Headache is a common symptom in children and adolescents, with up to 75% experiencing a significant headache by age 15. Headaches can be primary, such as migraines or tension-type headaches, or secondary to other conditions such as viral infections. A thorough history and physical exam are usually sufficient for diagnosis, though imaging may be required if symptoms suggest increased intracranial pressure. Treatment involves acute medication to stop attacks as well as preventive medication and lifestyle modifications if headaches are frequent or disabling.

1. Headache in children
1
By:-
Jwan Ali Ahmed AlSofi

2. OUTLINE
2
• EPIDEMIOLOGY
• CLINICAL MANIFESTATIONS
• DIAGNOSTIC STUDIES
• TREATMENT

3. EPIDEMIOLOGY
3
• Headache is a common symptom among children and
adolescents.
• Up to 75% of children report having a significant
headache by the time they are 15 yr of age.

4. Cephalgia:-
• The International Classification of
Headache Disorders (ICHD)
defines headache as “pain located
above the orbitomeatal line
4

5. 5

6. Headaches can be:-
1. a primary problem (migraines, tension-type headaches)
• Primary headaches are most often recurrent, episodic
headaches.
• For most children are sporadic in their presentation .
• frequent headaches can have an enormous impact on the
life of the child and adolescent .
2.secondary to another condition.
1. are most often associated with minor illnesses such as
viral upper respiratory infections or sinusitis
2. but may be the first symptom of serious conditions
(meningitis, brain tumors), so a systematic approach is
necessary .
6

7. Four temporal patterns of childhood
headache:-
1. Acute
2. Acute recurrent
3. Chronic progressive
4. Chronic nonprogressive or chronic daily
7

8. 1. Acute headache:-
• Single episode of pain without a history of such
episodes.
• The “first and worst” headache raises concerns for
aneurysmal subarachnoid hemorrhage in adults, but is
commonly due to febrile illness related to upper respiratory
tract infection in children.
• Regardless, more Ominous causes of acute headache
(hemorrhage, meningitis, tumor) must be considered.
8

9. 2. Acute recurrent headache:-
• Pattern of attacks of pain separated by symptom-free
intervals.
• Primary headache syndromes, such as migraine or tension-
type headache, usually cause this pattern.
• Recurrent headaches are occasionally due to
▫ specific epilepsy syndromes (benign occipital epilepsy),
▫ substance abuse,
▫ recurrent trauma.
9

10. 3.Chronic progressive headache:-
• Implies a gradually increasing frequency and severity
of headache.
• The pathological correlate is increasing ICP.
• Causes of this pattern include
1. pseudotumor cerebri,
2. brain tumor,
3. hydrocephalus,
4. chronic meningitis,
5. brain abscess
6. subdural collections.
10

11. 4. Chronic nonprogressive or
chronic daily :-
•Pattern of frequent or constant headache.
•Chronic daily headache generally is defined as >3-mo
history of >15 headaches/mo, with headaches lasting
>4 hr.
•Affected patients have normal neurological
examinations; psychological factors and anxiety
about possible underlying organic causes are common.
11

12. Approach to a case with headache:-
12

13. Points in history childhood headache:-
• Onset of headache (sudden onset)
• Duration of headache and frequency (daily, weekly, monthly)
• Location of headache (frontal, temporal, occipital)
• Severity of headache (mild, moderate, severe)
• Types of headache (one type or more than one type)
• Static or progressive frequency/severity of headache
• Associated nausea, vomiting
• Associated photophobia, phonophobia
• Relation to specific circumstances, food, medication
• Is child able to perform his/her activities despite headache
• Past medical history: minor head trauma, viral infection, surgery, stress
• History of drug intake (anticonvulsants, anticoagulants,asthma medication)
• History of school experiences, dietary habits and family relationships
• History of dental pain, nasal discharge, facial pain
• History of seizure, altered sensorium, vertigo, gait abnormality, weakness,
vision and hearing difficulties
• Family history of headache
13

