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Pediatric Pain:
Headaches in Children
Overview Children and Pain Peer
Review Committee Content
Editor: Brenda C. McClain, M.D., DABPM, New Haven, Conn. Editorial
Review Board: Deirdre Logan, Ph.D., Philadelphia, Pa. Rollin Gallagher, M.D., M.P.H., Overview Headaches have existed since the dawn of civilization, with reports
of headaches dating back 25 to 30 centuries to the times of the ancient
Egyptians; however, little emphasis was placed on the impact of headache
disorders in children until 1873 when William Henry Day, a British
pediatrician, included an entire chapter on head disorders in his book, Essays
on Diseases in Children.1 Although
health care providers have learned much about headaches since then, many of Dr.
Day's impressions are applicable today, including his assertion that
non-vascular headaches are most common and that many headache disorders in
children are related to psychosocial stresses. The potential impact of headaches on the everyday lives of
children should not be underestimated. Headache disorders can be chronic,
recurrent problems that interfere with usual childhood activities including
school attendance. By age six, more than 30% of children have reported having
headaches and up to 75% of children suffer from this malady by age 15.2 Children miss more than one million days of
school each year because of headaches. Foremost in the minds of parents and health care providers
is the fear that some underlying problem is responsible for the headache (eg,
brain tumor). In most cases, no life-threatening problem is found to be the
cause of the pain, but a thorough history and physical examination performed by
a physician is necessary rule out potentially life-threatening problems. In one
study of 74 children younger than 16 years of age admitted to a neurosurgical
unit with brain tumors, researchers reported that 60% had headaches that
occurred everyday, interfered with activities of daily living, and were not
relieved by simple analgesics such as acetaminophen or ibuprofen.3 An average of 4.6 consultations occurred before
a brain tumor was diagnosed—19% had been previously diagnosed as migraine. This
underscores the importance of having your child evaluated by a physician who is
familiar with the appropriate work-up and treatment of pediatric headache
disorders even though must are not related to life-threatening problems.
Depending on training and experience, appropriate health care providers include
pediatricians, neurologists, or family practice physicians. Many of the following symptoms may occur with migraine and
other headache disorders, but also may suggest underlying pathology and the
need for further diagnostic testing to rule out a brain tumor: Most importantly, if an underlying reason is responsible for
the headache (e.g., brain tumor), early diagnosis may help treatment success
and improve a child's outcome. Most recurrent headaches in children are due to one of
several possible headache disorders. A thorough history and physical
examination and, when indicated, diagnostic laboratory and radiologic studies
help your child's physician arrive at a correct diagnosis. Depending on the
diagnosis, the physician may prescribe specific therapies and medications to
treat and prevent subsequent headaches. In many cases, these therapies will
help lessen the severity and/or frequency of the child's headache. ·
Headaches can be a
chronic, recurrent disorder that interferes with a child's daily activities,
including school attendance, and can have a significant negative impact on
daily life. ·
Headaches are a common
event in the lives of children—31% of children report headaches by age six and
75% report headaches by age 15. Twenty-six percent of children ages seven to 16
years report having at least one headache per month. ·
Headaches account for
children missing one million school days per year. ·
Children diagnosed with
having migraine headaches miss 8.5 more days of school per year than children
without migraines or those with tension-type headaches. ·
Researchers estimate
that 2% to 10% of the general population experience migraines. ·
The number of children
who experience headache (one episode or more per month) has increased 40% over
the past 20 years. ·
The risk of migraine in
children is approximately 45% when one parent has migraine headaches and 70%
when both parents have migraines. ·
Motion sickness is
observed in almost half of children with migraines. Other associated conditions
include asthma or eczema. ·
No definite study
exists linking the occurrence of migraine with anxiety, depression or
psychiatric problems. Myth: Hardworking, high-achieving people — "type A" personalities — are
more likely to suffer recurring headaches than others. Myth: Children who get headaches all the time are simply trying to
avoid school or chores. Myth: "Headaches are a part of life and my child should just
suffer them." Myth: Headaches are caused by brain injury or damage. Myth: It's possible to cure chronic headaches once and for all. Myth: There are no good treatments for chronic headaches. All types of headaches cause pain, and regardless of the
type or cause, the pain can range from mild to severe to incapacitating. The number
of headaches a child has and the length of pain vary from child to child and
headache type. Headache types include primary, ordinary, and secondary. Primary headaches. Primary headaches are classified as
such because the pain or headache is the primary symptom related to a
disturbance of the brain or the blood vessels within the brain. Primary
headaches include migraine, tension, cluster, and ordinary headaches (a mild
form of either migraine or tension headache). Ordinary headaches. Ordinary headaches are the most
common form of headache. We all experience ordinary headaches at some point in
our lives. They usually are easily treated with simple analgesics (eg, acetaminophen, non-steroidal
anti-inflammatory drugs [NSAIDs]
like ibuprofen). This type of
headache does not significantly interfere with daily activities, has no
associated symptoms, produces mild pain, lasts a few hours, and does not recur
at regular intervals. Secondary headaches. Secondary headaches are related an
underlying problem like a sinus infection or brain tumor. There are hundreds of
causes for secondary headaches including head trauma, dental problems,
hypertension, carbon monoxide poisoning and viral illnesses. Headaches may be further classified as: ·
acute, ·
acute, recurrent, ·
chronic, progressive,
or ·
chronic,
non-progressive.4
An acute headache is a one-time event where severe pain
occurs suddenly and without warning. Possible causes of an acute headache
include ordinary headache; the first time the child experiences a migraine, in
which case the headache will recur and become an acute, recurrent headache;
tension headache, or a wide range of systemic illnesses some of which may be
life-threatening and require immediate medical attention (eg, infections of the
central nervous system, toxins such as carbon monoxide, high blood pressure or
a brain tumor). Acute, recurrent headaches are characterized by severe pain that occurs
suddenly, lasts several hours, and occurs at regular intervals with pain-free
periods in between. This type of headache does not increase in intensity or
frequency over time. Migraines and tension-type headaches are included in this
group. Chronic progressive headaches become more painful and more frequent over time.
