Research Review By Dr. Ceara Higgins©

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Date Posted:

February 2014

Study Title:

Headaches in Children: Update on Complementary Treatments

Authors:

Schetzek S, Heinen F, Kruse S et al.

Author's Affiliations:

Department of Paediatric Neurology and Developmental Medicine, University of Munich; Department of Neurology, University of Essen; Centre for Palliative Care for Children, University Children’s Hospital, Homburg; Children’s Hospital, Paderborn; Centre for Pediatrics, Department of Neuropediatrics, Ruprecht-Karls-University of Heidelbergm Baden-Wurttemberg, all in Germany.

Publication Information:

Neuropediatrics 2013; 44: 25-33.

Background Information:

Complimentary and Alternative Medicine (CAM) therapies are commonly used by adults with headaches and may be valuable in the management of childhood headaches, as many medical doctors and parents are hesitant to give pharmacologic treatments to children. As a result, CAM therapies are becoming increasingly popular in the treatment this, and other childhood conditions.

Past research has shown a variety of CAM therapies to be helpful in treating headaches in adults. For example, Jena et al. (10) and Melchart et al. (16) found that acupuncture added to pain relievers was more effective in the treatment of tension-type headaches than the use of pain relievers alone, while a study by Linde et al. (13) found that adding acupuncture to acute or routine care for migraines was beneficial in reducing migraine intensity and frequency. Literature reviews, such as the one by Bronfort et al. (2) in 2011, suggest that spinal manipulation may be beneficial in the treatment of tension-type headaches and may help to prevent migraines as well.

The purpose of this review paper was to give an overview of the current evidence surrounding the main alternative therapies used in the treatment of primary headache syndromes of childhood.

Pertinent Results:

Overall, 29 articles met the study’s inclusion criteria – the results are summarized below for each treatment option.

Acupuncture:

Six articles looked at the use of acupuncture to treat headaches. Of these, 2 articles specifically pertained to children, 3 to adults, and 1 to all ages. A study by Pintov et al. (22) examined children between 7 and 15 years of age with migraines who were treated with either true or placebo acupuncture. They found that the children treated with the true acupuncture showed a significant reduction in both the frequency and intensity of migraine attacks, as well as a significant increase in the levels of beta-endorphins in the blood after treatment.

Gottschling et al. (8 – also see Related Reviews) examined the use of laser acupuncture to treat migraines and tension-type headaches in children and found a significant reduction in the number of headaches per month, the severity of their headaches, and the monthly hours with headaches reported.

Linde et al. (12, 13) presented two Cochrane reviews, one on acupuncture for migraines and another for acupuncture for tension-type headaches. The migraine review found higher response rates and fewer headaches with acupuncture treatment when compared to prophylactic drug treatment, but no significant differences when compared to sham acupuncture treatments. The review on tension-type headaches showed statistically significant benefits of acupuncture over sham acupuncture and other treatments, including physiotherapy, massage, and relaxation techniques.

Vickers et al. (29) performed a meta-analysis, which found acupuncture effective in the treatment of chronic pain and significant differences between the results of true versus sham acupuncture. This is indicative that acupuncture has more than a placebo effect.

Finally, Melchart et al. (17) showed that acupuncture was superior to placebo in preventing an acute migraine attack. However, sumatriptan showed a faster response and was more effective as an intervention when a patient has developed a full blown attack.

Overall, acupuncture may be a useful tool in the treatment of headache in children. However, it is important to consider that acupuncture requires the cooperation of the patient, as they need to remain still throughout the treatment. Therefore it may be necessary to reserve this treatment for older children who would be more cooperative.

Homeopathy:

Six articles investigated the use of homeopathy, with one specific to children and five looking at adults. The only study to focus on children was by Danno et al. (6) and focused on homeopathic treatment for migraines. The study showed significant decreases in frequency, severity, and duration of migraine attacks, and fewer missed days from school with homeopathic treatment.

Observational studies by Muscari-Tomaioli et al. (18) and Witt et al. (33) on adults with migraine and tension-type headaches showed improvements in pain severity, quality of life, and decreases in the use of conventional treatments. However, randomized control trials by Walach et al. (30), Whitmarsh et al. (32), and Straumsheim et al. (27) showed no benefit to treatment with homeopathy versus placebo.

