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Headache Assessment and Treatment - Pediatric - Ambulatory/Emergency Department

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1
Headache Assessment and Treatment –
Pediatric –
Ambulatory/Emergency Department
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................................................... 3
SCOPE .................................................................................................................................................................... 3
METHODOLOGY ..................................................................................................................................................... 4
DEFINITIONS .......................................................................................................................................................... 5
INTRODUCTION ..................................................................................................................................................... 5
RECOMMENDATIONS ............................................................................................................................................ 6
EVALUATION ................................................................................................................................................................. 6
PRIMARY CARE TREATMENT OF HEADACHES AND MIGRAINE .................................................................................................. 7
MIGRAINE TREATMENT FOR PEDIATRIC PATIENTS IN THE EMERGENCY DEPARTMENT OR INFUSION SETTING ..................................... 8
PREVENTIVE THERAPY ..................................................................................................................................................... 9
Non-pharmacologic interventions ...................................................................................................................... 10
Pharmacologic prophylaxis of migraine .............................................................................................................. 10
UW HEALTH IMPLEMENTATION ........................................................................................................................... 12
TABLE 1. PRIMARY CARE TREATMENT- PHARMACOLOGIC TREATMENT OF MIGRAINE ........................................ 14
TABLE 2. ABORTIVE MEDICATIONS FOR MIGRAINE IN EMERGENCY DEPARTMENT/INFUSION SETTING .............. 15
TABLE 3. PHARMACOLOGIC OPTIONS FOR MIGRAINE PROPHYLAXIS ................................................................... 16
APPENDIX A. EVIDENCE GRADING SCHEME(S) ..................................................................................................... 17
APPENDIX B. PEDIATRIC EMERGENCY DEPARTMENT HEADACHE/MIGRAINE MANAGEMENT ALGORITHM ........ 19
APPENDIX C. PEDIATRIC HEADACHE DIARY EXAMPLE 1 ...................................................................................... 20
APPENDIX D. PEDIATRIC HEADACHE DIARY EXAMPLE 2 ...................................................................................... 21
REFERENCES ......................................................................................................................................................... 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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2
Contact for Content:
Name: Meredith Schultz, MD – Pediatric Neurology
Phone Number: (608) 890-6500
Email Address: mschultz@neurology.wisc.edu
Contact for Changes:
Name: Katherine Le, PharmD – Center for Clinical Knowledge Management
Phone Number: (608) 890-5898
Email Address: kle@uwhleath.org
Coordinating Team Members:
Michael Kim, MD – Emergency Medicine
Mary Jean Erschen-Cooke, RN – Emergency Medicine
Alana Winchel, RN – Pediatrics
Cassandra Meffert, PA – Pediatric Neurology
Elaine Rosenblatt, NP – Unity Health Insurance
David T. Bernhardt, MD – Pediatrics
Alison Miller, MD – Family Medicine
Megan Weimer, NP- Group Health Cooperative
Josh Vanderloo, PharmD- Drug Policy
Mary Anne Long, RN- Quality Care
Jeffrey Royce, MD- Swedish American Hospital
Review Individuals/Bodies:
Megan Kroll, PharmD- Pediatric Pharmacy
Heather LaRue, PharmD- Pediatric Pharmacy
Jessica Poehls, PharmD- Pediatric Pharmacy
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 3/23/17)
Release Date: March 2017 | Next Review Date: April 2019
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3
Executive Summary
Guideline Overview
The purpose of treating headache is to provide relief of symptoms, reduce patients’ disability
due to headache and to reduce patient reliance on Emergency Department/Urgent Care for
headache management. This guideline has been developed to assist in the assessment and
treatment of pediatric headaches. The recommendations include abortive therapy, preventive
therapy and lifestyle modifications.
Key Revisions (2017 Periodic Review)
1. Expanded section on evaluation of headache with recommendations on when to image and
when to seek headache specialist
2. Expanded discussion on primary treatment and emergency department treatment of
migraines including updating drug class information for treatment options and creation of
Emergency Department headache/migraine treatment pathway algorithm
3. Emphasized recommendation against opioids for migraine treatment
4. Expanded discussion on non-pharmacologic and pharmacologic interventions for prevention
of migraine
Key Practice Recommendations (2017 Periodic Review)
1. A detailed history of the headache should be obtained including the circumstances and
onset of the pain, its character and severity, its location, accompanying symptoms,
precipitating factors, relief measures, and degree of impairment. Asking the patient how
long they have had headaches can be helpful in identifying the difference between a primary
and secondary headache. The Pediatric Migraine Disability Assessment (PedMIDAS)
questionnaire is a developmentally sensitive, validated tool that can be used to assess the
impact of migraine headaches on a child’s life and monitor response to treatment.
2. A medical history should be obtained from the child and parent including patient’s past
medical history, family history of headaches in first and second-degree relatives and
relevant social history (e.g. changes or stressors in home, school or extracurricular
environments.)
3. According to the American College of Radiology (ACR) Appropriateness Criteria, the
American Academy of Neurology, and the Practice Committee of the Child Neurology
Society, radiographic imaging is not recommended for chronic or recurrent primary
headache (including migraine without permanent neurologic signs or signs of increased
4. If the patient’s headache pain cannot be controlled accordingly by his or her headache
treatment plan or other at home treatments, it is recommended that medical care be sought.
5. Ibuprofen is recommended by the AAN as first line treatment for the acute treatment of
migraine in children.
6. It is strongly recommended to educate parents and children on the importance of
incorporating non-pharmacologic interventions into daily lifestyle to improve acute treatment
and management of headache outcomes.
7. It is strongly recommended that parents and patients be counseled appropriately on
migraine medication, both prophylactic and abortive therapies.
Companion Documents
1. Pediatric Migraine Disability Assessment (PedMIDAS) (301822-DT)
2. Pediatric Emergency Department (ED) Headache/Migraine Management Algorithm
Scope
Disease/Condition(s): Migraine, Headache
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4
Clinical Specialty: Pediatrics, Family Medicine, Neurology, Emergency Medicine
Intended Users: Primary Care Physicians, Speciality Care Physicians, Emergency Department
Physicians, Advance Practice Providers, Pharmacists
Objective(s): To provide an evidence-based guideline that assists clinicians in the evaluation
and treatment management of pediatric patients with migraine and headaches.
Target Population: Pediatric patients 17 years or younger
Interventions and Practices Considered:
1. Non-pharmacologic therapies for treatment and prophylaxis
2. Pharmacotherapy for treatment and prophylaxis
3. Factors related to lifestyle behaviors and possible triggers
Major Outcomes Considered:
1. Relief of migraine and headache symptoms
2. Reduction of migraine-associated disability
3. Reduction of frequency of recurrent migraines and headaches
4. Reduced patient reliance on Emergency Department/Urgent Care and non-scheduled
visits
5. Increased usage of preventive therapies and prophylactic medications for frequent
migraine and headache sufferers
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).
Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.
Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).
Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.
Recognition of Potential Health Care Disparities: None identified
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Definitions
Primary headache is a headache that is due directly from a neurological basis and not caused
by another medical condition.
Abortive medication is a pharmacologic treatment taken at the first sign of an impending
migraine and works to stop the migraine process itself.
Introduction
The two most common types of primary headaches that children experience are tension type
headache and migraine. It is estimated that the incidence of tension-type headaches in the
general pediatric population varies from 10-25% whereas pediatric migraine occurs in 5%-10%
of children.
1-3

