Headaches

https://en.wikipedia.org/wiki/Headache

Introduction

Headaches are a common pediatric complaint and it is important to be able to differentiate organic etiologies from benign causes. Headaches may be classified as

1. Acute: often associated with viral or bacterial illnesses
2. Acute recurrent: migraine headaches
3. Chronic non-progressive: tension headaches
4. Chronic progressive: includes tumors, hydrocephalus

Common Headache Syndromes

Primary headaches

1. Migraines. Throbbing pain, nausea, vomiting, abdominal pain, and desire to sleep. Often phonophobia and photophobia. Complications include hemiplegia, opthalmoplegia, tinnitus, vertigo, ataxia, weakness, confusion, and paresthesias. Strong family history is often present.
   • Migraine with aura (classic):  Often one sided. Auras are most commonly visual disturbances, second most common is tingling of lips, lower face, or fingers of one hand.  
   • Migraine with no aura (common):  Pain is often frontal, less common to have vomiting and nausea, rare to have eye symptoms. Often a prodrome of pallor, alteration of personality, or change in appetite or thirst. 
2. Tension or muscle contraction headaches: Pain is bilateral, described as pressure/tightness, non-throbbing. Waxes and wanes, greater incidence during the school day or during periods of stress, not very common in young children and pre-adolescents. Nausea/vomiting is uncommon. May be occipital or cervical as well as frontal.
3. Chronic daily headache: Headache present for more than 15 days a month for more than 3 months without any detectable organic etiology.

Secondary headaches

1. Acute febrile illness. Flu, URI, sinusitis, meningitis, abscess
2. Head trauma
3. Medications – oral contraceptives, steroids, SSRIs, etc
4. Hypertension.
5. Brain tumor
6. Hydrocephalus, chiari malformations, etc
7. Hemorrhage, subdural hematomas
8. Pseudotumor cerebri – think about in certain acne treatments
9. Toxin – lead, ingestion, carbon monoxide, cocaine

Evaluation

History

1. Description of headache: when did it start? Was it sudden? Is the pain throbbing or squeezing or stabbing or something else?
2. Time course: How often do you get them? Are they always the same? Are they getting worse? How long do they last? Does the pain change over time (peak)?
3. Associated symptoms: Ever have any signs that a headache will start? Any vomiting or nausea? Numbness, weakness? Visual changes?
4. Any specific times or events when headaches occur?
5. What makes them better, what makes them worse?
6. What do you do when you have the headache? Do you stop doing everything or can you still function?
7. Family history
8. Medicines
9. School performance and behavioral changes.
10. Family/social changes and problems
11. Trauma
12. Relation to sleep

Physical examination

1. Vitals, BP, temperature, general appearance
2. Palpation of head and neck – sinus tenderness, thyromegaly, nuchal rigidity
3. Head circumference, height, weight
4. Neurologic examination – altered mental status, abnormal eye movement, optic disc distortion, motor or sensory asymmetry, coordination, abnormal reflexes, visual field
5. Skin – signs of neurofibromatosis or tuberous sclerosis
6. Bruits in the head

Imaging/labs – Usually not necessary, imaging only if history and physical are concerning

1. Probably warranted if: Acute headache, worst headache of life, thunderclap, focal neurologic symptoms, papilledema, hemiparesis, ataxia, abnormal reflexes, age younger than 3yo, neurocutaneous syndrome.
2. Maybe warranted if: headaches/vomiting on awakening, unvarying location of headache, meningeal signs
3. Imaging/work-up: MRI, CT, or EEG if necessary, lumbar puncture if meningitis suspected. Also consider CBC, ESR, serum or urine toxicology, and thyroid function tests

Management (Migraines)

General measures

1. Reassurance!!! Often the parents believe that the child has a brain tumor or other serious intracranial disease
2. Have the parent or child keep a diary to document frequency and associated events (this should happen before pharmacologic therapy)
3. Behavioral changes - exercise every day 20-30 mins, relaxation techniques, stress management
4. Avoidance of precipitating factors - lack of sleep, dehydration, caffeine, analgesia overuse
5. Encourage regular activities and school, evaluate psychosocial issues

Abortive treatment – early medication, rest/sleep in quiet/dark room, cool cloth on forehead

1. NSAIDs and acetaminophen – early administration is helpful, the most common medication for migraines in children
2. Triptans – 5-HT receptors agonists – commonly used for migraines, but not technically FDA approved for children. Many routes of delivery – oral, nasal (useful when vomiting), subcutaneous
3. Antiemetic –relieve symptoms and facilitate sleep
4. Dihydroergotamine – protracted migraine that is not responding to other therapies – last resort

Prophylaxis – uncommon in children, but necessary if interfering with daily life

1. Beta-blockers – propanolol most common prophylaxis used in children. Contraindicated in children with asthma
2. Anticonvulsants – Ex: Valproate, topiramate – mainly used in adults
3. TCAs, Cyproheptadine – also used, but less common

References

1. Forsyth R. and Farrell K. Headaches in Children Pediatrics in Review 1999
2. Singh B. and Roach E. S. Diagnosis and Management of Headaches in Children.  Pediatrics in Review 1999
3. Goadsby P.J. Lipton R.B. Ferrari M.D. Migraine-current understanding and treatment.  NEJM 2002
4.  Lewis D.W. Headaches in Children and Adolescents. American Family Physician. Feb 2002
5. Fisher P. Help for Headaches.  A strategy for you busy prctice.  Contemporary Pediatrics Nov 2005
6. Lewis D. Pediatric Migraine.  Pediatrics in Review Feb 2007
7. Tarannum M. et. al. Headaches in Young Children in the Emergency Department.  Use of Computed Tomography.  Pediatrics 2009
8. Loder E. Triptans Therapy in Migraine.  NEJM July 1, 2010
9. Gladstein J. Mack K.J. Common presentations of chronic daily headache in adolescents. Pediatric annals 2010