Nutritional Supplements:

Twelve articles were reviewed that looked at treatment of headaches with nutritional supplementation. Of these, six looked at supplementation with Magnesium (one in children, five in adults), four looked at supplementation with Riboflavin (three in children, one in adults), and two looked at Coenzyme Q10 (both in children).

Magnesium Supplementation:
Wang et al. (31) performed the only RCT on magnesium supplementation in children included in this review. They examined the prophylactic effect of magnesium in children with migraines and found that while those given the magnesium supplementation showed significantly lower headache severity, they did not show any reduction in headache frequency when compared to placebo.

In studies on adults, results were mixed. A study by Mauskop et al. (15) of women with menstrual-related migraines showed that magnesium supplementation provided in the days from ovulation to the first day of the menstrual flow significantly reduced the days with headache and the pain intensity. Gender-mixed studies by Peikert et al. (21) and Koseoglu et al. (11) showed that magnesium supplementation prophylactically led to a reduction in frequency of attacks, severity of attacks, and drug consumption while symptomatic for patients with migraines. Contrarily, studies by Pfaffenrath et al. (23) and Cete et al. (4) showed no effect of supplementation in individuals with migraines, whether given orally or through IV. In the studies included, the most common side effect noted was diarrhea.

Riboflavin (VitB2) Supplementation:
In a study by Condo et al. (5), prophylactic riboflavin supplementation in children was shown to significantly reduce the frequency of attacks but similar studies by MacLennan et al. (14) using high-dose riboflavin, and Bruijn et al. (3) using medium-dose riboflavin in children showed no significant difference in the frequency of migraine headaches when compared to placebo. However, Bruijn et al. (3) did find a significant reduction in headache frequency in individuals with tension-type headaches.

In a study by Schoenen et al. (25), adults given prophylactic, high-dose riboflavin showed a significant reduction in both attack frequency and days with headache when compared to placebo treatment.

Coenzyme Q10 Supplementation:
Hershey et al. (9) studied Coenzyme Q10 supplementation as a prophylactic treatment for childhood migraines after finding that nearly 1/3 of children presenting to the study with frequent headaches showed Coenzyme Q10 levels below the reference range. They found that as levels of Coenzyme Q10 rose under supplementation, headache frequency and associated disability showed significant reductions. A more recent study by Slater et al. (26) showed significant reductions in migraine attack frequency, severity, and duration during weeks 1 to 4, but no reduction from weeks 5 to 32, suggesting that Coenzyme Q10 supplementation may only have a temporary effect on migraines.

Herbal Preparations:

Three studies were reviewed that looked at the use of herbal preparations in migraine treatment. Of those, two looked at the use of Butterbur root (petasites hybridus) in children and one looked at the use of Feverfew (Tanacetum parthenium) in adults.

The studies by Oelkers-Ax et al. (20) and Pothmann et al. (24) showed Butterbur to be superior to placebo in reducing migraine attack frequency while being well tolerated in children. The study by Diener et al. (7) showed Feverfew supplementation in adults to be superior to placebo in reducing attack frequency. However, it is important to note that side effects can include GI disorders, mouth ulcers, and joint aches. As well, Feverfew should not be used during pregnancy.

Manual Therapies and Osteopathy/Osteopathic Medicine:

Three studies on manual therapy were reviewed. Of these, one was specific to children and two were performed on adults. The study by Borusiak et al. (1) found no significant difference between manual therapy and placebo in the treatment of children with cervicogenic headaches. A study by Vernon et al. (28) found that headache intensity was reduced comparably with the use of amitriptyline, spinal manipulation, and a combination of the two. On post-treatment follow-up, spinal manipulation was found to be most effective. Finally, Nelson et al. (19) performed a systematic review looking at randomized clinical trials of CAM for the treatment of tension-type and cervicogenic headaches. They found evidence from high-quality studies supporting the use of CAM therapies for the treatment of these types of headaches.

