INTRODUCTION

Headache (commonly defined as pain located above the orbitomeatal line) is one of the most common complaints in children and adolescents. It is recognized as one of the top medical and neurologic contributors to the global burden of disease and is a leading cause of disability in adolescents and young adults (age 10 to 24 years).

The prevalence of headache increases with age. Children who complain of headache usually are brought to medical attention by their caregivers due to missing school or social activity or concerns of an ominous etiology such as a brain tumor or other serious disease. The first steps in evaluation are a thorough history, physical, and neurologic examination. If these are abnormal or suspicious for a secondary etiology, then additional diagnostic testing is performed.

 

EPIDEMIOLOGY

Headaches are common in children and adolescents. nearly 60 percent of children reported having had headaches over periods of time (ranging from one month to “lifetime”). By age 18 years, more than 90 percent of adolescents report having had a headache.

Recurrent severe headaches also are common in children. Approximately 20 percent of children aged 4 to 18 years report having had notable recurrent headaches (including migraine) in the past 12 months. The prevalence of recurrent headaches increases with age from 4.5 percent among children 4 to <6 years to 27.4 percent among children 16 to 18 years. In a population-based study, 1.5 percent of middle school students (age 12 to 14 years) had “chronic daily headache” (15 headache days per month with chronic migraine and chronic tension-type headaches making up the majority, and chronic migraine most frequently presenting for evaluation).

Before 12 years of age, the prevalence of headaches is similar among males and females (approximately 10 percent). After age 12 years, the prevalence is higher in females (approximately 28 to 36 percent versus 20 percent). Headaches occur more often in children who have a family history of headaches in first- or second-degree relatives.

 

ETIOLOGY

Childhood headaches are rarely caused by a serious underlying disorder. The most common headache etiologies vary depending upon the setting in which the child is evaluated.

Most children who present to pediatric emergency departments with acute headache have a viral illness or an upper respiratory infection as the symptomatic etiology of their headache. However, more serious conditions occasionally are diagnosed, and primary headaches, especially status migrainosus, also present to the emergency department. As many as 90 percent of adults who have been diagnosed (self-diagnosed or diagnosed by a clinician) with recurrent sinus headaches actually have migraine headaches.

In the primary care setting, primary headaches and infectious etiologies are most common.

 

Characteristics of common headache syndromes in children and adolescents

Symptom	Migraine	Tension-type headache	Trigeminal autonomic cephalalgia (eg, cluster headache)
Location	Commonly bilateral in young children; in adolescents and young adults, unilateral in 60 to 70% and bifrontal or global in 30%	Bilateral	Always unilateral, usually begins around the eye or temple
Characteristics	Gradual in onset, crescendo pattern; pulsating; moderate or severe intensity; aggravated by routine physical activity	Pressure or tightness that waxes and wanes	Pain begins quickly, reaches a crescendo within minutes; pain is deep, continuous, excruciating, and explosive in quality
Patient appearance	Patient prefers to rest in a dark, quiet room	Patient may remain active or may need to rest	Patient remains active
Duration	2 to 72 hours	Variable	30 minutes to 3 hours
Associated symptoms	Nausea, vomiting, photophobia*, phonophobia*; may have aura (usually visual, but can involve other senses or cause speech or motor deficits)	None	Ipsilateral lacrimation and redness of the eye; stuffy nose; rhinorrhea; pallor; sweating; Horner syndrome; focal neurologic symptoms rare; sensitivity to alcohol

* May be inferred from the behavior of young children.

 

 

CLASSIFICATION

Headaches can be classified as primary (those in which the head pain is due to the headache condition itself) and secondary (those in which the head pain is a symptom of an underlying condition).

 

 

Primary headache — The most common primary headaches in children are migraine and tension-type headache. Trigeminal autonomic cephalalgias (including cluster headaches) are rare in children younger than 10 years and uncommon in older patients.

