Pediatric  Dental  Health

• A headache is a symptom of an underlying medical problem.
• The pain which is perceived in the head (referred pain) actually arises from dilation, pressure, or displacement of:
  large cranial veins or venous sinuses, head and neck muscles, intracranial or extracranial arteries, the basal meninges (covering of the brain), or structures outside of the cranium – such as teeth and nasal sinuses.
• Migraine headache pain is even more complex. During a migraine attack, cerebral blood flow is increased in the upper brain stem. This painful vasodilation of the cranial vasculature is perceived in the front of the head as a headache. Complex neurochemical changes are associated with migraine. Nitric oxide has a key role in initiating and maintaining a migraine headache.
  
  WHAT TYPES OF HEACHES ARE THERE?
• Acute Headache: a single episode of head pain without previous headaches.
• Acute-recurrent Headache: a pattern of headache, separated by pain-free intervals. Migraine is the most common form of acute-recurrent headache in children.
• Chronic-progressive Headache: this is the most ominous pattern of headache. There is a gradual increase in the severity and frequency of headaches. Intracranial pathology should be suspected in these cases.
• Chronic-nonprogressive (daily) Headache: frequent, constant headache. It is typically a tension or muscle contraction headache. This headache is diffuse, symmetrically distributed, and often described as “band-like.”
  
  WHAT CAUSES HEADACHES?
• Most isolated and non-traumatic headaches in children are caused by conditions such as: upper respiratory infection, sinusitis, or migraine.
• Common triggers for childhood migraine include: disrupted sleep, stress, overuse of pain medication (rebound headache), and skipped meals. Caffeine abuse or caffeine withdrawal can also cause headaches in children.
• The headache diary is an important tool in the diagnosis and treatment of headache, because it helps children and parents to identify triggers factors that may induce headache.
• Chronic progressive headaches are a cause for concern. The possible causes for this ominous form of headache include: brain tumor, brain abscess, subdural hematoma, pseudotumor cerebri (benign), or hydrocephalus.
• Chronic nonprogressive headaches are more common in girls, and are frequently associated with stress, depression, anxiety, or somatic preoccupation.
  
  CAN A HEADACHE BE DANGEROUS?
• Headache signs or symptoms which require additional medical investigation include:
  Recent onset of headache, increasing severity and frequency of headache, morning or night-time occurrence, headache which awakens a child from a deep sleep, increased severity and frequency of vomiting, drowsiness, mood swings, or visual problems.
• Intracranial pathology may exist when a chronic-progressive headache is accompanied by:
  Abnormal eye movements, asymmetry of body movements, altered mental status, distortion of the optic disc (papilledema), or abnormal deep tendon reflexes.
• Headache due to increased intracranial pressure typically worsens upon lying flat, and during movements which increase venous pressure – such as coughing, sneezing, or bending over.
• In one study of children with primary brain tumors, only 19% had an initial diagnosis of migraine headache, however.
  
  WHAT IS A MIGRAINE HEADACHE?
• A migraine headache is a severe, incapacitating headache that is described as “throbbing” or “pounding.” The pounding pain usually begins in the forehead, the side of the head, or around the eyes.
• Unlike adult patients, children with migraine suffer for shorter periods of time – often for less than one hour.
• The migraine attack is often associated with nausea or vomiting, and abdominal pain is common. Motion sickness is observed in 49% of children with migraine headache.
• A family history of migraine is present in 80% of children with the problem, and a family history of motion sickness is also common.
• Migraines can be triggered by several factors, including: hypoglycemia (low blood sugar), emotional stress, loud noises, bright lights, sleep deprivation, or strenuous physical exercise.
• Simple migraines are usually relieved by sleep and analgesics.
  
  STEPS FOR PREVENTING MIGRAINE HEADCHE:
• Try to identify the triggers of migraine, evaluate lifestyle for other possible causes, consider using biofeedback techniques, try assisted relaxation, encourage regular physical exercise, provide a well balanced diet, and consider pharmacologic treatment (analgesics) if necessary.
• Physicians should prescribe a home schedule for the child that will help to eliminate migraines. Important elements of the child’s schedule include: keeping a headache diary, getting regular and well-balanced meals, going to be early, getting regular physical exercise, and a having a reasonable amount of extracurricular activity.
  
