Headaches in Children

BAD signs and symptoms

• Positional headaches
• Focal headache which doesn't shift sides
• Intractable (or increasing intensity -- progression of symptoms -- occur daily)
• Headache wakens child at night
• Fever
• Precipitated by exertion
• Recurrent morning vomiting (with or without nausea)
• History of trauma
• Family history of cerebrovascular disease early in life
• Meningismus (nuchal rigidity)
• Focal neurological signs
• Altered consciousness
• Headache severely exacerbated by coughing or sneezing

Tumors

"While many patients with brain tumors have headaches, very few patients with headaches have brain tumors.  Headaches due to brain tumors commonly are accompanied by other neurological symptoms such as vomiting, diplopia, unsteadiness, weakness, neuroendocrine abnormalities, or personaltiy and behavioral changes.  Findings from neurological examination and funduscopic examination are often abnormal."
• Posterior fossa tumors are more common in children (finger to nose) ~ 80%
• Astrocytoma of cerebellum (eye movements)
• Medulloblastoma (tandem walk)
• Craniopharyngioma (visual fields)
• Giant cell astrocytoma
• Tuberous sclerosis (ash leaf skin lesions)

Hydrocephalus (fundi)

• Post-meningitis
• Post-bleed

Pseudotumor cerebri (benign intracranial hypertension)

• Ask about vitamin A or D, tetracycline
• Early morning headaches
• Cranial nerve VI palsy (loss of abduction of eye)
• Worse when recumbent
• Visual field constriction
• Papilledema (if increased pressure greater than three weeks)
• Diagnosis:  Scan and lumbar puncture
• Treatment: Diamox (acetazolamide), sometimes steroids (dexamethasone), sometimes optic nerve decompression, or glycerol

Migraine

• Neurotransmitter (serotonin) problem then vascular cascade with constriction followed by dilation
• Repeated episodes of headache with at least three of the following: recurrent abdominal pain, nausea or vomiting, an aura, throbbing, pounding pain, pain restricted to one side of the head, relief with sleep, family history of migraines
• 50% of chronic or recurrent headaches
• Differential diagnosis: ocular inflammation, astigmatism, sinusitis, otitis, mastoiditis, dental problems, TMJ problems, vasculitides, CNS abcess, meningitis, seizures (postictal headache), trauma (postconcussion), CNS bleed, depression, HIV, pregnancy
• 30% of children with migraines get a scan; all have something on exam
• Characteristics
• Bifrontal or unilateral
• Nausea and/or vomiting
• Throbbing
• Visual aura (2-30% of cases)
• Photophobia, phonophobia
• Resolution with sleep
• Family history of migraines in 50% of cases
• History of motion sickness
• Lifestyle triggers
• Need to sleep the same amount of time each night
• Foods
• Tyramine (aged cheeses, parmesan, cheddar)
• Nitrates and nitrites (hotdogs, bologna, pizza)
• MSG (dried soups, Chinese foods)
• Yeast
• Chocolate
• Nuts
• Caffeine containing beverages
• Alcohol
• Stress; menses; OCPs; strobe lights; bright sunlight
• Classic migraine: migraine with aura (10% of children with migraine)
• Common migraine: migraine without an aura (80-90%)
• Complicated migraine: stroke-like transient deficits.  Hemiplegic or hemisensory migraines: phenomena persists after headache.
• Basilar migraine: Acute confusional state; vertigo, syncope, numbness.  Dysarthria, most prevalent in adolescent girls
• Cluster headaches:  Unilateral, ipsilateral autonomic changes (tearing, nasal discharge) -- rare in children
• Migraine equivalents
• Benign paroxysmal vertigo (1 to 2 minutes)
• Benign paroxysmal torticolis
• Cyclic vomiting
• Sea sickness
• Abdominal migraine
• Space adaptation syndrome
• Ophthalmoplegic migraine
• abnormal eye movements and diplopia preceed headache
• Evaluation:
• History
• Exam (B/P, head circumference, pharynx, neuro, skin)
• Acute headache: CT (r/o bleed)
• Headache with neurological findings: MRI (do with dye if there is a family history of aneurysm)
• ANA
• Lyme titer
• Treatment:
• Analgesics (ibuprofen, caffenie, aspirin; not acetaminophen)
• Eliminate triggers
• Sleep; dark and silent room
• Imitrex (sumatriptan) -- serotonin agonist
• if greater than 100 pounds, give 50 mg at first sign of headache
• repeat dose in 30 minutes (or im Toradol 30 mg)
• Imitrex nasal spray tastes nasty
• Status migraine
• IV dihydroergotmaine with or without steroids
• Consider prophylaxis if school failure, missing school more than twice monthly, or if headache twice weekly:
• Inderal (propanolol)
• Tricyclic antidepressants
• Periactin
• Zoloft
• Depakote
• Biofeedback; relaxation therapy

Tension Headaches

• Present all day with worsening in the afternoon
• Tight trapezius muscles
• Muscle massage

Other

• Hypertension
• Post-lumber puncture
• Viral syndrome
• Pharyngitis

References

McIntire, SC.  1997.  Recurrent and Chronic Headaches.  Chapter 5, in Common and Chronic Symptoms in Pediatrics, pp.51-62.
 

Acknowledgment