14. Focused examination for children with headache:-
• General physical examination:
• Cervical spine examination
• Palpation of bones and muscles
• Ears including external auditory meatus
• Temporomandibular (TM) joint, throat, dental examination
• Examination of 9-12th cranial nerve
• Blood pressure measurement
• Height (short stature often point to endocrinal causes)
• Eye examination
• Sinus examination (Miller's maneuver)
• Evaluation of increased intracranial pressure
• Teeth inspection, palpation
• Cardiovascular system (CVS) examination: murmur,
• Any evidence of neurocutaneous markers
• Presence of organomegaly, lymphadenopathy
14

15. 15

16. 16

17. Primary headaches:-
17

18. Tension-type headaches ( TTH )
18
• are the most common (48 % ) type of recurrent primary
headaches in children and adolescents.
• Because they are generally mild, without associated
symptoms, they typically do not disrupt daily activities.

19. 19
Analysis of the
Headache –
SOCRATES-
Tension-type headaches
Site Global
Character Squeezing or pressing – constriction band
Associated
Symptoms:-
• There is NO associated –
o Nausea
o Vomiting
o Phonophobia
o Photophobia
Timing Hours to days
Exacerbating
factors
1. Not aggravated by routine physical activity
2. Headaches can be related to environmental stresses or
symptomatic of underlying psychiatric illnesses, such as
anxiety or depression .
Severity Mild to moderate

20. Criteria to diagnose Tension-Headache:-
20

21. Migraine headaches
21
• Migraine headaches are another common type of recurrent headaches.
• Frequently begin in childhood.
 up to 10.6% between the ages of 5 and 15 yr.
 up to 28% of older adolescents.
• Headaches are stereotyped attacks
• Toddlers may be unable to verbalize the source of their discomfort and exhibit
episodes of irritability, sleepiness, pallor, and vomiting.
• Types of Migraine:-
1. Migraine With Aura
2. Migraine Without Aura
3. Childhood periodic syndromes
4. Chronic migraine

22. 22
Analysis of the
Headache –
SOCRATES-
Migraine headaches
Site frontal, bitemporal or unilateral,
Character pounding or throbbing pain
Associated
Symptoms:-
1. Nausea
2. Vomiting
3. Pallor
4. Photophobia
5. Phonophobia
6. an intense desire to seek a quiet, dark room for rest.
Timing last 1-72 hours.
Exacerbating
factors
aggravated by activity
Severity moderate to severe,

23. Criteria to diagnose Migraine:-
23

24. • Migraine Without Aura
• Migraine without aura is the most common form of migraine in both children and adults.
• (at least five headaches that meet the criteria, typically over the past year
• Migraine With Aura ( At least 2 attacks )
• Aura a neurologic warning that a migraine is going to occur. (start of a typical migraine or isolated aura ).
• Typical aura : visual, sensory, or dysphasic
• Visual auras are very common and consist of spots, flashes, or lines of light that flicker in one or both
visual fields .
• The most common type of visual aura in children and adolescents is photopsia (flashes of light or light
bulbs going off everywhere).
• Atypical aura :
1. hemiparesis,
2. monocular blindness,
3. ophthalmoplegia,
4. Vertigo
5. confusion
• lasting longer than 5 min and less than 60 min
• the headache starting within 60 minutes
• unilateral
• reversible
2
4

25. 25

26. Pathophysiology of Migraine:-
• Trigeminal centre – junctional box  perivascular nerve endings 
Calcitonin Gene-Related Peptide CGRP  mast cell
degranulation.
• CGRP monoclonal antibody - Erenumab
• CGRP receptor antagonists – ("gepants")
26

27. Secondary headaches:-
27

28. Red flags (snoopy) indicates secondary headache:-
• Fever / weight loss / projectile vomiting
S –
systemic
• Focal neurological signs /meningeal signs /
papilledema / CN palsy
N –
neurological
S/S
• Sudden onset
• Onset during sleep
O –
onset
• Positional –
• During upright posture  spontaneous intracranial hypotension
• During lying  Idiopathic intracranial hypertension
• Precipitated by – Valsalva  ↑ ICP
• Progressive
• Parents – lack of FMHx
P –
pattern
• Young age < 5-7 years
Y –
years

