How are headaches treated?
There are many factors that go into headache management. Your provider will decide the type(s) of headache your child has. Then he or she will evaluate the frequency of headaches. Finally, other health and lifestyle factors will help your provider choose the right treatments.
- Your provider will talk with you about everyday things you can work on to prevent or treat headaches (called lifestyle factors).
- There are medicines to take when a headache happens (called abortive or rescue medicines).
- If needed, there are medicines to take every day (called preventive medicines or prophylaxis). These can cut down the number and the pain of headaches.
- Many of the medicines used by neurologists are FDA approved for adult use, but not for children. We rely on years of use, research and work with neurologists around the world to decide which medicines are safe and effective.
Abortive Treatments (Rescue Medicines):
There are different medicines a child can take when headache pain starts. Early treatment (treatment given as soon as the headache starts) works best. We may recommend different medicines for different headaches.
- Over the Counter medicines (OTCs) include: ibuprofen (Advil, Motrin), acetaminophen (Tylenol), and naproxen (Naprosyn, Aleve). These are usually the first pain medicines to try for headaches.
- Prescription NSAIDs (non-steroidal anti-inflammatory drug) include: diclofenac, ketorolac, and indomethacin. If over-the-counter pain medicines do not stop headaches, your provider may prescribe a prescription NSAID to try for pain relief.
- Triptans: We refer to this class of medicines as ‘triptans’ because the generic names of each medicine ends with –triptan. This list includes Imitrex (sumatriptan), Maxalt (rizatriptan), Axert (almotriptan), Zomig (zolmitriptan), Amerge (naratriptan), Frova (frovatriptan) and Relpax (eletriptan). Triptans are a group of medicines used just for the treatment of migraine headaches. Triptans can lessen inflammation and narrow blood vessels in the brain to slow down the spread of migraine symptoms. The triptans may not work for all migraine patients and may not treat every migraine equally well. If one Triptan does not work, the provider may recommend trying a different one. Triptans work the best if taken at the start of migraine symptoms. Of this group, Almotriptan (Axert) is FDA approved for children 12 years of age and older. Rizatriptan (Maxalt) is FDA approved for children 6 years of age and older.
- Ergots: Ergotamine or dihydroergotamine may be used to treat migraine and similar headaches. They act by narrowing blood vessels in the brain, which may lessen inflammation and reduce the throbbing that comes with these severe headaches. Ergots are used less often than before due to common side effects. We keep this type of medicine for patients with severe migraine that is not helped by other treatments.
- Steroids: Corticosteroids (like prednisone) may be used for treatment of severe migraine headaches or for longer migraines (that last at least 72 hours). They may also be used to treat medicine overuse headaches. If your child has a long lasting migraine that is not helped by the typical medicines, steroids may be used.
- Hydroxyzine: Hydroxyzine (or Vistaril) is an antihistamine medicine. It is sometimes used to treat headaches. While this medicine is not proven to treat acute headaches, it may give some relief. This may be given to a patient who is overusing pain medicines. Hydroxyzine can help to lessen anxiety, and may allow someone suffering from a strong headache to relax.
Preventive medicines (Prophylaxis):
Daily medicine may be used if a patient often has headaches that interfere with work, school or social activities. Preventive treatments may not be needed long-term. After several months of successful treatment, we may consider giving less, then stopping the preventive medicine. This decision is different for each patient. There are several prescription and non-prescription medicines and supplements that might work.
At this time there are no daily headache preventive medicines for children that are FDA approved.
Non-prescription medicines and supplements for headache or migraine prevention include:
- Riboflavin (Vitamin B2)
- Coenzyme Q10
- Petasites (Butterbur root)
You can talk about these with your provider.
Prescription medicines for headache or migraine prevention:
- Amitriptyline (Elavil): This is in the drug category of tricyclic antidepressants. This does not mean we are prescribing this medicine for depression. Clinical studies in adults show that it helps to treat headaches. This has been used successfully in adolescents and younger children when used for frequent migraine or tension headaches.
- Topiramate (Topamax): This is a seizure prevention medicine which is also approved by the FDA for headache prevention in adults. It is used commonly in children with headaches. Dosing for headache prevention is much lower than dosing for seizure prevention.
- Propranolol: This is a beta (ß) blocker medicine which can help prevent migraine headaches. It should not be used for patients with asthma, diabetes, bradycardia (low heart rates), congestive heart failure or depression. This medicine is FDA approved for headache prevention in adults.
- Valproic Acid (Depakote): This is a seizure prevention medicine, but is also FDA approved for headache prevention in adults. It can be used in children with headaches.
