This document discusses headaches in children. It classifies headaches as either primary or secondary. The most common primary headaches in children are migraine, tension headache, and cluster headache. Migraines affect 3-23% of children and symptoms include throbbing pain, sensitivity to light/sound, and nausea. Tension headaches are caused by emotional or physical stress and eye strain. The document provides guidelines for evaluating and managing common childhood headaches.

2. • Headache is common complaint in paediatric
population.
• Headache in children is headache of patients as
well as Pediatrician.
• Prevalence :
• < 7 years old : 35-50 %
• < 15 years old : 60-80 %
:: INTRODUCTION ::

3. :: CLASSIFICATION ::
Primary
Headache
Secondary
Headache
2
1
• According to (ICHD-II) - International
Classification of Headache disorders;
headaches are classified in two groups.

4. • [1] Primary headache :
• Headache is considered primary when a
disease or other medical condition does
not cause the headache.
• Primary headaches are benign, chronic
and not life threatening.
• Primary headaches fall into three main
types:
1. Migraine (16%)
2. Tension headache (69%)
3. Cluster headache

5. • [2] Secondary headache :
• Secondary headaches are due to
underlying medical conditions.
• It may be resulting from life threatening
diseases, early diagnosis is essential
• Most common causes are :
1. Infectious (63%) Sinusitis, Pharyngitis,
ear infections
2. Vascular
3. Traumatic (49%)
4. Mass lession

6. :: Headache in
Adult ::
:: DIFFERENCE ::
:: Headache in
Children ::
1. Duration : Attacks last 1-4 hours
2. Location : In contrast to adults children
often feel pain on both sides of the head

7. 3. Aura (warning signs) infrequent
4. Associated nausea, vomiting, abdominal pain
5. Prodromes and trigger factors common
6. Children may look pale and appear restless or
irritable before and during an attack
7. Other children may become nauseous, lose their
appetite, or feel pain elsewhere in the body
during the headache

8. 1. Limited verbal, language abilities.
2. Poor localization, quality
3. Non‐specific complaint
4. Associated with other illnesses
Diagnosis : A Challenge in Children :
• Misconception : headache doesn’t happen to
children
• Misconcepton : headache in children doesn’t
need to be treated

9. : Common types of headache :
Migraine
Tension :
Sinus :
Cluster :
(1)
(2)
(3)
(4)
• There are four very common types :
Primary
Primary
Secondary
Primary

10. • [1] Migraine :
• Symptoms:
1. Pain in the face or neck,
2. Throbbing in one area,
3. Sensitivity to light and sound,
4. Nausea, distorted vision
• Duration: 4 to 72 hours

11. • [2] Tension :
• Symptoms :
• Dull pain on either side of the head,
and pressure across the forehead
• Duration: 30 minutes to several hours
• [3] Sinus :
• Symptoms :
• Pain in the face, sinuses, eyes, ears or
forehead. Congestion, itching, runny nose,
fever, swelling in the face.
• Duration : several days to weeks (if treated)

12. • [4] Cluster :
• Symptoms :
1. severe pain on one side of the head,
2. usually around the eye,
3. accompanied with a drooping eyelid,
4. small pupil, tearing, runny nose or
redness on the same side of the head
• Duration :
• Can last for weeks or several months,
usually followed by a period of
remission that can last for several
months or several years.

13. 1. Acute recurrent : migraines
2. Acute Generalized : Systemic illness (Malaria, Flu,
Dengue)
3. Acute localized : OM, Sinusitis, Trauma
4. Acute Progressive : masses, haemorrhage
5. Chronic Non-progressive : depression, anxiety,
refractory error.
:: Common Clinical Headache Patterns :

14. :: Migraine in Children ::
• Migraine headaches are common in children,
their frequency increases through
adolescence.
• The mean age of onset : 7.2 yrs for boys and
10.9 yrs for girls, with prevalence rates :
1. 3% for children age 3-7 years
2. 4-11 % for children age 7-11 years (M>>>F)
3. 8-23% for children age 11-15 plus years
(F>M)

15. :: Clues to identify Migraine attacks ::
1. Sensitivity to light and noise : suspected
when a child :
2. Refuses to watch television or use the
computer
3. When the child stops playing and lie down
in a dark room.
4. Irritable and complaint of abdominal pain
during headache (abdominal migraine)

