I. Description of the problem.
A. Epidemiology.
Headaches represent the most common recurrent pain pattern in childhood and adolescence.
40% of children and 70% of adolescents have experienced a headache at some time.
Chronic recurrent headaches occur in 15% of children and adolescents. Chronic daily headache occurs in 2% of middle school-aged girls and 0.8% of middle school-aged boys; in high school, it occurs in 4% and 2%, respectively.
B. Etiology. Children experience headaches from many causes, but only a few pathologic mechanisms induce head pain:
Inflammation, traction, and direct pressure on intracranial structures.
Vasodilation of cerebral vessels.
Sustained contractions, trauma, or inflammation of scalp and neck muscles.
Sinus, dental, and orbital pathologic processes.
The brain parenchyma, most of the dura and meningeal surfaces, and the ependymal lining of the ventricles are insensitive to pain. Central nervous system causes of headache result from stretching or inflammation of a limited number of pain-sensitive intracranial structures.
II. Making the diagnosis. Most headaches are brief and do not significantly alter a child’s life. Recurrent headaches may be accompanied by fears and anxieties about brain tumors and other life-threatening diseases. The diagnostic challenge for the primary care clinician is multifaceted:
To differentiate benign, self-limited headaches from those that suggest a serious organic disease.
To explore the potential relationship between headaches and a child’s home, school, and social environment.
To recognize patients with headaches secondary to internal stressors (depression, anxiety, phobias) and those with environmental causes.
To develop a therapeutic plan consistent with the cause, severity, and significance of the headaches for the child and family.
A. Differential diagnosis. A useful clinical model to differentiate the large variety of headaches in children and adolescents focuses on four categories: (1) tension headaches, (2) migraine headaches, (3) extracranial headaches, and (4) intracranial headaches (Table 49-1). Tension-related and migraine headaches occur most frequently. An alternative model of headaches in children deemphasizes the migraine-tension dichotomy and places greater emphasis on a headache continuum. Migraine with associated anatomic nervous system symptoms is at one end of the continuum and muscular tension headache at the other end. Symptoms and signs of both tension and migraine headaches in children are often nonspecific compared with the less common causes. Headaches in younger children, especially infants and toddlers, are more likely to have a specific organic cause. A focused clinical interview, coupled with age-appropriate behavioral observations and a comprehensive physical examination, will result in the probable diagnosis at the initial office visit for most patients.
B. History: key clinical questions. Whenever possible, questions should be directed to the patient, inquiring of the parent only after the child or adolescent has had an opportunity to describe the headache to the clinician. Most recurrent forms of pediatric headaches are associated with a behavioral diagnosis (in the presence or absence of migraine). The clinical interview should develop in a manner that raises questions simultaneously about both organic and behavioral causes. An open-ended question (“Tell me about your headaches.”) will allow the child and parent to explore what seems important to them and may lead to further exploration in the direction of either organic or behavioral etiologies. Focused
questions that may suggest common (sinusitis, migraine) or uncommon (increased intracranial pressure, chronic infection) organic etiologies should be directed to the patient or parent.
The history should begin with a description of the headache pattern. In infants and toddlers, nonspecific symptoms may reflect a headache (e.g., irritability, inconsolability, sleep disturbances, poor appetite, head banging, or repetitive placing of a hand to the head or face). In older children and adolescents, an open-ended question may yield important information about the location, quality, onset, duration, and frequency of the headache.
An aura, unilateral location and throbbing pain will be present in some children with migraine. Those with a “common migraine” may have a generalized aching headache with nausea or vomiting but without an aura. A morning headache; awakening with
vomiting; worsening of pain with coughing, sneezing, and straining; and progression of pain in severity and frequency should suggest an intracranial source.
Table 49-1. Classification of headaches
Mechanism
Features/etiology
Tension headaches (muscle contraction headaches)
Contraction of scalp and neck muscles
Sensation of tightness or pressure over frontal, temporal, occipital regions, or generalized
Life-event change/stress: home, school, social relations, activity overload, depression
Normal physical examination (occasional tightness or tenderness of posterior cervical muscles)
Migraine headaches
Vasoconstriction and/or vasodilation of cerebral vessels
Family history (70%-80%)
Paroxysmal attacks
Gender: in childhood, boys and girls equally; in adolescence, girls more than boys
Common migraine
Unilateral or generalized
Throbbing or aching
Nausea/vomiting
No aura
Classic migraine
Aura (visual)
Nausea/vomiting
Unilateral
Throbbing
Complex migraine
Ophthalmoplegia
Hemiparesis
Acute confusional state
Cyclic vomiting
Paroxysmal vertigo
Extracranial sources
Inflammation or trauma of structures or sustained contracture of scalp and neck muscles
Typically regional pain in area of pathology but often generalized in young children
Otitis media and mastoiditis
Sinusitis (chronic purulent rhinorrhea and/or nocturnal cough)
Dental infection
Tonsillopharyngitis (streptococcal)
Refractive errors and strabismus
Cervical spine osteomyelitis or discitis
Systemic infection with fever
Temporomandibular joint syndrome
Severe malocclusion
Intracranial sources
Inflammation
Meningitis, encephalitis, cerebral vasculitis, subarachnoid hemorrhage
Traction
Central nervous system tumor
Cerebral edema
Abscess
Hematoma
Postlumbar puncture
Pseudotumor cerebri
Toxic substances
Lead-Alcohol
Carbon monoxide
Hypoxia
Foods and food additives (nitrates, nitrites, monosodium glutamate, phenylethylamine)
Paint, glue (including model glue)
Oral contraceptives
Renal disease
Direct pressure
Hydrocephalus
Trauma
Vascular (nonmigraine)
Hypertension
Arteriovenous malformation
Fever
Miscellaneous
Noise
Sensory overload
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Headaches
Headaches
Martin T. Stein
