Headache

Published on 24/03/2015 by admin

Filed under Emergency Medicine

Last modified 22/04/2025

Print this page

This article have been viewed 910 times

Chapter 15 Headache

Jane F. Knapp, MD, Robert D. Schremmer, MD

1 Do children get migraine headaches?

Migraine is one of the most common causes of headache in children. The reported prevalence is 3–10%. The variation in prevalence between studies is due primarily to differences in diagnostic criteria used and the age range of children studied. Of children referred to pediatric neurologists for the evaluation of headache, migraine is diagnosed in 75%.

2 Are the international headache society (IHS) criteria for the diagnosis of migraine headache applicable to children?

The IHS criteria were developed primarily for the diagnosis of headache in adults. The second edition of the International Classification of Headache Disorders (ICHD-2), published in 2004, reduces the duration requirements of the headache from 4–72 hours in adults to 1–72 hours in children under age 15 years. It also acknowledges that photophobia and phonophobia must be inferred from behavior in young children. The IHS guidelines do not account for other possible symptomatic differences, including intensity and location of pain. Pediatric migraines are often bilateral. A higher incidence of photophobia or phonophobia alone also occurs, especially in younger children.

4 List the criteria for pediatric migraine headache with aura.

A At least two attacks fulfilling criteria listed for B

B At least two of the following:

One or more fully reversible aura symptoms, including focal cortical and/or brain stem dysfunction

At least one aura developing gradually over more than 4 minutes, or two or more symptoms occurring in succession

Headache follows less than 60 minutes after aura symptoms

5 List some common triggers for migraine in children.

Stress, fatigue (including lack of sleep), hunger, glare, head trauma, and certain foods containing nitrates, caffeine, tyramine, glutamate, or salt are common triggers. Eye strain, cold foods, and high altitude are less common.

6 Do children get tension-type headaches?

The prevalence of tension-type headaches in children and adolescents ranges from 10% to 25%, but one study reported a prevalence of 73% in Brazilian children and adolescents age 10–18 years. The ICHD-2 lists three subtypes of tension-type headaches: (1) infrequent episodic (headaches on <1 day per month), (2) frequent episodic (headaches on 1–14 days per month), and (3) chronic (headaches on ≥15 days per month). These headaches are characterized by mild to moderate pressing or tightening pain that is nonpulsatile. The pain is usually bilateral and not aggravated by routine activity. Nausea and vomiting do not occur, but phonophobia or photophobia may be present. Clinical features are the same in children and adults.

Anttila P: Tension-type headache in children and adolescents. Curr Pain Headache Rep 8:500–504, 2004.

7 Are causes of tension-type headaches the same for adults and children?

Pediatric tension-type headaches probably share some risk factors, but there are some differences. Analgesic overuse, psychosocial stress, psychiatric disorders, muscular tension, and oromandibular dysfunction are potential causes of tension-type headaches in adults. Analgesic overuse has not been found in children. Psychosocial stress (divorced parents, physical changes during adolescence, difficulty with peer relations, and chronic illness) are more often reported in children with tension-type headaches. Also, children with frequent episodic tension-type headaches more commonly manifest depressive symptoms. The presence of scoliosis may also precipitate tension-type headaches in some children.

8 Can children suffer from both migraines and tension-type headaches?

Although the ICHD-2 does not recognize a separate category of mixed migraine and tension-type headache, characteristics of both types of headache may be found in many children. In one Canadian study, one third of the patients with migraine symptoms fulfilled the IHS criteria of tension-type headaches as well. Some researchers have postulated that episodic tension-type headache and migraine may fall along the same continuum of disorder.

Sarioglu B, Erhan E, Serdaroglu G, et al: Tension-type headache in children: A clinical evaluation. Pediatr Int 45:186–189, 2003.

Seshia SS: Mixed migraine and tension-type: A common cause of recurrent headache in children. Can J Neurol Sci 31:315–318, 2004.

