Headaches In Children
Headaches are one of the most common physical complaints of children. Many
school days are lost because of headaches. By seven years of age, forty percent
of children have experienced a headache. In fact, many adults with chronic daily
headaches report that their headaches began in childhood or adolescence.
A headache is a symptom of an underlying problem. The most common causes of
childhood headache include: viral infection, colds, flu, sinusitis, or migraine.
Brain tumors can also cause headaches, but they are very rare. Any child with a
complaint of headache should have a thorough medical history and physical
WHAT EXACTLY IS HEADACHE PAIN?
A headache is a symptom of an underlying medical problem.
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
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
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
CAN A HEADACHE BE DANGEROUS?
Headache signs or symptoms which require additional medical investigation
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
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
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
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
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
Narcotics should not be used in the treatment of chronic childhood
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.