Kids as young as 6 who get frequent headaches may be using over-the-counter pain relievers too much

Jun 11 2004

Kids as young as 6 who get frequent headaches may be using over-the-counter pain relievers far more than they should, and often without their parents' knowledge, suggests a study being presented at the 46th Annual Scientific Meeting of the American Headache Society (AHS).

Not only is the overuse of those medications potentially harmful, the practice may lead to rebound-chronic daily headache, according to researchers from the Cleveland Clinic.

"I've been astounded by the large numbers of kids using over-the-counter medications five or six times a week - sometimes 15 to 20 times a week. A few of them even went into kidney failure or developed gastrointestinal bleeding because of all of the medicine they were taking," said the study's lead investigator, A. David Rothner, M.D., director emeritus of child neurology and director of the Pediatric/Adolescent Headache Clinic at The Children's Hospital at The Cleveland Clinic, Cleveland, Ohio. "Even more frightening was that a lot of them were taking medication without telling their parents. Physicians need to specifically ask children and adolescents who get headaches how much over-the-counter medicine they are using."

One popular medication being used by children and teens and marketed as a migraine remedy contains aspirin, which children shouldn't have until they are at least 19 years old, because it has been linked to potentially deadly Reye's Syndrome. Children and adolescents most often use acetaminophen and non-steroidal anti-inflammatory (NSAID) drugs such as ibuprofen and naproxen. All of these medications are available without a prescription.

Headache experts define overuse of over-the-counter medications - in children and adults - as taking more than three doses a week for more than six weeks. More than 1 in 5 children and adolescents who participated in the study were using over-the-counter pain relievers too often. Although researchers didn't track the numbers, they said about 1 in 7 children and adolescents admitted to using the medications without telling their parents. The kids weren't doing it surreptitiously, they just didn't realize that their parents should be consulted before they took medications, said Dr. Rothner.

The prevalence of chronic daily headache - occurring daily or nearly daily - increases as children get older: about 15 percent of 15-year-olds suffer from them. Chronic daily headaches can be tension-type, or a mixture of tension-type and migraine. More than 1 in 10 school-aged children and adolescents suffer from migraine headaches and three times as many children and adolescents suffer from a tension-type headache at some time during their school years.

The study involved 680 children and adolescents, ages 6 to 18, who had been referred to The Cleveland Clinic's Pediatric/Adolescent Headache Clinic: 41 percent had migraine headaches; 28 percent had tension-type headaches; 22 percent had a mixture of migraine and tension-type headaches; 5 percent had headaches due to a disease or physical problem (such as an infection or brain tumor); and 4 percent had other forms of headaches. Overuse of over-the-counter pain relievers occurred in 22 percent of study participants, and was more common in girls who had chronic tension-type headaches or a mix of migraine and tension-type headaches. Additionally, 14 percent of patients had missed more than 15 days of school in a school year. Most of those who missed school had chronic tension-type headaches or a mix of migraine and tension-type headaches.

Nearly 1 in 5 (19 percent) of the kids in the study had headaches every day or nearly every day; 80 percent were girls and 85 percent were straight A or A/B students.

"If you have a child or teen with frequent headaches who is missing a lot of school, you need to be forceful in getting an accurate diagnosis," said Dr. Rothner.

Research has shown that adults who regularly take over-the-counter medication for their tension-type headaches are more likely to have rebound headaches, and also are more likely to have their headaches "transform" into chronic migraine headaches. Previously, experts thought this phenomenon didn't occur in children and adolescents, but it's increasingly apparent it does, said Dr. Rothner.

A positive note for parents of kids who get frequent headaches: It's not your fault your children are suffering, said Dr. Rothner.

"All school kids are under stress, but some children and adolescents seem to be biologically predisposed to having headaches and stress may play a significant role in developing chronic daily headaches," he said. "We were surprised to discover that it's not the parents pressuring the kids, it's the kids pressuring themselves. You've got a group of Type-A kids who want to do well and are pushing themselves."

Most of the children and adolescents in the study named school as a major cause of stress. Many of them unconsciously were attempting to avoid stress by insisting that they were in pain and needed to stay home from school, and their empathetic parents kept them home, said Dr. Rothner.

"Part of the cure is that they must go back to school," said Dr. Rothner. "They need tough love. Staying home doesn't cure the headaches. They often benefit from professional help to learn how to deal with the stress and pain. If needed, a doctor can prescribe medication to prevent the headaches."

In addition, parents should monitor their children's use of over-the-counter medications, and limit it to two doses per week, he said. If the headaches are frequent, a doctor can prescribe daily preventive medication. Although not approved by the Food and Drug Administration (FDA) for use in children and adolescents, tricyclic antidepressants often are effective in preventing their headaches, even though most of them aren't depressed. Researchers are unsure why they work. They seem to get the most benefit from the combination of counseling, medication and daily school attendance, said Dr. Rothner.

Unfortunately, no headache medications have been approved by the FDA for use in children or adolescents, although many physicians will prescribe them because there has been limited research showing some are safe. Another study being presented at the AHS meeting suggests one of the triptans is safe and effective in children. Triptans are one of the most effective acute or symptomatic migraine medications available, Dr. Rothner said.

The pediatric neurology community is focused on conducting more studies to determine safety and effectiveness of headache medications in children and adolescents, said Dr. Rothner.

Dr. Rothner's coauthor of a paper written on the topic was Y. Guo.

The American Headache Society (AHS), founded in 1959 as the American Association for the Study of Headache, is based in Mt. Royal, N.J. AHS is a professional organization for those interested in the study and management of headache and face pain. AHS has approximately 2,500 members. For more information, visit the AHS Web site at www.ahsnet.org. To fill the need for patient education, AHS established the American Council for Headache Education (ACHE), a non-profit patient-physician organization for the advancement of the treatment and management of headache and the encouragement of more constructive social attitudes toward the disease. Individuals who would like more information about headache, who would like a referral to a specialist who treats headache or who would like information on support groups can call (800) 255-ACHE at 19 Mantua Road, Mt. Royal, N.J. 08061, or visit the ACHE Web site at www.achenet.org.