  HOW ARE CHILDREN’S HEADCHES DIAGNOSED?
• First: any child with a complaint of headache should have a thorough medical history and physical examination performed. This step will help to determine whether the headache is: acute, acute-recurrent, chronic progressive, chronic non-progressive, or mixed. The general medical history will identify signs and symptoms such as: neurologic changes, fever, head trauma, gastrointestinal problems, anxiety, or depression. The child’s social and family history also needs to be evaluated.
• Potentially ominous causes of headaches must be considered if there has been an increase in the frequency or severity of headaches. Headaches which awaken a child from sleep, or which have an early-morning onset, suggest increased intracranial pressure – and are potentially serious.
• Second: physical and neurological examinations of the child should be completed. Children who have intracranial disease will show: altered mental status, optic disc distortion, abnormal eye movements, problems with coordination, motor or sensory disturbances, abnormal deep tendon reflexes, lethargy, seizures, visual disturbances, or personality changes.
• Children with signs of increased intracranial pressure have a high priority for obtaining CT or MRI neuroimaging. Computed tomographic (CT) scanning or magnetic resonance imaging (MRI) is strongly recommended for those children who have chronic progressive headache, and those with abnormal neurological findings.
  
  PHYSICAL AND NEUROLOGIC EXAMINATION FOR HEADACHE IN CHILDREN:
• First, the physical examination must include taking vital signs – such as blood pressure, pulse, temperature.
• The head and neck should be carefully palpated and for searched for: enlarged thyroid, sinus tenderness, or nuchal (posterior neck) rigidity.
• Head circumference must be measured to rule out progressive increases in intracranial pressure.
• The skin should be examined for signs of neurofibromatosis or tuberous sclerosis – both of which are associated with intracranial (brain) tumors.
• The child’s head should be auscultated (with a stethescope) for cranial bruits (noises) which may indicate intracranial arteriovenous malformation.
• Second, the neurological examination must include examination of: eye movements, the optic disc, physical coordination, physical reflexes, and asymmetrical movements. If the fundoscopic (back-of-the-eye) examination demonstrates optic atrophy, papilledema (swelling of the optic disc), or retinal hemorrhage – then an underlying CNS or systemic problem may indeed exist.
  
  WHAT IS THE TREATMENT FOR HEADCHES IN CHILDREN?
• First: place child in a dark, quiet room where he or she can rest and sleep. A cool, wet cloth should be placed on the child’s forehead.
• Second: give migraine medications quickly – at the beginning of the attack. Avoid the oral route of administration if nausea or vomiting is a problem.
• General measures for treatment include: reassuring the child and parents, identifying and eliminating the triggers for headache, modifying the child’s lifestyle, and possibly initiating behavioral therapy.
• An essential element in headache management is keeping a headache diary. By controlling stress, there is less activation of the mast cells in the outer covering of the brain (meninges), and therefore less incidence of migraine. Biofeedback and stress management techniques have been effective when used in children as young as 8 years of age.
• Pharmacologic management includes: oral analgesics, anti-emetics, and sometimes the daily use of preventive medications. Very few headache drugs have been approved for use in children, however.
• Liquid ibuprofen (children’s Advil) in a dosage of 10 mg per kg, is effective in many children.
• Oral anti-emetic medications prevent nausea and vomiting – which occurs in up to 90% of children who have migraine headache. Phenergan is an anti-emetic that is available in tablet, syrup, and suppository form. The dosage is 0.5 mg per kg per dose – up to three times daily.
• Children with disabling headaches may benefit from a daily prophylactic administration of cyproheptadine (Periactin), in a dosage of 4 mg at bedtime.
• Narcotics should not be used in the treatment of chronic childhood headaches.
  
  An article in American Family Physician reviews the topic of headaches in children. The article discusses medical evaluation and management of pediatric headaches. The most important first step in therapy is reassuring the child and parent that the headaches are not due to a serious neurologic disease.
  
  Lewis DW: Headaches in children and adolescents. Am Fam Physician. Feb 15, 2002; 65(4):625-632.
  
  
  

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