Headache in Children

Question 1

How common are headaches in boys vs girls?

Answer 1

Equally as common in boys and girls until puberty then there is a 3:1 ratio of girls to boys.

Question 2

When should a headache be referred to neurology?

Answer 2

Headaches of increasing intensity or if aged < 6
Headaches not relieved by paracetamol and ibuprofen
Neuro signs and symptoms
Head circumference greater than 97th centile

Question 3

How is a migraine headache described?

Answer 3

Pulsatile, temporal/frontal with aura

Question 4

How is a tension headache described?

Answer 4

Symmetrical gradual tightness

Question 5

Other than migraine and tension what else can cause headaches?

Answer 5

Vascular malformations
Overuse and withdrawal
Infection e.g. meningitis, encephalitis, abscess and sinusitis, hypercapnia and hypertension.

Question 6

What are the diagnostic criteria for migraine without aura in children?

Answer 6

Migraine is the most common cause of headache in children.

Criteria for Migraine without aura in children

1. =/> 5 migraines fulfilling criteria 2-4
2. Headache lasting 4-72 hours
3. Headache has at least 2 from: bilateral or unliteral frontal or temporal, pulsating quality, moderate to severe intensity and aggravated by routine physical exercise
4. Accompanied by at least 1 of: nausea and/or vomiting, photophobia and phonophobia (inferred from behaviour)

Question 7

What can trigger a migraine?

Answer 7

Diet (chocolate, cheese and citrus) 
Dehydration 
Over-tiredness
Stress
Hormonal changes 
Analgesic overuse 
Caffeine 
Sleep problems 
Bright or flickering lights

Question 8

How should migraines be managed in children?

Answer 8

Paracetamol and ibuprofen as early as possible
Domperidone to treat nausea
If this fails and over 12yrs try sumatriptan (nasal spray) but must be followed up. Poorly tolerated due to poor taste however oral triptans not licensed in under 18s.

Question 9

When is migraine prophylaxis required in children?

Answer 9

Only required when migraines are impeding the life of patient e.g. school or activity.
Avoid triggers and get a good amount of sleep
3 months trial of pizotifen and failing that propranolol
Amitriptyline/Valproate/topiramate are second line

Question 10

What are the diagnostic criteria for tension type headaches?

Answer 10

Second most common cause in children.

Criteria for TTH

1. At least 10 previous headache episodes fulfilling criteria 2-4
2. Headache lasting from 30mins to 7 days
3. Headache has at least two of following characteristics: pressing/tightening (non-pulsating), mild or moderate intensity and doesn’t prohibit activity, bilateral location and no aggravation by routine physical activity.
4. No nausea or vomiting and no or one of photophobia or phonophobia

Question 11

What are the red flag signs and symptoms you should keep an eye out for associated with headaches?

Answer 11

A headache that: is persistent in under 6s, is worse with cough/straining, worse overnight and in morning, changes in nature, causes early morning nausea/vomiting and has a duration > 6 moths.

Neurology: behavioural changes, changes in school performance and seizures
Growth development: regression from targets and centiles and rapid head growth

Uncooperative child, any abnormal neurological signs (ataxia, weakness, squint, tilting head), papilledema, cranial bruit and skin lesions suggesting neuro-cutaneous syndrome.