A Blueprint for Pharmacologic and Nonpharmacologic Approaches

By Susan M. Rowley, NP

Case 1: A 14-year-old boy reports almost daily headaches that are interfering with his sports and band activities. He recalls an onset of headaches 2 years earlier, but at that time the frequency was occasional. He has tried seven medications without achieving adequate management: acetaminophen (Tylenol), Tylenol with codeine, ibuprofen (Motrin, Advil), naproxen sodium (Aleve), sumatriptan (Imitrex), propranolol (Inderal) and feverfew. As an adjunct to medication, he applies cool cloths to his forehead or takes warm baths. He reports that the headaches are worse when he skips meals and when he gets overheated during games. He is a good student, and the headaches have not influenced his grades. For the past 3 months, he has primarily used Tylenol or Advil. He drinks between 24 and 40 ounces of caffeinated beverages each day. Vital signs, height, weight and physical exam all produce normal findings.

This patient's history of using several medications and strategies is quite common. The overuse of medications and caffeine is a key issue, since both substances lead to rebound. Some common confounding factors are also present, such as hunger and thirst. The treatment goals for this patient are to reduce overuse, assist with ongoing healthy lifestyle changes, and identify and develop coping strategies. Background or baseline headache types often emerge after the washout period, when confounding factors are eliminated.

Case 2: A 10-year-old girl reports headaches dating back 8 months, with onset during chickenpox. The headaches have increased in incidence and severity over time, and are worse when she awakens each morning. Vomiting has emerged as a recent coinciding symptom, and headaches worsen with Valsalva and bending over. She reports a recent onset of vision problems. Her grades have dropped. Her body mass index (BMI) is 30. The results of her physical exam are abnormal, with blurred optic disk margins, visual acuity of 20/80 and abnormal deep-tendon reflexes.

This is the presentation we all fear — the rare case of increased intracranial pressure caused by interference or impingement on the pain-sensitive areas of the brain. This patient could have a space-occupying lesion or a pseudotumor cerebri. It is common for an acute illness to be accompanied by headaches (e.g., mononucleosis and influenza). Her case raises several red flags: headache worse in the morning on arising; headache worse with events that increase intracranial pressure; escalating vomiting; visual changes; and a high BMI. This patient requires a careful, thorough examination with appropriate imaging studies for possible brain pathology.

Case 3: A 3-year-old girl has a strong family history of migraine and motion sickness in first- and second-degree relatives. Her parents report that she vomits for several days each month and dehydrates to the point of requiring rehydration in an emergency department. The results of the physical exam are normal. The patient exhibits normal growth and development and no permanent weight problems except transient weight loss at the time of the vomiting.

This is a patient with a known precursor diagnosis for likely eventual migraines. Other precursors include episodic torticollis and benign paroxysmal vertigo of childhood. All are uncommon but possible presenting complaints in a pediatric practice. These should alert you to potential migraines later in life. This patient would benefit from an imaging study of the head, laboratory testing, anti-emetics, conservative headache treatments and referral to a gastroenterology specialist.

Case 4: An 8-year-old girl returns after discontinuing acetaminophen overuse therapy. She received a prescription for concomitant therapy with cyproheptadine (Periactin) for headache prophylaxis and underlying allergies. She now has headaches only once every 2 months, and is alerted to them by warning signs ("funny feeling" in her stomach and visual blurring). She reports no vomiting, but does experience phono- or photophobia and throbbing head pain that subsides with sleep in a dark, quiet room. She takes ibuprofen with caffeinated tea to boost the drug's effect and aid in achieving sleep. She uses imagery to aid initiation of sleep with the headache. She received instruction in abdominal breathing for acute and preventive pain relief and has instituted healthy lifestyle habits including regular, nutritious meals and snacks, adequate hydration and limited intake of caffeinated soda. She proudly reports that she taught abdominal breathing to her classmates when they developed headaches and upset stomachs as a result of a carbon monoxide leak in her classroom. The abdominal breathing helped everyone cope until they were evacuated and treated in the local emergency department.

This actual case demonstrates how well preventive and acute nonpharmacologic and pharmacologic methods can assist in relief from headache's debilitating effects.

