Headaches

Key Features

Essentials of Diagnosis

• Most common causes in children are migraine and tension-type headache

• Diagnosis is based on a thorough history and physical, excluding secondary causes such as mass or idiopathic intracranial hypertension

• Warning signs that may require further investigation

  • Headache in a young child

  • New onset and worsening headache

  • Unexplained fever

  • Awakening with headache or vomiting

  • Headache worse with straining or position change

  • Posterior headaches

  • Neurologic deficit

  • Neurocutaneous stigmata

General Considerations

• Approximately 11% of children and 28% of adolescents experience recurrent headaches

• Clinician must determine whether the headache is primary or secondary

• Based on the 2004 International Classification of Headache Disorders-IIR (ICHD-IIR), primary headaches are divided into three major categories

  • Migraine

  • Tension-type

  • Trigeminal autonomic cephalalgia

Clinical Findings

Symptoms and Signs

• More than 15 headaches per month (migraine or tension-type) is considered chronic, and medication overuse must be excluded

• Migraine without aura

  • Duration: 2–72 hours

  • Quality: Throbbing/pounding

  • Severity: Moderate to severe

  • Location: Unilateral/bilateral

  • Physical activity: Worsens headache

  • Associated factors: Nausea/vomiting or photophobia or phonophobia

• Tension-type

  • Duration: 30 minutes to 7 days

  • Quality: Pressure tight band

  • Severity: Mild to moderate

  • Location: Bilateral

  • Physical activity: No effect

  • Associated factors: Photophobia or phonophobia

• Trigeminal autonomic cephalalgia (or subcategory, cluster headache)

  • Rare

  • Presents as a unilateral severe headache with autonomic dysfunction (watery eye, congestion, facial sweating, miosis, and ptosis)

Differential Diagnosis

• Secondary causes include broad categories such as

  • Head trauma

  • Infection

  • Vascular, intracranial pressure changes

  • Structural, metabolic, toxic or substance related

  • Hematologic

• Medications that are commonly associated with medication overuse headache include

  • Aspirin, acetaminophen, NSAIDs

  • Triptans

  • Combination analgesics such as acetaminophen, butalbital, and caffeine

• Toxins such as lead, carbon monoxide, or organic solvent poisoning cannot be overlooked

Diagnosis

Laboratory Findings

• Not routinely needed in children with recurrent headaches

• History and examination may prompt basic screening studies for thyroid, anemia, or autoimmune disorders

Imaging

• Routine neuroimaging is not indicated unless a combination of red flags are present

• Imaging can be considered when

  • Historical features suggest recent onset of severe headache

  • There has been a change in headache

  • Features suggest presence of neurologic dysfunction

Treatment

Nonpharmacologic

• Rest, relaxation, and cold/hot packs

• Resting in a cool dark room may provide added benefit

• To prevent headaches, biobehavioral management can be used

  • Sleep hygiene

  • Improved fluid intake; elimination of caffeine

  • Nutritional meals; avoidance of skipping meals

  • Regular exercise and stretching

  • Stress management

Pharmacologic

• Simple analgesics

  • Acetaminophen, 15 mg/kg; max dose: 650 mg

  • Ibuprofen, 10 mg/kg; max dose: 800 mg)

  • Use should be limited to 2–3 times per week

• Migraine-specific medications

  • Almotriptan and rizatriptan are ...