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Childhood Headache

Childhood Headache

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SympoSium: neurology
pAeDiATriCS AnD CHilD HeAlTH 18:1
© 2007 esv ltd. A hts svd.
Evaluation o headachesin children
Sabh mkhadhaCatha p Wht
Ths vw vds a actca d t th c cass  hadachad th asssst  chd. Cta t a b, hadachsa v c  chd. Th a hadach dsds, whchcd a ad ts-t hadach, acct  th ajt  hadachs, wh scda hadach, .. ths wth d ath-, a ch ss c. A thh hst ad xaat s thk t dt th cas ad shd b th st tat as ass th chd ad a that th s  ss cas  th hadachs. T aa chdhd hadach  d t b ab tdstsh th a  th ha, ad th st czth c hadach atts ad th ss ad sts that adcat ss tacaa dsas. mst -act hadachs d td th vstat. na s a cssa. rcthadachs,  whatv cas, a a cas  csdab bdt,sca  ts  sch absc.
act hadach; ba a; dta dass;a; ts-t hadach
Headaches are common in children and the prevalence increaseswith increasing age. In our practice, almost hal o reerrals romprimary care are because o headache. Unortunately, most par-ents think that headache is an uncommon symptom in children,hence their understandable concern. As well as hoping to relievethe pain, parents are oten seeking reassurance that their child’sheadache is not a sign o serious intracranial disease, such asa brain tumour. I this is understood, then we do not need toexplain every headache, but we must be able to reassure thechild and amily that it is not a sign o serious illness.Migraine and tension-type headache are by ar the common-est causes o headache.
Other rarer causes include hemicraniacontinua, cluster headaches, idiopathic intracranial hypertensionand, o course, the headache associated with raised intracranialpressure secondary to a tumour.Studies o Swedish school children have indicated that 39%o children experience headache by 7 years o age and 70%
 Sourabh Mukhopadhyay 
is a Specialist Registrar inPaediatric Neurology at Morriston Hospital, Swansea, Wales, UK.
Catharine P White
is a Consultant Paediatric Neurologist at Morriston Hospital, Swansea, Wales, UK.
by age 15.
Other studies have reported similar incidences andtrends.
The prevalence o headache increases with age andreaches an adult population prevalence in the early teens.Migraine aects 1–3% o children by age 7 years and 4–11%by age 15 years.
Abu-Aereh and Russell estimated the preva-lence o tension-type headaches in school children to be 0.9%.
 Secondary headaches are rare, and brain tumour as a cause o headache even rarer. For every child with a brain tumour thereare around 5000 children with recurrent headaches, including2000 children with migraine.
Headaches have a signicant impact on the lives o childrenand adolescents, resulting in school absence,
decreased extra-curricular activities and poor academic achievement.A good history will provide a diagnosis in the vast majorityo children. This together with a careul examination will ensurethat serious causes are unlikely to be missed. This process shouldalso be therapeutic and reassuring to the parents and child.
Classiying paediatric headaches
In 1988 The International Headache Society
published a clas-sication scheme or headaches, including complex diagnosticcriteria. In essence, it divided headache into two categories –primary and secondary. Primary headache disorders, i.e. thosethat have no other underlying cause, include migraine, tension-type headache and cluster headache. Secondary headaches areassociated with underlying central nervous system (CNS) orother pathology. More recently, it was recognized that this clas-sication needed ne tuning, especially in relation to the classi-cation o headaches in children and adolescents, and the revisedclassication was published in 2004.
Although standard teaching is to consider migraine and ten-sion headache as completely dierent entities, it is much morelikely that they lie on a continuum.
This theory ts better withclinical practice.Clinically it can be more helpul initially to divide headacheinto one o our broad types depending on the temporal pattern
isolated acute; 
acute recurrent (episodic); 
chronic progressive; 
chronic non-progressive.
headache is dened as a recent onset headache with noprior history o similar episodes. In children, this pattern is mostcommonly due to ebrile illness related to upper respiratory tractinection,
but severe acute headache may also be the present-ing symptom o a variety o serious intracranial pathologiessuch as meningitis, raised intracranial pressure or haemorrhage(Table 1).Attacks o head pain separated by symptom-ree intervalsare classied as
acute recurrent 
headache. Primary headachesyndromes, such as migraine or tension-type headache, usuallycause this pattern. Inrequently, recurrent headaches are attribut-able to epilepsy or cluster headache.In
chronic progressive
headache the requency and severityo the headaches gradually increases with time. This is the mostominous o the temporal patterns and is commonly correlatedwith increasing intracranial pressure. Causes include idiopathicintracranial hypertension, tumour, hydrocephalus and subduralcollections.
SympoSium: neurology
pAeDiATriCS AnD CHilD HeAlTH 18:1
© 2007 esv ltd. A hts svd.
Chronic non-progressive
headaches dier rom acute recur-rent headaches by their greater requency and persistence. Theymay last or years with no associated neurological symptoms orchange in headache severity. A common headache in this cat-egory is chronic tension-type headache. An important newlyrecognized entity that also occurs with this temporal pattern ischronic daily headache.
Clinical assessment o headache in children
The cornerstone o headache management remains good historytaking and careul physical and neurological examination. Thisinvariably allows a diagnosis to be made, identies those chil-dren who have a secondary cause or their headache and recog-nizes the ew who require urther investigation.