Etiology

The brain parenchyma does not register pain, nor does the ependyma or the meninges. Instead, pain is registered in the arteries of the cerebrum, dura and scalp; the veins of the cerebrum; the cervical roots and cranial nerves; the skull muscles; the periosteum and the sinuses — including the nasal, facial and venous sinuses.¹

Headaches are believed to be related to one or more mechanisms of chemical or electrical (excitation) response in these structures. Theories of causation include vascular changes such as dilatation and constriction, nerve irritation (especially of the trigeminal nerve) and alterations in brain chemicals (especially low serotonin). Headache can be caused by direct change in tissue or by impingement on pain-perceiving structures from external forces such as masses or lesions. Chemical alterations may occur as a result of changes in metabolism. Headaches may be idiopathic, but migraine tends to be an autosomal dominant disorder with varying penetrance and specific locus not yet identified.^2,3 Scientists have documented significant verbal performance differences in adults who had migraine, implicating a possible prenatal formational source.⁴

Headaches are intimately intertwined with a number of correlates, such as concomitant illness, hormones, sociodemographics, lifestyle, medication or substance ingestions, and environmental influences.⁵ In children and adolescents, consider general principles of pediatric responses from a physiologic standpoint (dehydration occurs more quickly because of children's larger free water content), a chemical standpoint (chemical balances of sodium, potassium and glucose must be more rigidly maintained for proper brain function) and a developmental perspective (pain response and treatment may be influenced by chronologic or developmental stage).

Occurrence

The overall incidence of headache among children is sporadic. Incidence increases with age, perhaps related to physical changes. It may also be related to the greater ability of older children to articulate head pain and symptoms. Infants and toddlers may experience migraine, but they lack the ability to clearly articulate the pain. They also have more frequent comorbid or precursor diagnoses, such as benign paroxysmal vertigo, cyclic vomiting, episodic torticollis, motion sickness and recurrent vomiting.^6,7 With infants and toddlers, first consider possible associations with infections and increased intracranial pressure. These conditions are more common in younger children. By age 15, three times as many children have frequent non-migrainous headaches as migraine.⁸ By age 3 years, up to 8% of children have reported headaches; by age 5, 20%; and by age 7, more than half have reported headaches.⁹ Headache is one of the most common presenting complaints to emergency departments.¹⁰

Almost 20% of children have migraine compared with up to 13% of adults.¹¹ Girls experience migraine twice as often as boys.¹¹ Classic migraine (with aura) is more common in adults, while common migraine (without aura) is more common in children. Both forms of migraine are more common in girls and women.⁶ Children have more localized pain, nausea and vomiting, and a common precipitant is stress. One-third to two-thirds of children are affected by migraines as adults.

Definition and Terms

Surveys of adults show that more than half who meet International Headache Society criteria for migraine have never been officially diagnosed.¹² The International Headache Society has formalized the definitions of headache to facilitate diagnosis. Although the classification system has been helpful, many of the criteria don't necessarily apply to children, especially the duration criteria.^13,14

In actual practice, headache as a presenting complaint (at least initially) is often of mixed type and causation. Headache complaints are often a mixture of underlying entities such as trauma, acute illness, tension, migraine, sinus problems, chronic daily headaches (CDH), medication overuse, or other substance overuse — with the latter three often representing rebound headaches (Table 1).¹⁵

A diagnosis of mixed or transformed headache is often the most appropriate initial diagnosis in children. In many cases, the underlying, more pure type of headache emerges for chronic management only after appropriate treatment is initiated. Increasing evidence suggests that frequent comorbid emotional and behavioral problems occur in youth with primary headaches.¹⁶ The most common are depression, anxiety and somatization.¹⁷ Depression and addictive personality characteristics are surfacing in patients whose chronic headache pattern continues into adulthood, placing responsibility on providers to diagnose early to prevent complications and chronic dysfunction later in life.⁷

The least common type of headache in children is the one most feared: that associated with intracranial lesions or disease. Somewhat more common is the headache associated with viral illnesses or disorders of facial structures, teeth, vision and sinuses. The most common are tension headaches, psychogenic headaches, migraines and combination headaches, especially CDH and medication overuse headaches (MOH).

