Managing Headaches 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 occurs slightly more often among boys until the age of seven. By menarche, the prevalence of migraine in boys and girls is roughly equal. However, after menarche, migraine begins to predominate in girls, 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% to 80% of children with migraine headaches will experience disruption of their normal daily activities at home, in school, and in social settings. The burden of migraine also may result in the development or worsening of anxiety or depression. Because of quality of life (QoL) issues, early recognition and management of headaches in children and adolescents is crucial.
Headache disorders can be categorized as either primary or secondary. As in 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, although 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; as well as miscellaneous other causes: 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 often is enough to identify or rule out the most serious etiologies. The overwhelming majority of headache disorders are diagnosed via a thorough history and physical examination. A complete medical and psychiatric history, family history, medication history (including prescription, over-the-counter, and vitamins/herbals), allergy history, and social history also should be obtained.
Migraine tends to be underdiagnosed; 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—often are the key to an accurate diagnosis of migraine.
Potential indicators of organic pathology can include severe vomiting, a headache that awakens a child from sleep, and the absence of a family history of migraine. Progressive, unremitting daily pain, neurologic symptoms, and fevers also 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 who is suspected to have a primary headache disorder, laboratory investigation usually is not warranted beyond baseline labs. These usually include, but are not limited to, a complete blood count and metabolic panel.
Neuroimaging studies usually are not indicated in children with a normal neurologic examination and a history consistent with a primary headache disorder, especially migraine or tension-type headache. These children usually will not have significantly abnormal findings on head CT scans or intracranial magnetic resonance imaging (MRI). A small percentage may have incidental and/or unrelated findings, but routine neuroimaging is not absolutely indicated in children with typical primary headaches.
MRI is the preferred test of the brain. It usually does not need to be done with contrast. MRI is important for those with new-onset headaches, atypical head pain, or abnormal neurological symptoms or signs.
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 EEG results usually are normal.
Lumbar puncture (LP) is indicated if meningitis, encephalitis, subarachnoid hemorrhage, or high-low pressure syndromes are suspected. Cerebrospinal fluid and pressure measurement also should be performed. In patients in whom 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 LP. We attempt to avoid the LP unless it is absolutely indicated. However, if meningitis or encephalitis is suspected in a toxic-appearing patient, treatment should not be delayed for the CT scan.
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 QoL. The combination of both pharmacologic and nonpharmacologic treatments is ideal for those with frequent headaches. Nonpharmacologic treatments are particularly important because they typically are more effective in children and help to minimize the use of medications and their related side effects.
Nonpharmacologic 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 physiologic disorder is of primary importance. It helps to say that“…migraines are a genetic medical condition, just as asthma or diabetes are…”
Children and their parents usually want to hear 3 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 usually is helpful to introduce the use of a headache diary as a means to identify specific triggers. Of course, some triggers (eg, 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 and 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 also can help persuade children and adolescents of the need for lifestyle changes.