Migraines can occur in children at a very young age, including children under 5 years old.
4
The
prevalence is somewhat higher in boys than in girls until the age of menarche, when the
prevalence in girls becomes higher.
5
Compared to adults, pediatric migraine features may
include bilateral pain, frontal in location with the duration of pain lasting less than 2 hours.
Parents may observe other behavioral characteristics such as nausea, vomiting, osmophobia,
and photophobia, especially in young children.
Tension-type headaches are typically milder than migraines and can be further sub-divided
based on frequency of headache. Tension-type headaches tend to be diffuse in location, have a
pressing quality and occur late in the day.
3,6
These headaches also are not worsened or
aggravated by physical activity.
7

Headache treatment is directed at pain relief and relief of nausea and vomiting if necessary.
8

For many patients, a period of sleep will completely relieve the headache. Prophylactic
therapies may be considered if headaches, especially migraines are frequent or severe; the
goal of prophylactic treatment is a reduction in frequency and/or severity of headaches as
complete prevention of headaches may not be possible.
9

International Headache Society Diagnostic Criteria of Primary Headache
10
Migraine headache
5 or more headache attacks, each attack lasting 4-72 hours if untreated
Any 2 of the following:
• unilateral
• pulsatile
• moderate to severe intensity (the most important differentiation from tension headache)
• worse with exertion
And at least one of the following:
• nausea and/or vomiting
• photo and phonophobia
Secondary headache types not suggested or confirmed
Migraine headache in children and adolescents (age under 18 years) is more often bilateral than is the case in adults;
unilateral pain usually emerges in late adolescence or early adult life. Migraine headache is usually frontotemporal.
Occipital headache in children is rare and calls for diagnostic caution. A subset of otherwise typical patients have
facial location of pain, which is called “facial migraine” in the literature; there is no evidence that these patients form a
separate subgroup of migraine patients. In young children, photophobia and phonophobia may be inferred from their
behavior. Migraine attacks can be associated with cranial autonomic symptoms and symptoms of cutaneous
allodynia.
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6
International Headache Society Diagnostic Criteria of Primary Headache
10

Tension-type Headache
Patients with this disorder (in the absence of other headache types) typically self-medicate, without the advice or
assistance of a care provider.
At least 2 of the following pain characteristics:
• rhinorrhea (runny nose) facial sweating
• miosis (smaller pupil)
• pressing (non-pulsating) quality
• mild or moderate intensity (may inhibit, but does not prohibit activities)
• bilateral location
• no aggravation by walking stairs or similar routine physical activity
None of the following:
• nausea or vomiting
• photophobia or phonophobia
Secondary headache types not suggested or confirmed
Medication-overuse headache
Headache occurring on ≥15 days per month in a patient with a pre-existing headache disorder as a consequence of
regular overuse >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of
headache
Cluster headache
Severe unilateral pain in the orbit and/or surrounding areas lasting 15-180 minutes untreated
Headache is associated with at least one of the following signs on the side of the pain:
• conjunctival injection (reddened eyeball), lacrimation (excessive tears from the eye), nasal congestion (stuffy
nose)
• rhinorrhea (runny nose) facial sweating
• miosis (smaller pupil)
• ptosis (lowered upper eyelid)
• eyelid edema (lid becomes puffy)
Frequency of attacks: from 1 every other day to 8 per day
Restlessness; need to keep moving
Secondary headache types neither suggested nor confirmed
Recommendations
Evaluation
The initial evaluation of a child who presents with an acute severe headache or who has a
history of headaches and presents with an acute exacerbation includes assessment for nuchal
rigidity, focal neurologic signs or an altered level of consciousness and any indications that an
infection, intracranial hemorrhage or a mass might be responsible for the headache.
9
Other
indicators of acute neurological problems include fever, elevated blood pressure, papilledema
and retinal hemorrhages. A general physical examination should follow.

Particular attention should be paid to headaches that are unusually intense compared to the
patient’s usual headaches, headaches that are unresponsive to treatment, headaches that
occur in the morning with persistent vomiting and recurrent localized headaches.
11
Headaches
with a sudden onset of severe intensity, commonly referred to as a “thunderclap headache”
should be treated as a clinical emergency.
12


Headache red flags
13

• Head trauma
• Toxic exposure
• Presence of a shunt
• Skin findings (e.g. café au lait spots, petechiae,
hypopigmentation)

• Systemic symptoms of fever, weight loss
• Neurologic deficits, altered consciousness
• Sudden onset, abrupt or split second
(“thunderclap”)
• Previous headache history is different or there is
a significant change to headache

