Pharmacotherapy for Persistent Posttraumatic Headaches in Children and Adolescents: A Brief Review of the Literature

DOI: https://doi.org/10.1007/s40272- 018- 0299- 8

Abstract-Summary Concussion, now most often referred to as mild traumatic brain injury in recent lit- erature, is common in pediatrics, and headache is often the most common complaint post-injury.

Although most children and adolescents recover within 1–2 weeks, some develop

frequent and debilitating headaches that can last for months or longer.

This review is intended to help providers understand the current evidence, and sometimes the lack thereof, and ultimately to lead to improved care for children with headaches after mild traumatic brain injury.

Extended: Given its pathophysiologic resemblances, posttraumatic headache

may similarly benefit from this future treatment option.

Introduction There is evidence to suggest that one in five children will experience a mild TBI (mTBI) by the age of 10 years [146, 147].

Studies have reported that as many as 475,000 children aged 0–14 years sustain

TBI annually in the USA, and most of these injuries are defined as mild [146].

In a study of collegiate and high school football players with mTBI, as many as

86% reported headache after head trauma [148].

Eisenberg and others [70] reported 85% of youth presenting to a pediatric emer-

gency department (ED) reported headache following an mTBI.

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5 Future Directions

Posttraumatic Headache Whereas most children and adolescents report headache and other post-concussive symptoms immediately following mTBI, the vast majority of patients will experi- ence an improvement and often resolution within 2 weeks [149].

Blume and others [59] reported a trend toward female sex being a risk factor for

posttraumatic headaches.

A review of 500 adolescent patients seen for post-concussive symptoms found that females reported posttraumatic headache more often than did males (90% vs. 79%), but the authors still concluded that the role of sex was uncertain, perhaps because other potential risk factors, such as prior headache history, were not reported [150].

Kuczynski and others [62] showed that 51% of children with posttraumatic head- ache at 3 months after mTBI had preexisting headaches, and 31% had headaches fulfilling the ICHD-3 criteria for migraine or probable migraine prior to injury.

Management of and Pharmacotherapy for Posttraumatic Headaches It has been thought that susceptible patients who use analgesics (either OTC or pre- scription) excessively to abort headaches acutely after mTBI risk developing a medication- overuse pattern that may lead to the transformation from an acute to a chronic headache syndrome [151, 152].

Very few pediatric studies have looked at the relationship between analgesic

overuse and the development of persistent posttraumatic headache.

Babcock and others [153] reported that adolescents with post-concussive symp- toms 3 months after TBI, including those with headache, were more likely to have used analgesics to treat their symptoms at home than were patients with resolution of symptoms at 3 months post-mTBI.

Theeler and others [39] surveyed 196 US soldiers with chronic daily headaches post-deployment and found that 49% self-reported using analgesics to treat their headaches on ≥15 days per month for 3 consecutive months, meeting ICHD-3 cri- teria for MOH.

Preventive Therapy for Posttraumatic Headache Many agents are being used to treat persistent posttraumatic headaches; most have supporting data for management of migraine or chronic migraine and few have been studied for the treatment of persistent posttraumatic headaches in a system- atic manner.

Packard [95] performed a retrospective review of 100 patients treated with dival- proex for persistent posttraumatic headache and found that about 60% of patients with persistent posttraumatic headaches had mild to moderate improvement in their headaches after at least 1 month of treatment, whereas 40% either showed no response (26%) or discontinued treatment because of adverse effects (14%).

Kabbouche and others [154] conducted a retrospective review of pediatric patients receiving onabotulinumtoxinA for chronic migraine and reported that monthly headache frequency improved, with statistical significance.

There are several reports in the literature regarding onabotulinumtoxinA as an effective and well-tolerated treatment in adults with persistent posttraumatic head- aches [155].

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Discussion Posttraumatic headache in pediatric patients remains a frequent health problem for children and their families, yet many gaps in our knowledge remain with regards to its pathophysiology and treatment.

A survey by Brown and others [156] demonstrated that clinicians who treat patients with posttraumatic headache use a variety of approaches to diagnosis and treatment.

Several trials investigating the efficacy of various therapeutic treatments for post- traumatic headache have been conducted in recent years or are currently underway, and much has already been inferred from pediatric migraine studies.

Migraines and posttraumatic headache share many pathophysiological

similarities.

Some have suggested that, as with migraine, activation of the trigeminovascular system in posttraumatic headache is also associated with the release of pro- inflammatory factors such as CGRP [157].

Given its pathophysiologic resemblances, posttraumatic headache may similarly

benefit from this future treatment option.

Conclusion Headaches are a common complaint following mTBI in children and adolescents.

While acute posttraumatic headaches resolve within a few weeks for the majority of individuals, some may go on to develop persistent headaches that can cause sig- nificant disability and interfere with academic activities and family and peer-related interactions.

Because these headaches can be disabling and difficult to treat, new evidence- based approaches to this long-neglected field of research are urgently needed to improve outcomes for affected children.

Acknowledgement A machine generated summary based on the work of Kacperski, Joanne 2018  in Pediatric Drugs.

Acute and preventive pharmacological treatment of post- traumatic headache: a systematic review