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Editors

TuuliImmonen
MikaelRaisio
MillaYlijoki

Headache in Children

Essentials

  • Sporadic headaches are common and do not require further investigations or treatment. Headache may already occur in infants and young children.
  • Children may have migraine or tension-type headache, school-age children often both.
  • Severe headaches warrant an assessment by a physician; in most cases this can be done at primary care level.
  • Headaches of unvarying nature in children who are well and have no other symptoms that are neurological or considered alarming and no abnormality in neurological examination do not suggest an active intracranial process as their cause. Such patients can primarily be examined in primary health care.
  • Daily headaches that continue month after month may mask many problems that warrant an evaluation of the overall situation of the child.

General remarks

  • One in ten children at school starting age and nearly one third of teenage children have recurrent headaches.
  • Even if recurrent headache seldom is a symptom of a serious disease, it negatively affects the child's everyday life.
  • A thorough history, clinical examination and ruling out causes that require interventions are essential. In many cases a discussion about the problem may reveal factors in the child's life that precipitate the headache.
  • Often the sheer knowledge that the child does not have any serious disease alleviates the situation. Selection of suitable medication and sufficient follow-up are the cornerstones of treatment.

Primary investigations

  • Careful history taking and clinical examination of the child are often sufficient when investigating recurrent headaches. They suggest any organic causes of headaches and help to decide whether further investigations are needed.
  • Use of a headache diary is recommended.
  • Patient history
    • Physical activity, screen time, eating and sleeping habits, the amount of sleep at night
    • Matters related to school (e.g. learning difficulties, bullying), to the amount and ambitiousness of hobbies and to friends (are there friends?)
      • The occurrence of headache increases at school start. Migraineoccurs in 3-5% of children below school age. It occurs in 10-25% of children over 10 years of age; in 8-15% of boys and 10-25% of girls.
    • Situation in the family
    • The child's usual reactions; demands placed on the child's achievements by him-/herself or by the surroundings
    • Factors worsening or relieving the headache
    • History of headaches in other family members
    • Any other diseases and their medications
  • Careful somatic and neurological examination
    • Neurological examination includes an evaluation of the child's motor functions (balance, coordination, muscle strength, possible lateralized symptoms), of cranial nerves (especially squint, optical nerve) and of general development. Palpation of the head and neck muscles may reveal muscle tension or tenderness in muscle insertion points.
    • Examination of vision and fundoscopy; blood pressure
      • If the ocular fundi cannot be visualized, the overall situation (history and any other clinical findings) should be used to assess whether an ophthalmological examination is needed.
    • Assessment of growth using the growth chart; growth chart of the head circumference in small children.

Further investigations

  • Even if headaches are recurrent, no particular investigations are usually needed apart from careful history taking and clinical examination.
  • If a somatic disease is suspected (such as anaemia Anaemia in Children, sleep apnoea Sleep Disorders in Children and Adolescents), required investigations should be planned according to clinical suspicion.
  • In certain situations, cranial imaging may be needed. Magnetic resonance imaging is the primary method.
  • Cranial magnetic resonance imaging should be considered in the following cases:
    • headache and vomiting during the night or in the morning right after getting up
    • impaired consciousness associated with the headache
    • sudden physical exertion or coughing triggers a severe headache
    • consistently unilateral headache always on the same side or pulsating headache at the back of the head
    • progressive or treatment-resistant headache
    • alteration of the child's disposition or behaviour
    • the child's growth is abnormal or head growth accelerates in early childhood
    • there are prolonged or atypical aura symptoms here
    • abnormal neurological findings or abnormal development are detected
    • the child is below 5 years old
  • Suspicion of increased intracranial pressure requires emergency referral to specialized care. Increased intracranial pressure may be suggested by
    • vomiting in the morning, headache predominantly occurring in the morning or before noon, clinical neurological findings
    • papilloedema as a clinical finding (develops slowly; normal ocular fundi do not always exclude increased intracranial pressure).
  • Examination by an ophthalmologist
    • May be indicated to search for latent strabismus and refractory errors.
  • Examination by a dentist
    • Obvious malocclusion and pain on palpation of masticatory muscles suggesting bruxism
    • Recurring headaches beginning after placing fixed braces

Non-pharmacological prophylaxisPsychological Therapies for the Management of Chronic and Recurrent Pain in Children and Adolescents

