Headache in Children and Adolescents
Headache is a common complaint among children and adolescents. The prevalence of migraine in those with headache varies by age and gender throughout childhood and adolescence. Migraine begins earlier in boys than in girls and, until the age of seven, migraine occurs slightly more often among boys. By menarche, the prevalence of migraine in boys and girls is roughly equal. However, after menarche, migraine begins to predominate among females and this gender separation increases even further in late adolescence.
Headaches, especially migraines, have a significant impact on the lives of young people. Approximately 65-80% of children with migraine headaches will experience disruption of their normal daily activities at home, in school and other social settings. The burden of migraine may also result in the development or worsening of anxiety or depression. Because of quality of life issues, early recognition and management of headaches in children and adolescents is crucial.
Headache disorders can be categorized as either primary or secondary. As with adults, the vast majority of headaches in children and adolescents are primary headache disorders: migraine (with or without aura), tension-type headache and chronic daily headache.
Secondary headache disorders, al-though much less common, may be due to various organic etiologies which can range from the relatively benign to the serious. Such underlying organic conditions include:
- bacterial causes: acute febrile illness, rhinosinusitis, dental abscess, intracranial and extracranial infections;
- systemic illness: hypertension, diabetic ketoacidosis;
- miscellaneous: head or neck trauma, vascular malformations, subarachnoid hemorrhage, intracranial mass lesions, etc.
Although headache can be a presenting symptom of underlying organic pathology, accurate information from the patient and family is often enough to identify or rule out the most serious etiologies. The overwhelming majority of headache disorders are diagnosed by a thorough history and physical examination. A complete medical and psychiatric history, family history, medication history (including prescription, over-the-counter, and vitamins/herbs), allergy history, and social history should also be obtained.
Migraine tends to be under-diagnosed; patients and their parents often attribute headaches and nausea to “the flu” or dismiss them as “sinus headaches.” Careful attention must be paid to the patient’s description of headache onset, timing, frequency, duration, severity, quality, location, precipitating factors, and aggravating or alleviating factors. Associated symptoms—especially nausea, vomiting, photophobia and phonophobia—are often the key to an accurate diagnosis of migraine.
Potential indicators of organic pathology can include severe vomiting, a headache which awakens a child from sleep, and the absence of a family history of migraine. Also, progressive, unremitting daily pain, neurologic symptoms and fevers are important. If any of these red flags are present, the appropriate laboratory and imaging investigations should be performed.
In a patient with an unremarkable history, where a primary headache disorder is suspected, laboratory investigation is usually not warranted beyond baseline labs. These usually include, but are not limited to, a complete blood count and metabolic panel.
Neuroimaging studies are usually not indicated in children with a normal neurologic examination and a history consistent with a primary headache disorder, especially migraine or tension-type head-ache. These children will not usually have significantly abnormal findings on head CT scans or intracranial MRIs. A small percentage may have incidental and/or unrelated findings, but routine neuro-imaging is not absolutely indicated in children with typical primary headaches.
Usually, electroencephalography (EEG) is not helpful in the routine diagnostic assessment of pediatric headache patients. However, an EEG should be performed on patients with an atypical migraine aura, episodic loss of consciousness, or symptoms suggestive of a seizure disorder. Background slowing may be seen during some migraine attacks, but the EEG results are usually normal.
Lumbar puncture (LP) is indicated if meningitis, encephalitis, subarachnoid hemorrhage, or high-low pressure syndromes are suspected. Cerebrospinal fluid and pressure measurement should also be performed. In those patients where increased intracranial pressure is suspected—or in those with focal neurologic deficits—a head CT scan or similar neurologic imaging modality should be performed prior to a lumbar puncture. We attempt to avoid the LP unless absolutely indicated. However, if meningitis or encephalitis is suspected in a toxic-appearing patient, treatment should not be delayed in order to perform the head CT scan first.
For those with more severe or frequent headaches, a comprehensive biopsychosocial approach is needed. This approach requires the collaboration of medical and behavioral specialists working together to improve a patient’s overall functioning and quality of life. The combination of both pharmacologic and nonpharmacologic treatments is ideal for those with frequent headaches. Nonpharmacologic treatments are particularly important as they are typically more effective in children and help to minimize medications and side effects.
Non-pharmacologic modalities consist of patient education, lifestyle strategies, behavioral interventions, physical therapy, etc. Patient education should be the first step taken. Legitimizing the headache as a physiological disorder is of primary importance. It helps to say “…Migraines are a genetic medical condition, like asthma or diabetes…”
Children and their parents usually want to hear three things from the physician: (1) the cause of the headache (including triggers), (2) the treatment and prognosis, and (3) reassurance that a primary headache disorder is not serious. It is important that realistic goals and expectations are set. Children and their parents should understand that there are no miracle cures for headaches.
It is usually helpful to introduce the use of a headache diary as a means to identify specific triggers. Of course, some triggers (e.g., weather changes, stress, hormonal influences) cannot be avoided, but certainly many—such as missing meals, bright lights/sunlight, undersleeping/ oversleeping, foods, perfume, cigarette smoke and certain types of physical exertion—can be managed. Headache diaries should record the frequency and severity of headaches as well as document the efficacy and side effects of treatments. Using a diary will improve the patient’s or parents’ recall of the headaches and make office visits more productive. They can also help persuade children and adolescents of the need for lifestyle changes.