AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Headache is a common reason for children to seek medical care. Headaches in children may be due to numerous causes, such as migraine and its variants, intracranial masses, or sinusitis. This article discusses the important and common causes of headache in the pediatric population.

Pathophysiology

Because the brain is insensate, headache is due to the stimulation of pain sensitive nerve fibers in large cerebral arteries and veins, the periosteum of the skull, the muscle and skin of the scalp, the sinus mucosa, the temporomandibular joint, the teeth, or the gingiva.

The pathophysiology of migraine headache is multifactorial. The onset of a migraine headache is thought to be mediated by cortical spreading depression (CSD), which is due to neuronal activation followed by suppression, which spreads over the cortical surface. A simultaneous change occurs in cerebral blood flow, characterized by hyperperfusion, followed by hypoperfusion. CSD is thought to be caused by either trauma or changes in the local concentrations of hydrogen ions, potassium, and glutamate. CSD activates CNS nociceptors, possibly through the release of nitric oxide, atrionatriuretic factor, activation of noradrenergic pathways, and/or changes in cerebral blood flow. CSD also causes neurogenic inflammation, which also stimulates the release of several different neurotransmitters that lead to cerebral vasodilatation and activation of CNS nociceptors.

Frequency

United States

Nearly 40% of Americans have a significant headache at some time. Children frequently complain of headache. Headaches are very common during childhood and become increasing more frequent during adolescence. The prevalence of headache, in general, ranges from 37-51% during the elementary school years and gradually rises to 57-82% by the high school years. Before puberty, reports indicate that boys are more frequently affected than girls, but, following the onset of puberty, headaches are reportedly more frequent in girls.
 

Mortality/Morbidity

Headache can cause significant disruption in a child's daily activities. For example, children with migraine headache are often not appropriately diagnosed and thus go untreated. In a large study looking at the prevalence of migraine headache, 31% of patients reported that they had missed at least one day of school or work in the previous 3 months. In this same study, more than half of patients reported that their productivity was reduced by 50%.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

A thorough history should be obtained in any child presenting to the ED with a headache. The history should describe headache onset, duration, severity, and associated symptoms. A family history of migraines may be helpful in clarifying the diagnosis. A medication history should also be sought.