Clinical Application & Conclusions:

A variety of CAM interventions can be useful in the treatment of headaches in children, and should be considered on an individual basis as part of a personalized treatment approach. The strongest evidence supports the use of acupuncture, with moderately strong evidence for the use of manual therapy and certain herbal preparations for the treatment of headaches in children. It is also suggested that prophylactic treatment may be more useful than acute treatment.

The existing research must be expanded upon with studies using more rigorous and systematic research methods. It is also important to consider the existing evidence for treatment of headaches in adults and potentially apply this to the pediatric population. Since the placebo effect is typically much stronger in children, it may be difficult to obtain conclusive research in pediatric patients. Studies on children are likely to show a greater response to all forms of treatment rendered, as children are more likely to inherently believe in the treatment working when told by an authority figure that it will work (this is compared with adult subjects/patients).

Study Methods:

The authors searched MEDLINE and the Cochrane Library from September 1992 through September 2012 for articles in English and German. Due to the small number of articles available on CAM treatments for headaches in children, studies involving adults were also included in the review (see below). The reference lists of all relevant articles found through the initial search were then checked to find further relevant articles. In total, 29 relevant articles were found. Of these, 6 looked at acupuncture, 6 at homeopathy, 11 investigated nutritional supplementation, 3 looked at herbal preparations, and 3 looked at manual therapies.

Study Strengths / Weaknesses

The authors performed a thorough search and decided to include adult studies in order to make up for the small amount of pediatric research available for this review – a bit of an odd choice that must be taken into account when looking at this paper! Although it may be safe to presume that adolescents and perhaps younger children would respond similarly to some treatments (particularly manual interventions?), we must consider that adult studies may not always be directly applicable to a pediatric/younger population.

Additional References:

