Michael Smith, MD (Host): This is Pediatrics in Practice, a CME podcast. I'm Dr. Mike, and with me is Dr. Trevor Gerson from Children's Mercy. Today we will be diving into the topic of headache, common cases. Dr. Gerson, welcome to the show.

Trevor Gerson, MD: Thank you. Thank you for having me.

Host: What are the most common types of headaches you see in pediatric patients and how do they typically present across the different age groups?

Trevor Gerson, MD: So the most common type of headache period, is a tension type headache, which is what a lot of people will call a regular headache. And that's just more of a mild to moderate pain without nausea, without a lot of that light or sound sensitivity. And it doesn't really affect function quite as much. In our clinic and more of a tertiary clinic, we see migraine much more often. And that's a more severe headache that can have associated disability. It can affect function and will occur with vomiting, lethargy, fatigue, light, sound sensitivity, smell sensitivity, dizziness. It's worse with movement. Those are the common features that we see with or without a visual or a sensory aura.

Host: With migraine in kids, what age group are we talking about here where it usually presents?

Trevor Gerson, MD: So we see kids, I mean, four or five, sometimes even younger. Some of the most common highest incidence of migraine is 5, 6, 7. And sometimes it starts as a migraine variant called abdominal migraine or cyclic vomiting, where it starts off in younger kids just as this episodic belly pain that happens with or without vomiting.

 And then as they get older, maybe it transitions to head pain with the belly pain, and then over time it's just the head pain. So it transitions to migraine as they get older or similar kind of episodic vomiting that just comes outta nowhere, and then they're completely normal in between.

Host: We're going to come back to migraine a little bit later and talk about that more, but for now, how do you approach the initial evaluation of a child presenting with recurrent headaches? What are the red flags that you look for that might suggest a secondary cause?

Trevor Gerson, MD: So the initial approach is very much about the history and the physical. So a good history, a good neurologic exam, a good full body exam. And then really looking for those red flags, like are there systemic symptoms, so fever, weight loss, night sweats, some of those constitutional symptoms or are there systemic diseases. So kids with a bone marrow transplant history, or some other underlying medical history that puts them at a higher risk for a secondary headache.

How did the headaches come on? Has it just been going on for a few days or a few weeks, and it's been gradually progressive over time? That's a red flag. Vomiting in the middle of the night, that positional vomiting like in the middle of the night, they're just waking up and painting their room.

Not necessarily headaches when first waking up. That used to be more of a red flag, and now it's a little bit more of an orange flag. So an occipital headache or headache when they're first waking up. That can happen for a number of reasons. We might want to dive into that a little bit more, but it's not necessarily a red flag on its own. And then neurologic symptoms. So weakness with the headaches, focal deficits and then positional features. So the headaches are worse laying down or overnight, and then worse when they're standing up, can be a CSF leak, but not necessarily worse when they're moving to stand up.

Host: When you're seeing a child who's maybe checking off a couple of these red flags, maybe two or three of them, what's the next step? I mean, because a lot of these red flags, let's be honest, can, they could be almost anything. So, how do you evaluate that to make sure we're not missing a secondary cause for that headache?

And are there certain red flags that you're going to put first and you're going to investigate those first? What's your approach there?

Trevor Gerson, MD: So the first approach is a good thorough neurologic exam, including fundoscopy. Kids with a normal neurological exam are almost completely unlikely to have a nasty, scary secondary cause or something that's going to show up on imaging. So, having that good physical exam is really reassuring if it's normal.

 And then based on kind of the concerns, that's when I'll move towards MRI or lumbar puncture or good ophthalmologic exam.

Host: Do you think migraine in general is often underdiagnosed in children?

Trevor Gerson, MD: Absolutely. We know it is.

Host: I'm assuming you're seeing a lot of these patients after, maybe they've seen a couple other different doctors. Right.

Trevor Gerson, MD: Maybe. I think the referring providers in our area do a really good job of getting things settled and getting them to us quickly if needed. But I can put it this way, is that migraine in like school age kids up to high school, it's somewhere between five to 15% of kids have migraine.

Host: So what are some of the key features that could help distinguish a pediatric migraine from some of the other headache types?

Trevor Gerson, MD: So for me the two bigger symptoms are, does it affect their life? Is there disability? And we know that kids with migraine actually have similar levels of disability to kids with cancer and autoimmune diseases. Then that vomiting, that change in appetite, nausea, vomiting, that's a fairly distinguishing feature as well as when they get a migraine, they don't want to do anything. They're laying down in a dark room, they're burying their head under a pillow, things like that.

Host: When it comes to migraine, there's a lot of different proposed mechanisms out there. Right? What are your thoughts about migraines in kids. What are some of the top things that you believe are going on that's driving the incidence and prevalence of migraine?

Trevor Gerson, MD: So, number one is genetics and it's not just one gene that we can isolate. It's like a whole bunch of different genes and probably some epigenetics as well. That's the number one thing. We're still learning about the, the pathophysiology and the actual mechanisms. It's going to change, maybe tomorrow.

 It's just a rapidly evolving field. And one thing with that is this is the golden age of headache treatment and headache medicine. We finally have more resources, more treatment options, more attention and people working on this than we have in the past at all. So I think that's also helping with the diagnosis and the incidence.

Host: So you take the genetic aspect of this, as you said, it's not just one gene. But you mentioned some of the epigenetic factors. Some of those could be lifestyle, right? Like, sleep, hydration, stress. How are those impacting the frequency and severity of migraine in kids?

Trevor Gerson, MD: So lifestyle factors are very, very important. We go over lifestyle factors in depth in our clinic. And I tell people like, it's not a cause, it's not causing your headaches. I don't want them to get the message that this is your fault because you're not drinking enough water. But it's something that can help.

