Headaches

"Headache" is a common complaint of childhood. Most headaches occur in specific settings that allow classification and diagnosis of the cause of the headache. Most headaches are benign in origin and resolve with treatment. Most headaches have associated symptoms or findings on neurologic examination to assist in diagnosis. Unfortunately, when a child complains of a headache the worst possible cause is feared, i.e. brain tumor. Brain tumors are a rare cause of headache. This section will review the basics of headaches and outline information about classification of headaches to assist in diagnosis and treatment.

Symptom Classification of Headache
  1. Headache with Systemic Disease
  2. Explosive Onset, Acute or Sub-acute Progressing Headache
  3. Migraine
    1. Without Neurologic Symptoms
    2. With Neurologic Symptoms
  4. Tension Type Headaches
  5. Mixed Tension-Migraine Headaches
Approximately 80% to 90% of children report headaches at some time in their life. Most occur with an acute systemic illness usually with fever. Migraines occur in 9-12% of children. Before puberty, boys are more likely than girls to have migraines. After puberty, females are more likely to have migraines. Most chronic headaches fall into Tension-Type/Migraine spectrum Headaches. Severe Acute Headaches and sub-acute progressive headaches are more likely to be caused by increased intracranial pressure or a structural lesion.

The following sections provide further information on each headache type. Treatment information is provided based on current knowledge and is intended as a guideline for understanding treatment options. (See Disclaimer.)

Introduction to Headaches
  1. Headache with Systemic Disease
  2. Migraine Headaches
  3. Tension Type Headaches
  4. Explosive Onset, Acute or Sub-acute Progressive Headache
  5. Headache with Increased Intracranial Pressure
  6. Headache Treatments

Headache with Systemic Disease

Headaches are a common symptom in children with any febrile illness. The more common illnesses with headache include strep throat, the flu, and sinusitis. The presence of fever and associated symptoms lead to a diagnosis of the cause of the headaches in these conditions
  • Strep throat: headache, fever, and throat discomfort
  • The flu: headache, fever, generalized muscle aches and malaise
  • Sinusitis: headache, fever, nasal congestion and facial pain
More serious infections can also produce headaches. The key to recognizing one of these conditions is the presence of other neurologic symptoms or signs. Associated neurologic symptoms include: altered mental status (obtundation, somnolence, or aggitated stupor), seizures, focal motor signs (weakness or spasticity), speech or language dysfunction. Such conditions include: meningitis, enchephalitis, brain abscess or empyema. Treatment for headaches caused by systemic (or non-intracranial) infections should concentrate on treating the primary illness and use of analgesia and antipyretics for comfort. Intracranial infections need more agressive work-up and treatment.

Migraine Headaches are recurring attacks of systemic and neurologic symptoms, occasionally neurologic signs, that follows a typical pattern of presentation, progression and resolution. Severe head discomfort is the major neurologic symptom. Other common neurologic symptoms include photophobia (sensitivity to light), hyperacusia (sounds are precevied at excessive volume), and loss of apetite. Systemic symptoms include: nausea, vomiting, recurrent vomiting, generalized weakness, fatigue, exhaustion and need to sleep. Some children may develop pallor, become flushed and even run a temperature. Migraine Headaches are often frontal or more diffuse in location in younger children but may lateralize in older children and teens. The pain typically builds in intensity over 5 to 20 minutes and may last several hours to several days. The pain builds to moderate to severe intensity with a pounding, intense character often to the point of crying. If vomiting occurs, the pain may subside following the vomiting. The need to sleep is a feature of migraine and may be related to the reduced blood flow measured over the cortex as the migraine progresses. Most children have a strong family history of migraines. Most series indicate a positive family history in 66% to 75% of children with migraines. With family histories obtained from both parents and at least one grandparent the positive family history rate increases to 80-90%. Migraines occur in 9-12% of children. Before puberty, boys are more likely than girls to have migraines. After puberty, females are more likely to have migraines. A report by Drs. Lee and Olness from the Department of Pediatrics, Rainbow Babies and Childrens Hospital, Cleveland, titled "Clinical and demographic characteristics of migraine in urban children." published in Headache (37:269-76, 1997) tried to establish the frequency, symptoms, duration, and treatment methods of childhood migraine in an urban area. They provided a self-administered questionnaire survey that was designed according to criteria suggested by the International Headache Society (IHS). In 1994, with the help of school officials in 41 elementary and middle schools in the Greater Cleveland Area, 18,000 questionnaires were distributed to the parents of schoolchildren who ranged in age from 5 to 13 years. Of the total 2572 respondents, 222 children (8.6%) met the IHS criteria for migraine. The male to female ratio was 1:1.2 (99:120), 65.8% had a positive family history of migraine, 30.6% had onset of migraine at 4 to 5 years of age, and 54.1% reported having an aura (71% of these were visual aura). The headaches were mostly pulsating, poorly localized, lasted about 2 to 12 hours, and were aggravated by motion, noise, and bright light. The associated symptoms were nausea, vomiting, photophobia, and phonophobia. During the attack, 43% of the migraineurs had to stay in bed, and 27% were unable to attend school. Only 19.8% of the migraineurs were diagnosed to have migraine by their physicians, and most of these had not received treatment. The authors concluded that in an urban area childhood migraine is a common, often underdiagnosed disorder that causes significant suffering for children and their families.