The history is the key to diagnosing the cause o the headacheand to identiying those children with symptomatic (second-ary) headache. Asking both the child and their parents aboutthe headache is important but unortunately children under 10years are not good at describing pain, its requency, severity ordistribution. This does not mean that they should not be askedor listened to. Rothner has created a checklist to aid cliniciansin eliciting the important eatures o any headache
(Table 2).Whilst more applicable to the outpatient setting, it is still a useulaide memoir in the acute situation.In addition, questions need to be specically asked about othersymptoms that suggest raised intracranial pressure or progressiveneurological disease, such as unsteadiness, seizures or visual dis-turbances. Subtle behavioural disturbances or school dicultiescan be important early warning symptoms o a structural aetiol-ogy, but may also occur when the pain becomes chronic. A pasthistory o head injury or other neurological problems may berelevant. School absence can be a useul proxy measure or theseverity o the problem. A amily member with headaches maygive a clue to the cause but may also be acting as a role modelor the headache behaviour.Symptoms that suggest a secondary cause or the headachesare given inTable 3.
The ocus o the examination will be determined by the historyand clinical context. It is helpul to divide the child presentingwith an acute severe headache as an emergency rom the childwith other temporal patterns o headache as the causes are some-what dierent (Tables 1 and 4). Lewis and Qureshi
ound thatchildren presenting to the emergency room with an acute head-ache most commonly had a ebrile illness related to an upperrespiratory tract inection. A serious underlying neurological diag-nosis was uncommon, and all these patients had clear objectiveneurological signs. Signs o an inective aetiology, both intra- and
Important causes o acute headache
Ts hadach 
lh ds
Ata hts 
iaat dsas
Kawasak dsas
oth ca vasca dsas 
itacaa haha
Ba t 
Vasca aa
idathc tacaa hts
pst taatc
Table 1
Things to ask about headache
D  hav  tha  t  hadach?Hw dd th hadach b?Was th asscatd taa  ct?Hw  has th hadach b st?A th sts tt btt, ws  sta th sa?Hw t d th sts cc?Hw  d th ast?D th hadachs cc at a atca t  ccstac?is th hadach cdd b a wa?Wh ds t ht?What st  a s t? is t d  sha?D  hav a asscatd sts d th hadach?is th a asa  vt?D  st what  a d d th hadach?A th actvts that ak th hadach ws?Ds ath ak th hadach btt?D  hav a th dca bs?A  tak a dcat?Ds a    a hav hadachs?What d  thk s cas  hadach?
Table 2
SympoSium: neurology
pAeDiATriCS AnD CHilD HeAlTH 18:1
© 2007 esv ltd. A hts svd.
extra-cranial, must thereore be specically sought; as well assigns o acutely raised pressure and intracranial haemorrhage.In the outpatient setting most children will have acute recur-rent or chronic non- progressive headaches, but it is the rarechild with chronic progressive headaches that we need to iden-tiy.Table 4lists the major causes o headache in the clinicpopulation.
Given this list it is not surprising that the clinical examina-tion in this situation is invariably normal. Important aspects o the general physical examination are height, weight and bloodpressure. Specic eatures o the neurological examination thatmay indicate a secondary cause are given inTable 5.
Careul history taking and examination should allow identica-tion o the ew children who require urther investigation. It isagain helpul to divide the investigation o the child with an acutesevere headache rom the child with other temporal patterns o headache as the investigations that need to be considered aredierent.
 Acute severe headache
In acute severe headache, routine laboratory investigations maybe helpul given that intercurrent inection is the commonestcause. Lumbar puncture with measurement o the opening pres-sure may be needed i subarachnoid haemorrhage, meningitis oridiopathic intracranial hypertension are diagnostic possibilities.Skull X-ray and EEG are o extremely limited value. An urgentinitial computerized tomography (CT) scan may be required i acute hydrocephalus, haemorrhage or a structural lesion are sus-pected. A CT brain scan with contrast will demonstrate nearly allstructural lesions; one done without contrast is somewhat morelimited in its sensitivity, although it can dene hydrocephalusand haemorrhage easily. Magnetic resonance imaging (MRI) isless readily available; less good at demonstrating acute bloodand makes monitoring the ill patient more dicult so it is not theinitial method o choice in this situation.
Table 6lists the eatures in the history and examination thatindicate imaging should be strongly considered.
Other temporal patterns o headache
In the outpatient setting the cause or the child’s headache isusually clear rom the history and examination. Neuroimag-ing is rarely necessary and o little value, unless the historyor examination suggests a structural aetiology. I the history istypical or migraine and the neurological examination is nor-mal, no imaging is required. Raised intracranial pressure dueto a tumour is the major concern or the amily and the reer-ring clinician; however, the symptoms and signs should rarely
Symptoms suggestive o a secondary cause
Headache history 
Sht hst
‘Fst  wst’ hadach
rct sv hadach(s)  a w wks 
Accatd cs
icas qc
Ws sa hadach 
Hadach t ad st
ma  s
i th  b tt 
ma  ws wh  dw, vd whht (ssts asd ss)
Ws wth bd, ch, tc
ma ht, vd wh  dw (sstsw ss hadach)
 Associated symptoms
Vt  s  b tt 
Cs, ad cscsss
Atd sat
Fca wakss
Fv, s
Table 3
Major causes o headache in the clinic population
mawtht aa24.mawth aa 6.0Ccatd a2.4esdc ts-thadach15.0Chc tsthadach2.9mxd c a ad sdc tshadach4.2mxd c a ad chc tshadach6.2n-scfc hadach12.othscfc dass cbats 6.0
Table 4
Signs suggestive o secondary headache
Signs o raised intracranial pressure
la  accat had ccc 
Cackd t s 
iV v as
Other signs o CNS disease
oth caa v ass 
Bast ss 
oth ca ca ss, .. ha 
Cba ss, .. ataxa, stas
Signs o other systemic diseaseTable 5

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