And so eating a good, balanced, you know, healthy diet. There's no diet specific for migraine. I don't really have people look for food triggers; that's been mostly disproven. But just eating regularly, drinking a good amount of water, whatever that means for them. And sometimes for our migraine kids, that's more than normal.

Regular exercise and then stress, mood, cognitive behavioral therapy is actually one of the best treatments for migraine.

Host: You mentioned in high school kids, migraine is pretty prevalent. I think you said 10, 15% or so. And here you have an age group where, you know, there's lack of sleep, and a lot of screen time with the smartphones. How do you approach that with some of them, because that's, that's just part of being a high schooler, isn't it?

Trevor Gerson, MD: It's absolutely a thing. This is something we deal with on a daily basis, and a lot of times I just candidly tell them, I'm like I'm not going to tell you what you should and shouldn't be doing. I'm here to tell you this is what can help you, and it's up to you to make that decision about what's worth it.

Host: Yeah, and I guess if it does help with the migraine severity, frequency, they probably start to buy into it a little bit, right.

Trevor Gerson, MD: Absolutely.

Host: So what are your go-to strategies for managing pediatric headaches both acutely and to prevent?

Trevor Gerson, MD: I think one of the things is that medications are one piece. We have therapies, we have devices, neuromodulation devices. We have lifestyle factors. We have a lot of buckets to choose from, a lot of things to choose from. And so there's not one like, oh, this is where we start. And so each decision is an individualized one.

If it's medications, a lot of times we start with simple magnesium. It's really safe, effective. A lot of our kids have constipation, so it helps with that. There's some other supplements and then a number of different other medications or physical therapy if on my exam I find targets for physical therapy. Lifestyle factors, if there's really a lifestyle factor that I think is going to have good buy-in and good efficacy from the start.

Then yeah, like cognitive behavioral therapy, working on stress, working on exercise, just those different features as well as things like acupuncture and then the devices.

Host: Are you finding that you often have to do both medication and like behavioral therapies?

Trevor Gerson, MD: It's fairly common and like for the guidelines for migraine treatment, actually, amitriptyline is really recommended to be combined with cognitive behavioral therapy. So they're not mutually exclusive. They work really well together. Whether that's short term for the medications while we get the therapy on board, or vice versa sometimes.

Host: You mentioned a couple of times in this interview, Dr. Gerson, that things have changed. It's the golden era of treating migraines. When you look at the research that's going on now, I'm not just talking about medications, you know, maybe some of the mechanisms, causes, all that kind of stuff; what are you most excited about in the future?

Trevor Gerson, MD: I am excited about just the whole field in general. It's a great time. It's a wonderful community. And I think if I had to pick one, I would say the devices. So using neuromodulation devices to treat migraines both preventatively and acutely, really gives a locus of control to the patient.

And it's an acute treatment that they can use without being afraid of causing an overuse headache of using too often, especially now that insurance companies are starting to cover one of the devices and hopefully more in the future, that this is going to be an option that's actually accessible for our patients.

Host: So right now that's a little bit of a barrier is insurance with some of these devices?

Trevor Gerson, MD: Absolutely, and I've been lucky enough to participate in some advocacy and we're starting to turn the tide on that.

Host: And we know most likely there's a lot of different mechanisms that are causing this. And often that's going to require a lot of different treatments, right? So you got medications, you got therapies, you have the devices, hopefully someday that's going to be the norm. Right?

Trevor Gerson, MD: Absolutely.

Host: You seem confident that's where we're going with insurance and everything.

Trevor Gerson, MD: I'm hopeful. I mean, when we have a lot of other mechanisms, a lot of other treatments that were getting side by side. So one of our calcitonin gene related peptide targeting monoclonal antibodies was just approved for pediatric patients just a few months ago. So new avenues. Because there's rarely one thing that works for a migraine patient. You have to really treat the whole patient and individualize that approach.

Host: When you think back to all the patients you've seen, all the diagnoses you've made with migraine in pediatrics, is there any one case that really stands out that kind of illustrates how complex or nuanced this can be?

Trevor Gerson, MD: There's a number of cases that you know, both good and bad. But what I would say is the thing that really sticks out in my mind when I think about just overall cases in the past, is the effect that we can have in changing the trajectory of these kids' lives. So someone telling me, you gave me Jack back, or you gave me Sarah back, or whatever the name is and they go on to be functioning members of our society when at first they may not have been, and they were in their room and they were just debilitated.

So that overall sense is, is kind of what I think about.

Host: And we're seeing more of those outcomes, right?

Trevor Gerson, MD: Absolutely.

Host: When things first got started, as you said, there wasn't a lot of ways to treat and the outcomes weren't all that great, but now it does sound like it's a lot more exciting and, you know, with the advances being made, hopefully that's just going to continue to grow with those positive outcomes.

Trevor Gerson, MD: Exactly.

Host: Any last words that you'd like to share with general pediatricians who are maybe managing children with headaches, but maybe they don't have that immediate access to someone like you?

Trevor Gerson, MD: The big thing is you have a lot of the tools to treat migraines already at your fingertips. So, getting a fundoscopic exam or sending them to an eye doctor and then, you you can always contact our clinic. And then there's also a big push from the American Headache Society for a program called First Contact.

So that's a program to support primary care in treating headache patients, and they have a website with all kinds of great resources. And also the ability to bring a headache expert to your institution, paid for by the American Headache Society, to give you more in-depth training.

Host: Fantastic. This was great information. Thank you so much for coming on today, Dr. Gerson.

Trevor Gerson, MD: Absolutely. Pleasure to, to be here.

Host: For more information, you can go to CMKC.link/CMEpodcast. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. This is Pediatrics in Practice, a CME podcast.

I'm Dr. Mike. Thanks for listening.