Common Migraine or Migraine Without Neurologic Signs Common Migraine or Migraine Without Neurologic Signs are migraine headaches with systemic symptoms but without neurologic signs. (The neurologic exam is normal and there are not reports of focal neurologic disturbance.) These headaches are more common in boys than girls. Onset usually is around 5 to 6 years of age, often increase in severity and frequency at 9 to 11 years of age, and typically resolve at 13 to 14 years in boys. Headaches may start in infancy and consist of episodes of irritability followed by vomiting and sleep. They may not be recognized as migraines until years when the child can complain of headache. Migraine headaches are often infrequent at onset but over time become increasingly frequent and may occur from once per month to multiple times per week. Daily or nearly every day headaches should be taken as a red flag that pure migraine is unlikely and that the patient is having Tension Headaches or Mixed Tension-Migraine Headaches. Treatment with reassurance, rest, and early use of analgesia will contol migraines for many children especially if this plan isinstitued early along with a clear diagnosis of the headaches as Migraines. Migraine With Neurologic Signs Classical Migraines are migraines with a pre-headache aura or symptoms prior to onset of the headache. Symptoms resolve at the onset of headache or as the headache pain begins to intensify. Classical Migraines are less common in children but may occur and not be recognized since many pre-headache symptoms are visual. Visual aura include, visual loss, homonymous hemianopia, scintillations, and scotomata. Other auras may consist of hemianesthesia, hemiparesis or other focal neurologic symptoms. Complicated Migraines have prolonged auras producing neurologic dysfunction (hemianopia, hemiplegia, dysarthria) for 1 hour to several days. Symptoms may resolve before or along with headache. Prophylactic medication is more likely to be prescribed for indivduals with complicated migraines. There are several sub-types of complicated migraines identified by the pattern of neurologic symptoms that develop. The more common ones include, Hemplegic Migraine and Ophthalmoplegic Migraine. Hemiplegic Migraine as the name implies is a migraine headache with hemiplegia as the associated neurologic deficit. Hemiplegic Migraine is also unique in that families with multiple members having the same migraine symptoms and progressive ataxia or other family members with just progressive ataxia have been identified. This association has allowed the identification of mutations in a gene on Chromosome 19p13 likely responsible for this condition. (Ophoff RA, Terwindt GM, Vergouwe MN, et al., Familial Hemiplegic Migraine and Episodic Ataxia Type-2 Are Caused by Mutations in the Ca++ Channel Gene CACNL1A4. Cell 87:543-552, 1996.) Ophthalmoplegic Migraine are migraines where the associated neurologic symptoms include ophthalmoparesis (paralysis of the muscles that move the eyes). Children develop typical migraine headaches and associated symptoms and are noted to have ptosis and impaired eye movements that normalize once the headache resolves. These are called Basilar Migraines if ataxia, facial weakness, or signs of swallowing dysfunction are present.