The most common types of headaches in youth may fit some of the definitions set by the Headache Classification Committee of the International Headache Society (Table 2).¹⁸ If the characteristics are present, diagnosis of the specific type can be made. Pediatric variations from established headache criteria center around the issues of duration, unilateral versus bilateral pain, pain intensity and nature, whether to include phonophobia and photophobia, and whether one criteria is enough.⁸

Therapeutic phases of migraine in adults have been identified, along with treatment strategies that address specific stages of headache.¹⁹ If better delineation of stages is made for children, therapy may be more finely tuned for better intervention at specific stages. However, children often wait to alert adults to their headache. Or, they have difficulty articulating the prodrome or even the headache itself. Many children do not want to interrupt activities to deal with their headaches until well into the event, making early intervention difficult.

Evaluation

Begin the evaluation by gathering a thorough history of the chief complaint. Multiple tools are available, but many are based on adult information. Your own tool or a preprinted tool is helpful as long as you assess for the items listed in Table 3. The intensity of headache pain may neither be helpful nor related to the seriousness of the problem. Pain associated with tumors may be mild, and pain secondary to vasodilatation may be severe and throbbing. A positive family history is reassuring.

Next perform a thorough review of systems. Headaches associated with acute illness, meningitis, intracranial lesions or systemic illness may come to light with this review. Investigate what is known about possible correlated systems.

Gather a thorough past medical history, including neurologic factors. Note the type and severity of any past head injuries as well as antecedent head injuries or illnesses correlated with the onset of the headaches. Pay particular attention to concussion, open head injury, injury associated with recurrent vomiting, loss of consciousness, amnesia or confusion, and persistent headache.

Known precipitating factors of headache are psychological factors or stressors; physical exertion; head trauma; hormonal changes; motion sickness; upper respiratory tract infection; viral illnesses; and certain foods, environmental exposures or substances. Table 4 lists common food triggers. In girls, ask whether the headaches are associated with menstruation. Ask about caffeine and drug use, including tobacco and herbal products. How much medication does the patient use acutely and how long has he or she done so? Such medications may include the NSAIDs, the triptans, mixed preparations such as Excedrin migraine, Tylenol with codeine, isometheptene-dichloralphenazone-acetaminophen (Midrin) or the ergotamines. Is the patient going to the emergency department for narcotic injections or using anti-emetics? If the patient is using any of these strategies more than twice a week for weeks to months, the picture is complicated by rebound.^20,21

Review the family history carefully, noting any genetic predilection for headaches, motion sickness or other possible neurologic correlates.

A complete physical exam is imperative, especially in the new patient. More than 98% of children with brain tumors have objective neurologic findings.²² The most frequent abnormalities indicative of serious intracranial pathology are altered mental status, abnormal eye movements, optic disc distortion, motor or sensory asymmetry, coordination disturbances, and abnormal deep tendon reflexes.²² Exam findings will be normal if the patient is not experiencing headache at the time and if no serious underlying pathology is present.

If the patient is having a headache, this is a good opportunity to ascertain whether the demeanor of pain matches the complaint. Have the patient rate the pain using a pain scale and document any relief interventions used.

Check for altered vital signs indicative of pain, such as increased heart rate, blood pressure and respiratory rate. Does the patient wish for a dark, quiet environment? Does he or she display discomfort or refuse to perform some of the requested physical exam tasks, such as hopping during the neurologic exam? In addition to general examination markers, record or perform the following:

• height and weight

• head circumference, palpation and shape

• auscultation of the head for cranial bruits

• vital signs, especially temperature and blood pressure

• ectoderm derivatives: skin, hair, ears and nails (these form from the ectoderm in the fetus, as does the brain, giving clues to possible neurocutaneous disorders)

• movement of the head and neck

• visual acuity and visual fields

• neurologic exam including mental status, cranial nerves, sensation, tone, strength, reflexes and cerebellum findings

Palpate and percuss the sinuses and palpate the lymph nodes, thyroid and jaws — especially at the temperomandibular joint. Inspect the teeth.