• Migraine headache overview 
• • Because a migraine headache can be classified into several types, symptoms vary depending on the type. Many children with migraines have a previous history of motion sickness, paroxysmal dizziness, or vertigo. The prevalence of migraines is 5% in children and 17% in adolescents. Approximately 60% of all children with migraines are male. Nearly 70% of pediatric patients have a family history of migraine headache. Clinicians should suspect migraine headache in any child who presents with recurrent episodes of incapacitating headaches.
  • A possible relationship exists between children who have cyclic vomiting syndrome and migraine headache. A genetic predisposition also appears to exist for patients with cyclic vomiting syndrome and their family members to develop migraine headaches. Patients with cyclic vomiting syndrome, their mothers, and grandmothers may have a prevalence of migraine headache that is about twice that of the general population.
  • Classic migraine: Patients have a sharply defined headache that is preceded by motor or sensory disturbances, such as blurred vision, floaters crossing the visual field, or transient muscle weakness.
  • Common migraine: The headache is often less sharp and well defined. No preceding motor or sensory disturbance occurs. This type of migraine is observed more often in children.
  • Complicated migraine: In patients with complicated migraine, focal or diffuse neurologic deficits may occur with the headache. The 4 types of complicated migraine are as follows:
  • • Hemiplegic or hemisensory migraine: The headache is accompanied by unilateral motor weakness or sensory disturbance (eg, paresthesias) that may persist for several hours after the headache has subsided.
    • Basilar migraine: The pathogenesis of basilar migraine involves vasoconstriction of the basilar and posterior cerebral arteries. This results in an occipital headache, as well as diplopia, vertigo, tinnitus, or ataxia.
    • Ophthalmoplegic migraine: In addition to a unilateral frontal headache, patients have an ipsilateral third nerve palsy and reversible monocular blindness. This type of migraine is rare in children.
    • Acute confusional states: Acute confusional states are an unusual type of migraine headache and are characterized by sudden onset of confusion, unresponsiveness, memory disturbances, disorientation, and dysarthria. This type of migraine headache is thought to be more common in boys.
  • Cluster headache: Headaches occur in groups or clusters. Nasal discharge, congestion, and a watery red eye are present on the same side of the head as the headache. Cluster headaches often awake a patient from sleep and most often occur in adolescents.
  • The diagnosis of migraine can be made if 3 of the following 6 symptoms are present:
  • • Preceding motor, sensory, or vertiginous symptoms
    • Throbbing or pounding pain
    • Pain localizes to one side of the head
    • Associated nausea, vomiting, or abdominal pain
    • Sleep alleviates the pain
    • Family history of migraine
• Tension headache: Tension headaches are common in children. Distinguishing tension headache from migraine headache may be difficult, as many children with migraine headache also complain of neck pain. Distinguishing characteristics of tension headaches include the following:
• • They occur during times of obvious stress.
  • They involve the neck and occiput.
  • Pain is continuous.
  • No nausea, vomiting, or abdominal pain occurs.
  • Family history of migraine is less likely.
• Sinus headache
• •  Recurrent headaches occur in approximately 15% of children with sinusitis.
  • These patients complain of a throbbing headache that is worse in the morning or that occurs at the same time each day.
  • The pain may vary with changes in head position.
  • With ethmoid disease, pain may be referred to behind the ipsilateral eye.
  • With frontal sinusitis, pain may occur just above the inner canthi of both eyes.
  • A history of nasal discharge, congestion, and cough lasting more than 10 days is usually given.
  • Fever may be present.
• Head trauma
• •  Headaches frequently follow closed-head trauma.
  • The headache may appear acutely or be present for months after the initial injury.
  • Acutely, the patient may complain of headache shortly after the injury, which may worsen and be accompanied by vomiting, lethargy, or seizures; these may be the earliest symptoms of an intracranial hemorrhage.
  • In chronic cases, headache, dizziness, and personality changes may be present for months after the initial injury.
  • Headache is a key feature of the postconcussive syndrome.
• Intracranial masses: Distinguishing intracranial causes from extracranial causes of headache may be difficult. Patients with intracranial masses may complain of pain localized to the region of the mass. However, if a diffuse rise in intracranial pressure exists, the headache may be generalized. Some distinguishing historical features of intracranial masses include the following:
• • Severe occipital headache, sneezing, coughing, any Valsalva maneuver, or change in head position exacerbates the pain.
  • Pain is worse in the morning or awakens the patient from sleep.
  • Projectile vomiting without nausea and focal seizures may occur. However, morning headaches and projectile vomiting once thought to be hallmarks of raised intracranial pressure may also occur from etiologies other than intracranial masses.
• Benign intracranial hypertension (pseudotumor cerebri)
• • Benign intracranial hypertension produces headaches similar to headaches in conditions with raised intracranial pressure.
  • In addition to having pain worse in the morning and vomiting, patients may have vision problems (eg, diplopia) or gait abnormalities (eg, ataxia).
• Epilepsy: Children with a prior history of epilepsy may have a generalized or focal headache after a seizure. Headaches may also accompany the aura prior to a seizure.
• Meningeal irritation: Meningeal irritation due to inflammation, infection, or hemorrhage (eg, malignant hypertension [HTN], vascular lesions) results in the acute onset of diffuse severe headache. Neck pain or stiffness and alteration in consciousness may be present.
• Medication overuse headache (MOH): Chronic use of all medications used to treat headaches, such as analgesics or vasoconstrictors, can result in medication overuse headache. The International Classification of Headache Disorders (ICHD) has recently recognized this entity. It is defined as the development of a different type of headache or worsening of a migraine or tension headache, resulting in chronic daily headaches. It develops after use of medications such as analgesics or the triptans on more than 10 days per month or after use of over-the-counter (OTC) analgesics for more than 15 days per month for 3 months’ duration.

Physical

A thorough physical examination often can exclude systemic causes of headache.

• Attention should be paid to vital signs, especially presence of fever, elevated blood pressure, or bradycardia.
• A thorough neurologic examination should be performed to assess the level of consciousness and to evaluate cranial nerve dysfunction, hypertonia, hyperreflexia, hemiparesis, or hemiplegia.
• Perform funduscopic examination, looking for papilledema or subhyaloid hemorrhage.
• Look for nuchal rigidity.
• Check the head for hematomas or other signs of trauma.
• Search the skin for rashes or cutaneous lesions (eg, petechiae, purpura, Ash leaf spots, cafe-au-lait spots).
• Migraine headache
• • Most children with migraine headaches have a normal physical examination without focal deficits.
  • Some children with a complicated migraine may have focal neurologic abnormalities, such as weakness, third nerve palsy, or ataxia.
• Tension headache: Physical examination findings are usually normal. Pain on palpation of the posterior neck muscles may be noted.
• Sinus headache: Physical findings include pale edematous nasal mucosa, boggy turbinates, clear or yellow nasal discharge, pain with palpation of frontal or maxillary sinuses, and failure of these sinuses to transilluminate.
• Head trauma
• • In acute injuries, the child may have an altered level of consciousness, focal neurologic deficits, abnormalities in cranial nerve function (III, VI), and hemiparesis.
  • In chronic injuries, the physical examination findings often are normal.
• Intracranial masses
• • Patients with headaches due to intracranial masses often have focal neurologic abnormalities, especially if they have had headaches for several months.
  • These abnormalities include papilledema, sixth nerve palsy, ataxia, spasticity of the lower extremities, and indications of brain dysfunction regarding language, motor control, or vision (depending upon the location of the lesion).
  • Early in the course of the mass lesion, the physical examination findings may be normal.
  • Children with intracranial abscesses may have alteration of the level of consciousness only during the acute presentation.
• Benign intracranial hypertension (pseudotumor cerebri): These patients usually have papilledema and, occasionally, have other neurologic deficits (eg, sixth nerve palsy, ataxia, spasticity of the extremities).
• Epilepsy
• • Children with uncomplicated idiopathic epilepsy have normal physical examination findings.
  • Children with seizures due to metabolic or abnormal brain architecture may have baseline neurologic deficits (eg, hypertonia, hemiparesis).
• Meningeal irritation
• • Fever (meningitis), hypertension (malignant hypertension)
  • Altered consciousness, nuchal rigidity, or perivenous hemorrhage of the fundus (subarachnoid hemorrhage secondary to hypertension)

