Chapter 6. Headache

Headaches are common in children, with the average age of onset at 7 for boys and 11 for girls. The frequency of migraine increases through adolescence. An estimated 8% to 23% of children aged 11 to 15 experience headaches. Headaches can be divided into two categories, primary or secondary. Primary refers to headaches that occur on their own and not as the result of some other health problem. Primary headaches (Figure 6-1) include migraine, migraine with aura, tension-type headache, and cluster headache.

Secondary refers to headaches that result from some cause or condition, such as a head injury or concussion, blood vessel problems, medication side effects, infections in the head or elsewhere in the body, sinus disease, or tumors (Figure 6-2). Signs and symptoms of the underlying cause need to be searched for. Headaches associated with infection may represent a systemic reaction to the infection and do not necessarily signify severe disease. For example, strep throat is frequently associated with headaches. There are many different causes for secondary headaches, ranging from rare, serious diseases to easily treated conditions. Sometimes headaches occur almost every day and are called chronic daily headaches.

Migraine is a headache condition that comes back again and again. Ten percent of children get migraines, and an even higher percentage of teenagers have them. These headaches are very painful and throbbing, and children who have them often look ill and pale. Relief is usually linked with sleep. One should focus on ruling out other serious diseases or conditions when first examining migraineurs.

Migraineurs have various signs and symptoms. Typically, a child migraineur has a severe headache located around the eyes, in the front of the head, or in the temples. Some children experience vision changes ("auras") during a headache. A sick feeling in the stomach or vomiting is common. Many children avoid bright lights, loud noises, or strong odors, as these seem to make the headache worse. The severe head pain is often completely relieved by deep sleep. Recurring spells of dizziness may represent another form of migraine in children. An inherited tendency is believed to make some people more likely to have a migraine after some minor trigger (Table 6-1), although no single theory explains how the human body produces all the symptoms of a typical migraine headache. The key to recognizing migraines is identification of a pattern of short but very painful headache episodes that are relieved by sleep and separated by symptom-free intervals.

Although migraine headaches have long been considered a benign (relatively harmless) condition, they can cause a lot of damage to a person's quality of life and ability to take part in normal life activities. The pain is so intense that migraineurs often cannot think or function very well during or right after episodes.

About 65% to 80% of children with migraines interrupt their normal activities because of the symptoms. In one study of 970,000 self-reported migraineurs aged 6 to 18 years, 329,000 school days were lost per month. The burden of migraines may cause emotional changes like anxiety or sadness. Appropriate diagnosis and treatment of migraines can greatly improve quality of life.

Studies suggest that migraine headaches occur in 5% to 10% of school-aged children in the United States, a percentage that constantly increases through adolescence and peaks at about age 44 years. Many people experience spontaneous remission, meaning that the headaches go away on their own for no clear reason.

Migraine headaches begin earlier in boys than in girls. From infancy to 7 years, boys are affected equally or slightly more than girls. The prevalence of migraines increases during the adolescent and young adult years, during which 20% to 30% of young women and 10% to 20% of young men experience migraines. After menarche (the time when the first menstrual period occurs), a female predominance occurs. This continues to increase until middle age. The frequency of migraines declines in both sexes by age 50 years.

Most migraineurs begin to experience attacks before turning 20 years old. Approximately 20% have their first attack before their 5th birthday. Preschool children experiencing a migraine attack usually look ill and have abdominal pain, vomiting, and a strong need to sleep. They may show pain by irritability, crying, rocking, or seeking a dark room in which to sleep.

Migraineurs aged 5 to 10 years experience headache, nausea, abdominal cramping, vomiting, photophobia (sensitivity to light), phonophobia (sensitivity to sound), osmophobia (sensitivity to smells), and a need to sleep. They usually fall asleep within an hour of the time the attack starts. The most common accompanying symptoms include paleness with dark circles under the eyes, tearing, swollen nasal passages, thirst, swelling, excessive sweating, increased urination, and diarrhea. Older children tend to present with headache on one side. Many sinus headaches are really of migrainous origin. The headache location and intensity often changes within or between attacks.

As children grow older, headache intensity and duration increases, and migraines start to happen at more regular intervals. Older children also describe a pulsating or throbbing character to their headaches. Headaches often shift to the one-sided temple location that most adult migraineurs report. Childhood migraines often stop for a few years after puberty.