- Levitiracetam (Keppra): This is a seizure prevention medicine but is also used for headache prevention in adults and children.
- Cyproheptadine (Periactin): This is an antihistamine medicine that can have effect on the GI tract, blood vessels and respiratory tract. Limited information shows that it may help prevent headaches in children and adults. It is also frequently used to increase appetite.
- Zonisamide (Zonegran): This is a seizure prevention medicine. Studies suggest it may be helpful in headache prevention.
- Gabapentin (Neurontin): This is a seizure prevention medicine and can be used to treat a certain type of pain called neuropathic pain. It may also be used for headaches.
- Verapamil: This is a calcium channel blocker medicine. It may have mild effects on blood pressure that may help to prevent frequent headaches.
Botox Injections: (OnabotulinumtoxinA):
Botox is a medicine that may be used to treat chronic migraine headaches. It may be used if several other types of preventive medicines have been tried and did not help. Small amounts of Botox are injected into certain muscles of the face and neck. This causes small areas of muscle paralysis that can lessen nerve conduction of pain, reduce muscle tension, and help to relieve headaches over time. Injections are usually repeated after 3 months, and the treatment period varies for each patient.
Preventive measures other than medicines:
- Biofeedback: Biofeedback is a term for techniques used by a psychologist to help make a person more aware of the body and mind. Patients are shown their body’s responses to stress and relaxation. With practice, patients can learn ways to reduce stress in everyday life. This can help to lessen headaches and manage headache pain.
- Relaxation techniques: Relaxing can lessen the impact of stress on the body by easing tense muscles, controlling heart rate, lowering blood pressure and calming breathing. It can also improve sleep.
- Counseling (psychology): One-on-one counseling can help with depression, anxiety, frequent or chronic pain, and mood concerns. Counseling can improve your child’s overall health and well-being. It is believed that when symptoms of anxiety and depression get better it can ease some headaches.
- Massage: Massage can help your child relax and ease tense muscles.
- Acupuncture: Acupuncture is widely used to treat chronic pain. It is the skilled insertion of the tips of needles into the skin at certain points. Some studies have shown that this may benefit chronic headache disorders. Other studies have found no benefits from acupuncture.
- Aromatherapy: This treatment uses fragrant oils from certain plants to ease pain or help patients to relax.
Taking several medicines can be confusing. Sometimes patients need a daily preventive medicine, along with one or more medicines to stop a headache. Children who have headaches often may have both tension type headaches and migraines. Different headaches may need different medicines. Your provider will try to give clearly written instructions. Using alarms, phone reminders and labeled medicine boxes may make giving different medicines less confusing. We ask that parents give the medicine to young children and watch older children and teens take their medicine.
Preventive medicine (Prophylaxis): Preventive medicines should be taken as directed every day, even if your child does not have a headache every day. Daily medicines work best if they are taken every day, so the medicine will work the same all the time. Try to take daily medicines at or near the same time each day. You will see the benefits from a daily medicine in time. You will not be able to see an effect from one dose of this medicine. Usually it takes at least 6 to 8 weeks on a daily medicine before its effect on headaches is known.
Over the Counter (OTC/NSAID): If your child is diagnosed with mild and infrequent headaches, your provider may tell you to give an OTC pain medicine as needed when a headache starts. These could be used for tension type headaches and migraines. Ask your provider if these are part of your child’s headache care. Examples are: Tylenol, Motrin, acetaminophen, ibuprofen, Advil and Aleve. Sometimes your provider will advise not to give your child one of these medicines. In general, these should not be used more than 2 to 3 days in a week.
Triptans: Triptans are prescribed to treat migraines. They should be taken when a migraine starts. These should not be used more than 2 days in a week.
Zofran (Ondansetron): Zofran is a medicine to help nausea. Children with headaches, especially migraines, often have nausea and vomiting. Zofran can act quickly to give some relief for these symptoms. Your provider may tell you to give Zofran at the beginning of a migraine headache. For a child with severe migraines, you may be told to give Zofran with another medicine as soon the headache starts. Phenergan (Promethazine Hydrochloride) is also a medicine for nausea. Your provider may choose this for your child instead of Zofran.
Hydroxyzine: If your child was prescribed hydroxyzine (Vistaril, Atarax) for headaches, it is usually meant to replace pain medicines that are overused. If your child needs pain medicines more than 2 days a week, sometimes we offer hydroxyzine at the start of a headache. Your provider will decide if hydroxyzine is right for your child.