Headaches and Migraines in Children

Headache is very common in school aged children affecting as high as 75% of that group. Headache is primary If that is the only symptom/sign, whereas it is secondary if any known condition like infection, injury or a brain tumor is the underlying mechanism. Primary headaches are most commonly due to migraine, followed by tension type headache. Other rare types of primary headaches are very uncommon in children.

It is a genetic condition characterized by a throbbing headache, associated with nausea/vomiting, light and sound sensitivity, lasting more than 30 minutes. There may be many provoking factors like stress, hunger, specific type of smell or food. Sleeping in a dark, quiet room helps. Aura (visual symptoms, dizziness, abnormal sensation) may precede, follow or accompany headaches in some cases when we term that migraine as migraine with aura; the other type is migraine without aura. If headache persists more than 15 days a month for 3 months, the term chronic migraine is used. Overuse of caffeine, analgesics, untreated anxiety or depression, stress may be responsible for the chronicity. Migraine may manifest differently in an infant or young child: abdominal colic, torticollis (twisting of the neck), paroxysmal vertigo, motion sickness or cyclic vomiting. These are alternately termed as migraine variants. In between attacks, examination is completely normal.

These headaches are typically dull aches, non throbbing, located bilaterally, either in the front or back of head, modest in degree, not associated with aura or vomiting; minimal light sensitivity may be present. Prolonged abnormal posture, eye strain through overuse of computer, or stress may be the provoking factor/s. Examination is typically normal.

These are usually associated with viral infection, sinusitis, head injury, rarely meningitis or brain tumor or hemorrhage. Thorough history and clinical examination help in unraveling the secondary cause. The red flags pointing to serious causes for headache are progressive course, new onset with extreme severity, fever, head injury, prominent neck pain, awakening due to headache, and very young age.

Detailed history and examination are quintessential for deciding tests. No investigation is needed if history points to the diagnosis of migraine or tension type headache, further reassured by normal examination findings. In presence of red flags as mentioned above, either CT head (if injury) or MRI brain or other directed investigations may be ordered.

The management depends on the specific diagnosis of headache.

In migraine, lifestyle measures like healthy diet, management of weight, regular exercise, good night's sleep, maintaining a headache diary and avoiding the provoking factors are very important preventive measures. Medications like amitriptyline, topiramate, cyproheptadine, propranolol or riboflavin have been used as preventive medications. During acute episodes, triptans in the form of rizatriptan, sumatriptan, zolmitriptan or almotriptan have been used to abort a spell when used early. In case of fully established acute attack, sleeping in a dark quiet room after a cold shower, using ibuprofen or acetaminophen, medication to promote sleep like Benadryl, and symptomatic treatment for nausea/vomiting using ondansetron may help.

For tension type headache, correction of abnormal posture, minimizing stress, avoiding eye strain may prevent recurrence. During acute symptoms ibuprofen, naproxen or acetaminophen and relaxation help.

For secondary headaches, management of the underlying disorder is essential.