To young children, non-headache symptoms may be more troubling than the headache. Younger children may experience photophobia and phonophobia without accompanying stomachache or headache. Some children have repeated bouts of stomach pain without accompanying headache.

Migraine headaches are recurrent headaches that occur at intervals of days, weeks or months.1 There may or may not be a pattern to the attacks—for example, teenage girls may tend to have attacks at a particular point in their monthly menstrual cycle. Migraines generally have some of the following symptoms and characteristics:

• Untreated, they can last from 2 to 48 hours in children. Sleep or medical treatment can reduce this time period.
• Headache starts on one side of the head. This may vary from headache to headache and in children, they may start in the front or in both temples.
• Throbbing or pounding pain occurs during the headache.
• Pain is rated as moderate to severe.
• Pain gets worse with exertion. The pain may be so severe that it is difficult or almost impossible to continue with normal daily activities.
• Nausea, vomiting, and/or stomach pain commonly occur with the attacks.
• Light and/or sound sensitivity is also common.
• Pain may be relieved with rest or sleep.
• Other members of the family have had migraines or "sick headaches."
• Warnings called auras may start before the headache. These auras can include blurry vision, flashing lights, colored spots, strange tastes, or weird sensations, and usually precede the headache by 5 to 60 minutes.

Migraine Without Aura

• Much more common than classic migraine.
• 85% of children with migraine have common migraine.
• There is no aura.
• The headache is usually slower in onset then classic migraine, building over several minutes to hours. However, the time from onset to peak intensity may be as short as 15 to 30 minutes.
• These headaches are frequently bifrontal (forehead) in location but may be one sided.
• Many children will vomit within 30 minutes to 1 hour following onset of their headache.
• These headaches may be aggravated by exercise or movement.
• Child may have trouble concentrating when they have a headache.
• Other prominent symptoms may include
  • Nausea.
  • Vomiting.
  • Light sensitivity (photophobia).
  • Sensitivity to sound (phonophobia).
  • Sensitivity to strong odors (osmophobia).
• Children may seek a dark quiet room and attempt to sleep.
• Dizziness (an automatic feature) is seen, particularly in young females.
• Headaches last anywhere from 1 hour to 48 hours—sometimes longer.
• The child is normal between attacks.
• The children will frequently grab onto a nearby person or object.
• Episodes usually last less than 1 minute.
• Following the event, the child returns to normal.
• Though frightening to both child and parent, these are benign.
• If frequent, the attacks can be treated; however, treatment is usually not necessary.
• Typically this disorder resolves before age 5.
• A family history of migraine can usually be obtained.

Migraine with Aura

• Much less common than migraine without aura. (Common migraine.)
• Occurs in 10% to 15% of children with migraine.
• The aura may be visual, sensory, or somatic such as abdominal pain.
• An aura is an abrupt onset neurologic change and is fully reversible.
• The aura develops over minutes and lasts less than 1 hour.
• Visual auras are the most common and often frightening.
• They may consist of visual loss, flashing lights, or squiggly lines.
• The headache may begin during the aura or shortly after the aura clears.
• The headache should start within 60 minutes following the aura, although it may begin within the aura.
• The pain of a migraine headache is usually moderate to severe.
• In children it is frequently bifrontal (forehead) and throbbing.
• It may be unilateral (one sided) but is rarely in the back of the head.
• Other prominent symptoms may include:
  • Nausea.
  • Vomiting.
  • Light sensitivity (photophobia).
  • Sensitivity to sound (phonophobia or sonophobia).
  • Sensitivity to strong odors (e.g., perfume) (osmophobia).
• The child will seek a dark room and attempt to sleep.
• Dizziness may occur especially in young females as an associated symptom.
• The headache may worsen by movement or exercise.
• Sleep generally alleviates the headache.
• The headache may last for 1 hour to 48 hours or more.

Tension-type headache has also been called tension headache, muscle contraction headache, stress-related headache, and "ordinary headache." These headaches can be either episodic or chronic and may include tightness in the muscles of the head or neck.

A tension-type headache can last from 30 minutes to several days. Chronic tension headaches may persist for many months. The pain usually occurs on both sides of the head, is steady and nonthrobbing. Some people say "it feels like a band tightening around my head." The pain is usually mild to moderate in severity. Most of the time the headache does not affect the person's activity level.