When accompanied by other signs and symptoms such as nausea, vomiting or
findings on physical examination, a problem such as a brain tumor may be
present. Chronic, non-progressive headaches occur at regular intervals
(daily) or are constant. They do not increase in severity. There are no
associated clinical signs or symptoms. It is important to determine what type of headache your
child is experiencing because treatment options vary depending on the headache.
Following are criteria set by the International Headache Society for
determining if your child's headache is a migraine or tension headache. Migraine without aura (formerly called a common
migraine): The child must have experienced at least five attacks
meeting the following criteria: a. headache lasts from four to 72
hours—duration decreased to two hours in children less than 15 years old b. two of the following characteristics
i.
unilateral (meaning on
one side of the head)
ii.
pulsating
iii.
moderate to severe
intensity
iv.
aggravated by physical
activity (becomes worse with physical activity) c. associated problems with the
headache
v.
nausea or vomiting
vi.
photophobia or
phonophobia (abnormal sensitivity to light or sound)5 Migraine with aura (formerly called a classic
migraine): An aura is a sensation of light or warmth that is caused by
the nervous system and may precede a migraine. Visual changes are the most
common aspect of an aura and may include flashing lights, double vision,
partial vision loss, zig-zag lines, or size distortions. The aura also may
cause tingling in an arm or leg or a peculiar smell; weakness in an arm or leg
or an inability to speak; or even abdominal pain. The child must have experienced at least two attacks meeting
the following criteria: a.
one or more reversible
auras b.
gradual development of
the aura over more than four minutes c.
no aura lasts more than
60 minutes d.
headache follows the
aura within 60 minutes5 Tension-type headache: The child must have experienced at least 10 previous
episodes with: a.
headache lasting 30
minutes to seven days b.
two of the following
characteristics
i.
bilateral location
(meaning on both sides of the head)
ii.
non-pulsatile, pressing
(tightening) quality
iii.
mild to moderate
intensity
iv.
no aggravation by
physical activity (headache does not become worse with physical activity) b.
no associated nausea,
vomiting and no photophobia or phonophobia (abnormal sensitivity to light or
sound)5 Migraines occur equally in boys and in girls. Approximately
30% of migraines in children are migraines with aura. Boys typically experience
migraine at a younger age than girls—migraine with aura occurring at 5 years in
boys and 12 to 13 years in girls and migraine without aura occurring at 10 to
11 years in boys and 14 to 17 years in girls. The brain and the membranes covering the brain, called
meninges, have no pain fibers. Headache pain comes from the nerves in the blood
vessels inside the brain and outside the skull and the muscles of the head and
neck. Migraine pain typically is related to the nerves in blood vessels while
tension type headaches are related to the muscles in the head and neck.
