General Discussion

Headache is common among children and adolescents: 8% to 12% of 3-year-olds have been reported to have headaches, and the prevalence of headaches has been reported to be as high as 60% to 69% by the age of 7 to 9 years and 75% by 15 years of age. Before puberty, boys are affected more frequently than girls, but after the onset of puberty, headaches occur more frequently in girls.

Despite parental concerns, most cases can be established with an accurate history and physical examination. A detailed history and physical examination are usually all that is needed to make an accurate diagnosis. Children with serious underlying conditions usually have historical features or findings on the neurologic examination that suggest a serious cause. Laboratory tests, imaging studies, and electroencephalogram (EEG) are seldom required to make the diagnosis.

A useful clinical classification system for headache in children is to categorize the headache into one of five temporal patterns: acute, acute recurrent, chronic progressive, chronic nonprogressive, and mixed patterns. The potential causes of each pattern of headache are outlined in the following paragraphs.

Acute headache is a single episode of head pain, often without a history of similar previous events. In children this clinical pattern most often is due to a febrile illness related to an upper respiratory tract infection. Migraine headache is another common cause of acute headache.

Acute recurrent headache occurs when there are recurring episodes of head pain separated by symptom-free intervals. Most acute recurrent headaches in children are either migraine or tension-type headaches. The International Headache Society diagnostic criteria for migraine headache are outlined in Table 20-1. The diagnostic criteria for pediatric migraine without aura are outlined in Table 20-2. The diagnostic criteria for episodic tension-type headache are outlined in Tables 20-3 and 20-4.

Table 20-1 International Headache Society Diagnostic Criteria for Migraine with Aura

Table 20-2 2004 International Headache Society Criteria for Pediatric Migraine without Aura

Table 20-3 2004 International Headache Society Diagnostic Criteria for Infrequent Episodic Tension-Type Headache

Table 20-4 2004 International Headache Society Diagnostic Criteria for Frequent Episodic Tension Type Headache

Chronic progressive headaches are headaches that gradually increase in frequency and severity over time. This pattern of headache is the most worrisome and, if accompanied by neurologic symptoms or an abnormal neurologic examination, is indicative of increasing intracranial pressure. Potentially worrisome symptoms are outlined in the Key Historical Features section below. The 1991 Childhood Brain Tumor Consortium study published a report of 3291 children diagnosed with brain tumors. Of these children, 62% had headaches before the diagnosis; 98% of the children with headaches had at least one other associated symptom or abnormal sign present. The most frequent symptoms were nausea or vomiting, visual symptoms, difficulty walking, extremity weakness, and changes in personality, academic performance, or speech. The most frequent abnormal neurologic findings were papilledema, abnormal eye movements, ataxia, abnormal tendon reflexes, and defects in the visual examination.

Chronic nonprogressive headache, also called chronic daily headache, is defined as 15 or more headaches per month for 4 or more months and the headache usually lasts 4 hours or longer. Adolescents may complain of continuous, unremitting headaches. Neurologic examination is normal. These headaches may result from migraine or tension-type headaches transforming over time to a chronic condition. In children, the period of transformation from first migraine to chronic daily headache is, on average, 2 years, which contrasts with 10 years in adults. Another type of chronic daily headache is persistent daily headache, in which there is often a preceding viral infection or trauma followed by a mysterious onset of daily headache. A fourth and rare form of chronic daily headache is hemicrania continua, in which headache occurs for short bursts daily, is responsive to indomethacin, and is always unilateral. Common to all four of these categories of the chronic daily headache pattern is the absence of a positive work-up and the possibility that the condition was exacerbated by medication overuse.

The mixed headache pattern implies migraine attacks or analgesic abuse headaches superimposed on a chronic daily pattern.

The primary headache types are very similar to those encountered in older teens and adults. Tension-type headache and migraine are by far the most common causes of episodic headache. They are almost equally prevalent. Migraine, however, can be quite a diagnostic challenge as it can often present atypically. Recognizing the patterns of pediatric migraine is crucial because many of these headaches are “migrainous” without meeting criteria for migraine. There are numerous secondary headache types, but these are much less common. A small subset represents potentially serious causes, but usually several clues or “red flags” are present. The more sinister causes are rarely subtle to the informed clinician; almost all children with a mass lesion have objective findings.

Medications and Drugs Associated with Headache

Some of the medications listed below are infrequently used in pediatrics but are included for thoroughness:

Accutane

Acyclovir

Adalimumab

Albendazole

Alpha methyldopa

Amphotericin

Amyl nitrate

Analgesics (over-the-counter and prescribed)

Antibiotics

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Gynecomastia
2. Neck masses
3. Lymphadenopathy
4. Transaminase elevation

Stay updated, free articles. Join our Telegram channel

Join