9 How will I recognize the child with a brain tumor headache?

Brain tumors are an uncommon but feared cause of headaches in children. Certain features help to distinguish a headache that is caused by a tumor (Fig. 15-1) or other intracranial mass:

Figure 15-1 CT scan showing brain tumor.

Location—occipital headaches or headaches localized to the nape of the neck

Worsening with sneezing, coughing, or straining

Timing—headaches that awaken the child from sleep or that are worse in the morning and improve on arising

Positioning—headaches that worsen with body movement, especially bending forward, and improve with change in position

Headaches associated with blurred vision

Change over time—headaches that change in frequency, severity, or characteristics

Honig PJ, Charney EB: Children with brain tumor headaches. Am J Dis Child 136:121–124, 1982.

Key Points: Brain Tumor Headaches

1 Usually occipital

2 Worse with cough, sneezing

3 Worse in the early morning

4 May be worse with bending forward

5 Change in character over time

10 Are chronic daily headaches common in children?

Chronic daily headaches encompass a group of headaches not specifically described by the ICHD-2, although three of the four types in a proposed classification are included in the 2004 IHS revisions:

Transformed migraine: Daily headache with average duration of 4 hours for more than a month, and a history of increased headache frequency with decreased migraine symptoms

Chronic tension-type headache (ICHD-2 2.3): History of episodic tension-type headache in the past with evolution to daily headaches

New daily persistent headache (ICHD-2 4.8): Acute onset of headache on more than 15 days per month lasting at least 4 hours and without history of migraine or tension-type headache in the past

Hemicrania continua (ICHD-2 4.7): Unilateral, continuous headache of moderate severity known for its absolute relief with indomethacin

The prevalence of chronic daily headaches is reported to be almost 1% of children and adolescents, and as many as 30% of patients seen in pediatric neurology clinics suffer from them. They occur more commonly in females. Psychiatric comorbidity, including sleep, anxiety, and mood disorders, is high, which increases the difficulty of treatment. Transformed migraine is the most common type.

Esposito SB, Gherpelli JLD: Chronic daily headaches in children and adolescents: A study of clinical characteristics. Cephalalgia 24:476–448, 2004.

Galli F, Patron L, Russo PM, et al: Chronic daily headache in childhood and adolescence: Clinical aspects and a 4-year follow-up. Cephalalgia 24:850–858, 2004.

Seshia SS: Chronic daily headache in children and adolescents. Can J Neurol Sci 31:319–323, 2004.

11 Describe the most important aspects of the physical examination for children with headaches.

Pay special attention to the measurement of blood pressure to rule out hypertension, and perform a complete neurologic examination, an ocular examination including the fundi, and an assessment of linear growth and, if appropriate, head circumference. Look for signs of trauma, and examine the skin for evidence of a neurocutaneous disease. Multiple café-au-lait lesions suggest neurofibromatosis and possible intracranial tumor.

12 What is the role of emergent neuroimaging in children with headache?

Most headaches in children are benign. Neuroimaging is useful in identifying children with space-occupying or surgical lesions. An important concern is brain tumor, which, although rare, represents the largest group of solid neoplasms in children. Indications for neuroimaging are as follows:

Persistent headaches of >6-month duration that have not responded to medical treatment

Headache associated with abnormal neurologic findings, especially papilledema, nystagmus, or gait or motor abnormalities

Persistent headaches not associated with a family history of migraine

Headaches that awaken a child from sleep or are present immediately on awakening

Persistent headache associated with episodes of confusion, disorientation, or vomiting

Family history or medical history of disorders predisposing one to central nervous system (CNS) lesions (such as neurofibromatosis)

Clinical or laboratory findings suggestive of CNS involvement

A practice parameter on the evaluation of pediatric patients with recurrent headaches written by the American Academy of Neurology discusses the issue of neuroimaging for recurrent headache. The parameter concludes that routine neuroimaging should be avoided in children with a normal neurologic examination. It should be considered, however, in patients with headache who have a history of seizures, an abnormal neurologic examination, a recent change in type of headache experienced, or characteristics implying neurologic dysfunction.

