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  1. Gladstein, Jack MD

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WHEN A CHILD has a headache, her parents may be convinced that she has a?brain tumor. Addressing their fears is part of the healthcare provider's job. Fortunately, severe pain, nausea, vomiting, and photophobia or phonophobia, while distressing to the child and family, are much more likely to signal migraine headache than brain tumor. In this article, I'll discuss migraines and four other types of headaches in children.

Figure. Children wit... - Click to enlarge in new windowFigure. Children with migraine are more sensitive to emotional triggers, such as worrying about grades.


Childhood migraines differ from adult migraines in that the headache usually is shorter in duration (1 to 72 hours), and more often bilateral.1 Children often don't describe their pain well, so don't expect to hear descriptions such as knifelike, throbbing, or viselike. They may just say, "it hurts."2 When you obtain a family history, ask whether other family members ever have headaches, not migraine; this type of headache often is misdiagnosed. To get a good sense of the degree of disability during an attack, ask the child if she could run up and down the stairs a few times during the episode.


Migraine is a disease of young people, with peak prevalence in the first four decades of life.3,4 The headache can occur with or without aura, and most children have migraine without aura. However, the migraine can begin with another type of warning. For example, the child may feel sluggish, hungry, or have trouble finding words, and may have a feeling of doom similar to that described by seizure patients. If she does have an aura, it may be visual: She may see wavy lines that start peripherally and then move across the visual field, usually sparing the midline. The headache starts about 30 minutes after this visual aura.


Recognizing migraine is fairly easy-look for severe pain with autonomic signs and symptoms such as dizziness, light-headedness, and pallor. The patient or her parents may report more than five episodes of headache ranging from 4 to 72 hours each and accompanied by nausea or vomiting, photophobia, phonophobia, and inability to do strenuous exercise. Left to herself, the child will want to retreat to a dark, quiet place.


The time of day when migraine pain occurs isn't that helpful in assessing childhood migraine. Migraine triggers vary from patient to patient, but in general, children with migraine are more sensitive to emotional triggers, such as school (worrying about grades or bullies, or getting up too early). Regular meals, exercise, and sleep may help reduce attacks.


Encourage parents to try an elimination diet, in which one type of food is eliminated to determine whether it makes a difference in migraine frequency. If the food doesn't cause a problem, it can be reintroduced in moderation.5 Keeping a headache diary also can help identify triggers.


In the past, treatments focused on helping kids get to sleep. Today, with the advent of triptans, children can take medication at the first sign of a headache, rest for a short while, then return to their normal routine. School nurses can help by ensuring that children have prompt access to their medication.6


Migraine treatment is a race against the clock: The longer a patient waits, the less likely that drugs will work.7 Over-the-counter (OTC) drugs such as ibuprofen and naproxen, which are prostaglandin inhibitors and mitigate inflammation, can be used (in higher than usual doses) early in a headache, before nausea sets in and reduces their efficacy. Triptan therapy can be given orally, parenterally, or by nasal spray. The injection and nasal spray forms cause more adverse reactions, but absorption is less variable than the gastrointestinal route. Teach the child's parents the importance of administering headache medicine early when they're most effective.


Prophylactic drugs for children with migraine should be based on severity and frequency of headaches after a triptan has been prescribed. The child's other conditions should be taken into account: for example, a child with asthma or depression shouldn't take a beta-blocker, which may exacerbate these conditions. Beta-blockers should also be avoided in children who play sports, because they cause exercise intolerance.8


Valproate, gabapentin, and topiramate are suitable for patients with migraine and epilepsy.9 Nonprescription alternatives include feverfew, magnesium, coenzyme Q-10, and riboflavin.10 Biofeedback relaxation, hypnosis, and cognitive therapy also can work well if the child is motivated to practice daily.11


Tension-type headache

As with migraine, tension-type headache is an acute recurrent pattern. However, this type of headache doesn't cause autonomic signs and symptoms. Both migraine and tension headaches are exacerbated by stress, get worse as the day goes on, usually have no aura, and often respond to the same medications. This type of headache typically responds to OTC medications.


Chronic nonprogressive headache

Also known as chronic daily headache (CDH), this type of headache may be diagnosed when the patient has at least 4 hours of headache on at least 15 days/month. CDH can be exacerbated by medication overuse, although this is more common in adults. The four subtypes are:


* Transformed or chronic migraine. These migrainelike episodes usually respond to migraine-specific medications. In children, the transformation from migraine to CDH averages 2 years, compared with 10 in adults.


* Chronic tension-type headache. The patient has a history of tension headaches without autonomic symptoms, with the headaches transforming to daily or near-daily pattern. Triptans used to treat migraines play no role here.


* New persistent daily headache. This type occurs in a patient without a history of acute recurrent headache. A preceding viral infection or trauma may lead to the daily headaches. This type of headache often is refractory to treatment.12,13


* Hemicrania continua. This very rare form is characterized by short daily bursts of pain, always unilateral. Although very rare in children, it has been reported.14 This type of headache responds to indomethacin.



Acute headache

The most common cause of acute headache (new onset of headache for the first time) is a virus.15 Fever and headache with a normal exam aren't cause for worry. In other cases, however, acute headache may be less benign: Fever and a stiff neck may indicate viral meningitis; fever and a change in mental status may indicate encephalitis. Subarachnoid hemorrhage is characterized by a sudden, full-force headache accompanied by low-grade fever and a stiff neck. If subarachnoid hemorrhage is suspected, the patient needs an emergency computed tomography scan and neurology consult.16 Other possible causes of acute headache include wide-angle glaucoma and cavernous venous thrombosis. Acute angle closure glaucoma is characterized by eye pain and change in vision. Cavernous sinus thrombosis is characterized by a history of ear, nose, or throat surgery, localized nasal infection, or use of medications that could cause a hypercoagulable state.


Chronic progressive headache

In this type of headache, often caused by a tumor, pain increases slowly and steadily over weeks or months. Coughing, straining, sneezing, or bending forward may exacerbate the pain, which often is worse in the morning and improves slightly as the day goes on. Testing for patients with these symptoms includes magnetic resonance imaging.


Seeing the pattern

By understanding headaches in children, you can teach parents what they need to know and help your patients get appropriate treatment.




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