Download Paediatric Headaches - Dr Vivek Jain Specialist Child Neurology

Pediatric Headaches
Prevalence
Headache is a common problem in children. Studies of prevalence of any type of headache have
shown that up to 50% of 7-year olds and up to 80% of 15-year olds have experienced at least one
headache. Some reports have suggested that headache is more common in boys prior to puberty
but a definitive preponderance (3:1) of females after adolescence.
Common types
1. Primary Headaches
A) Migraine (with or without aura)This is the commonest type of headache in children. Typically the history will be of an acute
headache which evolves over few hours preceded typically by a sensory aura which could
be visual (grey dots, zig-zag lines, vision loss), olfactory(abnormal smell), gustatory(abnormal
taste) or auditory(sound hurts). The headache is frequently frontal (in front of the head) and
not unilateral (one side) like in adults and is associated with intense nausea, vomiting and
photophobia. The history often also given by child or parents is off loss of appetite during and
just preceding the migraine episode. Family history of migraine is often there.
Migraine equivalents instead of typical migraine can be seen in children in form of acute
confusion, recurrent abdominal pain, cyclical vomiting and intense vertigo (Basilar migraine).
A particular type of migraine can be associated with hemiplegia (weakness of one side of
body) mimicking stroke.
Most episodes last for 12-72 hours but occasionally not treated early can develop into status
migranosus which then can take upto 5-7 days to get better.
B) Chronic Muscular headache (Tension Headache)
The history here is of a dull constant headache which is present ‘all the time’. This headache
is typically worse in the afternoon and evenings. The history of aura, nausea or photophobia
is usually not there. Stress, anxiety and depression can sometimes precipitate these
headaches.
A useful history to differentiate migraine and tension headache is if a patient wants to lie in a
quiet dark room he is more likely to have migraine while the one who is restless moving
around in the room complaining of headache is more likely to have chronic muscular
headache.
C) Mixed Headache
Often not mentioned but this is a common form of headache seen in children. Initially child
has episodic migraines but later also starts to get mild daily or frequent tension headaches.
Often the history will be of occasional severe episodic headache (migraines) and a constant
daily headache which is ‘always’ there and does not shift.
2. Secondary Headache
When a child presents with headache acutely, it is essential to consider whether it may be
secondary to an underlying systemic disease process. The most important diagnoses to
consider are intracranial bleeding, infection or brain tumor.
Idiopathic intracranial hypertension is a secondary headache which is associated with
headache symptoms similar to chronic tension headache. These children can be overweight
with a sedentary lifestyle. The headache is caused by interruption of the drainage of CSF
(normal fluid in the brain which is recirculated everyday) causing increased pressure. On eye
examination there could be papilledema (swelling in the back of eyes) and visual field
defects. The Brain imaging though usually is normal. These headaches require Lumbar
puncture for diagnosis and treatment. Sometimes oral medications can also be prescribed to
relive the pressure as they decrease the amount of CSF formed.
Investigations
Neuro imaging should be considered in children with an abnormal neurological examination, the
coexistence of seizures, or both. Neuro imaging should also be considered in children in whom
there are historical features to suggest recent onset of severe headache, change in type of
headache, or If there are associated features that suggest ‘neurological dysfunction1.
Lumbar puncture has to be considered if there is suspicion of infection or idiopathic intracranial
hypertension.
Treatment
The biggest worry parents understandably have when a child has headaches is if child has got a
‘brain tumor’. Contrarily most headaches are not associated with brain lesion and often history
and examination will be enough to confirm this. Reassurance that the headache is not due to a
significant brain problem itself is often therapeutic.
Lifestyle Modification
It is always important to have good fluid intake especially in warm weather, sleep well and have
an active lifetstyle which goes a long way in helping any type of headache especially migraines.
Rarely people can identify food precipitants for their headaches like cheese, chocolate, banana or
citrus(orange, lemon etc.) fruits. Relaxation exercises can sometimes help with chronic daily
headaches.
Medications
In my experience most headaches especially chronic muscular headaches have been benefited
by gentle reassurance, setting up small goals and trying simple analgesics sparingly like
paracetamol and ibruofen. It is important that analgesics are only reserved for bad headaches
and not to be taken regularly otherwise can cause analgesic rebound headache.
Acute relief
Severe migraine often requires good doses of analgesics with some anitemetic (for vomiting). It is
important with migraines to take medication at the onset of headache or with aura otherwise the
analgesics often are not as effective.
Prophylaxis (Regular medication)
If migraine attacks become very frequent or if chronic muscular headache is affecting the child’s
functioning (missed school, tiredness, low mood) than daily medications can be tried for 3-6
months. Keeping a headache diary is also useful to monitor the effectiveness of daily medication.
Dr Vivek Jain
Paediatric Neurologist
PD Hinduja Hospital
Mahim, Mumbai.