Summer 2013

New Hope for Severe, Persistent Pediatric Headache

According to a 2009 study published in the Journal of Child Neurology, 17.1 percent of children experience frequent or severe headaches. While migraines are the most common primary headache disorder for which patients come to see a doctor, children can also suffer from:

Dr. Amy Gelfand

Dr. Amy Gelfand

Despite the prevalence of primary headache disorders in children, pediatric headaches are often misunderstood and undertreated, according to Amy Gelfand, M.D., a child neurologist at UCSF Benioff Children's Hospital who specializes in headache disorders. For example, Gelfand says there is little evidence supporting the use of restrictive diets in children with migraine, and that the risks of opioids and barbiturates — overuse and potential for dependency — outweigh the benefits.

Expanding the Options

For proper treatment of children with frequent, severe headache, it is important to get them to a facility like the UCSF Headache Center, where they can benefit from expert diagnostic services and a full range of stepped treatment capabilities, including:

  • Acute and preventive outpatient migraine therapies
  • Greater occipital nerve injections
  • Intravenous (IV) dihydroergotamine (DHE)
  • IV lidocaine

For many patients, especially those with an underlying genetic tendency for headache, these treatments will not entirely eliminate headache attacks; however, they can dramatically improve quality of life by reducing headache occurrence to just a few times a month.

Dr. Amy Gelfand with patient

Dr. Amy Gelfand with patient

For children with a chronic primary headache disorder that has not responded to first-line outpatient therapy, the next step is typically a greater occipital nerve injection, which quiets abnormally active areas of the brain and has been effective in approximately two-thirds of adults treated at the Headache Center.

"We have a lot of experience doing these injections in children," Gelfand says of the outpatient procedure.

Inpatient Procedures and Emerging Protocols

If the nerve injection is not effective, neurologists at the Headache Center consider two possible inpatient treatments. IV DHE, a five-day procedure, is usually first. It can cause nausea, which can compromise efficacy, so this treatment is usually accompanied by antiemetics.

If IV DHE proves ineffective, says Gelfand, the next step is IV lidocaine, a novel treatment and another inpatient procedure, though this one is administered in the Intensive Care Unit (ICU).

Finally, physicians at UCSF are developing a protocol for emergency room treatment of children presenting with severe headaches. The protocol will focus on delivering the most appropriate treatments without exposing the children to side effects. "Once the protocol is validated, we expect to disseminate it to any facility interested in using it," Gelfand says.

When to Refer for Migraine

Refer pediatric patients to the UCSF Headache Center if the following conditions apply:

  • They have had an adequate trial of one preventive therapy.
  • They suffer from headaches 15 or more days per month.
  • They have experienced at least three months of headaches.

For more information, contact Dr. Gelfand at (415) 353-8393.


Neuroscience Summer 2013 Index

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