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7
A detailed history of the headache should be obtained including the circumstances and onset of
the pain, its character and severity, its location, accompanying symptoms, precipitating factors,
relief measures, and degree of impairment. Asking the patient how long they have had
headaches can be helpful in identifying the difference between a primary and secondary
headache. If there is a history of headaches, then the chance of a primary, recurrent headache
is more likely.
7
The Pediatric Migraine Disability Assessment (PedMIDAS) questionnaire is a
developmentally sensitive, validated tool that can be used to assess the impact of migraine
headaches on a child’s life and monitor response to treatment.
6,14


A medical history should be obtained from the child and parent including patient’s past medical
history, family history of headaches in first and second-degree relatives and relevant social
history (e.g. changes or stressors in home, school or extracurricular environments.) A private
interview with the patient may be appropriate especially if needed to determine whether there is
physical, emotional, or sexual abuse present in the child’s life.
15


Imaging for headaches
According to the American College of Radiology (ACR) Appropriateness Criteria, the American
Academy of Neurology, and the Practice Committee of the Child Neurology Society,
radiographic imaging is not recommended for chronic or recurrent primary headache (including
migraine without permanent neurologic signs or signs of increased intracranial pressure.)
7,16

(UW Health GRADE Low quality of evidence, weak/conditional recommendation)

Neuroimaging is recommended for headaches with signs of increased intracranial pressure or
positive neurological signs, severe headache suggestive of vascular rupture, headaches that do
not meet primary headache criteria, and headaches in the presence of systemic symptoms
including but not limited to, fever and nuchal rigidity.
7
(UW Health GRADE Moderate quality of
evidence, strong recommendation)

When to refer to a headache specialist
12

A referral to a headache specialist may be advised if (UW Health GRADE Very low quality of
evidence, weak/conditional recommendation):
• headache with slow progression over time
• daily headache
• establish a specific headache type diagnosis
• significant disability from headache
• school absenteeism from headache
• failed preventive treatment
• diagnostic uncertainty of headache
• the parent requests for either consultation or magnetic resonance imaging (MRI) that
may/may not be necessary by provider.
Primary Care Treatment of Headaches and Migraine
A patient suffering from an acute migraine should be put in a dark, quiet area to avoid
stimulation and sleep is encouraged.
17,18
If vomiting has been frequent or if dehydration has
occurred, it is important to rehydrate the patient.
19
Patients should be encouraged to use
relaxation techniques such as visualization, deep breathing during this time to help alleviate any
stress and anxiety secondary to the migraine.
12
If the patient’s headache pain cannot be
controlled accordingly by his or her headache treatment plan or other at home treatments, it is
recommended that medical care be sought. (UW Health GRADE Very low quality of evidence,
weak/conditional recommendation)
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8
Pharmacologic treatment of migraine (Table 1)
The following are best practices for patients to follow with regards to abortive medications:
• Take medication as soon as possible when headache begins (within 20-30 minutes)
20

• Take appropriate dose for pain, age and weight
20,21

• Do not use analgesic more than two times per week to avoid analgesic overuse
headache.
3


Nonsteroidal anti-inflammatory agents (NSAIDs) and acetaminophen
Ibuprofen is recommended by the AAN as first line treatment for the acute treatment of migraine
in children.
8
(AAN Class I, Level A) Naproxen is also indicated for acute migraine treatment in
children ≥ 2 years.
22
Aspirin and combination products that contain aspirin such as
Excedrin
®
are not recommended for use in children under the age of 15 due to risk of Reye’s
syndrome.
8


Acetaminophen is recommended as another treatment option by the AAN and may be less
efficacious than ibuprofen. It is the preferred treatment for patients with documented NSAID
hypersensitivity, bleeding disorders, current anticoagulant therapy, renal impairment and upper
gastrointestinal disease.
6-8
(AAN Class I, Level B)

5-Hydroxytryptamine receptor agonists (“Triptans”)
Triptans may be a good first-line agent after analgesic failure with NSAIDs and acetaminophen
for triptan-naïve patients.
23
Almotriptan and rizatriptan are both US Food and Drug
Administration (FDA) approved for treatment of acute pediatric migraine.
7
(AAN Class I, Level B)
Sumatriptan nasal spray is effective and should be considered for acute treatment of moderate
to severe migraine in children.
8,21,24
(AAN Class I, Level A) There is inadequate data on the
efficacy of subcutaneous and oral sumatriptan in pediatric patients.
8
(AAN Class IV, Level U)
Migraine treatment for Pediatric Patients in the Emergency Department or
Infusion Setting
Headache is one of the most common reasons for presentation to the emergency department
(ED). Most pediatric patients present to the ED after 2-3 days of headache
25
and will have
typically already tried a migraine-abortive medication such as ibuprofen or acetaminophen.
17


Hydration
As children with migraine may have been vomiting before presenting to the ED, fluid
replacement can be beneficial. Fluid replacement may also be protective before certain
treatments, such as offering renal protection against ketorolac which is associated with acute
renal failure
17
and preventing hypotension with some dopamine receptor antagonists.
26


Pharmacologic Treatments (Table 2)

Dopamine receptor antagonists
Prochlorperazine and metoclopramide can be used to treat migraine and nausea accompanying
migraine. (AAN Class IV, Level U) Prochlorperazine may be more effective than
metoclopramide.
27
Side effects from these drugs include extrapyramidal symptoms thus
diphenhydramine may be given too.
28
Patients may also develop irritability and agitation in
response to infusion treatment.
7


Ketorolac
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9
Ketorolac can be used intravenously for the acute treatment of headache and may be more
effective when used in combination with prochlorperazine.
21,29,30
(AAN Class IV, Level U)
Dihydroergotamine (DHE)
DHE is considered an effective treatment for status migrainosus in children and adolescents. It
should not be used in patients who have received a triptan or ergot medication within 24 hours.
It should be administered with an anti-emetic and its use is limited to children ≥ 6 years. For
post-puberty female patients where pregnancy may be concern, a pregnancy test is
recommended prior to administration.
21
(AAN Class IV, Level U)

Magnesium
Intravenous magnesium has been shown to be safe and effective in adults with migraine but
there is limited literature on the efficacy and role of intravenous magnesium for abortive
treatment of headaches in pediatric patients.
7
It may be considered as an alternative to DHE if
DHE is contraindicated, has been ineffective or is not tolerated.
31
Caution with use is
recommended in combination with metoclopramide due to cerebral vasodilatory effects and
potential decreased efficacy.
19,32
(AAN Class IV, Level U)