  1. Borusiak P, Biedermann H, Bosserhoff S, Opp J. Lack of efficacy of manual therapy in children and adolescents with suspected cervicogenic headache: results of a prospective, randomized, placebo-controlled, and blinded trial. Headache 2010; 50(2): 224–230.
  2. Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database of Systematic Reviews. 2004(3): CD001878
  3. Bruijn J, Duivenvoorden H, Passchier J, et al. Medium-dose riboflavin as a prophylactic agent in children with migraine: a preliminary placebo-controlled, randomised, double-blind, cross-over trial. Cephalalgia 2010; 30(12): 1426–1434.
  4. Cete Y, Dora B, Ertan C et al. A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the Emergency Department. Cephalalgia 2005; 25(3): 199–204
  5. Condò M, Posar A, Arbizzani A, Parmeggiani A. Riboflavin prophylaxis in pediatric and adolescent migraine. Journal of Headache Pain 2009; 10(5): 361–365.
  6. Danno K, Colas A, Masson JL, Bordet MF. Homeopathic treatment of migraine in children: results of a prospective, multicenter, observational study. Journal of Alternative Complementary Medicine 2012; 19(2): 119-123.
  7. Diener HC, Pfaffenrath V, Schnitker J, et al. Efficacy and safety of 6.25 mg t.i.d. feverfew CO2-extract (MIG-99) in migraine prevention—a randomized, doubleblind, multicentre, placebo-controlled study. Cephalalgia 2005; 25(11): 1031–1041.
  8. Gottschling S, Meyer S, Gribova I, et al. Laser acupuncture in children with headaches: a double-blind, randomized, bicenter, placebo-controlled trial. Pain 2008; 137(2): 405-412.
  9. Hershey AD, Powers SW, Vockell AL, et al. Coenzyme Q10 deficiency and response to supplementation in pediatric and adolescent migraine. Headache 2007; 47(1): 73–80.
  10. Jena S, Witt CM, Brinkhaus B, Wegscheider K, Willich S. Acupuncture in patients with headache. Cephalagia 2008; 28(9): 969-979.
  11. Köseoglu E, Talaslioglu A, G.nül AS, Kula M. The effects of magnesium prophylaxis in migraine without aura. Magnesium Research 2008; 21(2): 101–108.
  12. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews 2009; (1): CD001218
  13. Linde K, Allais G, Brinkhaus B, Manheimer E, et al. Acupuncture for tension-type headache. Cochrane Database of Systematic Reviews. 2009; (1): CD007587
  14. MacLennan SC, Wade FM, Forrest KM, et al. High-dose riboflavin for migraine prophylaxis in children: a double-blind, randomized, placebo-controlled trial. Journal of Child Neurology 2008; 23(11): 1300–1304.
  15. Mauskop A, Altura BT, Altura BM. Serumionized magnesium levels and serum ionized calcium/ionized magnesium ratios in women with menstrual migraine. Headache 2002; 42(4): 242–248.
  16. Melchart D, Streng A, Hoppe A, Brinkhaus B, et al. The Acupuncture Randomised Trial (ART) for tension-type headache-details of the treatment. Acupuncture in Medicine 2005; 23(4): 157-165.
  17. Melchart D, Thormaehlen J, Hager S, Liao J, et al. Acupuncture versus placebo versus sumatriptan for early treatment of migraine attacks: a randomized controlled trial. Journal of Internal Medicine 2003; 253(2): 181-188.
  18. Muscari-Tomaioli G, Allegri F, Miali E, et al. Observational study of quality of life in patients with headaches, receiving homeopathic treatment. British Homeopathic Journal 2001; 90(4): 189-197.
  19. Nelson CF, Bronfort G, Evans R, et al. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. Journal of Manipulative and Physiological Therapeutics 1998; 21(8): 511–519.
  20. Oelkers-Ax R, Leins A, Parzer P, et al. Butterbur root extract and music therapy in the prevention of childhood migraine: an explorative study. European Journal of Pain 2008; 12(3): 301–313.
  21. Peikert A, Wilimzig C, Köhne-Volland R. Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study. Cephalalgia1996; 16(4): 257–263.
  22. Pintov S, Lahat E, Alstein M, Vogel Z, et al. Acupuncture and the opioid system: implications in management of migraine. Pediatric Neurology 1997; 17(2): 129-133.
  23. Pfaffenrath V, Wessely P, Meyer C, et al. Magnesium in the prophylaxis of migraine – a double-blind placebo-controlled study. Cephalalgia 1996; 16(6): 436–440.
  24. Pothmann R, Danesch U. Migraine prevention in children and adolescents: results of an open study with a special butterbur root extract. Headache 2005; 45(3): 196–203.
  25. Schoenen J, Jacquy J, Lenaerts M. Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized controlled trial. Neurology 1998; 50(2): 466–470.
  26. Slater SK, Nelson TD, Kabbouche MA, et al. A randomized, double-blinded, placebo-controlled, crossover, add-on study of coenzyme Q10 in the prevention of pediatric and adolescent migraine. Cephalalgia 2011; 31(8): 897–905.
  27. Straumsheim P, Borchgrevink C, Mowinckel P, et al. Homeopathic treatment of migraine: a double blind, placebo-controlled trial of 68 patients. British Homeopathic Journal 2000; 89(1): 4–7.
  28. Vernon H, McDermaid CS, Hagino C. Systematic review of randomized clinical trials of complementary/alternative therapies in the treatment of tension-type and cervicogenic headache. Complementary Therapies in Medicine 1999; 7(3): 142–155.
  29. Vickers AJ, Cronin AM, Maschino AC, et al; for the Acupuncture Trialists’ Collaboration. Acupuncture for chronic pain: individual patient data meta-analysis. Archives of Internal Medicine 2012; 172(19): 1444-1453.
  30. Walach H, Haeusler W, Lowes T, et al. Classical homeopathic treatment of chronic headaches. Cephalalgia 1997; 17(2): 119–126.
  31. Wang F, Van Den Eeden SK, Ackerson LM, et al. Oral magnesium oxide prophylaxis of frequent migrainous headache in children: a randomized, double-blind, placebo-controlled trial. Headache 2003; 43(6): 601–610.
  32. Whitmarsh TE, Coleston-Shields DM, Steiner TJ. Double-blind randomized placebo-controlled study of homoeopathic prophylaxis of migraine. Cephalalgia 1997; 17(5): 600–604.
  33. Witt CM, Ludtke R, Willich SN. Homeopathic treatment of patients with migraine: a prospective observational studt with a 2-year follow-up period. Journal of Alternative and Complementary Medicine 2010; 16(4): 347-355.