Neurology Society. (2002). Practice parameter: Evaluation of children and adolescents with recurrent headaches: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology, 59(4), 490-498.
■■ 2017
5
Department
Case Study
Pediatric Headache: A Case Study Emily Schumacher, BSN, RN KEY WORDS Headache, pediatric primary care, tension-type headache
Headaches are the most common neurologic issue in pediatrics, affecting up to 88% of children and adolescents, and are one of the most common reasons that children seek medical care (Langdon & DiSabella, 2017). Furthermore, headaches can significantly affect quality of life and cause children to miss school and extracurricular activities (Langdon & DiSabella, 2017). Knowing how to manage headaches and differentiate between types of headaches and understand symptoms of a potential serious underlying condition are important skills for the pediatric nurse practitioner. Most headaches in children are caused by a primary headache disorder; however, they can also be a sign of a serious underlying condition (Blume, 2012). It can be difficult for young children to verbally describe their symptoms, creating a challenge for the provider in identifying headache causes and classification, and developing an appropriate management plan (Langdon & DiSabella, 2017). This case presentation describes a school-age boy who is following up for headaches after his vision test from his last appointment showed that he needed prescription glasses. CASE PRESENTATION Chief Complaint and History of Present Illness A 9-year-old Hispanic boy presented for follow-up at his primary care provider’s clinic with a chief complaint of intermittent headache with dizziness for 3
Emily Schumacher, Doctorate of Nursing Practice Student, University of Wisconsin–Madison School of Nursing, Sun Prairie, WI. Conflicts of interest: None to report. Correspondence: Emily Schumacher, RN, BSN, University of Wisconsin–Madison School of Nursing, 6339 Arrowhead Trail, Sun Prairie, WI 53590; e-mail: [email protected] 0891-5245/$36.00 Copyright © 2017 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.pedhc.2017.08.007
www.jpedhc.org
months. He was seen 1 month earlier for headaches with dizziness by the same provider, and his Snellen vision test indicated that he needed prescription glasses, with each eye measuring 20/35. He was referred to an ophthalmologist, bought glasses, and returned to clinic for follow-up after wearing his new glasses for 2 weeks. During this follow-up appointment, he reported that his headaches improved since wearing his new glasses but that he was still experiencing intermittent headaches. His headaches occur twice per week and last approximately 1 hour. The patient’s mother, however, stated that his headaches occur daily and last longer than 1 hour. This practitioner focused mostly on the answers that the patient provided and interviewed him first. The patient described his headache as bilateral frontal forehead pain and denied any trauma to the head. He denied other locations of pain and denied headache at the time of examination. He said that when he has a headache, he would rate the pain as 5 out of 10 on the typical numeric rating scale for pain. The patient described the pain as “my forehead feels tight.” He said that he did not know if the pain has a pulsing quality. He reported that he was dizzy when he had a headache but denied losing balance, falling, confusion, vision changes, photophobia, phonophobia, nausea, vomiting, or auras. The child denied any recent or current illness or fever. He also denied history of headaches earlier in childhood. The headaches occurred at school and home; he had not missed school because of the headaches. The boy eats three meals per day and one midmorning snack, and he reports being hungry when he gets home after school. His mother said that he had a headache almost every day after school. He drinks water mostly but does have four cans of caffeinated soda per week, with no more than one can per day. He sleeps well through the night and never wakes up with a headache. He is not tired during the day. His headaches are relieved if he puts his head down on his desk at school or lies down at home; he has never gone to the school nurse. He takes ibuprofen 4 to 5 times per week, which he did not think helped improve his headache. His mother thought the ibuprofen did ■■ 2017
1
ARTICLE IN PRESS BOX. PedMIDAS questionnaire and key
Sources: Cincinnati Children’s (2001), Hershey et al. (2001).