16. :: Precipitating factors of Migraine ::
Anxiety
Emotional Problems
Fatigue
Weather changes
Irregular eating and sleep
Dehydration, Food, certain drinks .
1.
2.
3.
4.
5.
6.
Stress from
School activities
Tension in
family Members

17. :: Tension Headache ::
• Tension type headache clearly occur in
children but have not been rigorously
studied. The common causes are :
1. Emotional stress : family, school, friends
2. Eye strain
3. Neck or back strain due to poor posture
4. Depression may also be reason
5. Anxiety
6. Abuse : physical, sexual, verbal

18. Approach to child with recurrent
headache :
History
Physical Examination
Laboratory or imaging studies
1st step : rule out secondary cause
1.
2.
3.
4.
Radiological
CT, MRI
Pathological
CBC, LP, Culture,
Sensivity

19. :: When to perform
Neuroimaging studies ?
Age : < 3 years
Abnormal
neurological exam
Chronic
Progressive pattern
1.
2.
3.

20. :: WARNING SIGNS ::
1. Suspected headache in a child below 3
years
2. Headache that is most severe in the
morning or which awakens one from sleep.
It improves as day progresses.
3. Headache that is relieved by vomiting
4. Hypertension and bradycardia
5. 6th nerve palsy (abducens), papiloedema
(swelling of optic nerve)

21. 6. Mecewen’s sign : (A crack pot sign),
7. Headache Which is persistently
occipital
8. If headache worsens with sneezing,
coughing, valsailva manoeuvre
9. Pulsating tinnitus
10. Confusion
11. Lack of family History of migraine
12. Lack of response to analgesics
13. Focal neurodeficits, localizing signs

22. :: EVALUATION ::
1. The first step in evaluating a child with
headache is to rule out secondary causes.
2. Detailed history and medical examination
necessary to differentiate primary from
secondary headache.
3. If child's headache become worse or
become more frequent despite treatment
referral to a specialist is required.

23. EVALUATION . . . . . .
1. After ruling out secondary causes of
headache, detailed work up should be done
regarding nature, pattern, precipitating
factors and associated comorbidities.
2. Specifically different anxiety disorders,
depression, adjustment problems,
somatization etcs should be ruled out.

24. :: MANAGEMENT OF
MOGRAINE ::
Pharmacological Therapy
for acute attack
Preventive therapy
Non-pharmacological
methods (relaxation )
1.
2.
3.

25. 1. Intermittent use of oral analgesic is the
mainstay of treatment; Both Ibuprofen and
acetaminophen have been shown to be safe and
effective
2. Sumatriptan is the only 5HT1 agonist that has
proven effective for the treatment of children
and with migraine with the nasal spray having
the most favorable profile
3. Narcotics should be avoided
4. Nausea and vomiting can be relieved by
antiemetic agents
[1] Pharmacological therapy for accute
attack ::

26. 1. Use of prophylactic agents Propranolol
and Flunazine should be reserved for
children with frequent or disabling
migraine headaches.
2. The Optium duration of prophylactic
therapy is uncertain.
3. Data are limited on the effectiveness of
preventive agents in children
[2] Preventive therapy ::

27. 1. Education
2. Relaxation therapy
3. Stress management
4. Sleep Hygiene
5. Eliminate triggers
6. Regular Exercise
[3] Non-Pharmacological methods :

28. 1. Low dose amirtiptyline (10 mg per day) may be
efficacious
2. Biobehavioural therapies, including relaxation
techniques show the evapentic benefits.
• Increasing use of computers, Laptops, Video
games and other electronic gadgets are triggering
acute headaches among teenagers in India.
Management : Tension type
Headaches ::

29. 1. Migraine (16%)
2. Tension
headache (69%)
3. Cluster
headache
:: RECAP ::
:: Headache ::
Primary Headache Secondary Headache
1. Infectious (63%)
Sinusitis, Pharyngitis,
ear infections
2. Vascular
3. Traumatic (49%)
4. Mass lession

30. :: Common types of headache ::
Migraine Tension Sinus Cluster
1 2 3 4