Headaches and adolescents: why so many failures in their management

Abstract

Background The management of headaches in children and adolescents is still a challenge, with patients experiencing pain for years and polypharmacy. Methods We reviewed the medical history of 31 patients referred to our pain clinic for chronic headaches between April 2022 and March 2024. Results There were more female than male patients (73%). Patients have been reporting headaches for 52±44 months on average. Twenty-nine patients (94%) were experiencing different types of pain besides headaches. The most common medication prescribed in this group of patients was Topiramate (69%), followed by Tricyclic antidepressants (36%) and Triptans (21%). Patients had been prescribed and tried, on average, 4.5±2 (range 1-10) different medications to manage headaches and concomitant mood disorders. Twenty-two patients (71%) had been diagnosed with a mood disorder, including depression, anxiety, PTSD, and 14% had a history of attempted suicide/self-harm. Fourteen of them (64%) had been prescribed antidepressants or anti-anxiety medications. They had been prescribed, on average, 2±1 (range 1-4) mood stabilizer medications. We agreed with the referral diagnosis in 39% of the patients. We attributed the headaches to more complex chronic pain conditions, including fibromyalgia (15%) and AMPS (15%), autism with sensory integration problems (9%), and major depression (9%). Patients had seen an average of 3±1 (range 1-5) different specialists; none consulted a pain specialist. Patients underwent between 0 (12%) and 4 tests (6%), including MRI (52%) and CT of the brain (8%). These neuroimaging studies did not demonstrate any brain pathology. We prescribed new medications and treatments, including nerve blocks, in 19 (58%) patients. In 47% of the cases, patients reported improvement in their headaches, while 22% of the patients did not feel that our recommendations were effective. Twenty-one percent of patients never came back to the clinic for a follow-up. Significant catastrophizing was present in 57% of the patients, 76% of patients had mild to severe anxiety, and 81% had symptoms of depressive disorder. Conclusions Headaches are often the manifestation of more complex pain syndromes that require a more holistic approach, different from conventional pharmacological management