Anti-epileptics
While traditionally used for epilepsy and migraine prophylaxis, anti-epileptic medications,
specifically valproic acid, can be used intravenously for acute migraine attacks in children.
Valproic acid may be considered especially when DHE is contraindicated, has been ineffective
or is not tolerated. Valproic acid can also be used in addition to DHE therapy and is generally
well tolerated. Given it is teratogenic, a pregnancy test is recommended prior to administration
for post-puberty female patients where pregnancy may be concern.
7
(UW Health Grade Low
quality of evidence, weak/conditional recommendation)

Corticosteroids
Corticosteroids (e.g. dexamethasone, methylprednisolone) may be considered in the
management of a migraine attack. Based on adult studies, corticosteroids may be used in
combination with other abortive therapies and administered as a one-time dose with favorable
outcomes such as decreasing the rate of recurrence after treatment in the ED.
27
However there
is limited data on corticosteroid use in pediatric inpatients to treat status migrainosus.
31
(UW
Health Grade Low quality of evidence, weak/conditional recommendation)

Opiates as abortive medication
Opiates are not recommended for treatment of migraine or other headaches. They are not
endorsed by the American Academy of Neurology (AAN) as first-line treatment for adults
33

which is consistent with the UW Health clinical guidelines for migraine in adults. (UW Health
GRADE Moderate quality evidence, strong recommendation) Opiates have not been well
studied in the pediatric population for this use,
12
can potentially lead to worsening headaches
due to medication overuse
34
and interfere with the effectiveness of other abortive migraine
medications.
35

Preventive Therapy
Goals of Therapy
The fundamental goals of long-term migraine and headache treatment are
8,33
:
1. Reducing the frequency, duration and intensity of attacks
2. Reduction of and reliance on poorly tolerated, ineffective pharmacotherapies
3. Improvement in quality of life
4. Avoidance of acute headache medication escalation
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10
5. Education and enablement of patients to manage their disease to enhance personal
control of their migraine
6. Reduction of headache-related distress and psychologic symptoms.

Once a diagnosis of migraine has been established, an individualized treatment plan should be
implemented which incorporates both biobehavioral strategies and pharmacologic therapies.
20

Non-pharmacologic interventions
It is strongly recommended to educate parents and children on the importance of incorporating
non-pharmacologic interventions into daily lifestyle to improve acute treatment and management
of headache outcomes.
20


Nutrition and dietary patterns (UW Health GRADE Low quality of evidence, strong recommendation)
• Avoid skipping meals
12,22

• Eat green vegetables rich in riboflavin
21

• Avoidance diets are not recommended unless a known trigger food has been identified.
Identified trigger foods include: caffeine, cheese, chocolate, citrus fruits, processed
meats, fried foods, monosodium glutamate, aspartame, sucralose, ice cream, alcohol,
peanuts, peanut butter, fermented foods (i.e. yogurt, pickles, vinegar, sour
cream)
12,20,22,36

• Stay well-hydrated
23


Lifestyle modifications (UW Health GRADE Low quality of evidence, strong recommendation)
• Maintain headache diary/calendar to assist with identifying triggers, evaluation of
treatment efficacy and trigger identification.
12,22,37
See Appendix C and D - Pediatric
Migraine Diary Examples
• Reduce emotional mechanisms that provoke stress and favor headache attacks
38

• Get adequate rest/maintain good sleep hygiene
22,36,39

• Exercise
12,22

• Avoid recreational drugs
12

• Avoid overuse of over-the-counter analgesics
8,20

• Continue daily activities such as attending school and participating in extracurricular
activities. Unrestricted excusal letters for headaches and homeschooling are not
recommended. Blanket excuse letters for headaches are not recommended.

Biobehavioral strategies and alternate interventions (UW Health GRADE Low quality of evidence,
strong recommendation)
• Relaxation treatment alone or in combination with biofeedback.
20,39-41
Training in these
methods should be provided to children with recurrent migraine and headache as soon
as possible after diagnosis is made.
42

• Cognitive behavioral therapy
43

• Acupuncture may decrease the frequency of migraine headaches.
12,22


Pharmacologic prophylaxis of migraine Table 3
• Pharmacologic prophylaxis for migraine should be considered when migraines occur
more than once a week or 3 to 4 headaches per month, there are more than 15
headache days per month (definition of “chronic migraine”) or headaches are disabling
and/or significantly impact school attendance and daily activities.
44,45

• Prophylactic medication should be started at lowest dose and titrated up as needed and
as tolerated.
6,12,22

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11
• Allow adequate trial of prophylactic drug at target dose before deciding that medication
is ineffective.
6,8,12,33

• Take prophylactic treatment during calendar school year and eliminate daily agents
gradually during summer, when children tend to have reduced headaches
6,20

• May be weaned off prophylactic medication when at 1 to 3 headaches per month or less
for 4-6 months.

Cyproheptadine
Cyproheptadine can be used as first line treatment in patients ≤ 6 years who do not have
problems related to being overweight
20,21
and may be a good option in patients with comorbid
environmental allergies.
25
(AAN Class IV, Level U)

Tricyclic antidepressants (TCAs)
Tricyclic antidepressants have been studied for migraine prevention and amitriptyline is one of
the most widely prescribed for pediatric migraine prophylaxis.
44
(AAN Class IV, Level U)
Nortriptyline is sometimes used instead because it is less sedating and has less severe
anticholinergic effects.
21,44
A tri-cyclic antidepressant may be beneficial as prophylactic migraine
therapy for a patient who also suffers from anxiety or insomnia.
12
It is recommended to obtain a
baseline electrocardiogram (EKG) prior to initiating amitriptyline or nortriptyline because of the
potential for QT prolongation and repeat EKG if dosing above 50 mg. (UW Health GRADE Low
quality of evidence, weak/conditional recommendation)