Perform the examination carefully to rule out or identify concerning etiology or etiologies that warrant further investigation or alternative therapy in addition to headache management. The following are concerning problems to rule out:

• hypertension

• anemia

• abnormal thyroid function

• increased intracranial pressure, especially pseudotumor cerebri and hydrocephalus

• shunt malfunction (if shunt is present)

• hemorrhage

• stroke

• tumor or masses

• glaucoma

• toxins, especially lead and carbon monoxide

• infections, especially meningitis, encephalitis, sinusitis, pharyngitis, brain, dental or mastoid abscesses

• substance abuse.^22,23

To further delineate and assess the above etiologies, consider laboratory testing and neuroimaging. Consideration of cost versus yield would be advantageous, but once the following tests are performed, they may not need to be repeated and may identify correlates or causative factors amenable to simple interventions, saving morbidity and cost in the long run. For instance, identified low glucose, hemoglobin or hematocrit lends more motivation to good nutrition to avoid headaches. Lab tests to consider include the following:

• CBC (to look for anemia, infections); consider sedimentation rate or other indications if you suspect infection

• chemistry profile (chemicals the brain needs to function optimally)

• thyroid function (free T₄ and TSH)

• lead levels

• electrocardiogram if you are considering ergotamines, triptans or tricyclic antidepressants, to rule out underlying cardiac abnormalities that may contradict their use

• others as defined by history and exam.

In my experience, the most frequent lab abnormalities found with screening are low hemoglobin or hematocrit, low glucose and abnormal thyroid function. Lead levels are rarely elevated, but given national guidelines, it is prudent to investigate. Correction of the common abnormalities with improved nutrition or endocrine intervention (if persistent and necessary) often assists headache treatment and relief.

With regard to brain imaging with computed tomography (CT) or magnetic resonance imaging (MRI), red flags have been identified in a practice parameter published by the American Academy of Neurology and the Practice Committee of the Child Neurology Society in 2002. The expert panel stated that obtaining a CT or MRI on a routine basis is not indicated in children with recurrent headaches and a normal neurologic examination. Brain imaging should be considered, however, in children who

• have an abnormal neurologic examination

• have seizures

• have both headaches and seizures

• have recent severe headaches

• have a change in headache type

• have associated features suggestive of neurologic dysfunction.²⁴

The panel also concluded that electroencephalography is not particularly helpful and therefore not recommended.²⁴ By the time a child or teen presents for headache evaluation, headache has often worsened in severity or frequency or caused recent academic or behavior change.²⁵ This worsening lends support to the use of imaging studies. Consider referral if the following are present, since they are also red flags for more serious etiology:

• early-morning headache or headache that awakens patient from sleep

• worsening severity or frequency of headache

• headache worse with Valsalva or position changes that change intracranial pressure factors

• headache with vomiting (no nausea first)

• growth chart plateau or decline

• recent academic decline

• significant behavior change

• new onset seizures, especially focal seizures

• seizures associated with headaches

• abnormal neurologic exam.

If imaging turns out to be prudent, the best methods are CT for an urgent case to rule out stroke, increased intracranial pressure or for suspected bony abnormalities such as a fracture; CT with contrast for blood-brain barrier concerns, masses, edema, arteriovenous malformation or inflammation; or an MRI without gadolinium.

An MRI would be the preferred modality for nonurgent cases to visualize structure of soft tissue, brain, bone, sinuses and blood vessels, as well as brain formation and maturation.²⁵ Obviously, any significant abnormalities would require appropriate intervention — in addition to pain relief. A meta-analysis of patients with normal exam and migraine found significant intracranial lesions in two of 1,000 patients (0.18%), but many children do not fit strict definitions and a lower threshold for neuroimaging is appropriate in such cases.²⁶

Lumbar puncture is warranted if papilledema is present, to rule out or aid diagnosis and treatment of pseudotumor cerebri or if meningitis or encephalitis is a concern. Lumbar puncture usually involves referral, possible or probable hospitalization, and a prior imaging study to assess for a mass lesion that may cause herniation risk if the lumbar puncture were performed first.

Treatment Options

If you identify a concerning pathology, prescribe or refer for the most appropriate intervention. If you conclude that the patient's symptoms are a result of primary headache or benign underlying pathology, the goal is control and amelioration. Educate the patient and caregiver about the cause and that no serious pathology is present. This may be the most important therapeutic intervention.²²

Treatment for benign headache consists of prevention as well as acute treatments. Both can be delivered using pharmacologic and nonpharmacologic means, and a combination of the two is usually the most beneficial.