Tension Headaches are a common in children and are caused by chronic muscle contraction of the muscles of the face and scalp. Features of tension headache pain include a tight or pressure sensation that is felt all over the head. Some children may localize the discomfort across the frontal area similar to migraine pain but the discomfort is not as intense. The pain may last for hours to days or be continuous. The discomfort does not induce crying and may not even limit the child's activity. Fatigue, anxiety, hungar, and emotional factors play a role in the cause and therefore the treatment of Tension Headaches. Treatment for sporadic Tension headaches include reassurance that headaches are not serious, a brief rest, just a little additional attention. Small adjustments in the child's schedule oftenwill produce improvement. Over the counter medication, acetaminophen or ibuprophen, can be administered if the child does seem uncomfortable. Mixed Tension-Migraine Headaches exist when children have frequent mild to moderate tension headaches and occasional severe migraine headaches. Prophylactic prescription medication is often needed for control. A medication directed toward the most distressing type of headache will be helpful. If both headaches are an equal problem then amitriptyline is often the best choice. Analgesia can be used for the more typical migraine headache and avoided for the tension type to avoid excessive analgesic use and rebound headaches. Chronic Tension Headaches are tension headaches that occur at least 3 to 4 times every week. With time, Chronic Tension Headaches may be present everyday, all day. These are headaches that are present on awakening, last all day, may get more intense in the afternoon or evening and be present when going to bed at night. These headaches can have mild systemic symptoms such as fatigue, reduced appetite and reduced energy but rarely produce any distressing symptoms such as vomiting. Children may complain of light or noise sensitivity with chronic tension headaches but often can continue to watch television and play video games. Children may complain of inability to go to school with these headaches but do not look ill and are able to engage in play activities at home or accompany a parent on errands. Depression, School Avoidance, and separation or other anxiety issues may be present so that counseling or Child Psychiatric evaluation may be needed.

Explosive Onset Headaches, Acute or Sub-acute Progressive Headaches are rare in childhood. Occasionally a child will experience a sudden sharp pain that will cause a brief pause in activity and the child will will hold the head and the pain will resolve in several seconds without other symptoms. These types "headaches" are benign, likely caused by brief muscle cramps and do not need treatment. A Headache with explosive onset producing extreme pain, vomiting, loss of postural tone or awareness, or seizures can occur with the rupture of a arterio-venous malformation (AVM). Symptoms are caused by the rupture of blood vessles and leaking of blood into the cerbral spinal fluid space with a sudden increase in intra-cranial pressure. Immediate medical and an emergency evaluation is needed in this situation. A CT scan will diagnosis intracranial hemorrhage and an arteriogram may be necessary to diagnosis an AVM or aneurysm (which are very rare in children). A headache with less rapid onset but with a steady progression and worsening of the intensity over hours to days to even weeks may the sign of an expanding mass lesion. A mass with associated increase intra-cranial pressue is more likely if symptoms of visual change, weakness or new onset seizure are also present. Conditions that produce progressive, severe headache include brain tumors (especially if headaches are present on awakening and associated with vomiting), a sub-dural or epidural hematoma may be present if there has been preceding head trauma and pre-teens and teenagers with fever, chronic sinusits and a frontal headache and aggitation or depressed alertness, an empyema should be suspected. Drs. Giannoni, Sulek, and Friedman, from the Department of Otolaryngology, University of Florida, Gainesville, published "Intracranial complications of sinusitis: a pediatric series." in American Journal of Rhinology (12:173-8, 1998). They report on the Intracranial complications of sinusitis (ICS) (cerebral, epidural, and subdural abscesses, meningitis, and dural sinus thrombophlebitis). They note that the progressive pneumatization and continued development of the sinuses after birth and the late appearance of the frontal and sphenoid sinuses determines that some infections only appear in later childhood. They reviewed the records of a large pediatric hospital between 1986 and 1995 and found 10 children with 13 ICS (cerebral abscess, 5; extra-axial empyema, 5; and meningitis, 3). They also identified 43 other children with cerebral abscess and 16 with extra-axial abscesses treated in this period, 12% of cerebral and 63% of extra axial abscesses were due to a sinogenic source. Multiple intracranial and extracranial complications of sinusitis in a single patient were common. The average age of the 10 children with ICS was 12.2 years old. The majority presented with a classic picture of headache, altered mental status, and fever, a few had symptoms that were more subtle. One child had recurrent meningitis, believed to be due to skull base dehiscence after endoscopic sinus surgery (ESS). He required multiple otolaryngologic and neurosurgical procedures in an effort to prevent further episodes of meningitis. Ultimately, nine of 10 patients survived with an average hospital stay of 27.8 days (median of 17 days). They stress that the diagnosis of ICS requires a high index of suspicion, imaging of the brain and paranasal sinuses, and aggressive intervention. Treatment for these headaches are directed to relieving the cause of the mass lession and increased intracranial pressure and typically include neurosurgical drainage or removal and offending problem along with treatment of the associated increased ICP. Appropriate long term antibiotics are also needed.