Tension-type headaches are usually not associated with other symptoms, such as nausea or vomiting. Some people may experience sensitivity to light or sound with the headache, but not both. Muscle tightness may be noticed by some patients but does not always have to occur.

In adults, headaches that occur at least 15 days per month for at least 3 months have been called chronic daily headaches. In children there is not yet a clear definition.

Some chronic daily headaches may have started as migraine and build to a daily frequency. These are sometimes called transformed migraines. Tension-type headaches that increase to near-daily frequency are known as chronic tension-type headaches. Chronic headaches can result from taking some types of over-the-counter medication—for example, acetaminophen (Tylenol), ibuprofen (Motrin), caffeine—and some prescription medications almost every day. These are called drug rebound headaches. These headaches return either shortly after taking the medication or the medication stops working. The most effective way to make these headaches better is to stop taking pain medicines altogether for a few weeks. After that time, use of pain-relievers is limited to no more that 2 to 3 times per week.

Some people with chronic daily headaches are low in certain vitamins and minerals. It is important to eat balanced meals. Many children and adolescents may need to take a daily multivitamin.

There are different theories about the cause of migraine headaches. Often several family members are affected, suggesting genetic factors are partly responsible. Some individuals may become hypersensitive to triggers in their environment, such as flickering lights, changing weather patterns, or strong odors. The true cause may be a combination of factors. Some of the possible causes include blood vessel changes. Blood vessels in the head may first tighten and then expand during a migraine attack, changes that may explain the aura before and the throbbing pain during the migraine. Some migraine medication and other treatments may work by counteracting or blocking these changes in the blood vessels.

• Brain and nervous system changes. Imaging studies have identified an area in the brainstem at the back of the head that is activated during a migraine attack. A spreading wave of decreased activation occurs in the brain at the onset of an attack, which may account for the blurred vision or numbness that some people experience in the migraine aura.
• Serotonin system abnormalities. Serotonin is a natural chemical in the brain that has an important function in transmission of signals from one brain cell to another. Some migraine medication and other treatments affect serotonin action in the brain and can stop a migraine.

Benign Paroxymal Vertigo

• Usually occurs in young children between 1 and 3 years of age.
• These are sudden attacks of dizziness experienced by young children.
• The child usually becomes pale, appears frightened, and staggers around as if he or she is drunk.

Cyclic Vomiting

• Usually beginning between 4 and 8 years of age.
• Children experience repetitive episodes.
• May be quite dramatic and lead to dehydration and hospitalization.

Hemiplegic Migraine

• A frightening attack of sudden onset of unilateral weakness (one-sided weakness).
• Weakness may involve the face, arm, or leg.
• If the right side of the body is the affected side, the individual may not be able to speak.
• May be triggered by mild head injury.
• There is a familial form, with a first-degree relative affected.
• The headache follows the onset of weakness.
• The weakness may last 1 hour to days, but usually resolves in 24 hours.
• The familial form has been identified on chromosome 19 in 50% to 60% of cases.
• Other causes of acute onset weakness must be considered before the diagnosis is made.

Have the parent keep a record of the child's headaches. Have them write down everything that might relate to the child's headache (foods, odors, situations), how long it lasted, and how much pain the headache caused (Table 6-2).

Recommend that the child take pain medication for his or her headache as soon as pain is felt. He or she may be taking over-the-counter medication or prescription medication when getting a headache.

The child needs to be able to treat headaches at school. This means that the child's school nurse needs to know your treatment plan. It is important that permission is granted and all of the forms are completed for treating the child's headaches at school without having to go home. Suggest that the parent and you or your nurse educate the child's teachers about headaches and migraines.

Remember that using pain relievers (analgesics) every day can cause an increase in the child's headaches. Drinking more fluids (especially sports drinks) during a headache may also be very important to help it to go away faster.

The first step in treatment is to avoid known triggers, such as cheese or chocolate. The diagnosis of each headache type is dependent on a reliable history of the headache from the child or parent.