Antiepileptics
Antiepileptics such as valproic acid, topiramate, levetiracetam and zonisamide are routinely
used to treat pediatric epilepsy and are the most studied class of medication for migraine
prophylaxis in adults and children. Topiramate is also indicated by the FDA for migraine
prevention in children ≥ 12 years.
21
Valproic acid is often considered a first-line treatment for
migraine prophylaxis in adults and studies suggest it may be effective in for pediatric migraine
prophylaxis as well.
44
(AAN Class IV, Level U)

Beta Blockers
Propranolol is one of the most commonly used beta blocker medications for migraine
prophylaxis in children. (AAN Class II, Level U) While one of the original studies demonstrated
its effectiveness, follow-up studies have been more controversial. Moreover, adverse effects
include exercise-induced asthma, depression and hypotension which limit its use in the pediatric
population.
21
It may be a good option for a patient that is overweight or suffers from anxiety
issues.
12


Calcium Channel Blockers
Calcium-channel blockers such as nimodipine (AAN Class I, Level B) and verapamil can be
used for migraine prophylaxis too, however there are few to no studies regarding their use in
children for this purpose.
21


Botulinum Toxin
Onabotulinumtoxin Toxin is a purified neurotoxin. Its mechanism of action involves targeting the
neuromuscular junction via protein cleavage, which ultimately leads to the breaking of pain
neurotransmission.
46
It is FDA-approved to treat chronic migraine in adults but its use for
pediatric chronic migraine has not been well studied. The limited published literature currently
available however suggests it may be efficacious.
44
For usage within UW Health, refer to
the UW Health Botulinum Toxin- Adult/Pediatric - Ambulatory Guideline (AAN Class IV, Level U)

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12


Nutraceuticals
Some supplements have been studied for headache prophylaxis and are believed to be helpful
for treatment and prevention of pediatric migraine. Riboflavin, also known as Vitamin B2 is
related to the maintenance of energy-related cell functions. It may be especially beneficial as a
prophylactic supplement for pediatric patients whose diet lacks fruits and vegetables.
12
(AAN
Class I, Level U)

Magnesium is believed to be useful for migraine prophylaxis because low levels of magnesium
have been linked to migraine.
7
(AAN Class IV, Level U)

Coenzyme 10 (CoQ10) is believed to be useful in migraine prevention due to its activity related
to mitochondrial function.
47
It is best to take it in the morning as CoQ10 can cause insomnia.
12

(AAN Class II, Level U)

Butterbur comes from a perennial shrub and contains a substance with antispasmodic and
calcium channel blocking properties, thought to be the reasons it is effective for migraines in
adults. Although it is recommended in adults
48
for migraine prophylaxis and improvement in
migraine frequency was demonstrated in a small pediatric controlled study, butterbur is not
endorsed by AAN for migraine prophylaxis in the pediatric population.
7
(AAN Class II, Level U)

Patient education on pharmacologic migraine therapies
It is strongly recommended that parents and patients be counseled appropriately on migraine
medication, both prophylactic and abortive therapies. (UW Health GRADE Very low quality of
evidence, weak/conditional recommendation) Some suggested talking points include:
• Importance of medication compliance to reduce migraine frequency
• Be aware that it can take weeks for prophylactic medication to be titrated up thus it is
important to allow adequate trial of drug at target dose.
• When to/when not to take abortive medication to prevent medication overuse and
prevent analgesic overuse headache
• To seek medical care/advice if therapies outlined in treatment plan fail
UW Health Implementation
Potential Benefits:
• Optimized treatment in children with migraine headaches

Potential Harms:
• Adverse events associated with therapies
• Medication overuse headaches

Pertinent UW Health Policies & Procedures
None identified.

Patient Resources
1. Headache- Pediatric Neurology Packet 3181
2. Health Facts for You- Migraine Headaches
3. Health Facts for You- Medication Overuse Headaches
4. Health Facts for You - How to Encourage a Child to Take Medicine
5. Healthwise- Headaches in Children
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

13
6. Healthwise- Migraine Headaches
7. Kids Health- A to Z Migraine
8. Kids Health- Migraine Headaches
9. Kids Health- Headaches
10. Kids Health- Word! Migraine
11. Kids Health- Migraines: What a Pain!
12. Kids Health- Oooh, Your Aching Head!
13. Kids Health- How do Pain Reliever Work?
14. Kids Health- First Aid: Headaches
15. Kids Health- Migraines Special Needs Factsheet
16. Kids Health- Is it Common to Get Migraines Before Your Period?
17. Kids Health- Blood Test: Valproic Acid
18. Kids Health- How Much Sleep Do I Need?
19. Kids Health- Stress

Guideline Metrics
1. Number of patients with a reason for visit of “migraine” or “headache” who received an
opioid in the clinic or a prescription for opioids during that visit
2. Percentage of patients discharged from the emergency department with a diagnosis of
migraine who had a follow up visit arranged with PCP or headache specialist


Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.

Order Sets & Smart Sets
IP – Dihydroergotamine (DHE) – Pediatric – Supplemental [1420]


Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

14
Table 1. Primary Care Treatment- Pharmacologic treatment of migraine
3,21,22,49-52

Drug Dose Frequency Adverse Effects/Caution/Comment


Level of
Evidence
Ibuprofen

10 mg/kg (4-16
years)

Max dose 800 mg
Every 4-6 hours as
needed

Max 2-3 times/week
Nausea
Dizziness
May cause GI distress

Contraindicated for patients allergy to
NSAIDs, bleeding disorder, hepatic
insufficiency, renal insufficiency,
peptic ulcer disease
Class I, Level A
Acetaminophen 15 mg/kg (4-16
years)

Max dose 1000 mg
or
75 mg/kg/day
Every 4-6 hours as
needed
Hepatotoxicity
Caution with overdose

Avoid combination products with
aspirin in patients <15 years, due to
potential for Reye’s Syndrome
Class I, Level B
Naproxen 5-7 mg/kg

Max dose 1250
mg/day
Every 8-12 hours as
needed
Nausea
Dizziness
May cause GI distress

Contraindicated for patients allergy to
NSAIDs, bleeding disorder, hepatic
insufficiency, renal insufficiency,
peptic ulcer disease
UW Health AAN
Level U
Drug Dosing Adverse Effects/Caution/Comments


Level of
Evidence
Sumatriptan Nasal Spray: for patients ≥5 years
• <20 kg: 5mg
• 20-39 kg: 10mg
• ≥40kg: 20mg

Subcutaneous injection: for patients ≥ 6 yrs.