Headaches with Increased Intracranial Pressure Headaches of increased Intracranial Pressure (ICP) can occur with any condition that produces increased ICP. The hallmark symproms are early morning headaches and early morning vomiting. Symptoms occur in the morning after the child has been reclined all night and intracranial contents are expanded. Symptoms lessen or resolve as the child remains upright and active and gravity reduces the venous and CSF volumes. Symptoms usually progress in severity over days to months with the rate of progression dependent on the cause of the increased ICP. Symptoms may include a headtilt, double vision and vomiting. Neurologic signs may be produced by the lesion producing the increased ICP. False lateralizing signs can be produced by the pressure itself. Abductor paresis (Cranial nerve VI palsy) may produce double vision. Impaired up-gaze is also know as a "setting sun sign". Late signs of increased ICP include unilateral pupilary dilation and posturing. Papilledema is a sign of rapid onset increased ICP or of longstanding, very high ICP. Since chronic increased ICP can produce accelerated head growth, a head circumference is always part of a headache work-up. The work-up includes detailed history, physical and neurologic exams and neuro-imaging. Treatment consist of releiving the increased ICP. If hydrocephalus is present, a ventricular shunt or drain is needed. If there are signs of cerebral edema, treatment with hyperventilation, osmotic dehydrating agents, and steroids should be considered. If mass lesions are found, removal or steroids to shrink the lesion may be indicated. Pseudo-tumor Cerebri is a term applied to a syndrome of headaches, papilledema, and increased intracranial pressure without other identified cause. Patients usually present with headache and double vision and are found to have papilledema and VI nerve palsy on exam. There are no intracranial lesions, no hydrocephalus and no sign of central nervous system infection to cause the increased ICP. A MRI should be done to rule out the pressence of a venous sinus thrombosis. On lumbar punctur, the opening pressure is elevated above 25 cm of H20 and often greater than 55 cm of H20 so that the CSF overflows the manometer. Pseudo-tumor can produce optic nerve damage, visual impairment with enlargement of the blind spot, constriction of the peripheral visual fields and even blindness. Treatment of is needed to prevent visual complications and for patient comfort. Treatments include repeated Lumbar Punctures, acetazolamide, steroids, optic nerve sheath fenestration, and lumbar peritoneal shunt. Causes include obesity, vitamin A abuse, medications (tetracyclines, steroids), suspected viral, and chronic otitis media (Otitic Hydrocephalus is an old term for Pseudo-tumor from otits.)

Treatment of Migraine and Tension-Type Headaches Conservative Non-Medication Treatments: Personality traits, life-styles, and activity influence both Migraine and Tension-Type Headaches. Therefore, treatments to control headaches include an evaluation and adjustments in these areas. I often tell families that one of the best treatments includes, "Living Right." I also tell them that I can not be sure what "Living Right" really is but does include, getting adequate rest, proper food and fluid intake, and a balance in school work, family activities and exercise. At times, an additional dose of encouragement and support will go a long way to relieve headaches. I also tell the children to "Let the adults worry about the adult problems" and let them concentrate on doing their best on the "kid activities". A corollary is for the adults not to make their problems the child’s problem. The parents need to determine if the child is in too many activities and a reduction in their schedule can be very helpful. The attitude towards grades in school is also important since many children with migraines, like adults are high achievers. I encourage children to do their best on their work and be happy with the grade they obtain. If they did their best and received a "B" or "C" then they (and the parents) should not worry or make a "big deal" over the grade. This usually allows the child to relax and perform better with fewer headaches. Adequate quality sleep is also a part of the equation for headache control. A study in Cephalalgia (17:492-8, 1997) by Bruni O. Fabrizi P. Ottaviano S. Cortesi F. Giannotti F. Guidetti V. from the Department of Developmental Neurology and Psychiatry, University of Rome La Sapienza, Italy, entitled "Prevalence of sleep disorders in childhood and adolescence with headache: a case-control study" looked at the relationship between headache and sleep disturbances in children. The authors performed a survey to determine the prevalence of sleep disturbances in children with migraine and tension-type headache. A questionnaire of history and clinical data and of sleep disturbances was given to parents of 283 headache subjects (164 with migraine and 119 with tension-type headache). The results were compared to a normative group comparable for age and sex of 893 normal healthy subjects. Migraine subjects showed a higher prevalence of sleep disturbances during infancy as well as 3-month colic. In both headache groups, more parents had sleep disturbances and there was a higher occurrence of co-sleeping and napping. A high frequency of sleep disturbances involving sleep quality, night awakenings, nocturnal symptoms and daytime sleepiness was reported in headache children. No statistical differences were found in the prevalence of sleep disturbances between migraine and tension-type headache. However, the migraine group tended to have "disturbed sleep" more often with increased prevalence of nocturnal symptoms such as sleep breathing disorders and parasomnias. These results give further support to an association between sleep and migraine that may have a common intrinsic origin. This study does not test the idea of improving sleep as a treatment of headache but does give support that children without headaches sleep better than children with headaches. This study also gives insight that families of children with headaches have more problems with sleep as well. Counseling or consultation with a Child Psychiatrist may be needed if Depression or School Avoidance is present. School avoidance has to be suspected in any child frequently missing school or leaving school early because of reported headaches. Home school because of headaches or inability to do Home school work because of headaches should alert one to the need for psychological or psychiatric evaluation. Once a migraine headache develops and becomes severe, the best treatment is to go to bed in a quiet, darkened room. A trip to the emergency room or doctor's office is likely to produce increased discomfort, anxiety and distress and make the migraine pain intensify and last longer. An evaluation in the emergency room is needed only if new neurologic symptoms develop.