 

 

Migraine — Migraine is a disease characterized by intermittent attacks of headache. Recognition that migraine is a disease in which headache is just one of the symptoms is important. (A person does not have a “migraine,” but rather has a headache due to migraine.) An attack of migraine is characterized by recurrent episodes of head pain that are typically moderate to severe in intensity, lasting 2 to 72 hours if not treated, characterized by focal pain that is throbbing and worsens with activity or causes avoidance of activity. It can be accompanied by nausea, vomiting, light sensitivity (“photophobia”), and sound sensitivity (“phonophobia”). In children, particularly young children, the duration of headache is typically shorter than in adults, lengthening with age. Migraines in children are most often bilateral (bifrontal or bitemporal). Headaches that are occipital in location have an increased risk of a secondary cause (although migraine remains the most common cause of occipital headaches) and need to be investigated further.

Approximately 10 percent of children with migraine have associated auras that include visual, sensory, speech/language, motor, brainstem, or retinal symptoms (eg, scotoma), paresthesias, dysphasia, hemiplegia, weakness, ataxia, or confusion.

Chronic migraine is the most common chronic headache condition in children and adolescents. It is defined as headaches on 15 or more days per month, with at least eight having migraine features.

Avoidance of medication overuse is an important step in the prevention of chronic migraine. Medication overuse has been reported in 20 to 36 percent of adolescents with chronic headache and is an independent predictor of chronic migraine persistence. Discussion of medication overuse is one of the key outcome metrics recommended by the American Academy of Neurology. Major depression is another independent predictor of highly frequent headaches.

Episodic symptoms associated with migraine (formerly childhood periodic syndromes or migraine “variants”) have been reported to include benign paroxysmal vertigo, cyclic vomiting, abdominal migraine, and colic. Benign torticollis (recurrent, often short-lived, and spontaneously recovering attacks of head tilt in infants) also has been proposed as a variant of migraine.

 

Tension-type headaches — Tension-type headaches (TTH) are characterized by headaches that are diffuse in location, non-throbbing, mild to moderate severity, and do not worsen with activity (although the child may not wish to participate in activity). They can last from 30 minutes to 7 days. TTH may be associated with photophobia or phonophobia (but not both) but is not accompanied by nausea, vomiting, or aura.

Although TTH may share clinical features with migraine, migraine diagnosis takes priority over the diagnosis of TTH, so when in doubt between the two, the diagnosis of migraine, rather than “mixed headache disorder,” should be made.

 

 

 

 

Cluster headaches — Cluster headaches constitute the most common trigeminal autonomic cephalalgia. This group of headaches is characterized by trigeminal location and association with autonomic features. Cluster headaches are typically unilateral and frontal-periorbital in location. The pain of cluster headaches is severe and lasts less than three hours, but multiple headaches occur in a very short period of time (hence “cluster”). Cluster headaches usually are associated with ipsilateral autonomic findings, including lacrimation, conjunctival injection, nasal congestion and/or rhinorrhea, facial and forehead sweating, eyelid edema, and miosis and/or ptosis.

Cluster headaches have been reported in children as young as three years of age, but they are rare in children younger than 10 years and uncommon in older patients. They become more apparent between the ages of 10 and 20 years, although they remain infrequent.

Secondary headache — Secondary headaches are caused by an underlying condition. They usually develop in close temporal relationship to the underlying condition and usually successfully resolve with adequate treatment of the condition. Secondary headaches include exacerbation of primary headaches by an underlying condition.

Conditions that may cause secondary headache in children include [29]:

• Acute febrile illness (eg, influenza, upper respiratory infection, sinusitis). Such infections are the most common cause of secondary headache in children. However, recurrent rhinosinusitis is one of the most common misdiagnoses for headaches, with the majority actually being a primary headache and usually migraine.
• Posttraumatic headaches; acute posttraumatic headaches usually resolve within seven to ten days
• Medications (given the frequency of headache as a complaint, “headache” is listed on nearly every medication as a potential side effect)
• Medication overuse headache; frequent overuse of analgesic medication is one of the most common causes of secondary chronic headache
• Acute and severe systemic hypertension (may cause headache or be a response to increased intracranial pressure)
• Acute or chronic meningitis
• Brain tumor
• Idiopathic intracranial hypertension (pseudotumor cerebri)
• Hydrocephalus
• Intracranial hemorrhage (typically presents as sudden severe unilateral headache)

N.b. Headache attributed to visual refractive error is included as a type of secondary headache. However, in contrast to the secondary causes of headache listed above, definitive evidence that visual refractive errors cause headaches in children is lacking

 

 

CLINICAL PRESENTATION

Young children may express pain differently than older children and adolescents and often are able to attenuate or ignore pain through play. Headache pain may not be apparent to caregivers of younger children, who react by crying, rocking, or hiding, or altered activity level. Chronic pain may be associated with anxiety, depression, and behavior problems and affect the child’s ability to eat, sleep, or play. Older children are better able to perceive, localize, and remember pain. Emotional, behavioral, and personality factors become more important as the child enters adolescence.