Lewis DW, Ashwal S, Dahl G, et al: Practice parameter: Evaluation of children and adolescents with recurrent headaches. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 59:490–498, 2002.

KEY POINTS: INDICATIONS FOR COMPUTED TOMOGRAPHY IN A CHILD WITH A HEADACHE

1 Headache persists >6 months

2 Persistent headache without family history of migraine

3 Abnormal neurologic examination

4 Papilledema present

5 Headache that awakens child

6 Headache associated with confusion, disorientation, vomiting

7 Family history of neurofibromatosis

13 How should headache pain be managed acutely?

Evidence-based guidelines similar to those published for adults for the treatment of headache do not exist. Treatment recommendations are generally based on experience, tradition, or extrapolation of information from adult studies. Most headaches in children respond to reassurance, hydration, and simple analgesics, such as acetaminophen or nonsteroidal anti-inflammatory drugs (e.g., ibuprofen).

14 What lifestyle changes can be made to prevent headaches?

Good nutrition can help reduce frequency of headaches. A healthy, well-balanced breakfast that includes a source of protein and minimizes excessive sugar should be eaten every day. Magnesium and vitamin B2 may reduce the frequency of migraines, so a multivitamin may be taken if the patient’s diet does not have sufficient sources. Adequate hydration is also essential in the prevention of headaches. Water should be emphasized over juices and soda. Stress reduction through regular exercise and relaxation is important. Adequate, but not too much, sleep and a regular bedtime schedule are also a key to remaining headachefree.

Maizels M, Blumenfeld A, Burchette R: A combination of riboflavin, magnesium, and feverfew for migraine prophylaxis: A randomized trial. Headache 44:885–890, 2004.

Schoenen J, Jacquy J, Lenaerts M: Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized controlled trial. Neurology 50:466–470, 1998.

15 What treatments are available for migraine headaches?

Many children with migraines respond to over-the-counter analgesics and rest in a dark, quiet room. Sumatriptan nasal spray has been used in adolescents with migraine headaches, with results superior to placebo in one study but no significant difference in another. This treatment may be associated with taste disturbance, nausea, and somnolence. Prochlorperazine, chlorpromazine, and metoclopramide are preferred by some but may cause dystonic reactions. These reactions can be minimized by the concurrent administration of diphenhydramine. Isometheptene combines acetaminophen with a vasoconstrictor and a sedative, making it a useful agent for migraine headaches. Ergots are infrequently used for migraine in headaches because of the side effect of vomiting. Avoid narcotics or combination agents that can cause rebound headache. A practice parameter published by the American Academy of Neurology offers an evidence-based approach to treatment of acute migraine as well as prevention medications.

Barnes N, Millman G, James E: Migraine headache in children. Clin Evid 10:429–443, 2003.

Lewis D, Ashwal S, Hershey A, et al: Practice parameter: Pharmacological treatment of migraine headache in children and adolescents. Neurology 63:2215–2224, 2004.

16 Describe therapeutic options for tension-type headaches.

Infrequent episodic tension-type headaches can be treated with over-the-counter analgesics and do not generally come to the attention of the emergency department. For patients with frequent episodic or chronic tension-type headaches, either pharmacologic or nonpharmacologic therapies may be effective, though few studies regarding medication efficacy can be found in the literature. One preliminary study showed significant clinical improvement from daily oral amitriptyline as well as a relaxation program without medication. Biofeedback has also been shown to be an effective therapy, probably through relaxation of muscular tension in the head and neck.

Anttila P: Tension-type headache in children and adolescents. Curr Pain Headache Rep 8:500–504, 2004.

Related

Pediatric Emergency Medicine Secrets