help, which is why she encourages him to take the medication. The PedMIDAS tool (see Box) was completed by the child and his mother. Although the patient’s and mother’s answers differed somewhat, the patient fell into the little to none disability grade based on their scores. Past Medical History This patient is a healthy, developmentally appropriate child who is well known to this primary care clinic. His last well-child examination was 13 months ago, and results were unremarkable. His immunizations are up to date. He sees a dentist every 6 months and was last seen 3 months ago. He takes no medications other than ibuprofen. He has no known allergies. 2
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Family History The child’s mother and father have no significant medical issues. The child’s maternal grandfather has hypertension. Other family members have no significant medical issues. There is no known family history of migraine headaches. Personal, Social, and Developmental History This child lives at home with his mother, father, and 5-year-old sister. His father is employed outside the home, and his mother is a homemaker. There are no pets in the home and no secondhand smoke exposure. He has met all developmental milestones at the expected ages and does well in school. This child attends fourth grade and says he likes school, especially gym and math class. He likes to play football and soccer Journal of Pediatric Health Care
ARTICLE IN PRESS with his friends. He feels safe at school and at home. He has a best friend at school and denies getting teased or bullied. Review of Systems A 12-point review of systems was performed, and results were negative. Pertinent Physical Examination Findings This child was well-appearing, alert, and interactive. He was cooperative during the examination and answered questions appropriately. Vital signs were within normal limits for his age group. His weight and height were in the 50th percentile. A thorough neurologic examination was completed, during which the practitioner looked for abnormalities in mental status, vision, eye movements, speech, sensation, strength, reflexes, gait, or coordination, particularly noting any focal abnormalities, significant asymmetries, or cranial nerve palsies. A funduscopic examination looking for evidence of papilledema, optic atrophy, or other abnormalities was also completed, and results were unremarkable. Diagnostic Studies No diagnostic studies were completed. The American Academy of Neurology and Child Neurology Society recommends against routine laboratory studies, lumbar puncture, electroencephalogram (EEG), or neuroimaging when there are no red flags on history and a normal neurologic examination result (Lewis et al, 2002). DISCUSSION Differential Diagnoses Headache classification The differential diagThe differential noses for headaches are diagnoses for vast. Based on the inheadaches are formation that the child provided and his prevast. sentation, his headaches are classified as episodic recurrent headaches and are most likely related to a primary headache disorder, such as tension-type or migraine headache (Blume, 2012). Because his headaches are not severe and acute, or chronic and progressive, many serious causes can be eliminated, such as meningitis or encephalitis, intracranial hemorrhage, tumor, stroke, malignant hypertensions, vascular malformations, infection, elevated intracranial pressure, Chiari malformation, and thyroid disease. Tension-type headache In this case, the most likely diagnosis is tension-type headache, which is the most common type of headache in childhood (Blume, 2012). Tension-type headaches are typically less disabling than migraine www.jpedhc.org
headaches and involve mild to moderate pain that does not disable someone from routine physical activity or tasks (Blume, 2012). Langdon and DiSabella (2017) state that the emphasis of the interview should be placed on having the child report the headache history, with parents adding their comments only after the child’s account has been taken. The PedMIDAS tool (see Box) was completed by the child and his mother; this tool is a validated questionnaire to assess migraine disability in pediatric patients and to evaluate how headaches are affecting his daily life, regardless of a migraine diagnosis (Langdon & DiSabella, 2017). According to this child’s PedMIDAS score, he experiences little to no disability from his headaches (Hershey et al., 2001). The boy’s pain usually lasted for about 1 hour, occurred less than 15 days per month, and was described as tightness and as located bilaterally, which is consistent with tension-type headaches (Langdon & DiSabella, 2017). Triggers for tension-type headaches include stress, fatigue, depression, poor hydration, overuse of nonsteroidal anti-inflammatory drugs (e.g., naproxen, ibuprofen), inadequate sleep, inadequate or inappropriate food or caffeine intake, inadequate exercise, or anxiety. Identifiable triggers for this patient were caffeine intake, taking ibuprofen frequently, and not eating after school when he is hungry and often has a headache. Caffeine intake on more than 2 to 3 days per week or taking ibuprofen more than 15 days per month may cause rebound headaches (Langdon & DiSabella, 2017). Headaches associated with fasting typically improve with eating and are typically diffuse and mild; these are common in children because of picky eating habits and irregular meal schedules