Overview
Definition:
Tension-type headache (TTH) is the most common primary headache disorder in children and adolescents, typically presenting as bilateral, pressing, or tightening pain of mild to moderate intensity
Migraine is a complex neurological disorder characterized by recurrent, moderate to severe headaches, often unilateral, throbbing, and associated with nausea, vomiting, photophobia, and phonophobia
Differentiation is crucial for appropriate management.
Epidemiology:
Tension-type headaches affect up to 50% of children and adolescents
Migraine prevalence in children is approximately 5-10%, increasing significantly in adolescence, with girls more commonly affected than boys in later years
Both disorders can significantly impact a child's quality of life, school attendance, and social activities.
Clinical Significance:
Accurate diagnosis and management of pediatric headaches are vital to alleviate symptoms, prevent chronification, reduce disability, and improve the overall well-being of affected children
Misdiagnosis can lead to inappropriate treatments, missed diagnoses of secondary causes of headache, and increased healthcare burden.
Clinical Presentation
Symptoms:
Tension-type headache symptoms include: bilateral head pain
Dull, pressing, or tightening sensation, not throbbing
Mild to moderate intensity, rarely disabling
No nausea or vomiting
Photophobia or phonophobia may be present but not both
Migraine symptoms include: unilateral or bilateral head pain
Throbbing or pulsating quality
Moderate to severe intensity, often disabling
Nausea and/or vomiting
Photophobia and phonophobia
Aura may precede headache in about 10-20% of cases (visual, sensory, or speech disturbances).
Signs:
Tension-type headache: Generally, normal neurological examination
Tenderness in pericranial muscles may be present
Migraine: Normal neurological examination between attacks
During an attack, signs may include pallor, lethargy, and hypersensitivity to stimuli
Papilledema or focal neurological deficits are red flags for secondary headaches.
Diagnostic Criteria:
International Classification of Headache Disorders, 3rd Edition (ICHD-3) criteria are used
For TTH: Headache lasting 0.5-7 days
Two of the following: bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity
Both of the following: no nausea or vomiting, photophobia or phonophobia or both
For Migraine without Aura: Recurrent attacks lasting 4-72 hours
Two of the following: unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by or causing avoidance of routine physical activity
Both of the following: nausea or vomiting, photophobia and phonophobia.
Diagnostic Approach
History Taking:
Detailed history is paramount
Inquire about: frequency, duration, intensity, location, quality of pain
Associated symptoms (nausea, vomiting, photophobia, phonophobia)
Aggravating and alleviating factors
Triggers (stress, sleep, diet, weather, screen time)
Impact on daily activities
Family history of headaches
Red flags: sudden onset ("thunderclap" headache), new onset headache in a child under 6 years, headache with fever, stiff neck, neurological deficits, papilledema, morning headaches with vomiting, recent head trauma, persistent headache, or headache that progresses.
Physical Examination:
A thorough physical examination is essential
Include: Vital signs (BP, pulse, temperature)
General examination for signs of systemic illness
Detailed neurological examination: cranial nerves, motor strength, sensation, reflexes, coordination, gait
Fundoscopy to assess for papilledema
Examination of the head and neck for tenderness or masses.
Investigations:
In most cases of suspected TTH or migraine with typical presentation, investigations are not required
Neuroimaging (MRI brain) is indicated for red flag symptoms to rule out secondary causes like tumors, vascular malformations, or infections
EEG may be considered if seizures are suspected
Lumbar puncture is indicated for suspected meningitis or encephalitis.
Differential Diagnosis:
Differential diagnoses include: Secondary headaches (e.g., sinusitis, meningitis, encephalitis, brain tumor, subdural hematoma, post-traumatic headache)
Other primary headache disorders (e.g., cluster headache, chronic daily headache)
Ocular pathology (e.g., refractive errors, glaucoma)
Temporomandibular joint dysfunction.
