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MirjaHämäläinen

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.
  • Strong headaches warrant an assessment by a physician; in most cases this can well be done at primary care level.
  • Daily headaches that continue month after month often mask severe problems that warrant an evaluation of the psychosocial situation of the child.

General

  • One in ten children at school starting age and one third of teenage children suffer from recurrent headaches.
  • Even if recurrent headache seldom is a symptom of a severe 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 over 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

  • Thorough history
    • Situation in the family (divorce or other separation, unemployment, severe diseases, problematic consumption of alcohol, interparental conflicts, domestic violence)
    • 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. At school start, migraine is encountered in 3-5% of children, but already in 10-15% of children over 10 years of age.
    • Physical exercise, use of internet, eating and sleeping habits, the amount of sleep
    • The child's usual reactions; demands placed on the child's achievements by him-/herself and by the surroundings
    • Factors worsening or relieving the headache
    • History of headaches in other family members
    • 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 the insertion points of the muscles.
    • Examination of vision and fundoscopy; blood pressure
    • Assessment of growth using the growth chart; growth chart of the head circumference in small children. Use locally relevant charts.
  • Examination of the maxillary sinuses (ultrasonography or radiographs) particularly if the child has allergic symptoms affecting the airways or a tendency for recurrent infections.
  • Basic blood count with platelet count and CRP in children with symptoms of an infection

Further investigations

  • If the history of headaches is short the patient should be followed up for a few months to make sure that the symptom is not progressive.
  • Indications for magnetic resonance imaging include Ehttp://www.dynamed.com/condition/migraine-in-children-and-adolescents#IMAGING_STUDIES:
    • a 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 pulsating headache
    • progressive or treatment-resistant headache
    • alteration of the behaviour or the mood of the child
    • the child's growth is abnormal
    • head growth accelerates in early childhood
    • abnormal neurological findings (such as strabismus, impaired visual acuity, visual field defect, diplopia, blurred optic disks, difficulties in swallowing, equilibrium or coordination, or clonic tendon reflexes) or abnormal development
    • the age of the child is below 5 years old
  • Examination by an ophthalmologist
    • May be indicated to search for concealed strabismus and refractory errors and in a young child to exclude papillary stasis.
  • Examination by a dentist
    • Obvious malocclusion and pain in the palpation of masticatory muscles
  • EEG
    • Indicated if epilepsy is suspected.

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 in the background 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 Ehttp://www.dynamed.com/condition/migraine-in-children-and-adolescents#OTHER_DIAGNOSTIC_TESTING.
  • Continuous or recurrent headaches 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.
  • Regular meals and sufficient drinking are important in preventing headaches and migraine.
  • In a small share of migraine patients, a migraine attack may be triggered by some foodstuff or food additive. Special elimination diets are not recommended.
  • Regular rhythm concerning meals, outdoor recreation and sleep, as well as sufficient fluid intake may considerably reduce the number of migraine attacks. Similarly, protecting the eyes from bright light and the head from hard blows is important.
  • All modes of treatment for children's headache include a strong placebo effect, and different treatments have not been sufficiently compared with credible placebo therapy. 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.

Migraine

  • The diagnostic criteria for migraine in children Ehttp://www.dynamed.com/condition/migraine-in-children-and-adolescents#MAKING_THE_DIAGNOSIS are mainly the same as applied in adults. Children may have either common migraine or migraine preceded by aural symptoms.
  • The most common time of onset coincides with starting preschool or school. At school age the prevalence of migraine and headache increase steadily until early puberty.
  • There is a strong hereditary disposition.
  • Stress, fasting, fatigue, irritation by light or noise as well as head traumas sustained e.g. during ball games often 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 in 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, paraesthesias, or paralyses may also be associated with migraine in children. Aura symptoms precede the attack and disappear after the headache has started. If the aural symptoms last longer than one hour or occur concomitantly with the headache, further investigations in a specialized unit are warranted.
  • Even when highest, the frequency of attacks is only a couple of times a week. They may also occur at night.
  • Daily attacks are not typical of migraine.
  • The diagnosis is made by exclusion which requires a follow-up time of sufficient duration.
  • Familial haemiplegic migraine (FHM) is a dominantly inherited disease. Paralytic symptoms may start even without headache. The provoking factor often is a seemingly harmless knocking of the head e.g. during play. 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

Treatment of migraine attacks in children. Modified from: Current Care Guideline on Headache (children), 2015 (referenced on 18 Mar 2021) http://www.kaypahoito.fi/en/ccs00079

DrugSingle doseHighest dose; adult dose must not be exceededMinimum interval between doses (h)Mode of administration
Ibuprofen10-20 mg/kg40 mg/kg/24 h2Oral suspension
Tablet
Sustained-release tablet
Suppository
Paracetamol10-15 mg/kg60 mg/kg/24 h2Oral suspension
Effervescent tablet
Dissolving tablet
Tablet
Suppository
Sumatriptan10 mg (weight 20-39 kg)20 mg/24 h2Nasal spray
20 mg (weight ≥40 kg)40 mg/24 h
Rizatriptan5 mg (weight 20-39 kg)10 mg/24 h2Tablet
10 mg (weight ≥40 kg)20 mg/24 h
Zolmitriptan5 mg10 mg/24 h2Nasal spray
2.5 mg5 mg/24 h2Tablet
Prochlorperazine0.10-0.30 mg/kg0.4-0.5 mg/kg/24 h
Maximum dose at a time 10 mg		4Tablet
Inj. 0.1-0.15 mg/kg4Injectable (may require special permission)

Prophylactic treatment

  • May be indicated if the attacks are severe or they recur several times a month.
  • Pharmacotherapy may include propranolol, bisoprolol, amitriptyline or, in the most severe cases and prescribed by a specialist, topiramate.
  • The maximum duration of the prophylactic treatment should be 6 months at a time.

