Overview
Definition:
Headache in children is a common symptom with diverse etiologies, ranging from benign tension-type headaches to potentially life-threatening conditions
It is characterized by pain in any region of the head, with varying intensity, frequency, and duration
Understanding red flags is crucial for timely diagnosis and management.
Epidemiology:
Headaches are reported in 40-75% of school-aged children
Migraine is the most common type of recurrent headache, affecting 5-15% of children
Boys are more commonly affected before puberty, while girls are more affected thereafter
The prevalence of headaches increases with age.
Clinical Significance:
Headaches in children can significantly impact quality of life, school attendance, and daily functioning
Prompt identification of red flag symptoms is vital to rule out serious underlying pathology, such as intracranial mass, infection, or vascular anomalies, and to initiate appropriate management strategies, including prophylactic treatment for recurrent headaches.
Clinical Presentation
Symptoms:
Chief complaint of head pain
Location may be frontal, temporal, occipital, or generalized
Associated symptoms can include nausea, vomiting, photophobia, phonophobia, abdominal pain, dizziness, and visual disturbances
Onset may be sudden or gradual
Duration varies from minutes to days.
Signs:
Physical examination may reveal normal findings in primary headaches
However, specific signs can indicate secondary causes: papilledema, focal neurological deficits (weakness, sensory changes, gait disturbance), nuchal rigidity, fever, rash, altered mental status, and cranial nerve palsies.
Diagnostic Criteria:
International Classification of Headache Disorders (ICHD-3) criteria are used for diagnosis
For migraine, criteria include at least 5 attacks fulfilling specific duration, unilateral location, pulsating quality, moderate to severe intensity, and aggravation by physical activity, plus associated nausea/vomiting or photophobia/phonophobia
Red flags prompt investigation beyond primary headache diagnosis.
Diagnostic Approach
History Taking:
Detailed history is paramount
Inquire about onset, duration, frequency, location, character, severity, triggers, relieving factors, and associated symptoms
Crucially, screen for red flags: sudden onset ("thunderclap"), worsening headache, focal neurological signs, papilledema, nuchal rigidity, fever, seizures, change in personality or behavior, onset in infancy (<3 years), or headache worse with Valsalva maneuver.
Physical Examination:
Comprehensive neurological examination is essential
Assess vital signs, fundoscopy for papilledema, cranial nerves, motor strength, sensation, reflexes, coordination, and gait
Examine the head, neck, and skin for signs of trauma, infection, or systemic illness
Palpate the scalp and temporal arteries.
Investigations:
Neuroimaging (MRI with/without contrast preferred over CT) is indicated for red flags to rule out structural lesions (tumors, malformations, hydrocephalus)
EEG may be useful for suspected epilepsy
Lumbar puncture is considered for suspected meningitis or encephalitis
Basic labs (CBC, ESR, CRP) may be helpful in cases of suspected infection.
Differential Diagnosis:
Primary headaches: Migraine, tension-type, cluster headache
Secondary headaches: Meningitis, encephalitis, brain tumor, intracranial hemorrhage, subdural hematoma, hydrocephalus, sinusitis, ophthalmologic causes (e.g., glaucoma), systemic infections, trauma, venous sinus thrombosis, hypertensive encephalopathy.
Management
Initial Management:
For acute headache, rest in a quiet, dark room
Rehydration if vomiting is present
Analgesics such as paracetamol (acetaminophen) or ibuprofen can be used for mild to moderate pain
For severe pain or suspected secondary headache, immediate referral to a hospital is necessary for further evaluation and management.
Medical Management:
Acute migraine treatment: Triptans (e.g., sumatriptan, rizatriptan) may be used in older children (≥12 years) or adolescents when standard analgesics are ineffective
Antiemetics (e.g., ondansetron, domperidone) can manage nausea and vomiting
For recurrent headaches, prophylactic medication is considered if headaches are frequent, severe, or significantly impacting quality of life.
Prophylactic Treatment:
Migraine prophylaxis options include: Propranolol (0.5-2 mg/kg/day in 2 divided doses), Amitriptyline (0.25-1 mg/kg/day in 1-2 divided doses), Topiramate (0.5-2 mg/kg/day in 2 divided doses), Cyproheptadine (0.25 mg/kg/day in 1-2 divided doses)
Treatment is usually initiated at a low dose and titrated upwards
A trial of 2-3 months is typically needed to assess efficacy
Non-pharmacological strategies include behavioral therapy, biofeedback, and trigger avoidance.
Supportive Care:
Education for child and parents about the condition, triggers, and management plan
Regular sleep schedule, balanced diet, and stress management are crucial
Behavioral interventions like cognitive behavioral therapy (CBT) can be beneficial
Regular follow-up appointments to monitor treatment effectiveness and side effects.
Complications
Early Complications:
Status migrainosus (migraine lasting >72 hours)
Dehydration due to vomiting
Medication overuse headache from frequent use of acute treatments
Migraine with aura can sometimes present with persistent neurological deficits (rare).
Late Complications:
Chronic daily headaches
Significant impact on academic performance and social development
Psychiatric comorbidities like depression and anxiety
Reduced quality of life.
Prevention Strategies:
Strict adherence to prophylactic medication regimens
Identification and avoidance of headache triggers (dietary, environmental, emotional)
Regular follow-up with healthcare providers
Lifestyle modifications including adequate sleep, exercise, and stress management.
Prognosis
Factors Affecting Prognosis:
The prognosis for primary headaches like migraine in children is generally good, with many experiencing resolution or significant improvement by adulthood
Factors influencing prognosis include severity and frequency of headaches, presence of comorbidities, adherence to treatment, and family history.
Outcomes:
With appropriate management, most children with headaches can achieve good control, allowing them to participate fully in daily activities
However, some may experience persistent headaches into adolescence or adulthood, requiring long-term management.
Follow Up:
Regular follow-up is essential, typically every 3-6 months, or more frequently if treatment changes or headaches are poorly controlled
Monitoring for treatment efficacy, side effects, and potential development of new symptoms or red flags
Transitioning care to adult neurologists when appropriate.
Key Points
Exam Focus:
Always consider red flags in pediatric headaches: Worsening frequency/severity, focal neurological deficits, papilledema, nuchal rigidity, fever, seizures, thunderclap onset, headache with Valsalva
Differentiate primary from secondary headaches
Know the ICHD-3 criteria for common headaches.
Clinical Pearls:
Keep a headache diary for children to track frequency, duration, severity, triggers, and response to treatment
Prophylactic therapy initiation requires patience
assess efficacy after 2-3 months
For children < 6 years, headache may present as irritability or abdominal pain rather than typical head pain.
Common Mistakes:
Underestimating the impact of headaches on a child's life
Failing to adequately investigate red flag symptoms
Over-reliance on acute treatments leading to medication overuse headache
Inadequate trial of prophylactic therapy or incorrect dosing
Ignoring non-pharmacological management strategies.