 

EVALUATION

The evaluation of headache in children includes a thorough history, physical examination, and neurologic examination with particular attention to the clinical features suggestive of intracranial infection or space-occupying lesion. If the initial evaluation is suspicious for secondary headache, additional diagnostic testing is necessary. The neurologic examination is the most sensitive indicator of needing further evaluation, including neuroimaging. The headache pattern may help to suggest the etiology.

 

Headache history — The headache history provides most of the necessary diagnostic information in the evaluation of childhood headaches . A thorough history helps to focus the physical examination and prevent unnecessary investigation and neuroimaging.

The history of headache for a child should initially be obtained from the child and confirmed by the caregivers. In young children, caregiver observation of behavior can support the diagnostic criteria. Asking young children to “draw the headache” may assist in the diagnosis when the child is not able to express the headache characteristics in words. Children, adolescents, and young adults may be prone to the childhood periodic syndromes/episodic syndromes associated with headache. This includes motion sickness, sleepwalking, sleep talking, night terrors, unexplained fevers, recurrent abdominal pain, and episodes of anxiety. Motion sickness precipitated by reading in a car is a common feature in migraine sufferers.

A diary in which the quality, location, severity, timing, precipitating and palliating factors, and associated features of the headache are recorded prospectively may be a useful adjunct if the child is willing and able to complete on a daily basis. A diary is not subject to recall error, may reveal a pattern that is typical for a certain type of headache, and provides important diagnostic information for children who are unwilling or unable to provide sufficient detail during the office interview.

 

Headache pattern — Determining if a headache is new or represents a recurrent problem is useful in differentiating primary from secondary headaches. Most primary headaches are episodic headaches that may transform to more frequent headaches (chronification). Asking about all headaches, not just the one that is being brought to attention, can help identify this pattern. An acute change in an underlying recurrent, episodic headache disorder is a potentially concerning pattern.

