Pediatrics Headaches

Pediatric Headaches

Prevalence

Headache is a common problem in children. Studies of prevalence of any type of headache have shown that up to 50% of 7-year olds and up to 80% of 15-year olds have experienced at least one headache. Some reports have suggested that headache is more common in boys prior to puberty but a definitive preponderance (3:1) of females after adolescence. 

Common types

  1. Primary Headaches
    A.)Migraine (with or without aura)-  This is the commonest type of headache in children. Typically the history will be of an   acute headache which evolves over few hours preceded typically by a sensory aura  which could be visual (grey dots, zig-zag lines, vision loss), olfactory(abnormal smell), gustatory(abnormal taste) or auditory(sound hurts). The headache is frequently frontal (in front of the head) and not unilateral (one side) like in adults and is associated with intense nausea, vomiting and photophobia. The history often also given by child or parents is off loss of appetite during and just preceding the migraine episode. Family history of migraine is often there.

    Migraine equivalents instead of typical migraine can be seen in children in form of acute confusion, recurrent abdominal pain, cyclical vomiting and intense vertigo (Basilar migraine). A particular type of migraine can be associated with hemiplegia (weakness of one side of body) mimicking stroke.

    Most episodes last for 12-72 hours but occasionally not treated early can develop into status migranosus which then can take upto 5-7 days to get better. 

    B.)Chronic Muscular headache (Tension Headache)- The history here is of a dull constant headache which is present ‘all the time’.  This headache is typically worse in the afternoon and evenings. The history of aura, nausea or photophobia is usually not there. Stress, anxiety and depression can sometimes precipitate these headaches. 

    A useful history to differentiate migraine and tension headache is if a patient wants to lie in a quiet dark room he is more likely to have migraine while the one who is restless moving around in the room complaining of headache is more likely to have chronic muscular headache.

    C.)Mixed Headache- Often not mentioned but this is a common form of headache seen in children. Initially child has episodic migraines but later also starts to get mild daily or frequent tension headaches. Often the history will be of occasional severe episodic headache (migraines) and a constant daily headache which is ‘always’ there and does not shift.

  2. Secondary Headache- When a child presents with headache acutely, it is essential to consider whether it may be secondary to an underlying systemic disease process. The most important diagnoses to consider are intracranial bleeding, infection or brain tumor.
     Idiopathic intracranial hypertension is a secondary headache which is associated with headache symptoms similar to chronic tension headache. These children can be overweight with a sedentary lifestyle. The headache is caused by interruption of the drainage of CSF (normal fluid in the brain which is recirculated everyday) causing increased pressure. On eye examination there could be papilledema (swelling in the back of eyes) and visual field defects. The Brain imaging though usually is normal. These headaches require Lumbar puncture for diagnosis and treatment. Sometimes oral medications can also be prescribed to relive the pressure as they decrease the amount of CSF formed.

Investigations

Neuro imaging should be considered in children with an abnormal neurological examination, the coexistence of seizures, or both. Neuro imaging should also be considered in children in whom there are historical features to suggest recent onset of severe headache, change in type of headache, or If there are associated features that suggest ‘neurological dysfunction1.
Lumbar puncture has to be considered if there is suspicion of infection or idiopathic intracranial hypertension.

Treatment

The biggest worry parents understandably have when a child has headaches is if child has got a ‘brain tumor’. Contrarily most headaches are not associated with brain lesion and often history and examination will be enough to confirm this. Reassurance that the headache is not due to a significant brain problem itself is often therapeutic. 

Lifestyle Modification

It is always important to have good fluid intake especially in warm weather, sleep well and have an active lifetstyle which goes a long way in helping any type of headache especially migraines. Rarely people can identify food precipitants for their headaches like cheese, chocolate, banana or citrus(orange, lemon etc.) fruits. Relaxation exercises can sometimes help with chronic daily headaches.

Medications

In my experience most headaches especially chronic muscular headaches have been benefited by gentle reassurance, setting up small goals and trying simple analgesics sparingly like paracetamol and ibruofen. It is important that analgesics are only reserved for bad headaches and not to be taken regularly otherwise can cause analgesic rebound headache.

Acute relief

Severe migraine often requires good doses of analgesics with some anitemetic (for vomiting). It is important with migraines to take medication at the onset of headache or with aura otherwise the analgesics often are not as effective.

Prophylaxis (Regular medication)

If migraine attacks become very frequent or if chronic muscular headache is affecting the child’s functioning (missed school, tiredness, low mood) than daily medications can be tried for 3-6 months. Keeping a headache diary is also useful to monitor the effectiveness of daily medication.

Dr Vivek Jain
Child Neurologist
Jaipur