≥6 years: 0.06 mg/kg, round to nearest dose
• 3mg or 6mg

Tablet: efficacy not well established in
pediatrics
Take at onset of headache, may take
additional dose if no relief after 2
hours.

Max 2 doses in 24 hours, 4-6 times
per month


Vascular constriction
Somnolence
Weakness and fatigue
Chest pain or pressure sensations

Contraindicated with MAOI

Caution with SSRI antidepressants
for potential serotonin syndrome (e.g.
flushing, paresthesias, somnolence,
GI discomfort)

Patients should be educated on
maximum daily and monthly usage
Class I, Level A
(Nasal spray)

Class IV, Level
U
(oral and subQ)
Rizatriptan Tablet/oral melt: for patients ≥ 6 years

<40 kg: 5mg
do not use if taking propranolol
≥40 kg: 10mg
reduce to 5mg if taking propranolol
Class I, Level B
Naratriptan Adult dosing only
1 or 2.5 mg as a single dose
UW Health AAN
Level U
Almotriptan

Tablet:
for patients ≥12 years: 6.25 – 12.5mg

Class I, Level A
Zolmitriptan Nasal spray/tablet/oral melt:
for patients ≥12 years
2.5 – 5 mg

Class I, Level B




Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

15
Table 2. Abortive Medications for Migraine in Emergency Department/Infusion Setting
19,27,49

Medication Dose Onset (IV
administration)
Side Effects, Other Comments Administration
Ketorolac

10-30mg IV
or
0.5mg/kg
Max: up to 30 mg
30 min/2 hours Side effects: GI bleeding, Drowsiness

Interacts with anticoagulants
Caution with advanced renal or liver disease
Pregnancy class C












Refer to Intravenous
Administration of
Formulary
Medications-
Pediatric/Neonatal-
Inpatient/Ambulatory
Clinical Practice
Guideline
Ondansetron


IV/PO: 0.1mg/kg
PRN for nausea
Max: 4mg

<30 min/2 hours Side effects: Drowsiness, constipation

Generally well tolerated
Pregnancy class B
Prochlorperazine IM or IV: 0.1- 0.15 mg/kg
Max dose 10 mg

Max: up to 7.5-20mg/day based
on weight
<30 min Side effects: Extrapyramidal reactions, Sedation

Associated with QTc prolongation
Pregnancy class C
Promethazine 0.25-0.5 mg/kg/dose IV

Max: 25 mg
5 min Side effects: Extrapyramidal reactions, Sedation

Associated with QTc prolongation
Pregnancy class C
Metoclopramide 0.1-0.5 mg/kg IV

Max: 10 mg
Rapid Side effects: Sedation

Pregnancy class B
Diphenhydramine 25mg-50mg IV
or
1-2mg/kg

Max 50mg
<30 min/ 1-2
hours
Side effects: Sedation

Pregnancy class B
Methylprednisolone 15-30mg/kg IV


Max 1 gram/day
Rapid Side effects: Flushing

Can start methylprednisolone dose pack as oral
bridge if effective

Pregnancy class C
Valproic acid 500mg-1000mg
or
IV: 15-20mg/kg

Max 1000mg
30 min/2 hour Side effects: Sedation, Dizziness, Hypotension,
Tremors, liver dysfunction

Drug interactions with topiramate, lamotrigine

Urine pregnancy test prior for females of child
bearing age

Can start oral divalproex sodium 125mg BID x 4
days if effective

DO NOT GIVE IN PREGNANCY (teratogenic)
Magnesium Sulfate 25-50mg/kg IV

Max 2 grams
Immediate Side effects: Hypotension, flushing

Calcium gluconate if hypotensive

Ondansetron PRN for nausea

Can start oral magnesium 250mg BID if effective

Potential long infusion time

Pregnancy class D
Lorazepam 0.04-0.08 mg/kg IV, up to 5 mg

5-15 min Side effects: Respiratory depression, Sedation,
Dizziness

Can start oral lorazepam 0.5mg BID as oral bridge
if effective
Pregnancy class D
Dihydroergotamine 6-9 yrs: 0.1 mg IV every 8 hours
10-12 yrs: 0.2 mg IV every 8 hours
13-16 yrs: 0.3 mg IV every 8 hours

Max 16 doses
Side effects: nausea, anxiety

Contraindicated with uncontrolled hypertension,
pregnancy, stroke

DO NOT GIVE IN PREGNANCY
(May refer to IP Peds
DHE Order Set)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

16
Table 3. Pharmacologic Options for Migraine Prophylaxis
3,12,21,49,53

Medications are listed in descending order in terms of 1
st
line treatment.
Consider consulting pediatric neurology if any questions before initiating a prophylactic medication
Drug Target Dose Frequency Adverse Effects/Caution/Comments Consider Use in
Patients with
Level of
Evidence
Magnesium
Oxide
9 mg/kg/day

Typically 250 mg
twice daily
Twice daily Diarrhea or soft stool
Modify dose for renal dysfunction
Menstrual related
migraines

Guardians hesitant start
prescription drug
Class IV,
Level U
Riboflavin 200-400 mg/day Daily Bright yellow urine Diet lacking
fruits/vegetables

Guardians hesitant start
prescription drug
Class I,
Level U
Amitriptyline



Nortriptyline


0.25-1 mg/kg


up to 100 mg at
bedtime


Daily at bedtime Sedation *
Weight gain
Dry mouth
Constipation *
QT prolongation
• Caution in patients w/depression due to increased risk suicidal
ideation
• An EKG is recommended before starting the medication and be
repeated if increasing above 50 mg
Insomnia

Underweight

Mild Anxiety
Class IV,
Level U
Cyproheptadine > 3 years:
0.2-0.4 mg/kg/day
up to 12 mg per
day
One to two times
daily
Sedation *
Increased appetite/Weight gain *