Medication: Analgesia Over the counter: analgesics are helpful to reduce the severity of headache. Most pain medication will reduce headache pain by only 20 to 40%. Complete pharmacologic relief from pain is rare even with narcotics. Prescription pain medications produce additional symptoms of sedation, euphoria and at times add to GI discomfort which in the long run does more to complicate the treatment of headaches than help in control. Therefore, it is important to have the child take over-the-counter pain medication early in the course of a migraine to induce control before the pain reaches maximal intensity and systemic symptoms (nausea and vomiting) become intolerable. Often, stopping several headaches early in their course before the headaches reach maximal intensity will cause a change in headache pattern, usually with a reduction in the headache frequency. Continued early treatment often leads to headache relief. Avoid over treatment with more that two doses per day or more than 3 to 4 days per week of analgesia use. This can lead to complications of Rebound headaches or gastric upset with NSAIDS.

Over-the counter Analgesics: Acetaminophen: 15-20 mg/kg every 4 to 6 hours as needed Ibuprofen: 10 mg/kg every 8 hours as needed Prescription Analgesia: Acetaminophen 325mg, Butalbital 50mg, Caffeine 40mg Compounds: Age 6-12 years, 1 tablet: Over 12 years old, 2 tablets. Should be limited to migraine headaches and occasional severe tension headaches that do not respond to other analgesics. Overuse can lead to severe re-bound headaches, tolerance, and addiction. Midrin, (acetaminophen 325mg, isometheptene mucate 65mg, dichloralphenazone 100mg), is a prescription acute migraine drug classified by the FDA to be "possibly" effective for the treatment of migraine. Isometheptene is a symphatomimetic amine and is thought to cause vasoconstriction. Dichloralphenazone is a mild sedative. Adult dose recommendations are 2 capsules at onset of headache followed by 1 capsule every hour until headache subsides for a maximum of 5 in 12 hours time. This recommendation can not be used in children because of the risk of acetaminophen overdose. In children over 22 kg, one capsule every 4 hours allows dosing of the acetaminophen at 15mg/kg/d. Anti-nausea and Antiemetic Medications Promethazine HCL (Phenergan) is useful for its antiemetic and sedation properties. It is supplied in 6.25mg/5ml and 25mg/5ml syrups as well as 12.5mg, 25mg, 50mg tablets and suppositories. The dose is typically 12.5mg to 25mg (1.1mg/kg) and can be repeated in 4 to 6 hours. For children who always develop repeated vomiting with migraines, a promethazine suppository should be given as soon as possible after a headache has developed. Trimethobenzamide HCL (Tigan) 100mg and 200mg suppositories and 100mg and 250 mg capsules. Pediatric dosage 100mg up to every 8 hours for children under 30 pounds and 200mg up to every 8 hours.

