In Search of a Better Understanding – and Better Treatment – of Headache Disorders in Kids: A Conversation with Christina Szperka

“Headaches interfere with kids’ ability to learn, with their ability to attend school and to pay attention when they’re in school, and with their ability to graduate and to go on and be successful. This is such a vulnerable period. Kids are supposed to be in high school complaining about their parents and their teachers. They’re not supposed to have a lot of doctors.” – Christina Szperka

Christina Szperka, MD, is the director of the pediatric headache program and a pediatric neurologist at Children’s Hospital of Philadelphia (CHOP). Her work aims to improve care for children who experience headache disorders.

Debilitating headaches impact many people under the age of 18. Around 1 in 10 children experience migraine, which can hugely impact children’s lives, including their ability to attend school, socialize, and achieve success. However, children with headache disorders haven’t always received the care they need. 

Szperka sat down with science journalist Freda Kreier to talk about how she got started in the field, the peculiarities of pediatric migraine, and her work on new daily persistent headache (NDPH). The interview has been edited for clarity and length.

How did you become interested in pediatric headache?

Growing up, my family ran group homes for people with what we now call intellectual disabilities; that was my first job. Then, when I was a teenager trying to figure out what to do with my life, I was able to shadow a child neurologist at CHOP [Children’s Hospital of Philadelphia]. I remember watching and seeing that the neurologist played with kids as part of their exam. I thought that was really cool.

So, I was interested in child neurology. Then, when I was in college, I got sick. It’s sort of unclear exactly what the diagnosis was, but I developed chronic pain. I thought I would go into general chronic pain care, but in residency we saw a lot of kids with headache, and quite frankly, at that point we didn’t do a very good job treating them.

Christina Szperka

If patients did not respond to our first few approaches, the assumption was that there wasn’t much we could do. It seemed like it was an area that was ripe for taking the standard of care and moving it forward.

How many kids suffer from migraine or other headache disorders?

Overall, approximately 60% of youth experience significant headache, and about 9% to 10% experience recurrent migraine. There’s a lower proportion in younger children, and then it becomes more common in teenagers.

Studies that have looked at chronic migraine – meaning a headache that is present more days than not – have found it in probably 1% to 2% of teenagers. What that means – and I say this to kids all the time – is that one to two kids out of every 100 walking around your high school have headaches more days than not.

That means it’s common, right? That’s a lot more kids than make it to our office. Headaches interfere with kids’ ability to learn, with their ability to attend school and to pay attention when they’re in school, and with their ability to graduate and to go on and be successful. This is such a vulnerable period. Kids are supposed to be in high school complaining about their parents and their teachers. They’re not supposed to have a lot of doctors.

Headache disorders are underdiagnosed and undertreated in adults. Is that also true in children?

There’s an initial gut reaction that kids don’t get headaches. Or if a child has a headache, it must be something really dangerous like a brain tumor.

We’ve done a lot of work over the past decade in collaboration with our primary care colleagues to try to improve earlier diagnosis and treatment of migraine. I’ve had many conversations with parents who say that they’ve got migraine and recognize it in their child. But then they’ll say, “When I was a child, nobody talked about it, nobody treated it, nobody acknowledged it.” It was just sort of swept under the rug.

And then, alternately, I’ve had many parents come in really frightened because their child has migraine and they’re convinced it’s something life threatening. And then we can walk through the symptoms and say that the attacks are all consistent with migraine.

Are there differences between how migraine and other headache disorders manifest in children compared to adults?

If you look at our diagnostic criteria, migraine attacks are allowed to last for a shorter time in children than in adults. Migraine pain is typically unilateral in adults, whereas it’s often bilateral in children. Even aura may be bilateral – essentially across the visual field, rather than just on one side – in children.

And so, there can be different associated symptoms across childhood. Teens tend to report things that aren’t necessarily on the diagnostic criteria, like dizziness and blurry vision, whereas the younger children have more classic attacks.

What might be behind these differences between adults and children?

We don’t entirely know the reason why there are differences. I suspect it has to do with neuronal connectivity. One of the things that neurons do during childhood is form connections and undergo pruning. But to my knowledge, we don’t have a clear understanding of why we have that shift from bilateral to unilateral symptoms.

