Headaches are common in children, and the number of children having headaches increases with increasing age.
Published studies in Sweden and Britain have shown that approximately 40% of children have experienced a headache by seven years of age, and this number increases to 70% by 15 years of age.
Most parents think headache is an uncommon symptom in children and often seek medical advice to ensure that their child’s headache is not a sign of a serious brain disease such as a brain tumour.
In the vast majority of paediatric headaches, clinicians are able to assure the child and family that the headache is not a sign of a serious illness.
Types of headaches
Migraine and tension-type headaches are the most common types of headache seen in children.
The underlying cause is unknown.
About 10% of school-going children experience migraine.
Children with migraines often have headache affecting both sides of the head, described as throbbing/pounding in nature, may last for a few hours, and is usually preceded by a change in behaviour, occasionally with aura (warning) symptoms of visual distortions.
During a migraine, children can have nausea, vomiting, or be sensitive to light or sound.
Tension-type headache, seen in 1% of children, are usually described as pressing or tightening in nature, last longer than migraines, and do not have the other features associated with a migraine.
Headaches that are associated with underlying neurological diseases are uncommon, while those due to a brain tumour are even rarer.
To put into context how rare this is, brain tumours in childhood only occur in three to five of every 100,000 children and only one in 10 of them will present with headache.
It is estimated that for every child with a headache due to a brain tumour, there are around 2,000 children with migraine.
The key to diagnosing the cause of the headache is a good history-taking, together with a careful physical and neurological examination.
School absence is also often used as a proxy indicator for the severity of the headache.
This approach will ensure that serious causes of the headache are unlikely to be missed.
Important red flags that may suggest a sinister cause for the headaches include:
• A short history of severe headaches for a few weeks.
• Headaches that are increasing in frequency and worsening in severity.
• Headaches that occur from sleep or first thing in the morning before getting up from bed.
• Headaches that are made worse when lying down, bending or coughing.
• Associated with unexplained vomiting during sleep or before waking up.
• Associated with other neurological problems including confusion, change in personality, muscle weakness, vision problems and seizures.
Important aspects of the general physical examination include measuring head circumference, height, weight and blood pressure.
A complete neurological examination including examining the back of the eyes is important.
Any abnormal neurological examination may indicate a secondary cause and warrants consideration of further investigation.
Time for a scan?
Serious causes of headache, such as a brain tumour, are a real worry for both parents and doctors.
While brain magnetic resonance imaging (MRI) scans are safe and effective in excluding the diagnosis of a tumour, it is not readily available and is not cost-effective to be used in mass screening of children with headache.
Computerised tomography (CT) is more accessible.
However, it involves exposure to significant doses of radiation, which makes it also unsuitable for mass screening of children with headaches.
Numerous studies and guidelines have reinforced this notion and have stated that a brain scan is not needed and is of little value if the history is typical of a primary headache and the examination (general physical and neurological examination) is normal.
Given the potential risks of a brain scan (including finding incidental findings that can increase anxiety unnecessarily, risk of sedation for young children requiring brain MRI scan and possible allergic reactions to radiological contrast), clinicians should continue to follow the recommended guidelines of avoiding performing brain scans solely for reassurance of parents.
Indications for neuroimaging in children with headache include:
• Features of increased intracranial brain pressure: swollen optic nerve on eye examination, night or early morning vomiting, large and accelerating head growth.
• New neurological symptoms: squint, seizures, unsteadiness, muscle weakness.
• Abnormal neurological examination including personality change or deterioration of school performance.
• Headache in children who are younger than three years old.
Addressing the concerns of the child and family, and assuring them that the headaches are not caused by a serious brain tumour is the priority of the clinician.
In developing a treatment strategy, it is important to establish the burden of the child’s headache on daily activities and quality of life.
A non-pharmacological approach is the first-line treatment strategy for headache.
The key is to empower the child and family to assume control of the child’s headache. This includes:
• Identifying headache patterns by using a headache diary and minimising possible precipitating factors to the headache.
Precipitating factors include missing meals, stress, physical exertion, food, bright light and hormonal changes.
• Teaching the child (and family) lifelong strategies in managing headaches, including relaxation, a healthy and balanced diet, good sleep hygiene and behaviour modification.
In addition to the non-pharmacological approach, some children may require standard pain-relief medication like paracetamol or ibuprofen during the headache. Other medication options may be considered by the clinician if the headaches continue to persist despite the strategies mentioned.
Assoc Prof Dr Fong Choong Yi is a consultant paediatric neurologist at the University Malaya Medical Centre. This article is courtesy of the Malaysian Association of Paediatric Surgery. For further information, e-mail firstname.lastname@example.org. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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