Headache is a frequent symptom in children but deciding whether or not it is due to a serious problem can be a difficult task, even for the most experienced healthcare provider. A detailed history, physical examination, and appropriate tests are essential in determining the correct diagnosis. Fortunately, the large majority of children complaining of headache do not have any serious underlying disease as a basis for their complaints.
When taking a history, which is the most important factor in making an accurate diagnosis, it is necessary to question children and parents together to elicit signs of emotional friction that may provide a clue to reasons for the headache. It is also helpful to talk with the patient without parents present to address any issues the child did not discuss in front of parents. Equally important is a thorough and complete neurological examination to identify any variations from normal.
As in adults, headache in children can be classified into two types: primary or benign (migraine, tension-type) and secondary (due to underlying, organic causes).
Migraine pain is usually throbbing and is almost always accompanied by nausea and vomiting. In children, the headache is often on both sides of the head, instead of just on one side as in adults. The child may appear pale or glassy-eyed and may be irritable before or during the attack. Periodic vomiting without headache is viewed as a migraine variant and may indicate migraine in later years. Children exhibiting car or motion sickness, especially if there is a history of migraine in the family, will often develop migraine later.
Fortunately, the symptoms will disappear in some children with migraine in a period of five to seven years after their appearance. Migraine will occur in about one-quarter of migraine sufferers before the age of five and in about half before the age of 20.
It is important to realize that migraine may occur after head injury, especially after injury sustained in sporting activities such as football, baseball or soccer. The outcome is generally full recovery over varying time periods.
This is the most common type of primary headache in children, and emotional factors are the most likely cause. The pain is described as diffuse, sometimes like a tight band around the head, and is usually not associated with nausea or vomiting.
These headaches are almost always related to stressful situations at school, competition, family friction or excessive demands by parents. Discussion with the child and parents is required to determine whether anxiety or depression may be present.
Infectious illness (viral or bacterial) is the most common cause of headache in children and is self-limited to the course of illness. If a new or sudden onset headache is accompanied by fever, lethargy and stiff neck, meningitis or encephalitis should be suspected. Other symptoms may include nausea, vomiting, muscular incoordination, weakness, seizures, and personality changes.
For new or different headaches, a first priority is to rule out increased pressure in the brain and surrounding tissues, which may be due to tumors, infection or blood clots. It is important to remember that restlessness and irritability may be the only signs of head pain in young children unable to express themselves adequately.
Treatment is individualized depending on the age and weight of the child and the frequency and severity of attacks. Interestingly, many have fewer and less distressing attacks after they are reassured that no serious abnormality exists. Lifestyle changes such as regular sleep and eating habits are mandatory. Make sure the child drinks plenty of fluids, especially when playing in hot weather. Caffeine and sugar intake should be limited. Families should monitor the time spent by the child doing schoolwork, playing and watching TV. In children younger than age 12 years with infrequent attacks, analgesics and antiemetics are useful at the time of the attack. Narcotic analgesics should be avoided. Migraine-specific medications (triptans) have not yet been approved by the FDA for use in children under the age of 18. However, these medications have been studied in children and are safe and effective in certain cases. Healthcare providers and parents must work with the childýs school to ensure that treatment is available and provided at the onset of the headache. If attacks occur more than once a month or are particularly distressing, preventive therapy should be considered. Children should not miss school due to headache. Psychological counseling can be useful to deal with family and school issues. Children are very receptive to biofeedback therapy.