29. Secondary headaches
2
9
• Common causes :
1. viral illness
2. sinusitis
3. Medication-overuse headaches
4. Head trauma
• Serious causes :
• Increased intracranial pressure (ICP) caused by
• a mass (tumor, vascular malformation)
• intrinsic increase in pressure (pseudotumor cerebri )

30. Increased ICP should be suspected :
1. associated vomiting
2. worse when lying down or on first awakening
3. awaken the child from sleep
4. exacerbated by coughing, Valsalva maneuver, or bending over
5. Papilledema
6. focal neurological deficits
3
0

31. 31

32. DIAGNOSTIC STUDIES
3
2
• For most children, a thorough history and physical examination
provide an accurate diagnosis and obviate the need for further testing.
• The history needs to include a thorough evaluation of the
1. prodromal symptoms,
2. any potential triggering events
3. timing of the headaches,
4. associated neurologic symptoms,
5. a detailed characterization of the headache attacks, including
I. frequency,
II. severity,
III. duration,
IV. associated symptoms,
V. use of medication
VI. disability.

33.  Neuroimaging is usually not necessary.
 Imaging is indicated if
1. symptoms of increased ICP,
2. there are unusual neurological features during the headache
(atypical aura),
3. the headaches are progressively worsening.
4. the patient has an abnormal neurological examination,
 In these cases, brain MRI with and without gadolinium
contrast, is the study of choice, providing the highest sensitivity
for detecting posterior fossa lesions and other, more subtle
abnormalities.
3
3

34. When the headache has a sudden, severe onset, emergent CT
should be done.
 Brain CT can quickly evaluate for intracranial bleeding.
 If the CT is negative, a lumbar puncture should be performed
to
1. measure opening pressure
2. evaluate for pleocytosis,
3. elevated red blood cells
4. xanthochromia.
3
4

35. 3
5

36. TREATMENT
3
6
• Secondary headache : depending on cause
• Tension-type headaches :
1. acute therapy to stop attacks,
2. preventive therapy when frequent or chronic
3. behavioral therapy

37. TREATMENT
3
7
• Migraine headaches :
1. acute treatment for stopping a headache attack with the
goal being 2 hr maximum
2. preventive treatment
3. biobehavioral therapy

38. • Symptomatic therapy requires early analgesic administration
• Acetaminophen or a NSAID such as ibuprofen or naproxen
sodium is often effective.
• rest in a quiet, dark room.
• Hydration and antiemetics are useful adjunctive therapies
3
8

39. • If these first-line medications are insufficient, triptan
agents (serotonin receptor agonists ) may be
considered.
• Triptans are contraindicated for patients with focal
neurological deficits associated with their migraines or
signs consistent with basilar migraine (syncope) because
of the risk of stroke .
3
9

40. • The limitation of any analgesic to not more than three
headaches a week is necessary to prevent the
transformation of the migraines into medication-
overuse headaches .
4
0

41. Prophylactic treatment
41
• Children with more than one disabling headache per
week may require daily preventive agents to reduce both
attack frequency and severity.
1. When the headaches are frequent (more than one
headache per week)
2. disabling (causing the patient to miss school, home, or
social activities,

42. Preventive medications
4
2
1. tricyclic antidepressants (amitriptyline, nortriptyline)
2. anticonvulsants (topiramate, valproic acid)
3. antihistamines (cyproheptadine)
4. beta-blockers (propranolol)
5. calcium channel blockers (verapamil).

43. 43

44. lifestyle modifications must be put into place to
1. regulate sleep, daily routines
2. Exercise
3. to identify and eliminate any precipitating or
aggravating influences (caffeine, certain
foods, stress, missed meals, dehydration ).
4
4

45. Other adjunctive treatment options include
1. psychological support,
2. stress management
3. biofeedback.
4
5

46. • References
4
6