due to school and activities (Langdon & DiSabella, 2017). The boy’s headaches do not fulfill the migraine without aura criteria because he does not experience nausea, vomiting, photophobia, or phonophobia. Eliminating serious causes and conditions For the cause of episodic recurrent headaches, differential diagnoses include migraine with or without aura, tension-type headache, fasting or eating disorder, recurrent toxic exposure (alcohol, toxins, illicit drugs, medications), recurrent sinus disease, seizure-associated headache, mitochondrial disease, and trigeminal autonomic cephalalgias, dental disease, or psychosocial issues (Blume, 2012). Migraine with aura was eliminated because of the lack of aura according to the Pediatric Migraine Criteria (Blume, 2012). The provided health history eliminated fasting or eating disorder, recurrent toxic exposure, recurrent sinus disease, seizures, dental disease, or psychosocial issues as the cause of his headaches. There is no known family history of migraine headaches; it is important to obtain this information because there is an associated genetic risk (Langdon & DiSabella, 2017). Bullied children and adolescents have a significantly higher risk for headaches ■■ 2017
3
ARTICLE IN PRESS compared with non-bullied peers, but the boy denied being the victim of bullying (Gini, Pozzoli, Lenzi, & Vieno, 2014). He also did not show signs of depression or anxiety, which also have a correlation with increased headaches (Langdon & DiSabella, 2017). Trigeminal autonomic cephalalgias are rare in children and can be eliminated for this patient because of lack of severe stabbing pain and lack of autonomic symptoms, such as ipsilateral eye redness, tearing, nasal congestion, ptosis, facial sweating, and eyelid swelling (Blume, 2012). Mitochondrial disease can be eliminated because of lack of problems with other organ systems or other neurologic symptoms (Blume, 2012). Important considerations This patient had difficulty describing his headaches, including how often they occur, what they feel like, and how long they last. He was unsure of some answers to examiner questions, and his mother’s report was not consistent with information provided by the patient. Langdon and DiSabella (2017) state that headache drawings may aid in the clinical diagnosis of headache type, but they need to be interpreted by someone who is trained. This patient did not complete a headache drawing, and no one in this clinic was trained to interpret such a drawing. If this patient is having headaches as frequently as his mother said, then his headaches could be considered chronic daily headaches because they are occurring more than 15 days per month and could possibly warrant a work-up for migraines as well (Blume, 2012). Chronic tensiontype headaches may share similarities with chronic migraines if the headaches occur daily, and it can be difficult to classify daily headaches as tension or migraine (Blume, 2012). Also, many children suffer from multiple headache types, and tension-type headaches often coexist with migraine headaches (Gofshteyn & Stephenson, 2016). Pathophysiology The pathophysiology of The tension-type headaches pathophysiology of suggests a muscletension-type based source. Painful nociceptor input from headaches cranial and cervical suggests a musclemyofascial components based source. can trigger these headaches initially. If this painful input is sustained, it can cause an individual to become more sensitive to these impulses. This can result in the development of recurrent headaches that may extend to the neck and shoulders (Blume, 2012; Langdon & DiSabella, 2017). Management Education was provided about primary headaches to the patient and mother to reassure them that there is 4
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no underlying disorder or problem (Blume, 2012). Lifestyle choices that could be potential headache triggers, such as inadequate or irregular sleep, stress, inadequate or inappropriate food or caffeine intake, inadequate exercise, and poor hydration, were discussed thoroughly. Regular aerobic exercise is an important part of a headache management plan, as is elimination of caffeine, stress management, adequate uninterrupted sleep, and staying well hydrated (Blume, 2012; Langdon & DiSabella, 2017). Goals were developed between the provider, mother, and patient using motivational interviewing techniques and were as follows: drink at least three bottles of water per day, exercise at least 30 minutes per day four times per week, sleep 8-10 hours per night, drink two or fewer caffeinated beverages per week, eat three meals per day with at least one fruit and one vegetable at each meal, eat a healthy snack after school, remove electronics from his bedroom, less than 2 hours of screen time per day, and keep a headache journal that the mother and child will fill out daily. Keeping a headache journal can help identify headache timeline details and potential triggers (Gofshteyn & Stephenson, 2016; Langdon & DiSabella, 2017). Significant stressors at home and school were not identified, nor were concerns for depression, abuse, or anxiety; referral to a counselor was not made at this time but was discussed as a future option (Blume, 2012; Langdon & DiSabella, 2017). Complementary therapies, including biofeedback therapy, relaxation techniques, hypnosis, and acupuncture, can be helpful in the management of recurrent episodic headaches, but may not