Download Treating recurrent headaches in children

Forum
Clinical Review
child headache-NH2
27/08/2008
16:26
Page 1
Treating recurrent
headaches in children
Careful history-taking and a headache diary are key to proper
evaluation of headaches write Valeria Ricotti and Alf Nicholson
MOST RECURRENT HEADACHES IN CHILDREN and adolescents
are due to either migraine or tension headaches. As adult
definitions of migraine do not always apply in children, there
may be a continuum between migraine and tension
headaches. In most cases, potential underlying serious
pathology can be ruled out by careful history-taking and
examination. Reassurance is very important and GPs should
concentrate on advice on lifestyle, the removal (if possible)
of trigger factors and simple analgesia. Investigations such
as EEG and CT or MRI scanning are rarely indicated.
The aim of this article is to discuss the epidemiology of
recurrent headache and the differential diagnosis, and to
provide an update on management.
Points in history
History-taking is most important and both the child and
the parent should be questioned to identify a number of
important factors.
Description of the headache episode
One requires a clear description of the nature of the
headache: its localisation; its time course; its pattern (eg.
diurnal variation, postural changes); radiation (eg. to the
eye); and if there are any associated features (aura, blurred
vision, nausea, marked pallor, photophobia and vomiting).
Length of symptoms
The length of time the headaches have been present and
any change in the severity and tempo of headaches are very
important points in the history. Longstanding headaches
that have not changed over the past 12 months are most
unlikely to be associated with serious underlying pathology.
In many respects, a recent change or increase in the tempo
or severity of headaches is the most important aspect of the
history and should always arouse concern.
Timing of the headache
Ask whether the headaches tend to be in the evening or in
early morning, just on school days or at weekends, and
inquire as to how long they last.
School days lost
It is very important to know how much time off school the
child has had due to headaches and how academic progress
has been thereby affected, if at all. If many school days are
being missed, a report from the class teacher and enquiry
into general progress and happiness at school is required.
Ask also about the length of time spent on homework and
the number of extracurricular activities taken by the child.
Precipitants of headaches
It may or may not be clear from the history whether particular foods, light, stress or intense exercise bring on
headaches. Enquire also what the child does to relieve the
headaches, how quickly they tend to take analgesics, and
whether they need to lie down to relieve the headache.
Remedies tried
Explore what remedies have been tried by the parents,
including use of analgesia, dietary changes, home remedies
and preventive medications.
Family history
Ask about a family history of migraine, travel-sickness, vertigo and epilepsy. It is also important to check if there is any
family history of strokes at a young age. Although cerebral
autosomal dominant arteropathy with subcortical infarcts
and leukoencephalopathy (CADASIL) is a rare condition, it
should be kept in mind in the differential.
Important exam findings
All children with headaches should have a complete physical examination concentrating on:
• Measurement of head circumference (watch for macrocephaly)
• Height and weight centiles (short stature in craniopharyngioma)
• BP measurement (may be elevated if raised intracranial
pressure)
• Assessment for neuro-cutaneous stigmata (eg. café-au-lait
spots of neurofibromatosis type 1)
• Full cranial nerve assessment including extraocular movements, fundoscopy, looking for loss of venous pulsation,
papilloedema, and optic atrophy
• Assessment of visual acuity and visual fields
• Look for head tilt (may be a presenting feature of a posterior fossa tumour)
• Gait analysis (ataxia may be a feature of posterior fossa
tumour).
FORUM September 2008 61
child headache-NH2
27/08/2008
16:27
Forum
Page 2
Clinical Review
Migraine and its variants
Migraine affects 3-10% of children and 20% may experience their first attack prior to five years of age. Incidence
increases steadily with age, affecting boys and girls equally
before puberty, and girls more commonly thereafter.
Migraine is characterised by episodes of head pain that is
always throbbing and frequently unilateral, frontal, or temporal in position. Pallor is a prominent feature and the child
may be described as being ‘ghostly pale’.
Most children with significant migraine stop what they are
doing, go to a darkened room, lay down and fall asleep. The
headache is often gone on awakening. Headache due to
migraine lasts over three hours and less than 72 hours
(status migrainosus is greater than 72 hours in duration and
needs emergency management).
Acute migraine is of relatively sudden onset and can occur
with or without a prodrome, also known as aura. In migraine
without aura (or common migraine), attacks are associated
with nausea, vomiting or sensitivity to light, sound or movement. Up to 15% of patients suffer from migraine with aura
(or classic migraine). In such patients migraine is preceded
by transient focal neurologic symptoms, which are commonly visual (eg. scotoma, fortification spectra) and resolve
with the onset of head pain. Derealisation phenomena such
as macropsia-micropsia are experienced by some children,
also known as Alice in Wonderland syndrome.