Management
Acute Therapy:
Tension-type headache: Simple analgesics like acetaminophen (paracetamol) 10-15 mg/kg/dose every 4-6 hours or ibuprofen 5-10 mg/kg/dose every 6-8 hours
Rest in a quiet, dark room if symptoms are bothersome
Migraine: Mild to moderate attacks: Acetaminophen or ibuprofen as above
Moderate to severe attacks: Triptans (e.g., sumatriptan, rizatriptan) are effective but typically reserved for children aged 12 and above, or younger children with severe, refractory migraines under specialist guidance
Dosing varies by age and weight
Anti-emetics (e.g., ondansetron) for nausea and vomiting
Non-pharmacological measures: rest, hydration, cool compress.
Preventive Therapy:
Indications for preventive therapy: Frequent headaches (e.g., >2 per month), disabling headaches, poor response to acute treatment, significant impact on quality of life
Tension-type headache: Lifestyle modifications (stress management, regular sleep, exercise, avoidance of triggers)
Cognitive behavioral therapy (CBT)
Pharmacological options are less commonly used but may include amitriptyline or topiramate in select cases
Migraine: Pharmacological options (used when headaches are frequent or severe): Propranolol (most common first-line agent for children, 0.5-1 mg/kg/day divided BID)
Amitriptyline (start low, titrate slowly, 0.25-1 mg/kg/day HS)
Topiramate (start low, titrate slowly, 0.5-1 mg/kg/day BID)
Cyproheptadine (useful for appetite and sedation, 0.25-0.5 mg/kg/day divided BID)
Non-pharmacological: Biofeedback, CBT, relaxation techniques, optimizing sleep hygiene, regular meals, and hydration.
Lifestyle Modifications:
Regular sleep schedule
Consistent meal times and adequate hydration
Regular physical activity
Stress management techniques (mindfulness, relaxation exercises)
Identifying and avoiding individual triggers (specific foods, environmental factors)
Limiting screen time.
Education And Counseling:
Educating parents and children about the nature of the headache disorder is crucial
Reassurance that these are generally benign conditions
Establishing a headache diary to track frequency, severity, triggers, and treatment response
Encouraging adherence to treatment plans.
Complications
Early Complications:
Tension-type headache: Chronic tension-type headache
Migraine: Status migrainosus (migraine lasting >72 hours)
Migrainous infarction (rare).
Late Complications:
Chronic daily headache, medication overuse headache
Significant psychosocial impact: school absenteeism, social isolation, depression, anxiety
Reduced academic performance.
Prevention Strategies:
Early identification and effective management of acute headaches
Prompt initiation of appropriate preventive therapy when indicated
Lifestyle modifications and behavioral therapies
Regular follow-up with a healthcare provider.
Prognosis
Factors Affecting Prognosis:
Severity and frequency of headaches
Presence of comorbidities (anxiety, depression)
Adherence to treatment
Family history
Early diagnosis and intervention.
Outcomes:
With appropriate management, many children experience significant reduction in headache frequency and severity, leading to improved quality of life
Some children may outgrow their headaches by adulthood, while others may experience chronic headaches
Early and consistent treatment is key to preventing chronification.
Follow Up:
Regular follow-up appointments (e.g., every 3-6 months) are important to monitor treatment efficacy, adjust medications as needed, reinforce lifestyle modifications, and assess for new symptoms or complications
Referral to a pediatric neurologist or headache specialist may be necessary for complex or refractory cases.
Key Points
Exam Focus:
Differentiate between tension-type headache and migraine based on ICHD-3 criteria
Recognize red flags for secondary headaches
Understand first-line acute treatments for TTH and migraine
Know common preventive medications for pediatric migraine (propranolol, amitriptyline) and their starting doses
Emphasize lifestyle modifications and non-pharmacological approaches.
Clinical Pearls:
Always consider the impact of headaches on a child's life and functioning
A detailed headache diary is invaluable for diagnosis and management
Be cautious with prescribing triptans in younger children and always under specialist supervision
Lifestyle modifications are the cornerstone of both TTH and migraine management
Reassurance and education are powerful therapeutic tools.
Common Mistakes:
Over-reliance on imaging for typical primary headaches
Underestimating the impact of chronic headaches on a child's well-being
Inadequate management of associated symptoms like nausea/vomiting
Incorrect dosing of preventive medications
Failing to identify and address psychosocial factors contributing to headaches.