Prevention

Prevention strategies center around healthy lifestyle choices. Patients need adequate hydration and minimal caffeinated and sugared beverages to avoid glucose and insulin swings.²⁰ Thirst indicates a deficiency in fluid intake and the goal should be to drink enough to avoid thirst. Encourage nutritious meals and snacks on a regular basis. A headache trigger for many growing children is hunger or missed meals. Encourage protein and carbohydrate in combination because of the brain's heavy reliance on a steady glucose source.

Provide a note for school, if necessary, to allow such patients to carry water bottles and snacks. For patients who are particularly sensitive to heat or atmospheric changes, write a note to the physical education teacher requesting modification of physical activity during hot weather. Strongly encourage aerobic activity to promote endorphin release and decrease stress hormones.

The use of stress management and relaxation techniques can also increase endorphin release and help with the mind chatter that accompanies pain. Initial studies of thermoregulation biofeedback show that two-thirds of children experienced a 50% reduction in headache with this therapy.²⁷

Other stress management and relaxation modalities, such as guided imagery, can reduce the incidence of headaches and decrease their severity when used in addition to individualized headache theapy.^22,28 Once learned, such techniques can promote healthy adaptation to many of life's stressors.

In my practice, I teach stress management and relaxation techniques and emphasize that each patient needs to find the method that will work for him or her for the long term. I teach abdominal breathing and imagery to children younger than 10 or 12, and I add progressive relaxation for adolescents older than 12. Abdominal breathing can be performed while seated and without others noticing.

Relaxation techniques are often therapeutic because they aid restful sleep. And performing stress management and relaxation techniques for 10 to 12 minutes each day can have a preventive effect by promoting increased endorphins and decreased cortisol.

Headaches are among the chronic conditions for which patients are most likely to use alternative therapies.29 There is some evidence that acupuncture is useful, but children are not the best candidates for it because of perceived pain from needle insertion. Feverfew, evening primrose oil, omega 3 fatty acids, hawthorn, valerian, peppermint, angelica, balm mint, lavender, chamomile, skullcap, violet flowers and white willow bark all show inconsistent results in adults.³⁰ Vitamins and supplements have produced mixed results in studies.⁵ Physical therapy, ultrasound and electrical stimulation have been used, but electrical stimulation may have limited use in children, who may be reluctant to try it because of fear of pain. Energy modalities such as healing touch and Reiki are sometimes used, and chiropractic is another option some families pursue. Families try whatever modality they believe may help without causing harm. Always ask about the use of complementary therapies.

Many patients, especially adolescent girls, may also need evaluation for comorbidities (depression, anxiety, somatization) or hormonal adjustment. Medications to block prostaglandin release, such as the NSAIDs, may be helpful intermittently, particularly around the time of menses. A gynecologic referral may be appropriate for hormone management.

Patients with psychological comorbidities often require antidepressant or anticonvulsant therapy for headache prophylaxis, with the caveat that antidepressants must be carefully stored and use tracked to avoid suicidal overdose risk. Antidepressants can help significantly with sleep. Pregnant patients generally should avoid any medications and use behavioral therapy and other nonpharmacologic therapies.³¹

Currently available prophylactic medications have been studied for other chronic conditions and coincidentally relieved headaches. These medications fall into the broad categories of beta blockers, calcium channel blockers, antihistamines, antidepressants and anti-seizure medications.

Consider preventive medication when severe headaches are interfering with life or school, when headaches occur more than twice a month, or in a rebound or chronic daily headache scenario. Some preventive medications will not work until the medication overuse has been stopped for weeks to months.

Consider prophylaxis for a trial of 4 to 6 months, rather than forever. Many parents and children object to taking a daily medication indefinitely for a benign condition. There is some evidence that a significant percentage of patients can stop medication after the trial period and not need it again — or at least for a significant amount of time. A hiatus from therapy is often preferred by some families.

Use caution with pregnancy risk since some drugs fall in category C or worse. Most preventive medications do not have an FDA indication for children younger than 12 to 16, but use is documented in the literature. In addition to the literature guidance, rely on what your experience has taught you to be reasonable and safe.

When used for headache prophylaxis, most medications can be given at bedtime only — and most can also be given in much lower doses than that used for their primary indications. The goal is to decrease headache incidence and severity with no medication side effects. "Start low and go slow" is generally good advice.

