Headaches are a common complaint in older children and are nearly always due to non-specific viral infection, local infection (e.g. sinusitis) or related to tension. Most pathological and serious headaches due to raised intracranial pressure can usually be differentiated clinically. If a headache is acute and severe, and the child is ill, then serious pathology such as intracranial infection, meningitis, haemorrhage or tumour must be considered. The following are features which should cause concern:

• Acute onset of severe pain
  
• Worse on lying down
  
• Associated vomiting
  
• Developmental regression or personality change
  
• Unilateral pain
  
• Hypertension
  
• Papilloedema
  
• Increasing head circumference
  
• Focal neurological signs.

Migraine

This is a common condition in school-age children and is slightly commoner in boys than girls. It is thought to result from constriction followed by dilatation and pulsation of intracranial arteries. Onset is usually in late childhood or early adolescence. Classically the attack starts with an aura such as ‘zigzag’ vision, followed by a throbbing unilateral headache with nausea and vomiting, although only 20% describe a preceding aura. Sleep usually ends the attack. In younger children the headache may be bilateral with no preceding aura and no vomiting. Parents often describe the child going very pale. Migraines always cause some reduction in the child’s ability to function normally during the attack. There is no diagnostic test and physical examination is normal. The diagnosis is made clinically on the basis of the following.

• Episodic occurrence of headache (rarely every day, but can occur several times a week)
  
• Completely well between attacks
  
• Aura (often visual), though aura is less common in childhood (20%)
  
• Nausea in 90% of cases, sometimes vomiting
  
• Throbbing headache, sometimes unilateral
  
• Positive family history, usually in the mother
  
• Impairment of normal function during an attack
  
• Attack lasts between 1 and 72 hours.

The first line treatment is rest and simple analgesia. Combination therapy containing paracetamol and anti-emetics may be useful. Sleep deprivation and stress can predispose to migraine. Avoiding cheese, chocolate, citrus fruits, nuts and caffeinated drinks may be helpful. Ask the child to keep a migraine diary so you can identify triggers. Very frequent or severe attacks may warrant prophylaxis with beta-blockers or pizotifen. Migraine often persists into adulthood, but spontaneous remission does occur. In adolescents serotonin agonists (e.g. sumitriptan) can be given during an acute attack. Migraine can occasionally cause a post-migraine third nerve palsy or hemiparesis, though more serious cerebrovascular causes must always be excluded if this occurs.

Tension Headache

Tension headaches are common in older school-age children. They may be due to contraction of neck or temporal muscles and are felt as a constricting band-like ache, which is usually worse towards the end of the day but does not interfere with sleep. The cause is often difficult to identify, but a proportion of children will be under some stress, either at home or school. Other family members may suffer similar headaches. Physical examination is normal. Management involves reassurance that there is no serious pathology, rest, sympathy and simple analgesia. Any underlying stress or anxiety in the child’s life should be addressed. School absence should be minimized, and the school may need to be involved in developing a management strategy for when the headaches occur. Tension headaches usually become less frequent or resolve spontaneously as the child gets older.

Cluster Headache

These may occur in older children. There is sudden onset of very severe unilateral periorbital pain. Attacks occur in clusters a few times a day for a period of weeks. The pain is non-pulsatile and can occur at night as well as during the day and is exacerbated by alcohol. There may be unilateral eye redness, orbital swelling or tears. The cause may be due to neurotransmitter activity around the superficial temporal artery. Sumitriptan, a serotonin agonist, can be used acutely and calcium channel blockers (e.g. nifedipine) may help in recurrent attacks.

Raised Intracranial Pressure

Brain tumours, subdural haematomas and abscesses are all rare causes of headache in children. Anxiety about brain tumours is common amongst parents, though these rarely present with headache alone. If a headache is particularly persistent then neuroimaging may be required to put everyone’s mind at rest. If neurological signs (e.g. nerve palsy or weakness) are detected then neuroimaging is mandatory.

Headaches due to raised intracranial pressure are classically worse on lying down and worse in the mornings, and may wake the child from sleep. There may be associated vomiting, often with surprisingly little nausea. Raised intracranial pressure may also cause blurred vision, high blood pressure and focal nerve palsies (e.g. sudden onset of squint). If papilloedema, hypertension, bradycardia or focal signs are present an urgent CT or MRI brain scan is indicated. The majority of brain tumours are in the posterior fossa or brainstem, so the site of the pain is usually non-specific. They will often have cranial nerve palsies or cerebellar signs. See also Chapter 49.

Other Causes of Headache

Headaches are most often a feature of minor non-specific viral infections. These should be treated with simple analgesia such as paracetamol. Dental caries, sinusitis and otitis media are all treatable local infections that can cause headache. If headaches seem particularly related to school it is worth checking the child’s visual acuity and recommend they see an optician. Always consider whether the headaches may be a manifestation of anxiety about school—is the child being bullied, or do the parents have unreasonable expectations?