How Common Are Headaches in Children?

Headaches occur from infancy through adolescence, and prevalence increases with age. Headaches may be difficult to diagnose in the preverbal child. The most common causes of acute headache in children include febrile upper respiratory infections, sinusitis, and migraine. Up to 11% of adolescents have migraine headaches. Chronic headaches represent a significant reason for a neurology consultation.

How Are Headaches Classified?

Frequency and time course are used to classify headache patterns, with many different etiologies in each pattern (Table 35-1).

Table 35-1 Headache Patterns and Their Causes

How Do I Evaluate the Patient with Headache?

History should focus on timing, location, character, and quality of pain and should identify exacerbating and relieving factors. A diary of the headaches can be extremely useful in delineating the type(s) and patterns of headache suffered by the patient, as outlined in Table 35-1. The location of the headache can help differentiate one type of headache from another. A sleep history should be obtained (because some children with obstructive sleep apnea complain of headaches). It is sometimes helpful for a patient to draw what the headaches “look like,” especially when he or she is too young to articulate their character (Figure 35-1). Careful general and neurologic examination may identify findings characteristic of specific headache types, including optic disc edema seen with pseudotumor cerebri. The first diagnostic priority should be the consideration of etiologies known to cause sudden morbidity, followed by a reasonable investigation for underlying causes.

Figure 35-1 Depiction of a migraine headache by a 5-year-old girl who suffers from severe migraines.

What Are the Characteristics of Acute Headache?

Acute headaches have a sudden or rapid onset. Fever and constitutional symptoms such as rhinorrhea or myalgias usually accompany headaches associated with viral infections. A patient with meningitis usually appears “toxic” (see Chapter 33) and has physical examination findings that may include meningismus, Kernig’s sign, or Brudzinski’s sign. Sinus tenderness accompanies headache caused by sinusitis. Bleeding from arteriovenous malformations, berry aneurysms, and subdural hemorrhages often present suddenly with severe pain after seemingly minor head trauma. Depending on the history obtained from the patient and others who witnessed the patient’s behavior, workup may include imaging, a lumbar puncture, or other laboratory studies. Hypertension, bradycardia, and irregular respirations (“Cushing’s triad”) in a patient with acute headache signals impending brain herniation and is a medical emergency.

How Are Acute, Recurrent Headaches Evaluated?

Acute, recurrent headaches typically have the characteristic features of migraine or cluster headaches. Migraines are the result of overly excitable neurons, which then affect cranial neurovascular structures. History identifies an intermittent, throbbing headache that is often associated with constitutional symptoms such as nausea, vomiting, photophobia, or phonophobia. Migraines can occur with or without auras, are relieved by rest, and can run in families. Focal neurologic findings are only rarely associated with migraines. There are now specific diagnostic criteria for migraines in children. Some precursors of migraines in children include benign paroxysmal vertigo and abdominal migraine. Migraine variants include hemiplegic migraine and ophthalmoplegic migraine. Headache may also follow toxic ingestions or seizures, and the history and physical examination will allow the diagnosis.

How Should I Evaluate Chronic, Nonprogressive Headache?

Chronic, nonprogressive headaches are identified by careful history and a physical examination that excludes neuropathologic processes. Patients with this headache type typically are in their early teens and many are academic “overachievers.” They describe their headaches as chronic tension-type headaches, usually characterized by frontal pressure that is worse at the end of the day. Pain may be throbbing, but not as intensely as a migraine, and may be associated with nausea or vomiting. A thorough history of the home, school (including the number of days missed because of headaches), substance use, analgesic use, and psychiatric comorbidities should be obtained from the patient and parents. It is wise to discuss the history with the patient and caregivers together and separately. Patients typically report headaches related to school attendance on at least 15 days of the month, with some relief during activities that the patient enjoys, or on weekends. Symptoms can be highly variable, and this headache type often coexists with migraine headaches, so it is important to ask if the patient has more than one type of headache. Most cases are either idiopathic or have psychosocial associations. The differential diagnosis includes caffeine or analgesic withdrawal and carbon monoxide poisoning. The physical examination should be thorough. In the absence of findings that point to a specific diagnosis, a headache diary can be useful to delineate pain frequency, severity, and possible triggers. Imaging is rarely useful. Psychometric testing may be extremely useful because it can identify problems such as anxiety, depression, or learning disabilities