Many children have difficulty explaining their headaches, so to gain clues to the diagnosis you may want to include questions for the parents such as the following:

• Q. When did the headaches first begin?
• Q. How frequent are the headaches now?
• Q. How often did they occur when they first began?
• Q. Has there been a change in the severity of the headache?
• Q. What time of day do they occur?
• Q. Is there any warning that a headache is about to occur, such as changes in appetite, attitudes, or behavior?
• Q. Do the headaches appear sudden in onset?
• Q. Are there any outward physical changes? (pale, sweaty, color change)?
• Q. What does your child do when he or she complains of a headache?
• Q. Do they interfere with his or her ability to participate in activities?
• Q. Does he or she go lay down?
• Q. Does he or she seek a dark room?
• Q. Does he or she watch TV or listen to the stereo?
• Q. Does your child sleep to get rid of his or her headache?
• Q. How long does the headache appear to last?
• Q. When it is over, is there change in behavior and appetite?
• Q. Has there been any head trauma prior to the onset of the headache?
• Q. What have you used to treat the headache thus far?
• Q. Has the medication been effective?
• Q. Have you identified any triggers (food, weather, or stress)?
• Q. Is there a family history of headaches, migraine or otherwise?
• Q. Has there been any personality change in your child?
• Q. Has he or she missed any school because of the headache?
• Q. Has he or she missed any extracurricular activities because of the headache?

You may ask your patient many of the above questions plus:

• Q. Where does your head hurt?
• Q. What does it feel like?
• Q. Do you know when you're going to get a headache?
• Q. Do you see flashing lights or other changes in your vision before the headache starts?
• Q. What do you do when you get a headache?
• Q. When do you tell your parents?
• Q. Does sleep help your headache?

Aside from the above, a complete medical history should be obtained in addition to inquiring about the family's significant medical history, especially history of headaches.

After a complete exam, a specific diagnosis such as common migraine or classic migraine may be given, and medication options for both acute and if needed preventive medications can be considered.

In cases of "worrisome" headache symptoms or an abnormal neurological examination, you may want to consider ordering a brain MRI, head CT, and blood tests (Figure 6-3).

Acute Treatment

• Treatment of acute headaches can usually be accomplished at home with over-the-counter medication.
• Dosages in children over 12 years of age are usually written on package labels for medication like Tylenol or ibuprofen.
• However, dosages of over-the-counter pain medication for children under 12 vary with age and weight.
• Triptans can be used in select circumstances.
• Aspirin is to be avoided in children because of its association with Reye syndrome.2,3

Preventive Medications

• If headaches are frequent and disabling, medications to prevent headache occurrences may need to be considered.
• These medications are given on a daily basis to prevent headaches from occurring.
• Treatment with preventive medications needs to be individualized.
• These medications can frequently be withdrawn after a period of good headache control.
• There are several different medications that can be used in this regard.
• After a complete medical evaluation, the child and parent can decide if preventive medication is needed and which one to choose.2,3

If you decide to prescribe daily medication to reduce headache frequency, remember to have the patient take it every day, whether having headaches or not.

Good sleep habits, going to bed at a consistent time and arising at about the same time each day, may alleviate some headaches.

Taking good care of the child can decrease the frequency and severity of his or her headaches

1. Make sure the child drinks enough fluids. Children and adolescents need 4 to 8 glasses of fluid a day. Caffeine should be avoided. Sports drinks may help during a headache as well as during exercise by keeping sugar and sodium levels normal.

2. Make sure the child gets plenty of regular sleep at night (but do not let him or her oversleep). Fatigue and over-exertion are two factors that can trigger headaches. Most children and adolescents need to sleep 8 to 10 hours each night and keep a regular sleep schedule to help prevent headaches.

3. Be sure that the child eats balanced meals at regular hours. Do not let him or her skip meals.

4. Try to avoid foods that seem to trigger headaches. Remember that every child is different, so the child's triggers.

5. Plan and schedule the child's activities sensibly. Try to avoid overcrowded schedules or stressful and potentially upsetting situations.

It is important to remember that the most headaches in children are benign, but when headaches begin, a thorough medical evaluation is important.

Treatment of headaches in children can be as simple as an over-the-counter medication in the correct dose. Some children need more aggressive treatment with both a preventive medication and possibly acute medication with subcutaneous injections of newer antimigraine headache agents such as sumatriptan.

The child need not suffer: appropriate treatment can significantly alter the course of headache frequency and severity.