What do we know about Childhood Headaches?
Headaches are one of the most common types of pediatric pain prompting referral to pediatric neurology clinic. The prevalence of headache ranges from 20% in children younger than 5 years, 37 to 51% in seven-year-old children, gradually increasing to 57–82% by 15 years of age. Before puberty, boys are affected more frequently than girls, but after puberty, headaches occur more frequently in girls. Headache may result in significant disability, including missed school days and extra-curricular activities, suboptimal participation in regular activities, and loss of productivity.
What are different causes of Headaches in Children?
There are various types of childhood headaches but the common ones which are encountered in Pediatric Neurology Clinic include Migraine, Tension Headache, Cluster Headache and Chronic Daily Headache. Let’s briefly go through the common headaches occurring in children.
Migraine headache (without aura) is defined as multiple attacks, at least 4 or 5, of intense headaches with a throbbing sensation, around the forehead, temples, back of the head, which is usually one sided but can be both sides. These headaches (especially in younger patients) can be accompanied by nausea, vomiting, insensitivity to bright lights and sounds, photophobia, and phonophobia and the attacks can last from 1 hour to 72 hours. Children may have associated “Aura” which include commonly visual symptoms e.g seeing zig-zag lines and patterns, rainbow colours, blurred vision, smell, or speech changes etc. which van last from 5 minutes to an hour on occasions followed by a migraine headache. Younger patients also have periodic variants such as abdominal migraines (associated with tummy pains), cyclic vomiting, and vertigo or dizziness.
Why does my child have Migraine?
Migraines seem to be due to a combination of inherited genetic susceptibility (60%–70%) and environmental factors. There are a few genes implicated as Migraine causatives, and these run in the families. Therefore a family history of migraine is important for your doctor. There are also couple of theories: the vasogenic theory and the neurovascular theory, with latter being more “scientific” in the recent past.
How can I treat Migraine?
It is very important that the parents seek advice of a Child Neurologist who will carry out a proper history taking and simple bedside tests which include checking for fundi (back of the eys) before making a diagnosis of Migraine. Neuroimaging e.g. CT or MRI Brain is not needed once a convincing history and normal neurological examination is established.
The author usually recommends 2 prong approach to manage migraine which includes life style modification and medical management.
Many children quickly recognise that they have certain trigger factors causing migraine and they learn to avoid these triggers e.g caffeine containing food products. Apart from this, drinking plenty of water to remain hydrated, a regular sleep schedule, good stress management, attending school, avoiding monosodium glutamate, and regular exercise are very helpful for reducing migraines. Modifying sleep hygiene in children may play a significant role in improving headache symptoms. These life style changes are under-rated but are extremely affective and many a times are enough to stop the migraine attacks. A headache diary is extremely important for your doctor to establish the frequency, intensity etc. of the migraine before embarking on starting medications.
Once an attack starts, acting fast is very important to abort the attack, and sooner the abortive medication is given, the more effective it will be to decrease the intensity of the attack. Triptans (Sumatriptan, Zolmitriptan etc) are commonly used abortive medication which can effectively abort the attacks. Sleep and dark quiet rooms are sought by patients until the episode has passed. If a child is having to use abortive medications regularly, or has two or more Migraine attack per week, then prophylactic medication is recommended. The usual medications used in children include Pizotifen, Beta-Blockers, and anti-epileptics e.g. Topiramate which has shown immense promise in adults and children. These prophylactic medications are given for a few months on a daily basis, following which your Neurologist will slowly taper them off before completely stopping them.
2. TENSION HEADACHE
Tension headaches can occur upto 15% of young people and are usually less painful than migraines. These headaches have a “bandlike” quality and are shorter in duration, bilateral, usually in the temples. They are typically worsE in the afternoon or evening. There may be a muscular component to them, especially in the neck and upper back.
The treatment of Tension headaches is usually conservative, and the purpose is to decrease the stress related event giving rise to headaches. The usual life style changes mentioned above also apply here. The author usually treats these with simple over the counter medications like paracetamol and Ibuprofen with an advice not to overuse these medications as “overuse headaches” is commonly seen with paracetamol abuse.
3. CLUSTER HEADACHE
Cluster headaches are rare in children, but are quite distinctive. Children with cluster headaches have multiple severe headaches (up to 8 per day) in a period of several weeks or months, followed by relatively long headache-free intervals. The pain is usually unilateral, frontal and watering of the eye on the side of headache is common. The pain is so severe that children cannot lie still, bang their head with their fists, or rock back and forth.
The attack must be recognised early and treated with a Triptan (Sumatriptan, Zolmitriptan etc.)
3. CHRONIC DAILY HEADACHE
The term chronic daily headache does not define any particular type of headache, but children usually complain of “dull ache” to high intensity pain on a daily basis. The cause may include overuse of analgesic medications, depression, and poorly treated migraines or tension headaches. More often than not there are underlying psychological issues which may aggravate the headaches.
In Author’s opinion, these are by far the most difficult group of headaches to manage. Therefore a multi-disciplinary approach is important in the management of Chronic Daily headaches. It is important to discontinue overuse of analgesics and stick to various life style modifications mentioned above. Various medications e.g Topiramate, Lamotrigine, Valproate, Amitriptyline have been used with beneficial effects. It is important to involve a Child Psychologist to unpick any underlying psychological factor aggravating the headache. They would suggest various Relaxation techniques which increase a sense of control over body’s physical processes and increase both physical and psychological well-being to counteract pain states. They may also carry out Cognitive Behaviour Therapy (CBT). The usual goals of CBT include gaining a sense of control over pain, reducing fear of pain, enhancing function, increasing feelings of hopefulness and resourcefulness, and improving mood.
In Summary, Headaches in Children are under-diagnosed entities which need careful monitoring and need to be treated by experienced clinicians to avoid long term morbidity and improving the child’s psycho-social well being. A Multi-discipilary approach including Pediatric Neurologist, Pediatrician and Child Psychologists should be undertaken wherever possible.