pAeDiATriCS AnD CHilD HeAlTH 18:1
© 2007 esv ltd. A hts svd.
Evaluation o headachesin children
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Headaches are common in children and the prevalence increaseswith increasing age. In our practice, almost hal o reerrals romprimary care are because o headache. Unortunately, 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 oten 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%
MB BS MRCPCH
is a Specialist Registrar inPaediatric Neurology at Morriston Hospital, Swansea, Wales, UK.
Catharine P White
MB BS FRCP FRCPCH
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 aects 1–3% o children by age 7 years and 4–11%by age 15 years.
Abu-Aereh 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 signicant 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 careul examination will ensurethat serious causes are unlikely to be missed. This process shouldalso be therapeutic and reassuring to the parents and child.
Classiying paediatric headaches
In 1988 The International Headache Society
published a clas-sication 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-sication needed ne tuning, especially in relation to the classi-cation o headaches in children and adolescents, and the revisedclassication was published in 2004.
Although standard teaching is to consider migraine and ten-sion headache as completely dierent entities, it is much morelikely that they lie on a continuum.
This theory ts better withclinical practice.Clinically it can be more helpul initially to divide headacheinto one o our broad types depending on the temporal pattern
acute recurrent (episodic);
headache is dened 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 tractinection,
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 classied as
headache. Primary headachesyndromes, such as migraine or tension-type headache, usuallycause this pattern. Inrequently, recurrent headaches are attribut-able to epilepsy or cluster headache.In
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.