Headache Help (30 page)

2. A
SPIRIN

Although aspirin is quite effective and well tolerated, it is not a first choice because of the fear, founded or unfounded, of Reye’s syndrome. However, unless a child has chicken pox or the flu with fever, aspirin is a safe bet. Nevertheless, many parents are reluctant to use aspirin in any situation.

Taking aspirin with caffeinated soda can relieve pain even more.

TYPICAL DOSE
: For ages six to eight, 325 mg three times a day. For ages nine to ten, 400 mg three times a day, at most. Children’s aspirin is available in 65, 75, and 81 mg tablets, and in 81 mg chewable tablets. Aspergum (chewing gum) has 227.5 mg each. Standard aspirin is 325 mg per tablet.

SIDE EFFECTS
: Gastrointestinal upset.

When none of the first- or second-line medications is useful and your child continues to suffer from severe, prolonged headaches, which will probably be diagnosed as migraines, your doctor may recommend Prednisone or DHE. When prescribed for children, these drugs are used in very limited doses and for very short periods of time. Also remember that you can ask a pharmacist to formulate these medications into lozenges.

THIRD-LINE MEDICATIONS FOR TREATING HEADACHES IN CHILDREN

1. P
REDNISONE

Prednisone becomes useful when your child is enduring a prolonged pattern of migraines that have been resistant to other medications. It should be able to break the painful cycle. Occasionally, small doses of Decadron, a corticosteroid (see Chapter 5), may be used instead.

TYPICAL DOSE
: Usually 10 mg by mouth twice a day, with food, as needed, for one or two days only; 40 mg total per migraine. If the headache is relieved with smaller doses, then medication should be stopped.

SIDE EFFECTS
: In these small doses, side effects are minimal. Anxiety or gastrointestinal upset are the most common. Fatigue, insomnia, and dizziness may also occur.

2. M
IGRANAL
(DHE) N
ASAL
S
PRAY AND
I
NJECTIONS
(FOR AGES NINE AND OLDER)

DHE is sometimes the only medication that effectively relieves a severe and prolonged migraine. Administering this medication intravenously is more effective, less painful, and better tolerated by children than intramuscular injections. The Migranal Nasal Spray is well tolerated.

NASAL SPRAY TYPICAL DOSE
: One spray in one nostril once every thirty minutes, two sprays total in one day at most.

INJECTION TYPICAL DOSE
: One-time dose of 0.3 to 0.5 mg intravenously. When the migraine is severe and resistant to other therapies, a second dose may be given.

SIDE EFFECTS
: Nausea, lightheadedness, a feeling of heat about the head, muscle contraction headaches, and leg cramps may occur. Migranal may cause stuffiness of the nose.

(See Chapter 5 for a detailed discussion of this medication.)

3. T
RIPTANS
(I
MITREX
, M
AXALT
, A
MERGE
, Z
OMIG
, R
ELPAX
)

Although not officially approved by the FDA for children, the triptans are occasionally used for children nine or older. Very low doses are used—half a tablet only, or the low-dose 5-mg Imitrex Nasal Spray.

ANTINAUSEA MEDICATIONS FOR CHILDREN

As we mentioned previously, many children get nauseated with a migraine, especially early in the headache. It is usually better to let children throw up and then give them an abortive medication to ease the pain. If they can’t keep the medication down, then try an antinausea medication. Unfortunately, there sometimes is little choice but to use a suppository (although a pharmacist may be able to formulate a flavored lozenge for you). These medications not only ease nausea, but in some cases, such as with promethazine, they will sedate the child, thereby helping to relieve the migraine.

Trimethobenzamide (Tigan) or promethazine (Phenergan) are the most commonly prescribed antinausea medications for children. They are detailed in Chapter 5. Other, more effective medications, such as prochlorperazine (Compazine), cause more disturbing side effects, such as anxiety, in children.

1. T
RIMETHOBENZAMIDE
(T
IGAN
)

Tigan is extremely well tolerated, which is why it is so commonly used in children.