Headache Prevention: Medication taken daily should be considered with chronic tension-type headaches that continue despite a trial of life-style adjustments and for migraine headaches that occur more that once per month. Migraines with debilitating systemic symptoms (protracted vomiting) and complicated migraines that occur irregularly may also need prophylactic medical treatment. Many parents will refuse daily medications until headaches occur consistently every week. Medication for Headache Prevention Cyproheptadine HCL (Periactin) is an antihistamine and antiserotonergic agent supplied in 4 mg tablets and a syrup 2mg/5ml. Migraine prophylaxis is typically achieved with a dose of 2-8 mg per day divided into two doses. More common side effects include sedation, dry mouth, and weight gain. Cyproheptadine HCL is the classical anti-migraine drug for pediatrics. A single bedtime dose can be tried if sedation and weight gain are a problem. Amitriptyline HCL (Elavil) is a tricyclic antidepressant that prevents re-uptake by the neurons of serotonin and norepinephrine and is supplied in 10 mg, 25mg, 50mg, 75 mg, 100mg and 150 mg tablets. Migraine, Tension, and Mixed Tension-Migraine headaches can be prevented with a dose of 10mg to 50mg per day. Side-effects are more likely with higher and higher doses. Because of concerns over conduction defects and heart block, ECGs are now recommended for children receiving amitriptyline. Amitriptyline is known to increase slow-wave sleep. The mechanism to prevent headaches is unknown. Side effects include dry mouth, sleepiness and weight gain. Be aware of the risk of overdose. Giving the entire daily dose at bed-time is usually well tolerated. Nortriptyline HCL (Pamelor) is the active metabolite of amitriptyline and is supplied in 10mg, 25mg, 50mg, and 75 mg capsules and a 10mg/5ml suspension. The liquid preparation is useful for the younger child that can not (will not) swallow tablets. A dose of 2.5 to 20 mg/day at bedtime is often effective. See side effects for amitriptyline especially the risk of overdose. Propranolol HCL (Inderal) is a beta-adrenergic receptor blocker, supplied in 10mg, 20mg, 40mg, 60mg. and 80mg tablets that need to be given 2 or 3 times per day or once daily with the long acting 60mg-LA, 80mg-LA, 120mg-LA, and 180-mg-LA tablets. The usual pediatric dose is 1mg to 4mg/kg per day. As a beta-blocker, it should not be used in children with reactive airway disease which increasingly limits it usefulness in children. Propranolol can accumulate in the brain due to its fat solubility and produce depression, moodiness or irritability. Usual starting dose of 5-10mg bid and increase gradually based on response. Propranolol should be withdrawn slowly to avoid rebound hypertension. Topiramate (Topamax) is approved as an anti-seizure medication for children over 2 years of age and is reported to be good for headache prevention. The availability of multiple dose formulations, overall good safety profile, and approval for use in children for seizures are appealing features of Topamax. Topamax is supplied in 15mg and 25mg sprinkle capsules, 25mg, 100mg, and 200mg tablets. Headache prophylaxis is usually achieved at much lower doses than needed for seizures and often with 1 x/day dose scheduling which avoids some of the side effects that can occur when Topamax is used to treat seizures. Side effects seen when treating seizures are related to the dose and speed of dose increases. For headache prevention, a starting dose of 15mg to 25mg at bed time can be effective. Dose increases after 2-3 weeks may be needed if headaches show no improvement. Sise effects include fatigue, sedation, word finding difficulties, appetite suppression and constipation. Rare reports of closed angle glaucoma developing with topiramate proding acuity changes, eye pain and redness that resolve with discontinuation. If eye symptoms develop, topiramate should be discontinued and an ophthalmologic consultaion obtained. Topiramate should not be used if pre-existing eye disorders exist. Second-Line Drugs for Migraine Prevention: Verapamil HCL (Calan) is a calcium channel blocker and is supplied in 40mg, 80mg, and 120mg coated tablets. A sustained released Calan-SR is available in 120mg, 160mg and 240mg scored tablets. Not approved for headache but effective in adults. Tolerance is variable in children. Valproate Sodium (Depakene, Depakote) is an anticonvulsant that now has FDA approval for anti-migraine therapy that is supplies in 125mg (tablet and sprinkle), 250mg, and 500mg tablets and a 250mg/5ml syrup. The dose for migraine prophylaxis is 250mg twice daily. Doses above 1000mg per day did not show any increased effectiveness. Folate supplementation is recommended in teenagers. Side effects are potentially numerous which inhibits valproates usefulness.