Causes

• Migraine headache
• • Minor headache
  • Onset of menses
  • Sleep disturbances
  • Chemicals (eg, tyramine in cheese, chocolate, nuts, monosodium glutamate [often in Chinese food])
  • Children with epilepsy are at an increased risk of developing migraine headaches.
• Tension headache
• • A subgroup of patients with tension headaches has obvious symptoms of depression, such as depressed mood, feelings of worthlessness, anhedonia, or anorexia.
  • In this subgroup of patients, the headaches are relieved when the depression is treated.
• Benign intracranial hypertension (pseudotumor cerebri)
• • Expansion of 1 or more of the intracranial fluid spaces, such as the vasculature, the extracellular fluid compartment, or the cerebrospinal fluid (CSF) space
  • Several drugs, such as tetracycline, minocycline, penicillin, gentamicin, oral contraceptives, steroids, indomethacin, thyroid hormone, and lithium carbonate may be inciting agents.
• Meningeal irritation
• • Infection (meningitis)
  • Inflammation (eg, tumor)
  • Hemorrhage (eg, vascular malformation, malignant hypertension)

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Pseudotumor cerebri
Lyme disease
Medication overuse headache (MOH)

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Migraine headache
• • A thorough history and physical examination usually is all that is needed.
  • Laboratory, radiologic, or encephalographic studies are not useful to confirm the diagnosis of migraine but may help exclude other etiologies of headache. For example, an EEG may be helpful to exclude seizures in children with acute confusional migraines.
• Tension headache
• • A thorough history and physical examination is all that is needed to make the diagnosis of tension headache.
  • With a suggestive history and normal physical examination findings, no additional tests are required.
• Head trauma and headache due to a significant intracranial hemorrhage: A consumptive coagulopathy, such as thrombocytopenia, and prolonged prothrombin and activated partial thromboplastin times, may be evident.
• Intracranial abscess: Lumbar puncture may reveal elevated opening pressure, leukocytosis, elevated protein level, and low glucose level.
• Benign intracranial hypertension: Lumbar puncture reveals elevated opening pressure without leukocytosis or abnormalities in glucose or protein concentration.
• Meningeal irritation
• • In patients with meningitis, a lumbar puncture may show an elevated opening pressure, WBCs, low glucose level, high protein level (meningitis, encephalitis), and bacteria on Gram stain.
  • In patients with a subarachnoid hemorrhage, a lumbar puncture demonstrates hemorrhagic CSF that does not clear during the collection of the first and last tubes. Opening pressure may also be elevated.
  • Lumbar puncture is the most sensitive test in the diagnosis of subarachnoid hemorrhage.
• Check anticonvulsant levels in patients with a headache and a known history of epilepsy because adequate seizure control usually prevents the headache.

