CHICAGO—Child neurologists differ in their approach to diagnosing and managing posttraumatic headache, according to survey results presented at the 47th Annual Meeting of the Child Neurology Society.
Dr. Rachel Pearson
For example, practice differs as to when posttraumatic headaches are considered persistent and when to recommend preventive therapy.
“As there are no established guidelines on management of posttraumatic headache, it is not surprising that diagnosis and management vary considerably,” said Rachel Pearson, MD, a child neurology resident at Children’s Hospital of Orange County in Orange, California, and colleagues. “Further studies are needed to define the best evidence-based practices for pediatric posttraumatic headache.”
Research indicates that about 7% of children ages 3 to 17 experience a significant head injury, and headache is the most common postconcussive symptom. Headache persists at three months in as much as 43% of cases, according to current studies. To better understand the current clinical practices of child neurologists in the diagnosis and treatment of posttraumatic headache, Dr. Pearson and colleagues sent all active, nonresident members of the Child Neurology Society a link to an online survey. The survey covered diagnosis, management, and return-to-play guidelines. Ninety-five members responded to the survey.
Persistence Threshold: Four Weeks or Three Months?
Although 39% of respondents reported that they always use ICHD diagnostic criteria to diagnose posttraumatic headache, and 31% sometimes use ICHD criteria, “only 19% of respondents correctly defined persistent posttraumatic headache per ICHD diagnostic criteria” as lasting more than three months, the researchers said. “The largest number of participants considered posttraumatic headache to be persistent at four weeks,” they said. “This may have implications for when prophylactic headache medications are considered.”
More than 90% recommend NSAIDs as abortive therapy. One-third consider starting preventive headache therapy within one month, and one-third between one and two months.
The most commonly used preventive medications are amitriptyline and nortriptyline (93.7%) and topiramate (71.6%). Amitriptyline and nortriptyline may be widely used because they “can also address other postconcussive symptoms, such as sleep or mood disturbance,” the investigators noted.
Treatment Options
In addition, 59% of providers use vitamins and supplements (eg, magnesium, riboflavin, melatonin, and CoQ10) as preventive treatments. “These are considered generally safe and have few adverse effects,” and “families may prefer these treatment options as they are perceived as ‘natural,’” Dr. Pearson and colleagues said. More than half of respondents use nonmedicinal therapies such as physical therapy, pain-focused cognitive behavioral therapy, and biofeedback.
Thirty-eight percent use injection-based therapies (eg, nerve blocks, botulinum toxin, and trigger point injections), and 14% of providers administer injections themselves.
One-third of respondents recommend cognitive and physical rest for one to three days, followed by a progressive return to activities, consistent with evidence-based recommendations. Approximately one-third advise patients to rest for seven to 14 days before returning to play.
“As a whole, these findings can guide additional research in this area and serve as a platform on which to base future randomized controlled trials,” said Dr. Pearson and colleagues.
—Jake Remaly
Suggested Reading
Blume HK, Vavilala MS, Jaffe KM, et al. Headache after pediatric traumatic brain injury: a cohort study. Pediatrics. 2012;129(1):e31-e39.
Blume HK. Headaches after concussion in pediatrics: a review. Curr Pain Headache Rep. 2015;19(9):42.
Choe MC, Blume HK. Pediatric posttraumatic headache: a review. J Child Neurol. 2016;31(1): 76-85.