Headaches
Headaches
Headache is the most common pain syndrome in children. Recurrent headaches are a health problem. Recurrent headaches can be primary (e.g. migraine) or secondary (e.g. raised intracranial pressure). The actual perception of headache varies according to age and is influenced by factors like experience, memory and cultural environment. It is essential to exclude organic causes by taking a good history and clinical examination.
Classification of headaches
Migraine (without aura)
At least 5 or more headaches lasting 1– 48 hours fulfilling at least 2 of the following:
- bilateral or unilateral, frontal or parietal in location
- pulsating in character
- moderate or severe
- aggravated by routine activity
- nausea and/or vomiting plus photophobia and/or phonophobia during headache
Migraine (with aura)
At least 2 attacks fulfilling at least 3 of the following:
- one or more reversible aura symptoms
- at least one aura developing over > 4 minutes or 2/more successive symptoms
- no aura lasting > 1 hour
- headache follows aura in less than 1 hour
Episodic tension-type headache
At least 10 prior episodes, occurring less than 15 times per month and lasting 30 minutes to 7 days with at least 2 of the following:
- pressing or tightening quality
- mild or moderate intensity
- bilateral location
- no aggravation by routine physical activity
- no nausea or vomiting, and photophobia and phonophobia absent during headache
Cluster headache
One-sided headache that may involve tearing of the eyes and a stuffy nose. Attacks occur regularly, but are separated by long pain-free periods. Rare in childhood.
Management
Each of the above can occur in combination in any patient, i.e. mixed, comorbid headache. Headaches can also be sub-classified according to temporal patterns, i.e. acute recurrent, chronic progressive/non-progressive, episodic or constant. Most important aspect is to exclude secondary causes of headache, e.g. raised intracranial pressure.
Red flags in childhood headaches: Exclude secondary causes of headache (eg raised intracranial pressure)
- Change in pattern (e.g. “worst headache ever”),
- Progressive course over time,
- Age younger than 3 years,
- Nocturnal/wakes child from sleep,
- Early morning vomiting,
- Ataxia,
- Focal neurological signs,
- Alteration of level of consciousness.
Non-drug treatment
- Environmental and lifestyle changes, e.g. Avoid precipitants such as bright lights, sleep deprivation and certain foods
- Headache diary
Drug treatment
Analgesics
- Paracetamol, oral, 10–15 mg/kg/dose 6 hourly as required.
- Ibuprofen, oral, 5–10 mg/kg/dose 6 hourly
Anti-emetic
- Metoclopramide oral, 0.15–0.3 mg/kg as a single dose
Migraine prophylaxis
Indicated when headaches occur frequently, impacting on the child’s activity and requiring substantial relief medication. Discuss with consultant first. Treat for six months then review.
- Propranolol, oral, 0.5–3 mg/kg/day in 2–3 divided doses. Contraindicated in asthma and heart block. Avoid in diabetes and depression.
In children who are unable to take propranolol, e.g. asthma:
- Topiramate, oral, 1–3 mg/kg/day in 1–2 doses. (Specialist initiated) Starting dose: 0.5 mg/kg/day. Titrate dose slowly every 1–2 weeks. Reinforce behavioural management before considering topiramate. Treat for six months, then review.
Alternatives
- Sodium valproate oral 10–20 mg/kg/day
- Amitriptyline oral 0.25 mg/kg at night starting dose for a 6 week period. If no response, increase dose slowly to 1 mg/kg at night. ECG monitoring prior to dose increases.
Referral
- Secondary intracranial pathological cause suspected.
- No response to treatment.