Headaches in ChildrenHeadaches in Children
Learn the Causes of Headaches inLearn the Causes of Headaches in
Learn common causes of chronicLearn common causes of chronic
headache and common causes of severeheadache and common causes of severe
Learn to evaluate a patient withLearn to evaluate a patient with
Understand parental concerns.Understand parental concerns.
The term headache should encompass all
aches and pains located in the head, but in
practice its applications is restricted to
discomfort in the region of the cranial volt.
Headache, or cephalalgia, is defined as
diffuse pain in various parts of the head, with
the pain not confined to the area of
distribution of a nerve
Incidence of Chronic or recurrent headacheIncidence of Chronic or recurrent headache
40% by age 7 years.40% by age 7 years.
75% by age 15 years.75% by age 15 years.
Accounts for 10% referrals to NeurologistAccounts for 10% referrals to Neurologist..
(International headache society)
•Migraine without aura.
•Migraine with aura.
2.Tension type headache
4.Miscellaneous headache not associated with
Idiopathic stabbing headache.
Cold stimulus headache .
Benign cough headache .
Headache associated with sexual activity .
5.Headache associated with head trauma.
6.Headache associated with vascular disorder.
Acute ischaemic (CVD)
Intracranial haematoma .
Arteritis- Giant cell arteritis.
7. Headache associated with non vascular
8. Headache associated with substances or their
9. Headache associated with non
10. Headache associated with
11.Headache or facial pain associated
withdisorders of facial or cranial structures.
12.Cranial neuralgias ,nerve trunk
13.Headache not classified
TENSION TYPE HEADACHE.
Case history 1Case history 1
7 year old boy with history of frequent7 year old boy with history of frequent
headaches for the last 4 monthsheadaches for the last 4 months
Not responding to paracetamole andNot responding to paracetamole and
Ibuprofen and CodeineIbuprofen and Codeine
Not associated with vomitingNot associated with vomiting
CNS , eye, ears, and systemic examinationCNS , eye, ears, and systemic examination
were normalwere normal
Cranial CTCranial CT
More anxietyMore anxiety
The word "tension" implies that this typeThe word "tension" implies that this type
of headache can be attributed entirely toof headache can be attributed entirely to
tension or stress, which may maketension or stress, which may make
people with this type of headachepeople with this type of headache
reluctant to consult a physician.reluctant to consult a physician.
.. International Headache SocietyInternational Headache Society
diagnostic criteria for tension-typediagnostic criteria for tension-type
Primary diagnosisPrimary diagnosis
1.1. Headache hasHeadache has at leastat least two of the followingtwo of the following
Bilateral painBilateral pain
Mild to moderate painMild to moderate pain
No increased pain with physical exertionNo increased pain with physical exertion
2.2. AndAnd no more than one of the following:no more than one of the following:
Sensitivity to lightSensitivity to light
Sensitivity to soundSensitivity to sound
3.3. AndAnd neither of the following*:neither of the following*:
4.4. AndAnd duration of 30 minutes to 7 daysduration of 30 minutes to 7 days
Subdivision diagnosisSubdivision diagnosis
1.1. Episodic (<15 days/mo)Episodic (<15 days/mo) oror chronic (chronic (>>1515
days/mo for >6 mo)days/mo for >6 mo)
2.2. Associated withAssociated with oror not associated withnot associated with
coexisting pericranial muscle tenderness**coexisting pericranial muscle tenderness**
**Chronic tension-type headache may include oneChronic tension-type headache may include one
of these symptoms.of these symptoms.
**Diagnosed by manual palpation or**Diagnosed by manual palpation or
electromyographic studies.electromyographic studies.
Adapted from Headache Classification Committee of the InternationalAdapted from Headache Classification Committee of the International
Headache Society (2).Headache Society (2).
Raeder’s syndrome, Histamine cephalalgia, Red
migraine, paroxysmal nocturnal cephalagia.
Age – 20 to 50 yrs.
Sex – men are affected 7 to 8 times more than
The pain begins without warnings & reaches a
crescendo within 5 minutes. Each attack last for
30 min to 2 hours.
1 – 3 short-lived attacks/day over a 4 – 8 weeks
period, followed by a pain free interval that
average one year.
Almost always the same orbit is involved
The pain is excruciating in intensity &
deep, non-fluctuating and explosive in
Associated with - homolateral
lacrimation, red eye, miosis, lid ptosis, nasal
stuffiness & nausea.
Onset is nocturnal is about 50% of the
cases & then pain usually awakens the
patients within 2 hours of falling asleep.