TYPICAL DOSE
: 100 to 200 mg every four hours as needed to relieve nausea. Available in capsules, suppositories, syrups, and injections, or may be formulated as a flavored lozenge by a compounding pharmacist.

SIDE EFFECTS
: Fatigue. Low blood pressure (hypotension), confusion, blurred vision, disorientation, muscle cramps, and dizziness occasionally occur.

2. P
ROMETHAZINE
(P
HENERGAN
)

Phenergan is also well tolerated and often causes sedation, which may be desired.

TYPICAL DOSE
: 12.5 to 25 mg per dose, or 0.15 to 0.25 per pound (0.25 to 0.5 mg per kg per dose), which may be repeated if necessary; three doses per day is the usual maximum. Available in tablets, syrup, suppositories, or injection. Flavored oral lozenges may be formulated by a compounding pharmacist.

SIDE EFFECTS
: Sedation, which is helpful for relieving pain by inducing sleep. Low blood pressure (hypotension), blurred vision, disorientation, and dizziness may occur but are not common.

PREVENTING HEADACHES IN CHILDREN UNDER AGE ELEVEN

If biofeedback and nonmedication therapies have been earnestly tried to no avail and your child is taking an abortive medication frequently and still getting more than three or four moderate to severe migraines in a typical month, your doctor may recommend preventive medication.

When considering a preventive, be prepared to use it daily and expect the possibility of some side effects as well as the potential need to change medications if one doesn’t prove effective or causes severe side effects. Preventive medication in children and adolescents should be kept to a minimum and stopped periodically. As with adults, the goal is to return to abortive medications exclusively if possible.

For children younger than age eleven, the medications used to prevent migraines tend to be the same as for chronic (tension) daily headache, so they are not separated out here unless indicated.

QUICK REFERENCE GUIDE: PREVENTING HEADACHES IN CHILDREN

1. C
   YPROHEPTADINE
   ( P
   ERIACTIN
   )
         An antihistamine that’s inexpensive, safe, and sometimes useful.
   
2. NSAIDs (I
   BUPROFEN, NAPROXEN
   )
         Can be very effective and don’t cause sedation, cognitive changes, or decreased energy level.
   
3. P
   ROPRANOLOL
   (I
   NDERAL
   )
         A beta-blocker that’s often useful for migraines but not daily headaches. Fatigue and stomach problems are fairly common.
   
4. A
   NTIDEPRESSANTS
         Good for daily headaches because they affect serotonin levels; can have numerous side effects, from fatigue and sedation to a dry mouth, weight gain, and insomnia.
   

PRESCRIPTION MEDICATIONS FOR PREVENTING HEADACHES IN CHILDREN

1. C
YPROHEPTADINE
(P
ERIACTIN
)

This medication, an antihistamine often prescribed for allergies, also influences serotonin. It is inexpensive and safe, though it is not always the most effective choice. It tends to be most useful for children ten years old and younger. Because it may be taken just once a day and in liquid form, it can be quite convenient.

TYPICAL DOSE
: 4 mg per day, tablet or liquid, taken at night; doses may be gradually increased to as high as 12 mg, as needed. Larger doses are split for twice-a-day dosing.

SIDE EFFECTS
: Fatigue and weight gain due to increased appetite.

2. NSAIDs (I
BUPROFEN
, N
APROXEN
)

A daily anti-inflammatory can be very effective in preventing headaches and may be preferred to the other preventives because it has no effect on energy level, sedation, or cognitive functions (memory or concentration problems). Its doses should be kept to a minimum and, with blood tests performed periodically, long-term use can be quite safe. NSAIDs have been used safely for years, for example, for juvenile rheumatoid arthritis in doses much higher than used for headaches.

TYPICAL DOSE
: For ibuprofen, at age five, half a teaspoon of the 100 mg syrup, or 50 mg per day. At ages six to eight, the dose is half to one teaspoon, or 50 to 100 mg per day. At ages nine to ten, the dose increases to one or two teaspoons, or 100 to 200 mg per day. The regular tablets are 200 mg.