To break a cycle of medication overuse or chronic headaches, intravenous dihydroergotamine (DHE) may be needed. Oral steroids in a short burst and taper may allow transition to relief from the preventive medication without overusing acute medications.

Caffeine should be slowly tapered if it has been used in large quantity, allowing its later potential use to boost acute medications. Oral amitriptyline (Elavil) is one prevention agent that seems especially helpful with rebound situations and may be initiated with or without steroids while the targeted overuse is addressed.1 Prepare patients and parents for some difficulty with discontinuation so that they avoid getting back in the cycle of medication or caffeine overuse. Healthy lifestyle changes, stress management, counseling or other support methods are essential during this period.

Patients who successfully wean themselves from medication or caffiene overuse often feel so much better that they recognize the benefit of healthy life choices. Reiterating the difference between prophylaxis and acute interventions aids this process.

Table 5 outlines the more common preventive headache medications.

Acute Treatment

Interventions for acute management include nonpharmacologic and pharmacologic strategies. Many people can achieve relief by falling asleep in a dark, quiet room. A cool cloth, warm bath or gentle scalp massage can also be helpful. Stress management and relaxation techniques can aid sleep by managing pain for the 10 to 20 minutes until medications can begin to take effect.

Medications for acute treatment of headache also have some general parameters for guidance. Most prescription medications are not FDA-approved for use in children or teens, but their use is supported in the child neurology and neurology literature. Most of the medications are category C for pregnancy, but the ergots are in category X. Studies of adults have documented long-term addictive tendencies in headache patients, especially those who have used narcotics. Minimize their use since other options are available.

The family practice literature largely supports the use of NSAIDs as a first-line trial, while the child neurology literature largely supports use of the triptans first.

If the patient needs acute medication (or its recommended series of doses) more than twice per week, rebound is likely and preventive medications will likely be ineffective.

Write a note to the patient's school or day care setting to explain that he or she may need to leave class, see the school nurse, take medications, or have water, snacks or caffeine. Caffeine overuse leads to rebound and headaches, but if reserved only for the use with severe headaches and acute medication, it can boost the effect of the medication.

Some patients may also need an anti-emetic. Promethazine (Phenergan) can be used down to age 2 years, but use caution when the patient has asthma. Trimethobenzamide (Tigan) is a better choice in that instance. Both are generally given as a suppository. As an alternative, try herbal remedies of ginger or chamomile. Crystallized ginger is most palatable if one or two cubes are chewed (overuse can cause gastrointestinal upset); the tea can be bitter. Chamomile tea is generally palatable and gentle. All anti-emetics work best when given prior to vomiting. Some patients prefer to allow the vomiting because they feel better afterward.

Table 6 outlines commonly used medications for acute relief. Acute therapies may be effective for varying periods of time. A general rule of thumb is to only change prescriptions when a category is not working or side effects are perceived as intolerable. However, one classification may be unsuccessful at one point and successful later when co-existing factors are removed.

Most therapy trials are measured in weeks and more likely months, so patience is needed. Schedule visits once per month or every several months while the problem is acute. Once the condition has stabilized, semiannual or yearly visits may be adequate. Encourage patients and families to alert you if headaches are escalating, severe, or any dysfunction in physical, emotional or mental abilities emerge. All should prompt a re-evaluation of the etiology and treatment plan.

In summary, the documented best response to the long-term management of headache is to couple medication with nonpharmacologic interventions such as lifestyle change, relaxation and stress management. Include both preventive and acute management strategies. Nurse practitioners are wonderfully positioned to ameliorate the disruption that headaches cause and assist with long-term coping strategies and healthy lifestyle choices that will improve headaches as well as overall quality of life and health.

References

1. Fenichel GM. Headache. In: Clinical Pediatric Neurology. 4^th ed. Philadelphia: W.B. Saunders; 2001.

2. Aktar ND, Murray MA, Rothner AD. Status migrainous in children and adolescents. Semin Pediatr Neurol. 2001;8:27-33.

3. Aligne CA. Headaches, recurrent: migraine & others. In: Garfunkel LC, Kaczorowski J, Christy C (eds). Mosby's Pediatric Clinical Advisor: Instant Diagnosis and Treatment. St. Louis: Mosby Inc.; 2002.