Imaging Studies

• Sinus headache
• • The diagnosis of headache due to sinusitis is suggested by a history of persistent upper respiratory infection (URI) symptoms lasting longer than 10 days.
  • Confirmation of the diagnosis may be made by means of sinus radiographs depicting air fluid levels in the sinuses. However, this test is not sensitive, and false-negative results are common.
  • CT of the sinuses is more sensitive but is usually more expensive. Note that there is a high prevalence of mucoperiosteal thickening in the paranasal sinuses of children in general and serves to emphasize that when soft tissue changes of the sinuses are present, it does not necessarily indicate whether these changes are due to either bacterial infection or inflammation from other causes, such as viral infection, allergy, or chemical irritation. Thus, CT should not be used to make the diagnosis of sinusitis but should only be obtained in children in whom antibiotic therapy does not ameliorate symptoms or in whom sinus surgery is considered after failing appropriate antibiotic therapy for sinusitis.
• Head trauma
• • Any abnormality on physical examination in children with head trauma and headache should prompt radiologic evaluation, such as CT, provided that the child has a protected airway and stable cardiovascular status.
  • An MRI may not reveal accompanying skull fractures.
• Intracranial masses are most often diagnosed by means of CT (with contrast to enhance subtle lesions) or MRI.
• Benign intracranial hypertension (pseudotumor cerebri)
• • CT findings may be normal or may show slit-like ventricles.
  • CT is usually needed to exclude other causes of increased intracranial pressure, such as tumors.
• Meningeal irritation
• • CT findings are positive in only about 90% of patients with subarachnoid hemorrhage. For this reason, a lumbar puncture should be performed despite unremarkable CT findings in patients thought to have a subarachnoid hemorrhage.
  • CT is the best initial study to demonstrate intracranial hemorrhage from malignant HTN or vascular lesions.
• Epilepsy
• • If the baseline neurologic examination changes, neuroimaging should be considered.
  • If this is the patient's first seizure and it is coincident with a headache, neuroimaging (eg, CT, MRI) is warranted, despite normal baseline examination findings, to exclude the possibility of an intracranial mass.

Other Tests

• Electroencephalography (EEG) is useful to assess the status of an underlying seizure disorder associated with headache.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Emergency Department Care

• Migraine and tension headache
• • The goals of therapy are to relieve pain, alleviate nausea, and promote sleep.
  • Vasoconstrictive agents may be helpful, especially if the onset of headache has been recent.
  • Narcotic and nonnarcotic analgesics, sedatives, and antiemetics are helpful adjunctive therapy.
• The treatment of sinusitis includes appropriate antibiotic coverage, analgesics (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen), and nasal decongestants.
• Head trauma, intracranial mass/abscess
• • In the event of intracranial hemorrhage or an intracranial mass causing headache, appropriate airway management, with the goal of adequate oxygenation and hyperventilation to reduce cerebral blood flow and lower intracranial pressure is the immediate goal. Subsequent surgery is necessary to evacuate the lesion.
  • Analgesics are useful for chronic postconcussive headaches.
• To alleviate the increased intracranial pressure associated with pseudotumor cerebri, a lumbar puncture is used to reduce the volume of CSF. Carbonic anhydrase inhibitors decrease the production of CSF.
• The treatment goal of meningeal inflammation is to treat the underlying cause, such as HTN (antihypertensives), infection (antibiotics), or subarachnoid hemorrhage (surgical evacuation of intracranial hemorrhage; nimodipine can be used to reduce vasospasm).

Consultations

• Consultation with a surgeon is appropriate for headache caused by mass lesions, intracranial hemorrhage, or abscess.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

If the diagnosis is not a surgical condition that requires immediate operative treatment, the emphasis of medical therapy should be to provide analgesia and to treat the underlying cause of headache. In patients with migraine, tension, and posttraumatic headache, the goals of therapy are to relieve pain, alleviate nausea, and promote sleep. Vasoconstrictive agents may also be helpful, especially if the onset of the migraine headache is recent.

Drug Category: Analgesics

These agents are indicated for the treatment of mild to moderate pain and headache. They are the mainstays of headache treatment.

Drug Category: Sedative

This agent promotes sleep in children with migraine headache.

Drug Category: Vasoconstrictors

Although the pathophysiology is uncertain, abnormalities of the cerebral vasculature, causing vasoconstriction, and then vasodilation, is the most often cited mechanism for migraine. A reduction in regional cerebral blood flow during the aura and early headache phases of migraine has been demonstrated. This is the rationale behind the use of vasoconstrictive agents in the treatment of migraine. Therapeutic activity of the serotonin 5-HT1 receptor agonists (ie, triptans) in migraine is most likely attributed to agonist effects at 5-HT_1B/1D receptors. These specific receptor subtypes act on the extracerebral, intracranial blood vessels that become dilated during a migraine attack and on nerve terminals in the trigeminal system. Triptans have not been FDA approved for children younger than 18 years.

A recent report of the American Academy of Neurology quality standards subcommittee and the practice committee of the child neurology society has provided guidelines for treating migraine headaches in children and adolescents.¹

Drug Category: Antiemetics

These agents are useful in the treatment of symptomatic nausea.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Chronic recurrent headaches should be referred to either a pediatric neurologist or a neurosurgeon, depending on the cause.

Patient Education

• For excellent patient education resources, see eMedicine's Headache Center. Also, visit eMedicine's patient education articles, Causes and Treatments of Migraine and Related Headaches and Migraine Headache in Children.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• CT scans do not always identify subarachnoid bleeds. Therefore, remember to perform a lumbar puncture despite negative findings on CT scan for patients suspected of having a subarachnoid bleed.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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2. American Academy of Pediatrics. Clinical Practice Guideline: Management of sinusitis. Pediatrics. 2000;108(3):798-808.
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Article Last Updated: Feb 13, 2008