Headaches

Question 1

Causes of headaches in children?

Answer 1

Tension headaches
Migraines
Ear, nose and throat infection
Analgesic headache
Problems with vision
Raised intracranial pressure
Brain tumours
Meningitis
Encephalitis
Carbon monoxide poisoning

Question 2

What are tension headaches?
Symptoms in young children?
Triggers?
Tx?

Answer 2

Tension headaches are very common. Classically they produce a mild ache across the forehead and pain or pressure in a band-like pattern around the head. Tension headaches comes on and resolve gradually and don’t produce visual changes or pulsating sensations. They are typically symmetrical.

Symptoms may be very non-specific in younger children. They may become quiet, stop playing, turn pale or become tired. They tend to resolve more quickly in children compared with adults, often within 30 minutes.

There are certain triggers for tension headaches in children:

Stress, fear or discomfort
Skipping meals
Dehydration
Infection

Management is with reassurance, analgesia, regular meals, avoiding dehydration and reducing stress.

Question 3

Types of migraine?
Pathophysiology?
Symptoms?

Answer 3

There are several types of migraine:

Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine
Abdominal migraine

The pathophysiology of migraine has been studied for decades. Various mechanisms and theories have developed. There is no simple explanation for why migraines occur and it may be a combination of structural, functional, chemical, vascular and inflammatory factors.

Migraines present differently to tension headaches. Symptoms tend to be:

Unilateral
More severe
Throbbing in nature
Take longer to resolve

Migraines are often associated with:

Visual aura
Photophobia and phonophobia
Nausea and vomiting
Abdominal pain

Question 4

Management of migraines in children?

Answer 4

Management of migraines in children:

Rest, fluids and low stimulus environment
Paracetamol
Ibuprofen
Sumatriptan
Antiemetics, such as domperidone (unless contraindicated)

Where the migraines are having a significant impact on life, for example frequent attacks or missing school, prophylactic treatment can be tried to reduce the frequency and severity of the migraines. This is usually guided by a specialist. Options for migraine prophylaxis are:

Propranolol (avoid in asthma)
Pizotifen (often causes drowsiness)
Topiramate (girls with child bearing potential need highly effective contraception as it is very teratogenic).

Children are more likely than adults to suffer with a condition called abdominal migraine. This may occur in young children before they develop traditional migraines as they get older. They present with episodes of central abdominal pain lasting more than 1 hour. Examination will be normal. There may be associated:

Nausea and vomiting
Anorexia
Headache
Pallor

TOM TIP: When a patient presents with possible migraines ask about recurrent central abdominal pain as a child. They may have a history of abdominal migraine that started before the headaches.

Question 5

What should you always check for in a child with a new headache?

Answer 5

Infections can cause headaches in children. In a child with a new headache, always check for symptoms and signs of a viral upper respiratory tract infection, otitis media, sinusitis and tonsillitis. The headache should resolve along with the infection. Paracetamol and ibuprofen can be helpful for symptomatic relief.

Sinusitis causes a headache associated with inflammation in the ethmoidal, maxillary, frontal or sphenoidal sinuses. This usually produces facial pain behind the nose, forehead and eyes. There is often tenderness over the effected sinuses, which helps to establish the diagnosis. Sinusitis usually resolves within 2 – 3 weeks. Most sinusitis is viral.