  • The principles of non-pharmacological treatment can be applied to all types of headache that are not caused by any treatable underlying disease. Already the knowledge that there is no serious disease often brings relief in the situation. Support and information about the nature of the headache, about pain mechanisms and about self-treatment possibilities are important.
  • Observation of the headache by keeping a diary is usually helpful in the diagnostics and in treatment planning.
  • Continuous or recurrent headaches may greatly impede the child's school attendance and hobbies.Therefore, the causes of headache should primarily be tackled by assessing the factors that trigger the child's headache. Close co-operation with the school may be necessary. It is also important to recognize any learning difficulties; this may require co-operation with a school psychologist.
  • In a small proportion of migraine patients, a migraine attack may be triggered by some foodstuff or food additive. Special elimination diets are not recommended.
  • Regular routine concerning meals, outdoor recreation and sleep, restricting screen time, sufficient fluid intake and protecting the eyes from bright light may considerably reduce the number of migraine attacks and recurrent headaches of other causes.
  • There is no research evidence on which psychological treatment method or their combination (biofeedback therapy, relaxation therapy or cognitive behavioural therapy) would be most effective. Psychophysical physiotherapy has given good results in refractory cases.

Migraine

  • The diagnostic criteria for migraine in children are mainly the same as applied in adults. Children may have either common migraine or migraine preceded by aural symptoms. However, the duration of migraine attacks may be shorter in children (2-72 h) than in adults. In children, the pain is typically bilateral and predominantly frontal.
  • There is a strong hereditary disposition.
  • Stress, fasting, fatigue, as well as irritation by light or noise may trigger migraine attacks.
  • A typical migraine attack starts abruptly. The child is pale, definitely ill and nauseous, he/she prefers to stay in a dark, quiet room, and does not want to play. The attack often ends up with vomiting, after which the child falls asleep and is symptomless after awakening.
  • Migraine attacks may also occur in association with positive, exciting experiences (birthday parties, visit to an amusement park).
  • Visual disturbances, difficulties in speech, numbness or paralyses may also be associated with migraine in children. Aura symptoms precede the attack and disappear after the headache has started.
    • Single aura symptoms usually last 5-60 minutes, and headache typically begins during the symptoms or within one hour of them. A patient may have several aura symptoms with a total duration of more than an hour.
    • Nearly all patients (90%) with migraine with aura have visual aura symptoms at least sometimes.
    • If an aura symptom lasts longer than one hour or if aura symptoms are associated with abnormal clinical findings (such as hemiplegia), further investigations in specialized care are warranted.
  • Daily attacks or constant or nearly constant headaches do not belong to typical migraine. However, chronic migraine does occur in children too. In such cases, there have been at least 15 headaches per month over more than 3 months, with 8/month at least being migraine attacks.
  • The diagnosis is made by exclusion which requires a follow-up time of sufficient duration.
  • Familial haemiplegic migraine (FHM) http://www.orpha.net/en/disease/detail/569 is a dominantly inherited disease. Paralytic symptoms may start even without headache. Several different gene defects of the ion channels are known to cause FHM.

Treatment of a migraine attack Drugs for the Acute Treatment of Migraine in Children and Adolescents

  • To prevent pain sensitization, administer initially a sufficient dose of the drug, and repeat the dose after 2 hours if necessary.
  • For patients below 12 years of age, the primary drug is oral ibuprofen, which can be combined with paracetamol. There is no evidence of any benefit of the two being combined in the treatment of migraine in children.
  • For patients over 12 years, the primary drug is ibuprofen, which can after the aura phase be combined with a triptan.
  • The efficacy of triptans has mostly been shown in patients over 12 years but, according to clinical experience, they are safe for patients over 6 years weighing over 20 kg.
  • The first-choice triptan is sumatriptan nasal spray. If this does not produce a sufficient response, another triptan product or dosage form can be tried.
  • See also table T1.
  • The possibility of analgesic headache should be kept in mind.
  • Metoclopramide must not be used in the treatment of children due to the extrapyramidal adverse effects. Early administration of an analgesic may also prevent nausea. 5-HT3 receptor blockers (such as ondansetron) can be used to treat nausea and vomiting at a hospital emergency unit.
  • Intravenous medication administered at a hospital emergency unit may be required for severe migraine attacks.

