A 15-year-old girl presented to the office with her mother to discuss her migraines. She has episodic unilateral throbbing headaches accompanied by nausea, photophobia, and phonophobia. She also reports a visual prodrome, characterized by a jagged line pattern (Figure 201-1). She used to have a migraine about every 3 months, but is now having one almost every week. She misses a day of school with each migraine. She is not under any unusual stressors. Her mother has migraines and benefitted greatly from taking a prophylactic medication.

More than 50 percent of children report a headache in the past year. Headaches are either primary or secondary and the presence or absence of red flags is useful to distinguish dangerous causes of secondary headaches. The most common primary headaches are tension and migraine headaches. Medication overuse can complicate headache therapy. Treatment and prognosis is dependent on type of headache.

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  Prevalence of headache in children increases during childhood, peaking between ages 11 and 13.

  
  
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  Fifty-three percent of children have had a headache in the past year.¹

  
  
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  Episodic tension-type headache (TTH) prevalence is 15.9 percent in children.¹

  
  
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  Chronic (>15 days per month) TTH has a prevalence of 0.9 percent in children.¹

  
  
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  Migraine has a prevalence of 9.2 percent in children.¹

  
  
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  Chronic daily headache has lifetime prevalence of 4 to 5 percent.²

  
  
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  Cluster headache has a lifetime prevalence of 0.2 to 0.3 percent.¹

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  The most common causes of headaches in children and adolescents are migraine and TTH.³

  
  
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  TTH etiology is uncertain, but likely caused by activation of peripheral afferent neurons in head and neck muscles.⁴

  
  
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  Migraine headache is thought to be caused by central sensory processing dysfunction, which is genetically influenced.⁵ Nociceptive input from the meningeal vessels is abnormally modulated in the dorsal raphe nucleus, locus coeruleus, and nucleus raphe magnus. This activation can be seen on positron emission tomography (PET) scan during an acute attack.

  
  
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  Cluster headache is caused by trigeminal activation with hypothalamic involvement, but the inciting mechanism is unknown.⁶

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  For migraines—Family history reported in over 60 percent.

A headache diary is helpful for diagnosis and follow-up.

Clinical Features

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  Red flags for dangerous secondary cause:³

  
  
  
  
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    Worst headache of life.

    
    
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    Recent onset of headache.

    
    
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    Increase in severity or frequency of headache.

    
    
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    Headache occurring only in the morning with severe vomiting.

    
    
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    Headache worsened with Valsalva.

    
    
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    Presence of focal neurological signs, seizures, or papilledema (Figures 201-2 to 201-4).

    
    
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    Headache located in the occipital region.

  
  
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  Episodic TTH—At least 10 episodes of bilateral, mild to moderate, pressure (nonpulsating) type pain without nausea or vomiting, not aggravated by exertion, and rare photophobia or phonophobia, occurring less than 15 days per month.⁷

  
  
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  Migraine headache—At least 5 episodes of unilateral, pulsating, moderate-to-severe headache, often with visual prodrome or visual field defects, lasting 1³ to 72 hours, aggravated by physical activity, accompanied by nausea or emesis or photophobia and phonophobia.⁷ Children may also have a bilateral headache, and symptoms of lightheadedness, difficulty thinking, or fatigue.³

  
  
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  Chronic daily headache (CDH)—A primary headache 15 or more days per month, for 4 or more hours per day, for 3 months.² Four types of CDH:

  
  
  
  
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    Chronic migraine—Episodic migraines increase in frequency while associated symptoms decrease; resembles tension headache with occasional typical migraine; often accompanied by medication overuse.²

    
    
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    Chronic TTH—Bilateral, nonpulsating, without nausea. Photophobia or phonophobia can be present.²

    
    
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    New daily persistent headache—Abrupt onset of daily headache in patient without a history of a headache disorder; patient often remembers exactly where and when the headaches started.²

    
    
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    Hemicrania continua—Chronic unilateral pain with exacerbations, often associated with ipsilateral autonomic features.²

  
  
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  Medication overuse headache—Accompanies one of the CDHs; acute medications, such as triptans or opiates are taken more than 10 days a month, or analgesics more than 15 days a month, for more than 3 months.⁷

  
  
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  Cluster headache—The most common type of trigeminal autonomic cephalgias; can be episodic or chronic; sharp stabbing unilateral pain in trigeminal distribution, lasting 15 minutes to 3 hours, with ipsilateral autonomic features.² Typically occurs in children over age 10 years, but has been reported in younger children.³

  
  
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  Sinus headache—Purulent nasal discharge, co-onset of sinusitis, headache localized to facial and cranial areas.