Important components of the headache history for children and adolescents

Historical feature	Possible significance
Headache history
Age at onset	Migraines frequently begin in the first decade of life. Chronic nonprogressive headaches begin in adolescence.
Mode of onset	Abrupt onset of severe headache (“thunderclap headache” or “worst headache of my life”) may indicate intracranial hemorrhage.
What is the headache pattern: acute, acute recurrent, chronic progressive, nonprogressive daily, or mixed?	Helps to determine the cause
How often does the headache occur?	Migraines typically occur 2 to 4 times per month; almost never daily. Chronic nonprogressive headaches may occur 5 to 7 days per week. Cluster headaches typically occur 2 to 3 times per day for several months.
How long does the headache last?	Migraines typically last 2 to 3 hours in young children and may last longer (48 to 72 hours) in adolescents. The duration of tension headaches is variable; they may last all day. Cluster headaches usually last 5 to 15 minutes but may last for 60 minutes.
Is there an aura or prodrome?	Aura or prodrome is suggestive of migraine; if the warning symptoms are focal and repeatedly located to the same side of the body, a seizure or vascular or structural cause should be suspected.
When do the headaches occur?	Headaches that wake the child from sleep or occur on waking may indicate increased intracranial pressure/space-occupying lesion. Tension-type headaches typically occur late in the day.
What is the headache quality (throbbing/pulsating, dull aching, squeezing, etc)?	Migraines have a throbbing/pulsating quality. Chronic nonprogressive headaches have a squeezing pressure or tightness that waxes and wanes. Cluster headaches have a deep continuous pain.
Where is the pain?	Occipital location may indicate posterior fossa neoplasms but also may occur in basilar migraine. Cluster headaches are usually temporal or retro-orbital. Localized pain may suggest a specific secondary etiology (eg, sinusitis, otitis, dental abscess).
What brings the headache on or makes it worse?	Headache in the recumbent position or with straining/Valsalva may indicate an intracranial process. Migraines may be triggered by certain foods, odors, bright lights, noise, lack of sleep, menses (in females), and strenuous activity. Tension-type headaches may worsen with stress, bright lights, noise, strenuous activity. Cluster headaches may be worsened with lying down or resting.
What makes the headache go away?	Migraines typically respond to analgesic medications, dark, quiet room, cool compress, or sleep. Chronic tension-type headaches may respond to sleep (but not to analgesic medications).
Are there associated symptoms?	Neurologic deficits (eg, ataxia, altered mental status, binocular horizontal diplopia) may indicate increased intracranial pressure and/or a space-occupying lesion. Fever may indicate infection, or rarely intracranial hemorrhage. Stiff neck may indicate meningitis, complicated pharyngitis, or intracranial hemorrhage. Localized pain may indicate localized infection (eg, otitis media, pharyngitis, sinusitis, dental abscess). Autonomic symptoms (eg, nausea, vomiting, pallor, chills, fever, dizziness, syncope, etc) may indicate migraine or cluster headache. Dizziness, numbness, and/or weakness may occur with idiopathic intracranial hypertension.
Do symptoms continue between headaches?	Persistence of symptoms (neurologic symptoms or nausea/vomiting) between headache episodes is suggestive of increased intracranial pressure and/or mass lesions. Resolution of symptoms between episodes is characteristic of migraine headaches.
Headache burden
Do the headaches impair normal functioning (eg, school attendance, activity) and quality of life?	Children with chronic nonprogressive headaches have frequent school absences; impaired function may warrant referral.
Additional information
Past medical history	Certain underlying conditions increase the likelihood of intracranial pathology (eg, sickle cell disease, immune deficiency, malignancy or history of malignancy, coagulopathy, cardiac disease with right-to-left intracardiac shunt, head trauma, neurofibromatosis type 1, tuberous sclerosis complex).
Medications and vitamins	Medications that may cause headache include oral contraceptives, glucocorticoids, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors, among others. Medications associated with idiopathic intracranial hypertension include growth hormone, tetracyclines, vitamin A (in excessive doses), and withdrawal of glucocorticoids.
Recent change in weight or vision	May be associated with intracranial process (eg, pituitary tumor, craniopharyngioma, idiopathic intracranial hypertension).
Recent changes in sleep, exercise, or diet	May precipitate headaches; may be associated with mood disorder.
Change in school or home environment	May be a source of psychosocial stress.
Family history of headache or neurologic disorder	Migraine and some tumors and vascular malformations are heritable.
What do child and parents think is causing the pain?	Indicates their levels of anxiety about the headache.
Mental health history/symptoms, psychosocial stressors	Chronic nonprogressive headaches may be associated with depression or anxiety.

 

 

 

 

 

Physical examination — Important aspects of the physical examination in a child with headache are described in the table.

The physical examination, including the funduscopic examination, is usually normal in children with primary headaches (eg, migraine, tension-type headache).

Although the physical examination is also typically normal in secondary headaches, when the physical or especially the neurologic examination is abnormal, secondary headaches must be considered and the examination findings may provide clues to the underlying diagnosis (eg, fever and nuchal rigidity in a child with meningitis). Abnormal funduscopic examination requires additional evaluation, as indicated by the findings from the history and physical examination. In most cases of brain tumor-induced headache, some aspect of the neurologic examination is abnormal.

 