Triggers
Triggers for migraine include stress, fasting, sleep deprivation and extreme activity. Food triggers may sometimes be
identified and it may be useful to keep a record of what is
eaten just prior to a headache to see if a consistent pattern
emerges. Common culprits include: nuts; caffeine (including cola drinks); citrus fruits; spiced meats; monosodium
glutamate (MSG); chocolate; and blue cheese.
Exercise, especially if associated with competitive sports,
may precipitate migraine in some children. Oestrogens and
androgens are likely to be responsible for the change in the
incidence of migraine seen at or around puberty.
Treatment
Treatment in paediatric migraine includes an individually
tailored regimen of both non-pharmacologic and pharmacologic measurements. Non-pharmacologic modalities include
lifestyle adjustments, eg. regular sleep; regular meals; exercise; avoidance of peaks of stress and dietary triggers.
Parents should be encouraged to keep a headache diary,
as keeping a diary may indicate such factors as well as the
frequency of episodes. Once parents are familiar with their
child’s pattern of migraine they should be encouraged to
treat with analgesics as early as possible. In fact, analgesia
and rest in a quiet room, if initiated at the very first sign of
headache, may be effective in aborting the episode.
Most children with migraine can be treated with simple
analgesics such as paracetamol or ibuprofen. Other symptomatic medication include:
• Triptans (eg. sumatriptan, frovatriptan) are selective agonist of 5-hydroxytryptamine; three randomised controlled
trials have demonstrated that nasal sumatriptan is both
safe and effective in adolescents with a severe attack of
migraine. It can also be administered orally and by subcutaneous injection. Drowsiness is a recognised common
side-effect. Disadvantages include high cost and con62 FORUM September 2008
traindication in cardiovascular patients
• Calcium channel blockers (eg. buclizine, flunarizine) are
of proven benefit and relatively safe. Side-effects include
low blood pressure and tiredness
• Opiates as a rule should be avoided because they seem to
mask the pain without suppressing the pathophysiologic
mechanism of the attack, often leading to addiction
• Ergot alkaloids (eg. methysergide) are very potent and
should be avoided in children under 12 years due to the
possibility of vasospasm. Administer by specialists only.
• Anti-emetics (domperidone and metoclopramide) and
clonidine have all been found to have some beneficial
effect in small placebo-controlled studies, but were not
shown to reduce headache frequency or duration
• Herbal remedies such as feverfew, an easily-grown daisylike plant, has been shown to be effective in migraine
treatment in adults.
Preventative therapy
If a child is getting very frequent migraine headaches (eg.
more than two attacks a month) and thereby missing days
of school, prophylaxis is indicated.
Preventive therapy should also be considered if the patient
is at risk of rebound headache or if the frequency and severity of attacks is increasing. The available options include:
• Adrenergic-receptor antagonists (eg. propranolol, metoprolol). There is a paucity of studies showing a beneficial
effect, and in some patients adrenergic-receptor antagonists could potentially worsen symptoms. They should be
avoided in patients with asthma
• Calcium channel blockers (eg. buclazine, flunarizine), as
above
• Pizotifen has also been evaluated and in two clinical trials;
both had significant methodological flaws that considerably limited the interpretation of their results. Side-effects
include drowsiness and weight gain
• Amitriptyline (tricyclic antidepressant) use at low dose at
bedtime has a proven benefit in adult patients. Sideeffects include drowsiness
• Topiramate (a new generation anti-epileptic agent) is a
promising agent yet not fully studied in migraine. Sideeffects include weight loss and confusion.
Migraine variants
When the neurological symptoms and signs associated
with migraine appear after the headache onset (eg. Horner’s
syndrome, hemifield deficits), this is referred to as transformation migraine. In ophthalmoplegic migraine there is
often ptosis and a divergent squint, occasionally lasting for
more than 24 hours. Hemiplegic migraine is rare and often
familial and the hemiplegia may outlast the headache but
rarely lasts more than six to 12 hours. Basilar migraine is
characterised by dizziness and vertigo as predominant features. It is relatively short-lived and very occasionally there
may be an associated bilateral transient visual loss.
Outcome of childhood migraine
There are very few long-term studies but it appears that the
outcome seems to be better in boys than in girls. Outcome
seems to be worse if headaches start before the age of six
years. Many children with migraine will follow family patterns
and thus genetic factors appear important. Migraine tends to
decrease in frequency and severity with age, but this may not
occur until early middle-age has been reached.
child headache-NH2
27/08/2008
16:28
Page 3
Forum
Tension headaches
Tension headaches are the other main cause of headache
in childhood. Typically they are a response to stress. Tension
headaches have a number of characteristics in that they
tend to be bilateral, they vary in severity and have a pressing or tightening quality. Scalp pain needs to be elicited in
the history, suggested by pain on brushing hair, etc.
The triggers for tension headaches may include: school bullying; excess extracurricular activities; marital discord;
unemployment; death in the family; or moving home. Often
the family doctor is best equipped to elucidate these triggers.
