HEADACHE
Headache is a common but often under-recognized problem in children, due to their inability to describe it. Head-banging is an important indicator of headache in young children. Though all children occasionally experience headache, recurrent/persistent headache is a cause for concern and needs investigation.
Etiology: Headache disorders in children may be broadly classified as—(a) Primary (Functional) headaches, e.g. migraine or tension headaches; (b) Secondary (Organic) headaches due to underlying neurological or extra- neurological cause (Table 18.12).
Recurrent headache is more likely to be organic in pre-school children, while psychosomatic headaches are more common in older children. Tension headache is the commonest cause of headache in school age children. Diagnostic evaluation: A careful history and thorough neurological examination is often enough to differentiate benign headaches from potentially pathological causes. Important diagnostic clues in headache include:
• Location and character of headache along with other characteristics, e.g. mode of onset, frequency of attacks, diurnal variation and precipitating/relieving factors.
• Tension/stress headache
- Anxiety and stress
- Occipital neuralgia (unstable atlantoaxial joint)
• Vascular headache (Migraine)
• Intracranial pathology (#8593; ICP)
- ICSOL*- tumors, tuberculoma, NCC
- Infections - meningitis, encephalitis
- Hydrocephalus/pseudotumor cerebri
- Cerbrovascular malformations
- Hypertensive encephalopathy
- Post-traumatic brain injury
• Extracranial headache
- Ophthalmic - Refractive errors
- ENT - Chronic sinusitis
- Dental problems
• Psychogenic: Conversion reactions, depression
• Others: Lead poisoning, premenstrual syndrome
• Idiopathic
• Intracranial space occupying lesions.
• Presence of associated complaints, e.g.
vomiting, visual problems or other neurological symptoms.• Baseline examination for refractory errors and ENT check-up including sinus X-rays.
• Red-flag signs: Neuroimaging with CT/MRI is indicated only in children with—(a) abnormal neurological signs, (b) recent behavioral changes, (c) and
(d) predominantly morning headache with vomiting,
(e) papilledema, (f) associated seizures (? AV malformations), and (g) cluster headaches or severe headache during sleep.
Some important causes of headache in childhood are discussed here:
Tension headaches are related to periods of anxiety and stress at home or school, which may unconsciously produce constant isometric contraction of face and neck muscles.
Tension headaches are—(a) typically dull aching, (b) diffuse or variable in location, (c) more common after or during school hours and (d) not associated with nausea, vomiting or other symptoms. Persistent spasm of neck muscles indicates possibility of unstable atlantoaxial joint (occipital neuralgia) in some cases.
Diagnosis of tension headache depends on careful history including psychological evaluation and exclusion of other causes. Most cases may be treated with mild analgesics and behavioral therapy.
Intracranial or traction headache indicates raised ICP leading to traction/tension on cerebral vessels or dura matter. These headaches are typically—(a) common in early mornings, (b) localized in frontal or occipital region, (c) worsen after any activity that further raises ICT, e.g. coughing or sneezing, and (d) associated with projectile vomiting, behavioral changes and papilledema. Diagnosis and treatment depends on individual causative condition.
TABLE 18.13: Diagnostic criteria for migraine in children
a. Recurrent headache with at least gt; 5 attacks, and
b. Headache lasting for 2-72 hours, and
c. Headache with at least two of the following:
- Bilateral or unilateral (frontal/temporal)
- Pulsating quality
- Moderate to severe intensity
- Aggravated by routine physical activity
- Accompanied by at least one of the following:
#9830; Nausea and/or vomiting
#9830; Photophobia or phonophobia
Ophthalmic headaches, caused by uncorrected refractive errors, are often difficult to distinguish from tension headaches. These cases usually present with dull aching frontal headache, more common in evenings and frequent rubbing of eyes.
Sinus headaches due to chronic ENT problems are common in older children and typically become more prominent in head-low position like during reading. Localized sinus tenderness, sinus skiagrams and abnormal ENT findings can establish etiology in these cases.
Migraine: Migraine in children is classified as with or without aura, though Migraine without aura is more common in children, characterised by recurrent headache with at least gt;5 attacks fulfilling all pediatric migraine diagnostic criteria (Table 18.13). History of more than two attacks fulfilling above criteria can also be considered as significant in presence of aura.
Prevalence: Unlike general impression, migraine is not uncommon in children, with estimated incidence of ~4-5% in school-age group and higher (~20-25%) in adolescents, specially girls.
Etiology: Exact cause is unknown, but an inherited predisposition to vasomotor instability appears to be an important underlying factor.
Clinically, most cases of childhood migraine present in early school age with paroxysmal and recurrent attacks of throbbing/pulsating headache associated with vomiting and nausea. Each attack usually lasts for 2-3 hours. Family history is present in gt;90% cases. Characteristic hemicranial distribution and aura, seen in adults, is uncommon in children.
Other variants of migraine present with cyclical vomiting, benign paroxysmal vertigo, acute confusional states or rarely as complicated migraine with temporary localizing signs, e.g. alternating hemiplegia, ipsilateral III nerve palsies (ophthalmic migraine), impaired sensorium, vertigo, ataxia and diplopia (basilar migraine).
Diagnosis rests on clinical criteria mentioned earlier, with paroxysmal nature of attacks, positive family history and exclusion of other causes.
Management of migraine includes:
• Avoidance of precipitating factors, e.g. stress, fatigue, anxiety, hunger, blinking/bright lights, loud sound and probably certain foods, e.g. Chinese/spicy foods or chocolates.
• Management of acute attack with common analgesics, e.g. paracetamol or ibuprofen with/without antiemetics,
e. g. prochlorperazine or metochlopramide. Rizatriptan (PO 5 mg/dose, repeated in 2 hours to maximum 30 mg/day)-a 5-HT agonists, may be used in children gt;5 years of age with severe, refractory attacks of migraine. Other triptans, e.g. Sumatriptan, are not recommended in children. IV Sodium Valproate 15-20 mg/kg over 10 minutes has been used in adolescents with intractable attacks.
• Prophylactic therapy for very frequent and disabling attacks is not standardized in children and includes Propranolol (PO 2-4 mg/kg/day q12hr), Valproic acid (15-30 mg/kg/day q12hr), Flunarizine (5-10 mg/day HS), all taken orally. Topiramate and Amitriptyline may be used on adolescents above 12 years. Cyproheptadine (0.1-0.2 mg/kg BD) may be used in young children. Nutraceuticals, e.g. Riboflavin (25-400 mg/day) and Coenzyme-Q10 (1-2 mg/kg/d) have also shown promising results. Therapy should be continued for 4-6 months before tapering.
• Behavioral management and reassurance is needed to relieve the stress and anxiety associated with attacks. History of gt;2 attacks fulfilling above criteria can also be considered as significant in presence of aura.
18.6