Examination feature	Possible significance
General appearance	Altered mental status may indicate meningitis, encephalitis, intracranial hemorrhage, elevated intracranial pressure, hypertensive encephalopathy.
Vital signs	Hypertension may cause headache or be a response to increased intracranial pressure. Fever suggests infection (most commonly upper respiratory infection) but may occur with intracranial hemorrhage or central nervous system malignancy
Head circumference	Macrocephaly may indicate slowly progressive increases in intracranial pressure.
Height and weight	If abnormal may indicate intracranial pathology.
Auscultation of the neck, eyes, and head for bruit	Bruit may indicate arteriovenous malformation.
Palpation of the head and neck	Localized scalp tenderness may occur in migraine and tension-type headaches Scalp swelling may indicate head trauma Sinus tenderness may indicate sinusitis Temporomandibular joint (TMJ) and/or masseter tenderness suggests TMJ dysfunction Nuchal rigidity may indicate meningitis Posterior neck pain may indicate an anatomic abnormality (eg, Chiari malformation) Thyromegaly may indicate thyroid dysfunction
Visual fields	Visual field abnormalities may indicate increased intracranial pressure and/or a space-occupying lesion.
Funduscopy	Papilledema may indicate increased intracranial pressure Funduscopic examination is normal in primary headache
Otoscopy	May demonstrate otitis media; hemotympanum may indicate trauma.
Oropharynx	Signs of pharyngitis? Dental decay or abscess?
Neurologic examination	Abnormal neurologic examination (particularly mental status, eye movements, papilledema, asymmetry, coordination disturbance, abnormal deep tendon reflexes) may indicate intracranial pathology but also may occur with migraine headache.
Skin examination	Signs of neurocutaneous disorders (eg, neurofibromatosis, tuberous sclerosis complex, which are associated with intracranial neoplasms) or trauma (bruises, abrasions, etc).
Spine	Signs of occult spinal dysraphism (eg, midline vascular of pigment changes), which may be associated with structural abnormalities (eg, Chiari malformation).

 

 

Worrisome findings — Predictors for intracranial pathology (ie, space-occupying lesion or central nervous system infection) have been identified in small observational studies (table 5) . It is particularly important to ask about and look for these symptoms and signs of increased intracranial pressure, intracranial infection, and progressive neurologic disease. Worrisome findings are an indication for further evaluation and/or neuroimaging.

 

Headache characteristics

Headache awakens the child or occurs consistently upon awakening from sleep

Short or paroxysmal headache; thunderclap headache (uncommon in children)

Associated neurologic signs and symptoms (eg, persistent nausea/vomiting, altered mental status, ataxia, etc)

Headache worsened in recumbent position or by cough, micturition, defecation, or physical activity

Absence of aura

Chronic progressive headache pattern

Change in quality, severity, frequency, or pattern of headache

Occipital headache

Recurrent localized headache

Lack of response to medical therapy

Headache duration of less than six months

Patient history

Inadequate history (description of headache and relative features)

Risk factor for intracranial pathology (eg, sickle cell disease, immune deficiency, malignancy or history of malignancy, coagulopathy, cardiac disease with right-to-left intracardiac shunt, head trauma, neurofibromatosis type 1, tuberous sclerosis complex, pre-existing hydrocephalus or shunt)

Age <6 years

Personality change

Deterioration of school work

Associated symptoms in the neck or back

Family history

Absence of family history of migraine

Examination findings

Child uncooperative (unable to complete neurologic examination)

Abnormal neurologic examination (eg, ataxia, weakness, diplopia, abnormal eye movements, other focal signs)

Papilledema or retinal hemorrhages

Growth abnormalities (increased head circumference, short stature or deceleration of linear growth, abnormal pubertal progression, obesity)

Nuchal rigidity

Signs of trauma

Cranial bruits

Skin lesions that suggest a neurocutaneous syndrome (neurofibromatosis, tuberosis sclerosis complex)

 

Neuroimaging — Neuroimaging studies may detect a variety of disorders that cause secondary headache, including congenital malformations, hydrocephalus, intracranial infections and their sequelae, trauma and its sequelae, neoplasms, vascular disorders (such as arteriovenous malformations), and intracranial thrombosis. However, most children who present to primary care have signs and symptoms consistent with primary or uncharacterized headaches and do not require neuroimaging.

 

Indications — Decisions regarding neuroimaging in children with headaches should be made on a case-by-case basis.

• Children with an abnormal neurologic examination
• children younger than six years
• children who have features worrisome for a pathologic intracranial process severe headache in a child with an underlying disease that predisposes to intracranial pathology (eg, immune deficiency, sickle cell disease, neurofibromatosis, history of neoplasm, coagulopathy, hypertension).
• occipital headaches
• acute head trauma
• suspected infection (eg, sinusitis, meningitis, encephalitis),

Neuroimaging of children with headaches in the absence of neurologic abnormalities on examination and/or symptoms of neurologic abnormalities on history has a low yield of clinically significant findings (0.9 to 1.2 percent). Neuroimaging of such children may detect incidental findings that require additional evaluation or follow-up. Other potential adverse effects of neuroimaging include radiation exposure, exposure to anesthesia if sedation is required, and false reassurance from an inadequate study.