be very accessible to patients; this child and mother were not interested in these therapies (Blume, 2012). Physical or massage therapy can also be helpful but were not recommended at this time because of lack of patient interest, lack of accessibility, and lack of evidence (Blume, 2012). Early medication intervention is important in the acute treatment of tension-type headaches (Blume, 2012). For tension-type headaches, it is recommended that a nonsteroidal anti-inflammatory drug (e.g., ibuprofen or naproxen) or acetaminophen be taken when symptoms first appear. However, nonsteroidal antiinflammatory drugs should not be used more than 2 to 3 days per week, or more than 15 days per month, to avoid developing medication overuse or rebound headaches. The correct dose for the child’s weight was reviewed with the parent to prevent underdosing or overdosing, as was education regarding not taking ibuprofen and naproxen concurrently (Blume, 2012; Gofshteyn & Stephenson, 2016). Because this patient was potentially experiencing rebound headaches from ibuprofen, it was decided that acetaminophen and naproxen would be used for this patient’s headaches; his mother verbalized understanding of medication overuse headaches and would keep track of how often medications were taken in the headache journal. Journal of Pediatric Health Care
ARTICLE IN PRESS Preventive medication treatment is not indicated because this child was not having four or more days of disabling headache per month (Blume, 2012). Some families may want to try supplements or nutraceuticals for preventive headache management. If a supplement is started for preventive therapy, it is important to educate the patient and family that it takes 8 to 12 weeks to cause a recognizable effect. There are few randomized controlled trials of supplements for the management of headaches in children, but there are options that may be effective and unlikely to cause harm, including riboflavin (50-400 mg per day), magnesium oxide (3 mg/kg given three times per day ), coenzyme Q10 (100 mg/day), and melatonin (1-6 mg before bed; Blume, 2012; Gofshteyn & Stephenson, 2016). The option of using supplements was not discussed at this visit because of lack of evidence and lack of interest from the patient and mother. Follow-Up Eight weeks later, this child and his mother returned to clinic for follow-up to discuss the headache journal and goal progress. Both mother and child thought that he was experiencing fewer headaches; the journal showed that he was having about one headache every 3 weeks and that he had taken acetaminophen and naproxen one time in the past 8 weeks. His mother thought that his recent headaches were from dehydration. He increased his water intake to at least three bottles on most days and decreased his caffeine consumption to one soda per week. His mother has consistently provided him with an afterschool snack, which she thought helped improve his headaches significantly. He is continuing to work toward his goals of eating more fruits and vegetables, sleeping more, and exercising. Electronics are no longer in his bedroom. Both mother and child verbalized that they are satisfied with the current plan and will continue to work on his goals and write in his headache journal. SUMMARY Although tension-type headaches are the most common type of headache in childhood, it is critical to con-
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sider all of the possible Although tensioncauses of new-onset type headaches headaches. Creating a are the most thorough list of differential diagnoses is common type of important for the pediheadache in atric nurse practitioner, childhood, it is because there are many serious causes that critical to consider need to be eliminated all of the possible before such a diagnocauses of newsis can be made. This child did not exhibit onset headaches. any of the red flags that would warrant further work-up, so a conservative management plan was created with input from both the child and his mother. The child and his mother followed through with the plan, while working toward his goals, and were satisfied with the subsequent decreased headaches. REFERENCES Blume, H. K. (2012). Pediatric headache: A review. Pediatrics in Review, 33, 562-576. Cincinnati Children’s. (2001). PedMIDAS tool. Cincinnati, OH: Author. Retrieved from https://www.cincinnatichildrens.org/service/h/ headache-center/pedmidas Gini, G., Pozzoli, T., Lenzi, M., & Vieno, A. (2014). Bullying victimization at school and headache: A meta-analysis of observational studies. Headache, 54, 976-986. Gofshteyn, J. S., & Stephenson, D. J. (2016). Diagnosis and management of childhood headache. Current Problems in Pediatric and Adolescent Health Care, 46, 36-51. Hershey, A. D., Powers, S. W., Vockell, A.-L. B., LeCates, S., Kabbouche, M. A., & Maynard, M. K. (2001). PedMIDAS Development of a questionnaire to assess disability of migraines in children. Neurology, 57(11), 2034-2039. Langdon, R., & DiSabella, M. T. (2017). Pediatric headache: An overview. Current Problems in Pediatric and Adolescent Health Care, 47, 44-65. Lewis, D. W., Ashwal, S., Dahl, G., Dorbad, D., Hirtz, D., Prensky, A., … Practice Committee of the Child Neurology Society. (2002). Practice parameter: Evaluation of children and adolescents with recurrent headaches: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology, 59(4), 490-498.
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