Tension headache

  • The cause of tension headache is not exactly known. In some patients, tension headache is associated with continuous contraction of the muscles of the head, neck and shoulders and is usually related to problems with posture and working positions, to psychological stress or to functional disorders of the masticatory system.
  • The onset of headache is insidious, and it often occurs in the afternoon or evening after school.
  • Tension headache can also occur in children who have typical attacks of migraine.
  • Particularly when headache has become chronic it may be difficult to discern the different types from each other. The attacks occur rarely during weekends or holidays.
  • Tension headache may pass with rest or, depending on the cause, even with physical exercise.
  • Rest and relaxation usually help better than medicine.
  • Mild tension headache responds poorly to medication. Frequent use of analgesics may promote the emergence of analgesic headache.
  • The correction of postural deviations and working positions may be of help.

Other types of headaches

Headache associated with psychic factors

  • There is an underlying psycholosocial stress situation (e.g. change in family relations, busy parents, bullying at school, depression, fear of school or difficulties in sleeping). When it dissolves, also the headaches completely disappear.
  • The headache continues from day to day (not necessarily every day) in a similar form, it is described more vaguely, and does not affect normal activities as much as migraine or tension headache. There is considerable discrepancy between the history and the harm.
  • The diagnosis usually becomes clear by discussing with the child and the family. There are no abnormal findings in physical examination.
  • Discussion with the family and, as necessary, a follow-up visit may suffice as treatment.
    • If needed, family counselling or a child health clinic may provide support.
  • Sometimes psychic problems can be difficult and require long-term professional help.

Headaches of ocular or dental origin

  • Concealed strabismus and refractive errors may cause a headache in the forehead and temporal region that disappears after the child is given spectacles.
  • Devices for dental alignment may cause daily headaches that disappear as the device is removed.
  • Patients with bruxism or dental malocclusion who have even mild daily or frequent headaches should be referred to a dentist.

Sinusitis

  • See Sinusitis in Children.
  • The headache usually appears after an upper respiratory tract infection and is continuous. It is often located on the forehead and cheeks but may also be generalized.
  • Other signs of infection may be scant.

Cerebral tumours and blockage of cerebrospinal fluid circulation

  • A headache associated with malignant intracranial tumours usually progresses rapidly and does not cause differential diagnostic problems.
  • Benign intracranial tumours (often in the posterior fossa or in the midline) may cause rapidly progressing symptoms from increased intracranial pressure caused by obstructed CSF circulation.
  • A slowly developing hydrocephalus caused by obstruction of the aqueduct may cause headache after the second or third year of life.
  • The symptoms of increased intracranial pressure include:
    • vomiting in the morning, headache occurring in the morning or before noon
    • papilloedema as a clinical finding
    • strabismus, disturbance of balance.
  • A tumour in the sellar region may cause growth retardation.

Sleep apnoea

  • See Sleep Disorders in Children and Adolescents.
  • Continuous snoring is a sign of obstruction in the pharynx and in the respiratory passages.
  • Night-time hypoxaemia may cause headache, tiredness and difficulties with concentration.
  • Adenoidectomy, and possibly also tonsillectomy, is indicated.

Idiopathic intracranial hypertension (pseudotumor cerebri)

  • A rare condition where the intracranial pressure is elevated without disturbance of c.s.f. circulation or a space-occupying process.
  • Continuous daily headache is the lead symptom Ehttp://www.dynamed.com/condition/idiopathic-intracranial-hypertension#CHIEF_CONCERN__CC_. Clinical findings include papillary stasis Ehttp://www.dynamed.com/condition/idiopathic-intracranial-hypertension#HEENT and increased pressure upon lumbar puncture.
  • Known causative factors include overweight and various hormonal changes. In about half of the cases, however, the cause remains unknown.
  • Diagnosis and treatment take place in specialized care. Depending on the case, pharmacotherapy and/or reduction of intracranial pressure by mechanical means (fenestration, shunt) may be used.
  • If diagnosis and treatment are delayed, the condition may lead to permanent visual impairment.

    References

    • Kernick D, Campbell J. Measuring the impact of headache in children: a critical review of the literature. Cephalalgia 2009;29(1):3-16. [PubMed]
    • de Vries B, Frants RR, Ferrari MD et al. Molecular genetics of migraine. Hum Genet 2009;126(1):115-32. [PubMed]
    • Russell MB, Ducros A. Sporadic and familial hemiplegic migraine: pathophysiological mechanisms, clinical characteristics, diagnosis, and management. Lancet Neurol 2011;10(5):457-70. [PubMed]
    • Honorat R, Marchandot J, Tison C, et al. [Treatment and prognosis of idiopathic intracranial hypertension in children. Retrospective study (1995-2009) and literature review]. Arch Pediatr 2011;18(11):1139-47. [PubMed]
    • Hacifazlioglu Eldes N, Yilmaz Y. Pseudotumour cerebri in children: etiological, clinical features and treatment modalities. Eur J Paediatr Neurol 2012;16(4):349-55. [PubMed]
    • Per H, Canpolat M, Gümüs H et al. Clinical spectrum of the pseudotumor cerebri in children: etiological, clinical features, treatment and prognosis. Brain Dev 2013;35(6):561-8. [PubMed]