Naproxen doses are calculated by weight, half to one teaspoon daily. One teaspoon is equal to half of the 250 mg pill. (See “First-Line Prescription Medications for Treating Headaches in Children” for more details.) Over-the-counter Aleve dose is 220 mg.

3. P
ROPRANOLOL
(I
NDERAL
)

This beta-blocker that prevents blood vessel dilation is quite effective for migraines but only occasionally effective for daily headaches. It is very well tolerated but should not be taken by asthmatic children.

TYPICAL DOSE
: 0.5 to 1.0 mg per pound per day (or 1 to 2 mg per kg per day), starting with a low dose and increasing it if necessary. The long-acting capsule cannot be divided.

SIDE EFFECTS
: Fatigue and lower abdominal upset are fairly common. Less common is a decrease in heart rate and blood pressure, with a corresponding decrease in stamina. Memory or concentration difficulties, dizziness, and lightheadedness may occur.

4. A
NTIDEPRESSANTS

Because of their effects on serotonin, antidepressants, such as amitriptyline (Elavil), nortriptyline (Pamelor, Aventyl), or SSRIs (Prozac, Zoloft, Paxil), are a first-choice medication for moderate to severe chronic daily headaches. They are usually not prescribed for migraines, however, until cyproheptadine and the NSAIDs have been tried.

Amitriptyline and nortriptyline are similar medications, except that amitriptyline is less expensive and tends to be somewhat more effective. Nortriptyline, however, tends to have fewer side effects. (For a fuller discussion of amitriptyline and nortriptyline, see Chapters 6 and 9 on preventive medications for migraines and tension headaches in adults.)

TYPICAL DOSE
: The SSRIs (selective serotonin reuptake inhibitors, such as Prozac, Zoloft, Paxil) have been proven safe for children and adolescents. They may be safer, in fact, than the older (tricyclic) antidepressants. Low doses are used for headaches, 10 mg to start, usually at night, increased if necessary to 25 or 50 mg (occasionally up to 75 or 100 mg). The average dose in this age range is 25 mg. For the SSRIs, starting doses are low, such as 5 mg of Prozac, 25 mg of Zoloft, or 5 mg of Paxil.

SIDE EFFECTS
: Fatigue, sedation, anxiety, weight gain, a dry mouth, and dizziness; insomnia and memory or concentration difficulties may follow; occasional rapid heartbeat and blurred vision. These side effects are much more common with amitripty-lene or nortriptyline than with the SSRIs (Prozac, Zoloft, Paxil).

RELIEVING HEADACHES IN ADOLESCENTS OVER AGE ELEVEN

After age ten, many boys “outgrow” bad headache spells, and girls end up having headache woes about three times more often than boys do. Both tension and migraine are problems among adolescents.

As children plow their way through the stormy and highly stressful teen years, anxiety and depression become increasingly common. Teenagers feel a lot of stress and pressure, including pressure from and conflicts with parents, peer pressure, anxiety from coping with their new bodies, new kinds of relationships, and new kinds of responsibilities. All these factors can exacerbate headaches. To make matters worse, when headaches are not well controlled, just having the headaches intensifies feelings of stress, anxiety, and depression. Some research suggests that adolescents who get frequent headaches are more likely to be “Type A” personalities—hard-driving perfectionists with quick tempers.

Individual counseling or family therapy can be crucial to improving how a teenager copes with stress and depression, which, in turn, can dramatically relieve the frequency and intensity of headaches. Although many teenagers are reluctant to discuss their problems with parents or physicians, many respond very well to a sympathetic therapist. Adolescents also should be encouraged to learn relaxation techniques, such as deep breathing and biofeedback. Stress is a major trigger in this age range, and looking at stressors is crucial. Many studies have indicated that in adolescence, particularly with daily or frequent tension headaches, there is a high chance of finding anxiety or hidden depression or both. A good psychotherapist can be crucial in helping to improve the situation both through counseling and teaching relaxation techniques.