4. Waldie KE, et al. Migraine and cognitive function: a life-course study. Neurology. 2002;59:904-908.

5. Lin J. Overview of migraine. Journal of Neuroscience Nursing. 2001;33:6-13.

6. Sheveli H. A guide to migraine equivalents. Contemporary Pediatrics. 1998;15:71.

7. Rothner AD. Complicated migraine and migraine variants. Semin Pediatr Neurol. 2001;8(1):7-12.

8. Rothner AD. Headaches in children and adolescents: update 2001. Semin Pediatr Neurol. 2001;8:2-6.

9. Rothner AD, Linder SL, Wasiewski WW, O'Neill KM. Chronic nonprogressive headaches in children and adolescents. Semin Pediatr Neurol. 2001;8:34-39.

10. Lewis DW. Headache in the pediatric emergency department, Semin Pediatr Neurol. 2001;8:46-51.

11. The International Classification of Headache Disorders, 2^nd ed. Cephalalgia. 2004;24(Suppl 1):24-49.

12. Lipton RB, et al. Self-awareness of migraine: interpreting the labels that headache sufferers apply to their headaches. Neurology. 2002;58(Suppl 6):S21-S26.

13. Laurel K, Larsson B, Eeg-Olofsson O. Headache in schoolchildren: agreement between different sources of information. Cephalagia. 2003;23(6):420-428.

14. Gladstein J. Children and adolescents with chronic daily headache. Current Pain & Headache Reports. 2004;8(1):71-75.

15. Li D, Rozen TD. The clinical characteristics of new daily persistent headache. Cephalalgia. 2002;22:66-69.

16. Just U, Oelkers R, Bender S, et al. Emotional and behavioural problems in children and adolescents with primary headache. Cephalalgia. 2003;23(3):206-213.

17. Lipton RB, et al. Diagnostic lessons from the Spectrum Study. Neurology. 2002;58(Suppl 6):S27-S31.

18. Oleson J. The International Classification of Headache Disorders. Headache Classification Committee of the International Headache Society. Cephalagia. 2004;24(suppl 1):1-151.

19. Cady R. Better, faster therapies for migraine headache. Clinical Advisor. 2004;7(7):21-30.

20. Glassroth CH. Successful migraine management. Clinician Reviews. 2004;14(5):56-61.

21. Hering-Hanit R, Gadoth N. Caffeine-induced headache in children and adolescents. Cephalalgia. 2003;23:332-335.

22. Lewis DW. Headaches in children and adolescents. American Family Physician. 2002;65(4):625-632.

23. Polin RA, Ditmar MF, eds. Headache. In: Pediatric Secrets. 3^rd ed. Philadelphia: Hanley & Belfus Inc.; 2001:535-537, 2001.

24. Lewis DW, Ashwal S, Dahl G, et al. 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. 2002;59(4):490-498.

25. Halsam RHA. Migraine headache. In: Behrman RE, et al. Nelson Textbook of Pediatrics. 16^th ed. Philadelphia: W.B. Saunders; 2000.

26. Halsted M, Jones B. Pediatric neuroimaging for the pediatrician. Pediatric Annals. 2002;31:661-670.

27. Allen K. Using biofeedback to make childhood headaches less of a pain. Pediatric Annals. 2004;33(4):241-245.

28. Mannix LK, Chandurkar RS, Rybicki LA, et al. Effect of guided imagery on quality of life for patients with chronic tension-type headache. Headache. 1999;May:326-334.

29. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997. JAMA. 1998;280(18):1569-1575.

30. Rotblatt M, Zikment I. Evidence-Based Herbal Medicine. Philadelphia: Hanley and Belfus Inc.; 2002.

31. Whyte JJ, Winchell B. Diagnosing and Managing Headaches. Continuing Education for Iowa Nurses 2004. Sacramento, Calif.: CME Resource; 2004.

Susan Rowley is a pediatric nurse practitioner at Blank Children's Hospital in Des Moines, Iowa. She practices in the hospital's outpatient pediatric neurology clinic, as well as in school-based health and community clinics operated by the hospital. She is a member of the board of directors for the National Assembly on School-Based Health Care