Recurrent Headaches in Children

Recurrent Headaches are one of the three common recurrent pain syndromes, the others being recurrent abdominal pain & recurrent limb pain in children worldwide. 70% of school children have headache at least once a year.  Chronic recurrent headaches occurs in 30-40% of children by age of 7 yrs increases to 75% by the age of 15 yrs. In case of younger boys are more often affected but after puberty headaches are more common in girls.

• Children & adolescents are very different than adults with reference to rapid growth & development and psychological changes that occur at this time of life.
• A detailed history and clinical evaluation is helpful to make a specific diagnosis and also establish a therapeutic relationship with the child & the parents.

Types of Headaches:

From a practical approach Headaches can be divided into two categories – Primary and Secondary.

• Primary Headaches are Migranes & TTH commonly encountered in children. Secondary Headaches include Headaches due to systemic infection be viral & other infections, inflammation or swelling in the brain (meningitis) , brain tumors, head or neck trauma etc.
• Older children (> 8 yrs) can usually give a detailed account of their symptom whether the Headaches are throbbing or band like while in younger children, the severity of pain is best divided by change in behavior, interference in play & other activities.
• The history establishes the site, frequency, duration & periodicity of the headaches. Whether there is any change in behavior prior to Headaches or any warning like flashing of light or change in the size of objects or unability to see properly thus preceding the Headaches. Does any other family member suffer from recurrent Headaches.

Maintain a headache Diary. It helps a doctor:

A Headache Diary is very helpful in identifying triggering & aggravating factors and effectiveness of medication. Maintaining a headache diary by itself has been found to reduce Headache frequency. A diary with records of daily activities , patterns of sleep, workload in school & proportion of work & leisure time etc. Record of type and amount of pain relieving tablets intake & also its effect may also prevents medication overuse.

On clinical evaluation, not all patients need detailed investigation & neuroimaging (MRI- Brain, CT Head)

• Red Flags – Indicating investigation
• A short history – first or worst headache or recurrent headache for few weeks with progression. Awakening headaches with vomiting disturbing sleep, worsening with cough & straining on stools. Changes in personality & behavior visual disturbances, seizures weakness or fever.
• History of Trauma (H& N) or any systemic illness

Most common Recurrent Headaches are Migrane & Tension Type Headaches:

Migrane Headaches are similar to migrane in adults except that headaches are shorter in duration characterized by a throbbing pain that worsens on exertion, may be accompanied by abdominal pain with sensitivity to light & sound & accompanied by nausea or vomiting. It may be triggered by lack of sleep, certain foods chocolate, icecream, stress, missing meals or around periods in adolescent girls.

• Family history of headaches is positive in 65-80% of cases
• The headache may be relived with sleep & rest.
• Migrane episodes may be precipitated by a trival injury to the head.

Tension Type Headaches are usually mild to moderate in intensity, persistent for several hours. A band like sensation or a heavy weight on the head. Does not interrupt the daily activities of the child usually such Headaches may be triggered by physical stress or psychological stress or both.

Treatment for Headaches:

Treatment principles for primary headaches – Migrane & TTH are very variable & individualized. Education of the family regarding the diagnosis, its natural course & the different treatment modalities is of great importance. Apprising the family about different triggers that bring about the attack & how managing the triggers can reduce the no of attacks.

Reassurance that there is no underlying serious brain disorder as the cause of Headache. Management of the acute attack of headache by analegies and in case of frequent headaches preventive therapy is advised.

Non pharmacological treatment includes relaxation therapies, counseling such as cognitive behavior therapy. Maintenance of balance between studies & leisure time goes a long way in keeping the primary headaches away.

Most headaches are not serious but one must seek immediate medical attention if

• The child has awakening Headache
• Assoc with visual problems/ vomiting
• Change in behavior & personality
• Headache following a blow on the head or neck
• Headache accompanied by fever, neck pain or stiffness

Migraine is associated with other childhood syndromes like cyclical vomiting, Benign Paroxysmal Verligo and Abdominal Migraine.