Treatment of migraine attacks in children. Modified from: Current Care Guideline on Migraine, 2024 (referenced on 7.11.2024).

DrugSingle doseHighest dose; adult dose must not be exceededMinimum interval between doses (h)Dosage form
Ibuprofen10-20 mg/kg40 mg/kg/day (maximum dose 2 400 mg/day)2Oral suspension
Tablet
Capsule
Dexketoprofen
(i.v. NSAID, off-label use)		0.5-1 mg/kg (maximum single dose 50 mg)1. 5-3 mg/kg/day (maximum dose 150 mg/day)8I.v.
Paracetamol15 mg/kg60 mg/kg/day (maximum dose 3 000 mg/day)2Oral suspension
Effervescent tablet
Dissolving tablet
Tablet
I.v.
Sumatriptan
(from 12 to 17 years)		10 mg20 mg/day2Nasal spray
Rizatriptan
(from 12 to 17 years)		5 mg (20-39 kg)10 mg/day2Tablet
10 mg (HASH(0x2fb5b98)40 kg)20 mg/day2Tablet
Zolmitriptan
(from 12 to 17 years)		5 mg10 mg/day2Nasal spray
2.5 mg5 mg/day2Tablet
(off-label use)
Ondansetron0.15 mg/kg i.v. (maximum single dose 8 mg)0.45 mg/kg/day i.v. (maximum dose 32 mg/day)8I.v.
0.15 mg/kg p.o. (maximum single dose 8 mg)
N.B. The tablet must not be halved.		0.3 mg/kg/day p.o. (maximum dose 16 mg/day)12Soluble tablet

Prophylactic treatment

  • Prophylactic treatment may be indicated if the attacks recur several times a month or significantly affect the child's functional capacity.
  • Pharmacotherapy may include propranolol, bisoprololor, in the most severe cases and prescribed by a specialist, amitriptyline or topiramate (see table T2).
  • Topiramate must not be prescribed for women of fertile age not using effective contraception.
  • There is evidence for the use of propranolol in prophylactic treatment of migraine in children, and it is recommended as the primary prophylactic drug. Its use can be started in primary health care, too.
    • Blood pressure and pulse rate should be checked before beginning the treatment.
    • The dose for children of 7 years old or older is 0.5 mg-2 mg/kg/day (no more than 160 mg/day).
    • As an adverse effect, propranolol may aggravate asthma.
  • The duration of prophylactic medication (3-12 months) should be planned individually. It can be started again, as necessary, if the situation continues to be difficult.
  • Halving of the number of headaches can be considered to represent good efficacy.
  • In contrast to adults, there is no evidence of the efficacy of ARBs in prophylactic treatment of migraine in adolescents. If no response has been achieved with other medication, use of candesartan (off-label use) can be considered.
  • CGRP antibodies are used for prophylactic treatment of migraine in adults, and their efficacy in prophylactic treatment of migraine in children and adolescents is being studied.

Medications for migraine prophylaxis in children and adolescents. Modified from: Migraine: Current Care Guideline, 2024 (referenced on 7.11.2024).

Group of drugsDrugDose for children and adolescents
Beta-blockersPropranolol (p.o.)For children of 7 years or older 0.5 mg-2 mg/kg/day (no more than 160 mg/day)
AntidepressantsAmitriptyline (p.o.), off-label use0.2 mg-1 mg/kg/day (at night), no more than 50 mg/day
Antiepileptic drugsTopiramate (p.o.), off-label use1-2 mg/kg, no more than 100 mg/day

Tension headache

  • The cause of tension headache is not exactly known. It may be associated with problems with posture and working positions, with psychological stress or with functional disorders of the masticatory system.
  • Tension headache can also occur in children who have typical attacks of migraine.
  • Tension headache may pass with rest or, depending on the cause, even with physical exercise.
  • Rest and relaxation usually help better than medications.
  • Mild tension headache responds poorly to medication. Frequent use of analgesics may promote the emergence of analgesic headache.
  • Restricting screen time, correction of the sleep rhythm, as well as of postural deviations and working positions may be of help.

    References

    • [Migraine]. A Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim and Finnish Neurological Society. Helsinki: Finnish Medical Society Duodecim, 2024 (accessed 7 Nov 2024). Available in Finnish at http://www.kaypahoito.fi/hoi36050.