Clinical Review - Headache in children

Contributed by Dr David Kernick, a GPSI in headache, based in Exeter.

Section 1: Aetiology and epidemiology

Headache is the most frequent neurological symptom, and a common manifestation of pain in children.1

Patients want answers to three questions: what is the cause of their headache, what would make it better, and reassurance they do not have a life-threatening illness.

Unfortunately, the management of headache in children is often poor. The barriers to successful treatment are more prominent than in adults, because diagnosis is often more difficult and the patient less likely to articulate their problems and seek help.

Extent of the problem
Between 20-30 per cent of children report headaches at least weekly, and 6 per cent have headaches several times a week or daily. Migraine is the most common type of headache with a peak incidence at the age of 15 years in girls and 10 years of age in boys.

A large UK school clinical study reported an annual prevalence rate of 10.6 per cent for migraine and 0.9 per cent for tension type headache.2

Headache has an impact on a child's life in a number of ways, including school absences and decreased socialisation with peers. In a survey of 2,500 children in our practice, we found that 3 per cent of children had a significant problem with headache affecting them on one day in four, with an average of 14 days of school lost each year.3

Headache during childhood also has a high risk of persisting into adulthood with associated physical and psychiatric morbidity later in life. For example, over a third of children with migraine will experience the problem in adulthood.4,5

Children suffering from headache are more sensitive to other types of pain in general. However, the nature of a recognised link between migraine and other periodic syndromes is not understood.

Causes
The causes of headache in children are complex and the current view sees pain as emanating from a complex interaction between biological, psychological and social variables. These, combined with cultural contexts shape the origin of, and individuals' perceptions and response to pain.

Children with headache have higher levels of anxiety and depression, and demonstrate different personality and behavioural characteristics to children without headache.

However, the relationship between headache and these potential aetiological factors is complex and likely to be bi-directional. For example, persistent headache may lead to anxiety and depression, but these and emotional factors may influence pain modulation and the relationship between headache and impact on quality of life.

The family context is particularly important. Apart from an inherited biological pre-disposition - there is a positive family history of migraine in 77 per cent of children with migraine -parents may translate patterns of pain response and coping.

Other factors include dysfunctional parenting patterns and poor parental support, or conflict within the family such as financial difficulties or divorce.

Conditions associated with migraine in children

Cyclic vomiting

  • Usually a family history of migraine.
  • Symptoms often begin in the middle of the night. Girls more affected than boys.
  • Begins at approximately five years of age and resolves by puberty.
  • Recurrent stereotyped attacks (>5) of severe nausea and vomiting associated with pallor, lethargy +/- autonomic symptoms.
  • Explosive, frequent attacks of nausea and vomiting lasting hours to days.
  • Symptom-free between attacks.
  • History and examination do not show signs of GI disease.
  • Conventional migraine prophylaxis effective in reducing attack frequency.

Abdominal migraine

  • Also known as cyclic abdominal pain, but is less common and less severe than cyclic vomiting.
  • More common in children aged 7 to 13 years with a family history of migraine.
  • Recurrent, episodic, attacks (>5) of abdominal pain lasting 1 hour up to 3 days.
  • Abdominal pain has a dull character usually in a midline peri-umbilical location but can be more diffuse. Pain is sufficiently severe to affect daily activities.
  • At least two symptoms of anorexia, nausea, vomiting or pallor are present.
  • Treatment is with conventional migraine prophylaxis.

Benign paroxysmal vertigo of childhood

  • More commonly affects young children. Attacks begin suddenly, last minutes only and may occur in clusters lasting days to weeks.
  • Paroxysmal, recurrent, untriggered, attacks of severe vertigo +/- gait unsteadiness without warning.
  • During attacks the child may:
    • Appear frightened and find difficulty maintaining balance.
    • Have nystagmus during the attack, but normal neurological examination between attacks.
  • Have associated pallor, nausea and vomiting.

Section 2: Diagnosis

Migraine differs in children when compared with adults. The box shows the main differences between migraine in children and adults, and tension-type headache, which is broadly comparable in both groups.

In many cases there is an overlap between migraine and tension-type headache and it has been suggested that both types sit on the same headache spectrum.

Approach
A realistic practical approach is to adopt the same approach to management for all children with paroxysmal headaches who are well between attacks, with migraine the default diagnosis where an impact on performance is described and particularly against a background of a positive family history.

