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Chapter 119: Headache

Christelle Moufawad El Achkar; Annapurna Poduri

BACKGROUND

Headache is a common condition in children and adolescents. Patients can be hospitalized primarily for headaches or develop headaches during their hospital stay. In either situation, it is important to determine whether the headache represents a primary headache disorder, such as migraine or tension headache, or a secondary disorder resulting from potentially serious intracranial or systemic processes (Table 119-1).

TABLE 119-1International Headache Society Classification of Headache Disorders
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TABLE 119-1 International Headache Society Classification of Headache Disorders
Primary headaches
 Migraine
 Tension-type headache
 Cluster headache and other trigeminal autonomic cephalgias
 Other primary headaches
Secondary headaches associated with one of the following:
 Head and/or neck trauma
 Cranial or cervical vascular disorders
  Examples: stroke, hematoma, subarachnoid hemorrhage, unruptured vascular malformation, arteritis, carotid/vertebral artery pain, hypertension, other vascular disorder
 Nonvascular intracranial disorders
  Examples: high or low cerebrospinal fluid pressure, intracranial infection, inflammatory condition such as sarcoidosis, intracranial neoplasm, intrathecal injection
 Substances or withdrawal
  Examples: opiates, caffeine
 Infection
 Disorders of homeostasis
  Examples: hypoxia, hypercapnia, hypoglycemia, dialysis, lead
  Disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structure
  Psychiatric disorder
Cranial neuralgias, central and primary facial pain, and other disorders

Source: Data from Headache Classification Subcommittee of the International Headache Society. International Classification of Headache Disorders. 2nd ed. Oxford: Blackwell, 2003.

Epidemiologic studies in large cohorts of children reveal estimated 1-year prevalence rates of 6% to 20% for migraine and 11% to 18% for tension headache.1-7 In general, post-pubertal girls have the highest prevalence rates of both migraine and tension headache. The most recent classification criteria established by the International Headache Society (IHS) in 20138 provide a detailed classification of headaches in children.

CLINICAL PRESENTATION

Head pain (cephalgia) is a symptom, and the diagnosis of a headache disorder or migraine is a diagnosis of exclusion. Evaluation of headache consists chiefly of a detailed history and thorough physical examination. Any abnormalities on neurologic examination in a previously healthy child or changes from neurologic baseline in a child with previous abnormalities warrant expeditious evaluation. In the absence of worrisome symptoms and abnormalities in the physical (including neurologic) examination, the majority of headaches in children are not caused by serious pathology. The physician should consider the following key questions during the evaluation:

  • Are there any warning signs of symptoms suggesting increased intracranial pressure (ICP) or focal neurologic abnormalities?

  • Do the symptoms fit into the pattern of a typical headache syndrome?

  • Are there any predisposing factors to secondary headaches such as a ventriculoperitoneal (VP) shunt?

Although the majority of headaches in children do not represent life-threatening emergencies, the pain experienced by the child and the ensuing anxiety of the family can be great. Once a patient with headache is deemed stable and relevant secondary causes have been considered ...

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