Response may be improved in combination with propranolol
Allergies

Underweight

Insomnia
Class IV,
Level U
Propranolol


1-2 mg/kg/day

Max 240 mg/day
Three times a
day


Nausea
Abdominal pain
Hypotension *
Sleep disturbance/insomnia
Decrease in stamina *
Depression *
Exercise intolerance *
• Contraindicated in patients with asthma and/or diabetes
• Patients should be weaned off slowly to prevent hypotension,
which can occur with abrupt stopping
Anxiety Class II,
Level U
Topiramate 1-2 mg/kg/day

Up to 100 mg daily
in two divided
doses


Once or twice
daily

Titrate slowly,
typically over 8-
12 weeks period

Sedation
Fuzzy sensorium, forgetfulness *
Paresthesias *
Weight loss *
Glaucoma
Kidney Stones
Hypohidrosis
Overweight

Epilepsy
Class IV,
Level U
Gabapentin 10-40 mg/kg/day
per day
Or
300-2000 mg (total
daily dose)

One to three
times daily
Ataxia
Fatigue *
Tinnitus
Gastrointestinal complaints
Mood changes, depression *
Epilepsy UW Health
AAN Level
U

Valproic Acid > 7 years:
10-25 mg/kg/day

Max initial dose:
250 mg

Max daily: 1000 mg
Once or twice
daily (depending
on formulation)
Weight gain
Bruising
Hepatotoxicity *
Pancreatitis
Polycystic Ovary Syndrome (PCOS) *
Sedation
Behavioral changes
Caution in adolescent females due to -risk teratogenicity *
Underweight

Bipolar traits

Epilepsy
Class IV,
Level U
Zonisamide 5-8 mg/kg/day Twice daily Weight loss
Sedation
Behavioral changes
Epilepsy Class IV,
Level U
Levetiracetam > 3 years
20-40 mg/kg/day

Twice daily Somnolence
Dizziness
Behavioral changes
Epilepsy Class IV,
Level U
Verapamil 4-10 mg/kg per day
Or
80-240 mg (total
daily dose)
Divided three
times a day
Hypotension *
Nausea
Atrioventricular block
Do not take with grapefruit juice
May increase levels of carbamazepine and digoxin; avoid
combination
Epilepsy

Vertiginous Migraine
UW Health
AAN Level
U
* denotes common side effect
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

17
Appendix A. Evidence Grading Scheme(s)

Figure 1. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate
We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations Either For or Against Practice
Strong
The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/Conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

18
American Academy of Neurology (AAN) – Classification of evidence for therapeutic
questions
Class I A randomized, controlled clinical trial of the intervention of interest with masked or
objective outcome assessment, in a representative population. Relevant baseline
characteristics are presented and substantially equivalent among treatment groups
or there is appropriate statistical adjustment for differences.
Class II A randomized, controlled clinical trial of the intervention of interest in a
representative population with masked or objective outcome assessment that lacks
one or two criteria in AAN Classification Class I or a prospective matched cohort
study with masked or objective outcome assessment in a representative population
that meets be in AAN Classification Class I. Relevant baseline characteristics are
presented and substantially equivalent among treatment groups or there is
appropriate statistical adjustment for differences.
Class III All other controlled trials (including well-defined natural history controls or patients
serving as their own controls) in a representative population, where outcome is
independently assessed, or independently derived by objective outcome
measurements.
Class IV Studies not meeting AAN Classification Class I, II, or III criteria including consensus
or expert opinion.

AAN classification of recommendations
Level A Established as effective, ineffective, or harmful (or established as useful/predictive
or not useful/predictive) for the given condition in the specified population. (Level A
rating requires at least two consistent AAN Classification Class I studies.)
Level B Probably effective, ineffective, or harmful (or probably useful/predictive or not
useful/predictive for the given condition in the specified population. (Level B rating
requires at least one AAN Classification Class I study or two consistent AAN
Classification Class II studies.)
Level C Possibly effective, ineffective, or harmful (or possibly useful/predictive or not
useful/predictive) for the given condition in the specified population. (Level C rating
requires at least one AAN Classification Class II study or two consistent AAN
Classification Class llI studies.)
Level U Data inadequate or conflicting; given current knowledge, treatment (test, predictor)
is unproven



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19
Appendix B. Pediatric Emergency Department Headache/Migraine Management Algorithm