Suggested strategies to reduce tension headaches include:
looking for and correcting the cause of stress; avoiding frequent analgesia if possible; encouraging normal school
attendance; explaining the non-serious nature to the child;
relaxation exercises, physiotherapy and hypnosis may help.
Differential diagnosis
Brain tumours
Although much feared, brain tumours are relatively infrequent occurrences in childhood with an incidence of three per
100,000. Children with brain tumours usually have symptoms
other than headache only. Infratentorial tumours may present
in the absence of headache, with difficulty in walking, confusion, hyperreflexia, cranial nerve palsies and head tilt.
Supratentorial tumours presenting with a headache may also
have diplopia, poor academic performance, seizures, focal
hyperaesthesia of a limb or speech impairment.
It was traditionally thought that the headache of raised
intracranial pressure awakens the child from sleep, is maximal in the morning and improves during the day. While
such a history should always trigger concern, the lack of this
pattern does not exclude raised intracranial pressure.
As stated above, an increased tempo and severity of
headaches is most important and should arouse concern
regarding the possibility of serious brain pathology.
Children with brain tumours may present with a history of
initial mild headaches increasing in a crescendo fashion to
severe and frequent headaches. The reverse is also true in that
headaches recurring over a period longer than six months in
the absence of other neurological symptoms are rarely due to
a brain tumour. The one exception to this rule is a craniopharyngioma, in which there are usually other clues such as
short stature, delayed puberty and visual field defects.
Idiopathic intracranial hypertension
Idiopathic intracranial hypertension is the clinical syndrome of raised intracranial pressure in the absence of
space-occupying lesions or vascular lesions, without enlargement of the cerebral ventricles, for which no causative factor
can be identified. It was previously known as benign
intracranial hypertension; however, it is now recognised as
a malignant phenomenon. It can rapidly lead to irreversible
blindness. This may present with a severe frontal headache
that interferes with normal daily activities.
The headache may increase in intensity on bending over
and is often more frequent in the morning. The patient may
also complain of intermittent darkening of parts or the whole
of their visual fields (transient visual obscuration).
Neurological examination is abnormal including papilloedema and optic atrophy on fundoscopy, and at times a
sixth nerve palsy. Neuroimaging is normal.
Diagnosis is based on history, exam and lumbar puncture,
Clinical Review
with high opening pressure and formal visual field assessment. Associated factors are obesity, steroids withdrawal,
hormonal contraceptive use, some antimicrobial agents, vitamin A, and also venous sinus stenosis.
Prompt referral to a tertiary centre is warranted. Treatment
options include: carbonic anhydrase inhibitors; loop diuretics; fenestration of the optic nerve; high volume lumbar
puncture; and CSF shunting.
Sinusitis
Ethmoid and frontal sinusitis may be associated with
headache in older children. The headache is usually throbbing, dull, and made worse when the child bends over or
coughs. Percussion of the sinuses may elicit tenderness.
Sinus radiographs and ENT referral may be organised.
Hydrocephalus and shunt blockage
In those children with known hydrocephalus who have a
ventriculo-peritoneal shunt in-situ, shunt malfunction
(mechanical or infection) needs to be considered, especially
if headaches are associated with vomiting, altered consciousness, or signs of raised intracranial pressure.
Who needs investigations?
In a previously healthy child with headache, criteria for
requesting neuroimaging include: an accompanying change
in personality; abnormal neurological or visual examination;
frequent or persistent vomiting; crescendo pattern of
headaches; signs of raised intracranial pressure; and focal
and generalised seizures.
Up to 30% of CT/MRI brain scans performed are for
parental reassurance and, apart from resource and radiation
exposure implications, it is important to stress to parents
that early investigation and the finding of a normal CT/MRI
scan may give a false sense of reassurance and potentially
delay rescanning if the headache characteristics change.
Careful history-taking, examination, and follow-up with a
headache diary is the key to the proper evaluation of
headaches rather than resorting to neuroimaging.
It is important to stress to parents that CT brain scans are
equivalent in radiation exposure to some 80 chest x-rays and
therefore CT should not be performed for reassurance only.
Practice points
• Always review a child with simple headaches four to six
weeks post-initial consultation to see the pattern of
headaches using a diary
• Get expert opinion on any headache with focal features or
rapidly changing pattern
• Assess trigger factors for migraine and tension headaches
• Skull and sinus radiographs are generally unhelpful in
children with headaches
• Prompt analgesia and retiring to a quiet dark room is
effective in treating many migraine attacks
• Sumatriptan may be used selectively in children with
severe attacks
• Migraine prophylaxis is rarely required in childhood but
may improve school and social performance when
needed.
Valeria Ricotti is senior house officer with a special interest
in paediatric neurology at the CUH, Temple Street, Dublin; Alf
Nicholson is consultant paediatrician at CUH and professor of
paediatrics at RCSI
References on request
FORUM September 2008 63