Hormones likely also play a role. Migraine prevalence is relatively equal in boys and girls until around puberty, and then becomes three times more common in girls. Boys are also more likely to outgrow migraine by the age of 20, whereas girls are more likely to continue to have migraine at least until menopause.

Does that mean that adults and children with headaches receive different treatments?

There’s variation in different centers, but many of us will use supplements as a first line treatment for children, because sometimes the supplements can be helpful.

Is that because the riboflavin and magnesium are supporting mitochondria and the energy production of the cells? Or is it taking a pill-based therapy and being told you are likely to get better that helps the body to heal itself? I don’t really know, to be honest. But a lot of people respond to the supplements.

The Childhood and Adolescent Migraine Prevention [CHAMP] study was a large multi-site study that looked at topiramate versus amitriptyline versus placebo to treat migraine. It was interpreted by adult headache specialists to be a negative study because there was no benefit of the medications over the placebo. But amongst pediatric clinicians, we emphasize that two-thirds of the kids in every group got better. There are reasons why placebo response may be higher in kids. For example, a lot of children who enroll in trials are treatment-naïve, so they might have a stronger placebo response.

You also work on a specific type of headache called new daily persistent headache [NDPH]. What is it, and how is it different from migraine?

New daily persistent headache refers to a headache that is abrupt and continuous from onset. The story I hear all the time is, “I was sitting in the middle of math class, and I developed a headache. It didn’t seem different from usual, but it never went away. And it’s now been months, and I’ve never gotten rid of this headache. I wake up in the morning, and it’s there. I go to sleep at night, and it’s there. Maybe it waxes and wanes, but it’s always, always there.”

The features of continuous headache in migraine, NDPH, and post-traumatic headache are almost identical. The difference is how it started. For post-traumatic headache, a person had a concussion or some sort of head injury. For migraine, we go from non-continuous pain over time to continuous pain over time. Whereas NDPH is an abrupt-onset continuous headache.

Patients with NDPH are less likely to respond to typical therapies. With all of that in mind, we’ve had a lot of interest in studying NDPH, because clinically these are the children that we’re having more trouble helping.

NDPH sounds so debilitating.

Absolutely. It’s awful – it’s literally life-changing.

How do you treat NDPH?

I honestly had the bias that patients with NDPH needed to jump to prescription medications. But interestingly, what we found was about a third of the patients with continuous headache respond to a preventive pill, whether that pill is a supplement or a prescription.

However, one-third is not great, right? And so, while the pills had some chance of improving things, we also found that the bridge therapies – like IV medications and nerve blocks – had a higher chance of bringing at least a little bit of improvement.

What that says to me is that for my patients with NDPH, I’m going to give them both a bridge therapy and a preventive therapy. I also really want kids to go see our psychologist, and I want them to see our physical therapist, so we can give patients some tools to help them feel like they can manage their lives a little better.

Did we always know about NDPH? Or is this a new diagnosis?

We were treating it even when I was a fellow 15 years ago. I was taught that you treat NDPH as the headache it resembles. If the features are consistent with migraine, you treat it like migraine. If the features are consistent with tension-type headache, you treat it like tension-type headache.

So we knew it existed. But as we have grown our field, we have been able to start to think about how to tackle these relatively less common conditions. When I was a fellow, there were a handful of pediatric headache specialists. We now literally exceed our room at every single AHS [American Headache Society] meeting. There are regularly 50 people in the room. The field has just exploded.

What would you like people who study migraine to know about pediatric headache?

I suspect that I’m preaching to the converted, but the first piece in my mind is just acknowledging that migraine is a real disease. Because I do find that I sometimes still have those conversations where people ask, “Why are you doing this science?”

I also think that while we do have solutions for a large chunk of children who have migraine, there are still challenges that remain. It would be wonderful if, in the future, we could prevent migraine. Could we figure out that a five-year-old is likely to have it, and then there’s something we can do so they don’t manifest it? I feel like it’s possible. I’m not sure it’s going to happen in my career, but I think we could get there.

Freda Kreier is a science journalist based in Washington, D.C.

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