Although the exact cause has not been determined, the pain and other symptoms
(eg, nausea, tingling, sensitivity to light and sound) that occur during
migraine headaches are related to changes in blood flow to structures within
the brain. The changes in blood flow, in turn, affect nerve cells within the
central nervous system. Both blood flow changes and affected nerve cells alter
the concentration of several different chemicals (eg, nitric oxide, serotonin,
substance P) in the central nervous system. Current research suggests that
serotonin concentrations are low between migraine attacks and increase
significantly during migraine headaches, although the exact chemicals
(neurotransmitters) responsible for migraines are not delineated. Medications
that alter serotonin play a crucial role in the treatment of migraine. Effective treatment for childhood headache begins with an
accurate diagnosis of the condition. A physician will conduct a thorough
history and physical examination on your child, which may include measuring the
blood pressure in your child's arms and legs. Your child's physician may
conduct further tests based on his or her findings during the history and
physical examination. One way to help your child's physician accurately
diagnose what type of headache he or she is experiencing is to keep a headache
diary. A headache diary should include information about: ·
how often the headaches
occur (eg, once a month, every week, every other day); ·
how long the headaches
last; ·
how intense or severe
the headaches are; ·
factors that might lead
to the headache, such as certain foods and environmental factors like stress
and lack of sleep; and ·
the child's response or
lack of response to the treatments tried at home. Treatment options include simple analgesics, which are pain
medications that help control pain, or prophylactic medications, which are
medications taken daily that may help prevent headaches. Your child's physician
may recommend giving the child simple analgesics when he or she complains of
headache. Although many of these medications including acetaminophen (Tylenol)
and ibuprofen (Advil) are available over-the-counter, they are often effective
in treating pain and should not be underestimated.6
There are different ways of administering analgesics, including suppository
forms of acetaminophen when headaches are accompanied by nausea and vomiting
that prevent a child from taking an oral form of the medication. In one
research study, 54% of patients reported relief from acetaminophen while 68%
reported relief from ibuprofen.7 Although simple analgesics are effective in most children
with migraine headaches, some may need additional therapies. Some medications used
to treat migraine headaches specifically work to reverse blood flow changes
that are thought to cause migraine headaches. These medications generally are
more effective if they are taken soon after the migraine begins (eg, during the
aura phase if your child experiences aura). These medications should be used
only as directed by your child's physician. Additional agents include the
ergotamine derivatives (dihydroergotamine) that cause constriction of the
dilated intracranial vessels. Dihydroergotamine can be taken via nasal spray,
injection, or dissolved underneath the tongue. More recently, the serotonin1
receptor agonist, sumatriptan (Imitrex) has been introduced to relieve pain
related to migraine. This medication is available as a nasal spray, injection,
or tablet. These types of medications may have adverse side effects, including
increased blood pressure. Rare adverse effects of all of these medications
include increased blood pressure, decreased blood supply to the heart or other
vascular issues. Children who experience recurrent migraine headaches may be
given medications to prevent headaches (prophylactic medication). Such
medications include beta adrenergic antagonists such as propranolol, calcium
channel blockers such as flunarizine or nifedipine, and anti-depressants When
you and your physician decide to treat your child's headaches in this manner,
it is critical that you both closely monitor your child's reaction to such
medications to limit the incidence of adverse effects. ·
The potential impact of
headaches on the everyday lives of children should not be underestimated.
Headache disorders can be chronic, recurrent problems that interfere with usual
childhood activities including school attendance. ·
Foremost in the minds
of parents and health care providers is the fear that some underlying problem
is responsible for the headache (eg, brain tumor), but in most cases, no life-threatening
problem is found to be the cause of the pain, ·
All types of headaches
cause pain, and regardless of the type or cause, the pain can range from mild
to severe to incapacitating. The number of headaches a child has and the length
of pain vary from child to child and headache type. ·
Effective treatment for
childhood headache begins with an accurate diagnosis of the condition. One way
to help your child's physician accurately diagnose what type of headache he or
she is experiencing is to keep a headache diary that includes information
about: o how often the headaches occur (eg,
once a month, every week, every other day); o how long the headaches last; o how intense or severe the headaches
are; o factors that might lead to the
headache, such as certain foods and environmental factors like stress and lack
of sleep; and o the child's response or lack of
response to the treatments tried at home. 1. Prensky AL, Sommers D.
Diagnosis and treatment of migraine in children. Neurology
1976;29:506-510. 2. Sallanpaa M. Prevalence of
migraine and other headache in Finnish children starting school. Headache
1976;16:288-290. 3. Edgeworth J, Bullock P, Bailey A, et
al. Why are brain tumors still being missed. Arch Dis Child
1996;74:148-151. 4. Rothner AD. Headaches in
children: a review. Headache 1978;18:169-174. 5. International Headache Society:
Classification and diagnostic criteria for headache disorders, cranial
neuralgia, and facial pain. Cephalgia 1988;8:1-96. 6. Weak analgesics and non-steroidal
anti-inflammatory agents in the management of children with acute pain. Pediatr
Clin North Am 2000;47:527-544. 7. Hamalainen ML, Hoppu K, Valkeila E,
et al. Ibuprofen or acetaminophen for the acute treatment of migraine in
children: A double-blind, randomized, placebo-controlled, crossover
study. Neurology 1997;48:103-107. Journal articles
Singer HS. Migraine headaches in children.
Pediatrics in Review
1994;15:94-101.
Elser J. Migraine headaches in children. J Ark Med Soc
1988;85:207-210.
McCarthy AM, Mehegan J. Migraine headaches in children: treatment. Pediatr
Nurs 1982;8:173-176. Paulson GW. Migraine headaches in children. Pediatr Nurs
1980;6:41-42. Paulson GW. Migraine headaches in children. Ohio State Med J
1979;75:125-127. Websites American Academy of Family
Physicians P.O. Box 11210 Shawnee Mission, KS 66207-1210 (800) 274-2237 American Council for Headache
Education 19 Mantua Road Mt. Royal, NJ 08061 (856) 423-0258 www.achenet.org/kids/children.php www.upstate.edu/neurology/haas/hpchild.htm/headaches.html
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