Neuroimaging generally is not indicated for children with a history of recurrent, episodic headaches that have persisted for greater than six months and who have no signs or symptoms of neurologic dysfunction or increased intracranial pressure. Neuroimaging also is usually not indicated for children with migraine who lack neurologic abnormalities. However, it may be difficult to differentiate early migraine episodes from headache secondary to a space-occupying lesion because the criteria for migraine will not have been met, as five headache episodes are required.

 

 

Timing — The level of urgency is determined by the status of the patient and the speed with which the situation is evolving. Urgent neuroimaging is reserved for patients with signs of increased intracranial pressure and/or focal neurologic examination with concern for a space-occupying lesion (eg, brain tumor or brain abscess) or intracranial hemorrhage.

 

 

Which imaging study? — Brain MRI is usually preferred. Head computed tomography (CT) is performed if MRI is not available or imaging is needed immediately (eg, suspected acute hemorrhage, rapid diagnosis of space-occupying lesion). MRI with gadolinium or CT with contrast should be performed if the clinician suspects an inflammatory cause or breakdown of the blood-brain barrier (eg, abscess or tumor).

MRI is usually preferred in nonacute situations (or if there is persistent concern despite a normal head CT scan) because it minimizes radiation exposure and is more sensitive than CT. MRI demonstrates sellar lesions, craniocervical junction lesions, posterior fossa lesions, white matter abnormalities, and congenital anomalies more reliably than does CT. However, in young children, MRI may require sedation, which CT usually does not.

MR angiography or CT angiography may be indicated if subarachnoid blood or parenchymal blood is identified on initial MRI, CT, or lumbar puncture.

 

Laboratory evaluation — Laboratory testing rarely is helpful in the evaluation of childhood headache and is predominantly used to differentiate causes of secondary headache. the evidence is insufficient to support any recommendation regarding the value of routine laboratory studies or lumbar puncture in the evaluation of recurrent headache in children.

 

 

Lumbar puncture — Lumbar puncture (LP) generally should be performed in children in whom intracranial infection, subarachnoid hemorrhage, or idiopathic intracranial hypertension (pseudotumor cerebri) is suspected. Neuroimaging typically is performed before LP because LP is contraindicated in patients with space-occupying lesions. However, in patients in whom bacterial meningitis is suspected, the risks of delaying the LP and administration of antibiotics while awaiting neuroimaging must be considered.

Patients in whom idiopathic intracranial hypertension is suspected may require reassurance or sedation before undergoing the lumbar puncture because an accurate opening pressure measurement is crucial to the diagnosis. Inadequate technique (eg, Valsalva, straining, crying) can cause artifactually high opening pressure measurements.

 

 

 

 

 

 

Other tests — Other tests should be performed as indicated to evaluate suspected underlying medical conditions. These tests should be tailored to evaluate conditions suggested by information from the history and examination. Examples include:

• Complete blood count with differential and erythrocyte sedimentation rate (if infection, anemia, vasculitis, or malignancy is suspected)
• Serum or urine toxicology screens (if acute or chronic intoxication is suspected)
• Thyroid function tests (if thyroid dysfunction is suspected)

 

 

Electroencephalography — Electroencephalography is not recommended in the routine evaluation of a child with recurrent headaches and typically has no role to play. It is unlikely to be useful in determining the cause of headache or in distinguishing migraine from other types of headache.

DIAGNOSIS

The diagnosis of primary headache disorders is made clinically, based upon the International Classification of Headache Disorders, 3^rd edition:

• Migraine
• Tension-type headache
• Trigeminal autonomic cephalalgias, including cluster headaches

The diagnosis of a chronic headache is also made clinically in children with headache on more than 15 days a month for more than three months in the absence of detectable organic pathology

The diagnosis of secondary headaches depends upon identification of the underlying condition.

MANAGEMENT

The management of recurrent and chronic headache in children and adolescents depends upon the underlying etiology.