Main features of migraine in adults and children and tension-type
headache

Migraine in adults
Migraine in children Tension type headache

Usually unilateral
Usually bilateralUsually bilateral
Moderate-to-severe
headache
Mild-to-severe
headache. May be inferred from behaviour in younger children
Mild-to-moderate headache
Throbbing/stabbing
nature of pain
Can take any formPressure or band-like pain
4-72 hoursUsually less than four hoursVariable
Associated symptoms
include nausea,
vomiting, photophobia
or phonophobia
Not always presentNo associated symptoms
Can be associated with aura in 30 per centAura less commonNo aura
Frequently prevents
normal activity
Frequently prevents
normal activity
Sufferer usually able to
continue with normal
activities

Section 3: Management

Trigger factors can be subtle and children have a low threshold to stress, missing meals and irregular sleep patterns, all of which can trigger migraine.

Dietary irregularities, especially missed meals and lack of hydration, are also important. A high-fibre cereal snack taken at regular intervals is helpful, as is a regular intake of fluid and avoidance of caffeinated drinks.

Other dietary triggers may also be implicated. Although the evidence base is limited, it may be sensible to avoid food additives to see whether they have an impact.

Evidence base
Although a number of drugs are used to treat headache, the evidence base is weak. There is also a tendency for parents and practitioners to administer small doses of analgesia and delay treatment until the headache is established and severe enough to warrant treatment.

For the acute attack, effective pain relief analgesics should be given early in their optimum doses, 10-20mg/kg every 6-8 hours (maximum 60mg/kg/day) for paracetamol and 10-15mg/kg every 6-8 hours for ibuprofen.

In some children, nausea and vomiting are troublesome symptoms and early treatment with antiemetics such as metoclopramide or domperidone may help and improve the response to pain killers.

Although oral triptans are safe, due to the high placebo response in childhood trials, which can approach 60 per cent, efficacy and therefore licence has not been obtained.6 However, nasal sumatriptan at a dose of 10mg has been shown to be effective and safe in adolescents and is licensed in those above 12 years.

Prevention is indicated with frequent episodes of headache that interfere with the quality of life and education. Pizotifen is the drug of choice and works well in children. Weight gain can be a problem.

Propranolol can be useful, and other drugs include amitriptyline, topiramate and valproate, although the antiepileptics are best left to specialist practice. It should be noted that these drugs are not licensed for use in children. Preventive treatment should be used for at least two months in optimum dose before it can be judged as effective or unhelpful.

Where the emphasis is on tension-type headache, amitriptyline is the drug of choice.

PREVENTATIVE DRUGS USED IN CHILDREN'S MIGRAINE

Drug
Dose
Under 12 years12-18 years
Pizotifen0.5-1.0mg/day. Single dose at night1.5-3.0mg/day
Propranolol0.2-0.5mg/kg tds. Max 4.0mg/kg/day20-40mg tds. Max 160mg/day
Amitriptyline
Up to 50mg/night
Topiramate
2-3mg/kg/day. Gradual increase to target dose

Section 4: Alarm symptoms

With headache there is always a concern that there may be an underlying pathology, and in particular a tumour.

Although brain tumours are rarer in children than adults, their impact is potentially more devastating.

Investigation
The principles of investigation are the same as for adults.

As in adults, blood tests are rarely useful unless there are other clinical indications. Presentations that warrant careful scrutiny are shown in the box. The impact of headache in children often goes unrecognised even when severe.

Conclusion
An early diagnosis and an understanding of the problem by the patient is important because migraine frequently continues into adult life.

It is rewarding to treat and the majority of interventions are within the experience of the GP.

Warning features in a child with headache
  • Papilloedema or other abnormal findings on neurological examination.
  • Alterations in consciousness, memory, confusion or co-ordination.
  • New seizure.
  • Headache aggravated by exertion or Valsalva manoeuvre.
  • Headache associated with vomiting (migraine-related vomiting rarely occurs in children).
  • Headaches that have been present for some time but have changed significantly.
  • Unexplained deterioration in school work.
  • Headache in child under three years.

References

1. Goodman J, McGrath P. The epidemiology of pain in children and adolescents: a review. Pain 1991; 46: 247-64.

2. Abu-Arefeh, Russell G. Prevalence of headache and migraine in schoolchildren BMJ 1994; 309: 765-9.

3. Kernick D, Reinhold D. J Headache Pain In Press.

4. Guidetti V, Galli F. Evolution of headache in childhood and adolescents: an 8-year follow up. Cephalalgia 1998; 18: 449-54.

5. Fearon P, Hotopf M. Relation between headache in childhood and physical and psychiatric symptoms in adulthood. BMJ 2001; 322: 1-6.

6. Hamalainen M. Sumatriptan for migraine attacks in children. Neurology 1997; 48: 1,100-03.

Further Reading
Damen L. Prophylactic treatment of migraine in children. Cephalalgia 2006; 26: 497-505.

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