Diagnostic Criteria for ClusterDiagnostic Criteria for Cluster
A At least five attacks fulfilling criteria B through DA At least five attacks fulfilling criteria B through D
B Severe unilateral orbital, supraorbital and/orB Severe unilateral orbital, supraorbital and/or
temporal pain lasting 15 to 180 minutes (untreated)temporal pain lasting 15 to 180 minutes (untreated)
C .Headache associated with at least one of theC .Headache associated with at least one of the
following signs on the pain side:following signs on the pain side:
Nasal congestionNasal congestion
Forehead and facialForehead and facial
Eyelid edemaEyelid edema
D. Frequency of attacks: one attack every otherD. Frequency of attacks: one attack every other
day to eight attacksday to eight attacks
Case history 2Case history 2
A 10 year old boy with history of headache for 4A 10 year old boy with history of headache for 4
Started as funny feeling inside his abdomenStarted as funny feeling inside his abdomen
Pain round the right eyePain round the right eye
Pain spread all over his headPain spread all over his head
Fatigue, lethargic and want to sleepFatigue, lethargic and want to sleep
Periodic, commonly unilateral, often pulsatile headache,
begins in childhood, adolescence, or early adult life & recur
with diminishing frequency during advancing years.
Associated with nausea, vomiting and/or other symptoms
of neurological dysfunction of varying admixture.
The attacks cease during pregnancy in 75-80% of women.
Some patients link their attacks to certain dietary
items – chocolate, cheese, fatty foods, orange,
In others headache are consistently induced by –
exposure to glare or other strong sensory stimuli
Sudden jarring of the head.
Rapid change in barometric pressure.
Lack of sleep.
Migraine with aura:
Changes in mood (surge of energy & feeling of well
being), appetite (hunger or anorexia).
Visual disturbance – Unformed flashes of white or
multicoloured light (Photopsia), An enlarging blind spot
with a shimmering edge (scintillating scotoma), formation
of dazzling zigzag lines-, (fortification spectra), blurred or
Sensory disturbance – Numbness & tingling of the lips
face & hand.
Motor disturbance – Weakness of an arm or leg, mild
aphasia or dysarthria.
Ophtlamoplegic migraine :
Recurrent unilateral associated with weakness of the
extra ocular muscle – A transient 3rd or 6th nerve palsy.
More common in children.
Headache associated with monocular blindness due to
retinal or ant. optic nerve ischaemia.
The patient first develop total blindness which is
accompanied by admixture of – vertigo, ataxia,
dysarthria, tinnitus, & distal or perioral paresthesia.
The neurological symptoms are followed by throbbing
Childhood periodic syndrome:
Instead of complaining of headache, the child appears
limp & pale & complains of abdominal pain. Vomiting is
more common than in the adult..
Migraine with dramatic transient focal neurologic
features. Or, migraine attack that leaves a persisting
residual neurologic deficit.
Migraine patient who lapses into a condition of daily or
virtually continuous migraine.
Modified Diagnostic Criteria for Migraine
Episodic attacks of headache lasting 4-72hr
With two of the following symptoms:
•Aggravation on movement.
•Pain of moderate or severe intensity.
And one of the following symptoms:
•Nausea or vomiting.
•Photophobia or Phonophobia.
Diagnostic Criteria for MigraineDiagnostic Criteria for Migraine Migraine without auraMigraine without aura
At least five attacks fulfilling criteria B through DAt least five attacks fulfilling criteria B through D
Headache lasting 4 to 72 hours (untreated or unsuccessfully treated)Headache lasting 4 to 72 hours (untreated or unsuccessfully treated)
At least two of the following pain characteristics:At least two of the following pain characteristics:
Unilateral locationUnilateral location
Pulsating qualityPulsating quality
Moderate or severe intensityModerate or severe intensity
Aggravation by walking stairs or similar physical activityAggravation by walking stairs or similar physical activity
During headache, at least one of the following:During headache, at least one of the following:
Nausea and/or vomitingNausea and/or vomiting
Photophobia and phonophobiaPhotophobia and phonophobia
Migraine with auraMigraine with aura
At least two attacks fulfilling criterion BAt least two attacks fulfilling criterion B
At least three of the following characteristics:At least three of the following characteristics:
One or more fully reversible aura symptoms indicating focal cerebral corticalOne or more fully reversible aura symptoms indicating focal cerebral cortical
and/or brain-stem dysfunctionand/or brain-stem dysfunction
At least one aura symptom develops gradually over more than 4 minutes, or twoAt least one aura symptom develops gradually over more than 4 minutes, or two
or more symptoms occur in succession.or more symptoms occur in succession.
No aura symptom lasts more than 60 minutes; if more than one aura symptom isNo aura symptom lasts more than 60 minutes; if more than one aura symptom is
present, accepted duration is proportionally increased.present, accepted duration is proportionally increased.
Headache follows aura, with a free interval of less than 60 minutes (headacheHeadache follows aura, with a free interval of less than 60 minutes (headache
may also begin before or simultaneously with aura).may also begin before or simultaneously with aura).
B. Pharmacologic therapy:
Staged approach to migraine
StageStage DiagnosisDiagnosis TherapiesTherapies
MildMild • Occasional throbbingOccasional throbbing
headache (less than oneheadache (less than one
attack per month)attack per month)
• No major impairment ofNo major impairment of
• Control of migraineControl of migraine
attacks –attacks –
ModerateModerate • Some impairment of function.Some impairment of function.