Some management components of recurrent headache disorders include:

• Providing realistic expectations (ie, the frequency and severity of the headaches may decrease over weeks to months of therapy, but the headaches may continue to occur)
• Return to school for children who have been absent; if necessary, they can go to the school nurse or office once daily for 15 minutes when headache pain peaks
• Avoidance of headache triggers (eg, dietary triggers, caffeine, lack of sleep, inadequate hydration, overuse of electronic devices)
• Daily exercise for 20 to 30 minutes
• Addressing comorbid sleep problems (eg, delayed sleep onset, frequent night waking), mood problems, and/or anxiety

Additional nonpharmacologic approaches may be beneficial. Cognitive behavioral therapy and biofeedback-assisted relaxation therapy including guided imagery, progressive muscle relaxation, and deep breathing have some evidence of benefit, while other treatments, including physical therapy, acupuncture, hypnosis, meditation, and massage, may be helpful but are unproven.

Details of treatment of different types of headache into our concern in this topic

INDICATIONS FOR REFERRAL

Primary care providers can usually manage children and adolescents with acute, recurrent, episodic, and chronic headaches. Indications for referral include:

• Secondary headache requiring specialist management (eg, space-occupying lesions, idiopathic intracranial hypertension)
• Headaches associated with mood disturbance or anxiety
• Uncertain diagnosis
• Headaches refractory to primary care management
• Very frequent headaches unresponsive to typical therapy (ie, chronic migraine or chronic tension-type headaches)
• The need for more intensive management that can only be provided by a multidisciplinary headache program

OUTCOME

Headache that begins in childhood often changes in its characteristics with time and may remit or improve. Remission occurred in 44 percent of children with tension headache and in 28 percent of children with migraine.

 

 

Diagnostic approach to nontraumatic headache in the healthy child with a normal neurologic examination and no signs of increased ICP

This algorithm provides likely causes of headache in previously healthy children based upon a combination of history and physical examination findings. Further testing may be warranted to confirm the leading diagnosis.

* Rarely, visual refractive errors (anisometropia, myopia, and hyperopia) can cause chronic fronto-orbital headaches that progress throughout the day in children. Optical correction results in resolution in most causes. However, visual refractive errors remain a diagnosis of exclusion for chronic headaches in children; more urgent evaluation of signs or symptoms suggesting increased ICP should not be delayed while waiting for an ophthalmologic consultation.

 

 

SUMMARY

• Epidemiology– Approximately 20 percent of children aged 4 to 18 years have had frequent or severe headaches in the past 12 months.
• Etiology– Headache in children and adolescents may be due to a primary headache disorder (ie, migraine, tension-type headache, trigeminal autonomic cephalalgias) or secondary to an underlying medical condition.

Secondary headaches usually are related to fever or infection (eg, upper respiratory infection, influenza) but may be due to central nervous system infection or space-occupying lesion.

• Evaluation
• The evaluation of headache in children includes a thorough history, physical examination, and neurologic examination, with particular emphasis on clinical features suggestive of intracranial pathology. The headache pattern helps to determine the etiology.
• Neuroimaging should be performed in children with headache and neurologic signs or symptoms suggestive of intracranial pathology. Brain MRI is usually preferred. Head CT is performed if MRI is not available or imaging is needed immediately (eg, suspected acute hemorrhage, rapid diagnosis of space-occupying lesion). MRI with gadolinium or CT with contrast should be performed if the clinician suspects an inflammatory cause or breakdown of the blood-brain barrier (eg, abscess, tumor).
• Routine laboratory evaluation usually is not necessary for children with recurrent or chronic headaches. The laboratory evaluation for secondary headache should be tailored to evaluate conditions suggested by information from the history and examination.
• Diagnosis– The diagnosis of primary headache disorders is made clinically, based upon the criteria of the International Classification of Headache Disorders. The diagnosis of chronic headache also is made clinically (headache on >15 days per month for >3 months in the absence of detectable organic pathology). The diagnosis of secondary headaches depends upon identification of the underlying condition.
• Management– The treatment of recurrent and chronic headaches requires a systematic approach over several months through which the child returns to normal activities of daily living. It is critical to address excessive school absence and overuse of over-the-counter analgesic medications.