Headaches in children

Abstract

Headaches are common in children. Common primary headaches can also be experienced by children. The most common causes of innocent headaches among children are tiredness, short-sightedness, viral fever, sinusitis and psychosocial stressors. Consultation tasks include an attempt to diagnose the headache, the exclusion of sinister causes, and an effort to address any underlying concerns that the child and his/her family members may have. At a busy primary care consultation, the use of a headache symptom diary may provide important information for the evaluation of children presenting with chronic headaches.

Joel and his parents came to consult you on Joel’s frequent complaints of headaches in the morning. Joel had just started Primary 1 and had been experiencing headaches in the mornings for the past two months since mid-January. He used his thumbs and index fingers to form a large ring surrounding his forehead as he attempted to describe the discomfort that he experiences for 1–2 hours in the mornings. Joel’s mother had a deep frown on her face and had been staring intently at you since entering the room.

WHAT IS CHILDHOOD HEADACHE?

A headache is defined as pain located above the orbitomeatal line. Headaches in children can broadly be divided into primary headache syndromes or secondary headaches. The types of primary headaches found in children are almost the same as those found in adults. The most common primary headache syndromes in children are migraine headaches, tension-type headaches and cluster headaches. Secondary headaches can occur due to common causes(1,2) such as hunger and tiredness, and sinister causes such as life-threatening infections(3) and brain tumours.

HOW RELEVANT IS THIS TO MY PRACTICE?

Headaches can be very commonly experienced by children of schoolgoing age.(4-6) The types of headaches seen in adults can also be experienced in childhood. Common triggers of secondary headaches include sleep deprivation, congestion of the sinuses from allergic rhinitis, psychosocial stresses (e.g. from school), hunger and tiredness. Cluster headaches are not a common complaint in preschool children and such headaches seldom occur in primary school children. Migraine, while common in teenagers, is less specific in younger children. Younger children usually experience shorter (about 30 mins) bilateral headaches without aura.(7) Headaches are more common in postpubescent females and in children who have a family history of headaches or migraines.

MANAGEMENT OF CHILDHOOD HEADACHES

Appropriate assessment should include characterisation of the pain experienced by the child, identification of the triggers and relief, and identification of any relevant family history. Appropriate management targets the predisposing, precipitating and perpetuating factors identified. In the case of psychosocial stressors, targeted counselling for trigger avoidance and/or strengthening of coping mechanisms may be customised for the child. Simple over-the-counter analgesia such as paracetamol and ibuprofen can be prescribed; these medications are usually sufficient. Identification of any red flag symptoms (Table I) will warrant an immediate or urgent referral for medical attention at a hospital. Chronic headaches that have lasted for more than six months and frequent attacks (i.e. more than three attacks per week) with significant interference with school and any other activity may benefit from a referral to a pediatrician for further assessment.

Table I.

Red flag symptoms that warrant an immediate or urgent referral to a hospital.

Common causes of innocent headaches are tiredness (check sleeping times, and advise the child to get more rest), short-sightedness (find out when the child’s vision was last checked), viral fever (temporal relationship – headache should resolve with successful treatment of the viral infection), sinusitis (address symptoms, e.g. treat with nasal sprays), and psychosocial factors such as school stress/avoidance (initiate appropriate counselling sessions). It is important for primary care providers to recognise that the children and family members might have their own interpretations and concerns regarding the symptoms experienced.(8) Therefore, in the absence of red flag symptoms (Table I) and as part of holistic management, primary care providers should give a clear explanation of the clinical evaluation and address any further concerns the child or family members may have.

The following two tools may be useful in the diagnosis, and thus the management, of childhood headaches.

1. Headache symptom diary

A headache symptom diary is a diary in which the description of the pain, location, severity (including pain score, for older children), duration, timing, precipitating and relieving factors, and associated features of the headaches are recorded prospectively.(9) The use of such a diary may reveal a pattern that is typical for a certain type of headache, is less subject to recall bias,(10) and may provide important information that can be easily missed in a busy primary care consult.

2. Recommended diagnostic evaluations for children with recurrent headaches

In a report by Lewis et al,(11) the authors evaluated the evidence surrounding the use of investigations for children with recurrent headaches and developed a series of recommendations. These recommendations can serve as a useful guide for determining when referrals for further investigation should be made and who should be referred for further investigations. The recommendations are listed below:

• There is a lack of consensus concerning the role of diagnostic testing, including routine laboratory testing, cerebral spinal fluid examination, electroencephalography (EEG), and neuroimaging with computed tomography or magnetic resonance imaging, in the evaluation of recurrent headaches in children.

• There is inadequate documentation in the literature to support any recommendation regarding the use of routine laboratory studies or the performance of a routine lumbar puncture in the evaluation of recurrent headaches in children.

• Obtaining neuroimaging studies on a routine basis is not indicated in children with recurrent headaches and a normal neurologic examination.

• Neuroimaging should be considered in children with an abnormal neurologic examination (e.g. focal findings, signs of increased intracranial pressure and significant alteration of consciousness), the coexistence of seizures, or both.

• Neuroimaging should be considered in children who have historical features that suggest the recent onset of severe headache, a change in the type of headache, or if there are associated features that suggest neurologic dysfunction.

• EEG is not recommended in the routine evaluation of a child with recurrent headaches as it is unlikely to provide an aetiology, improve diagnostic yield, or distinguish migraine from other types of headaches.

• Although the risk of future seizures is negligible in children with recurrent headaches and paroxysmal EEG, future investigations for epilepsy should be determined by clinical follow-up.

After speaking to Joel, you identified that the headaches occurred when he was in school, consistently in the second to third hour of school, and that he feels much better during the second half of school, after recess. Your narrowed questioning of his parents uncovered that Joel had been skipping breakfast as he has been having difficulty waking up early in the morning since starting Primary 1. You also surfaced his mother's worry that Joel may have a brain tumour; she had read about this possibility on the Internet. As you pieced the information together, in the presence of Joel's parents, it was obvious that Joel was new to the school regime and was likely hungry. The introduction of regular healthy breakfasts back into his mornings was prescribed.

TAKE HOME MESSAGES

1. Headaches are common in children.

2. The types of primary headaches found in children are almost the same as those found in adults.

3. Common causes of innocent headaches among children are tiredness, short-sightedness, viral fever, sinusitis and psychosocial stressors.

4. Knowledge of red flag symptoms for headaches will help one to exclude sinister causes of headaches in children.

5. Holistic management should include providing the child and his/her family members a clear explanation of the clinical evaluation. Any further concerns that they may have should also be addressed.