• Moderate or severeModerate or severe
headache (1-3 attacks perheadache (1-3 attacks per
• Nausea commonNausea common
• Control of migraineControl of migraine
attacks –attacks –
SevereSevere • Severe headache (>3 attacksSevere headache (>3 attacks
per month)per month)
• Marked nausea and/orMarked nausea and/or
• Significant functionalSignificant functional
• Control of migraineControl of migraine
Control of acute migraine attacks:
The drugs should be taken as soon as the headache
component of the attack is recognized.
Drugs used in the control of migraine attacks are
5HT agonist (Oral, Nasal, SC, IM, or IV)
Dopamine antagonists (Oral, IM or IV).
The vast majority of migraine attacks can be treated solely
with mild analgesics such as –
• Other NSAIDs –
•The combination of Acetaminophen, Aspirin & Caffeine has
been approved for use by the FDA for the treatment of mild
to moderate migraine.
•The combination of Acetaminophen, Dichloral phenazone
& Isometheptene has been classified by the FDA as
“possibly” effective in the treatment of migraine.
5HT agonist (Oral, Nasal, SC, IM, or IV):
Ergot derivatives –
Ergotamine & Dihydro ergotamine (DHE)
Ergot preparation can be taken – Orally,
Sublingually, Rectally, IM, IV, Inhalers.
Indications for migraine
Attacks occur >2-4 times per month
Disability occurs > 3 days per month
Duration of attack > 48 h
Medications for acute attack are ineffective, C.I or
Attacks produce prolonged aura or true migrainous
Duration of prophylactic therapy
The optimum duration of prophylactic therapy is uncertain
The approach is to treat for 6-12 months and then taper
over the course of several weeks.
Data are limited on the effectiveness of preventive agents
DRUGS USED FOR PROPHYLAXIS OF MIGRAINEDRUGS USED FOR PROPHYLAXIS OF MIGRAINE
Sodium valproateSodium valproate
These drugs are approved by FDA, USA.These drugs are approved by FDA, USA.
Amitryptyline, Nortryptilline.Amitryptyline, Nortryptilline.
Phenelzine, Cyproheptadine.Phenelzine, Cyproheptadine.
Under research:Under research:
•Accurate history taking is fundamental
•Need for further investigation is
determined by red flag symptoms
•Or symptoms that do not corresponding
to a recognised primary headache pattern
1.Age, sex, occupation:
Migraine headache – more frequent in teenagers &
young adults, higher occurrence in female.
Cluster headache – almost exclusively in males.
Cranial arteritis – more frequently in late middle age & in
Tension headache -often has long duration.
Headache due to expanding of intracranial disease –
usually short duration.
Headache due to meningeal cause – acute in onset.
Migraine headache – recur over a long period of time,
with symptoms free interval between attacks
DIAGNOSTIC APPROACH: Contd..
3. Location of headache:
As a general rule localized headache is of greater
significance than diffuse headache.
Tension headache – typically generalized, band
like or bioccipital.
Migraine with aura – often unilateral & frequently
more prominent interiorly.
Migraine without aura – frequently bilateral.
Cluster headache – invariably limited to the same
side of the head in any given attacks & usually
8. Frequency, duration & diurnal variation:
Tension headache – often persist & may worsen as the day
Migraine headache – the frequency is variable & unpredictable.
Although usual variation is from 4 - 72 hrs, they may persist for
Cluster headache – occur repetitively over a period of weeks or
months. Often there are 1 or 2 attacks daily. The headache
typically nocturnal & of brief duration (30 min to a few hours).
9. Family history:
Migraine headache – strong family history.
Cluster headache – are not familial.
Red flag for secondary headache - Silberstein SD et al
Systemic symptoms or secondary
Fever,W. Loss,or known cancer,HIV,
immunosupression or thrombotic risks
Nerological symptoms or
persistent focal signs> 1 H
onset First and worst headache,sudden abrupt
from sleep, or progressively worsening
older New onset and progressive-Giant cell
Previous headache history Significant change in features, freq. or
Triggered headache By valsalva, exertion, sexual intercourse
When to scan a patient withWhen to scan a patient with
First or worst headache, particularly if of suddenFirst or worst headache, particularly if of sudden
Headache of increasing frequency or severity.Headache of increasing frequency or severity.
Increased frequency of vomiting and headache onIncreased frequency of vomiting and headache on
Headache triggered by coughing, straining orHeadache triggered by coughing, straining or
postural changes.postural changes.
Persistent physical symptoms or signs after attackPersistent physical symptoms or signs after attack
(neurological or endocrine)(neurological or endocrine)
Meningism, confusion,impairment ofMeningism, confusion,impairment of
consciousness or seizures.consciousness or seizures.