Child presents with
headache
Red flag
symptoms?
Off guideline, evaluate for
secondary causes, treat as
clinically indicated
Child likely has
migraine?
Initiate non-pharmacologic strategies
(place in dark room, quiet area)
Assess for contraindications, pregnancy, allergies
Can Child
tolerate PO?
Rehydrate/IV fluids as needed
(IV fluids likely needed if severe pain)
Consider triptan or
triptan/naproxen
(if not already taken)
Consider ondansetron for nausea
IV fluids
AND
Consider Ketorolac
AND/OR
Dopamine Receptor
Antagonist (+/-)
diphenhydramine
Assess for nephrotoxicity risk
w/Ketorolac if oral NSAID
taken already
Migraine
Relief?
Consult neurology
Consider triptan or
IV DHE or
IV corticosteroids or
IV Magnesium or
IV Valproic acid
Plan for possible admission for
Mg infusion
Migraine
Relief?
Admission, and treat
as indicated
Abortive Migraine Medications
Medication Dose Route Max
Ibuprofen 10 mg/kg PO 800 mg
Ondansetron 0.1 mg/kg PO, IV 4 mg
Ketorolac 0.5 mg/kg IV 30 mg
Diphenhydramine 1-2 mg/kg IV 50 mg
Metoclopramide 0.1-0.5
mg/kg
IV 10 mg
Prochlorperazine 0.1-0.15
mg/kg
IV 10 mg
Valproic Acid 15-20
mg/kg
IV 1000 mg
Magnesium 25-50
mg/kg
IV 2000 mg
*Opiates are NOT recommended for migraine
*Consider pregnancy test for adolescent females
before giving ketorolac, dopamine receptor
antagonists, DHE or valproic acid
NO
Discharge
Discharge
Emergency Department Pediatric Headache/Migraine Management Algorithm
YES
Discharging Patient:
*Reinforce lifestyle habits to improve/reduce
pain and prevent migraine recurrence
- adequate sleep
- diet (avoid trigger foods, caffeine)
- stay well hydrated
- exercise
- recognizing triggers, maintaining headache
diary
*Discharge with follow-up to PCPC or Peds
Neurology
*Prior to discharge, patient should have options
to treat headache at home. If no options or if
considering oral bridge of ED treatment, consider
discharge with medication(s) (e.g. if no previous
triptan prescription, oral prochloperazine or oral
methylprednisolone)
*Counsel patient to limit medication overuse to
prevent rebound headache (use abortive meds 2-
3 times per week max)
Discharging Patient:
*Reinforce lifestyle habits to improve/reduce
pain and prevent migraine recurrence
- adequate sleep
- diet (avoid trigger foods, caffeine)
- stay well hydrated
- exercise
- recognizing triggers, maintaining headache
diary
*Discharge with follow-up to PCPC or Peds
Neurology
*Prior to discharge, patient should have options
to treat headache at home. If no options or if
considering oral bridge of ED treatment, consider
discharge with medication(s) (e.g. if no previous
triptan prescription, oral prochloperazine or oral
methylprednisolone)
*Counsel patient to limit medication overuse to
prevent rebound headache (use abortive meds 2-
3 times per week max)
NO
Red flag symptoms:
* Systemic symptoms of fever, weight loss, chills
* Neurologic deficits, altered consciousness
* Sudden onset, abrupt or split second
*First headache or different from previous
headache history is different/change to
headache
Consider imaging headache with signs of:
-increased intracranial pressure
-positive neurological signs
-presence of systemic symptoms
including but not limited to fever and
nuchal rigidity
Migraine without aura criteria:
* ≥ 5 headaches, each lasting 4-72 h if untreated
* Any 2 of following:
-unilateral
-pulsatile
-moderate to severe intensity
- worse with extension
And at least one of following:
-nausea and/or vomiting
-photo and phonophobia
Red flag symptoms:
* Systemic symptoms of fever, weight loss, chills
* Neurologic deficits, altered consciousness
* Sudden onset, abrupt or split second
*First headache or different from previous
headache history is different/change to
headache
Consider imaging headache with signs of:
-increased intracranial pressure
-positive neurological signs
-presence of systemic symptoms
including but not limited to fever and
nuchal rigidity
Migraine without aura criteria:
* ≥ 5 headaches, each lasting 4-72 h if untreated
* Any 2 of following:
-unilateral
-pulsatile
-moderate to severe intensity
- worse with extension
And at least one of following:
-nausea and/or vomiting
-photo and phonophobia
YES
Home management
attempted?
YES
NO
YES
YES
NO
YES
NO
NO
Migraine
relief?
NO
YES

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

20
Appendix C. Pediatric Headache Diary Example 1

Patient Name:
DOB:
MR #:

MONTH: ________________ YEAR: __________
Day of Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Headache lasted
how long?

Time

Location of Pain

Intensity (1-10)

Missed
Work/School Y/N

Aura Y/N

Nausea Y/N

Light Sensitive
Y/N

Sound Sensitive
Y/N

Medications Used

Good response to
meds Y/N

Sleep for Relief
Y/N

Took Preventive
Medication Y/N


Day of Month 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Headache
lasted how
long?

Time

Location of Pain

Intensity (1-10)

Missed
Work/School
Y/N

Aura Y/N

Nausea Y/N

Light Sensitive
Y/N

Sound Sensitive
Y/N

Medications
Used

Good response
to meds Y/N

Sleep for Relief
Y/N

Took Preventive
Medication Y/N


Other Symptoms such as: Numbness/Tingling, Personality Change, Dizziness Vertigo, Double Vision, Motor Impairment, Vomiting, Speech Changes
Date:

Date:

Date:


Signature of Patient/Guardian: ______________________________ Date: __________ Time: _______ AM/PM
If signed by person other than patient, print name and state relationship:
Print Name: ____________________________________________ Relationship: ________________________________
Reviewed by: _____________________________________________ Date: __________________ Time: ___________ AM/PM

Scan to Health Diary PEDIATRIC NEUROLOGY HEADACHE DIARY

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

21

Appendix D. Pediatric Headache Diary Example 2

Patient Name:
DOB:
MR #:

Please use this chart to keep track of your headaches. This can help us find the best treatment. For each day of the
month, fill in the dates on the calendar.

Please indicate the severity of your headache as follows in the appropriate location:
• 0: No headache = Black Dot
• 1-4: Mild headache, doesn’t interrupt activities, but may be annoying = Green Dot
• 5-8: Moderate headache, you must limit or modify activities = Yellow Dot
• 9-10: Severe headache, you are unable to function and must remove all activities including all electronics = Red Dot

Please also indicate the time the headache occurred, what medications you took, and whether you had relief from the headache.
You may also indicate that you had nausea (N), Vomiting (V), Aura (A), Visual Changes (VC), Light Sensitivity (L), or Sound
Sensitivity (S).

Month: ___________________________ Year: _____________
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Dot: Dot: Dot: Dot: Dot: Dot: Dot:
Time
Med
Relief
Symptoms

Dot: Dot: Dot: Dot: Dot: Dot: Dot:
Time
Med
Relief
Symptoms

Dot: Dot: Dot: Dot: Dot: Dot: Dot:
Time
Med
Relief
Symptoms

Dot: Dot: Dot: Dot: Dot: Dot: Dot:
Time
Med
Relief
Symptoms

Dot: Dot: Dot: Dot: Dot: Dot: Dot:
Time
Med
Relief
Symptoms




Signature of Patient/Guardian: ______________________________ Date: __________ Time: _______ AM/PM

If signed by person other than patient, print name and state relationship:

Print Name: ____________________________________________ Relationship: ________________________________

Reviewed by: _____________________________________________ Date: __________________ Time: ___________ AM/PM

Scan to Health Diary PEDIATRIC NEUROLOGY HEADACHE DIARY
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

22
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