Headache fact file - Part 5 - Headache in children and the elderly

In the final part of this series, Dr David Kernick discusses the challenges of headaches in different age groups.

Headache in children
Headache is the most frequent neurological symptom and the most common manifestation of pain in children. Diagnosis is often more difficult and the patient less likely to articulate their problem and seek help.

About 20 per cent of children report headaches that trouble them at least weekly. Migraine is the most common (10 per cent of school children experience migraine), with a peak incidence at the age of 15 years in girls and 10 years in boys.

Migraine in children differs to that in adults. There is often an overlap between migraine and tension-type headache.

Management

  • Trigger factors can be subtle. Children have a lower threshold to stress, with irregular sleep patterns and dietary irregularities, especially missed meals and lack of hydration. A high fibre cereal snack, a regular intake of fluid and avoidance of caffeinated drinks is helpful.
  • For the acute attack, effective pain relief should be given early at optimum doses, paracetamol 10-20mg/kg every 6-8 hours (maximum 60mg/kg/day) and ibuprofen 10-15mg/kg every 6-8 hours.

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

  • Oral triptans are safe but, due to the high placebo response in childhood trials, a licence has not been obtained. Nasal sumatriptan at a dosage of 10mg is licensed in those over 12 years.
  • Pizotifen is the drug of choice for prevention although 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 (see box).

Investigations

  • The risk of a tumour in a child who presents to a GP with headache is 0.03 per cent, a third of the adult level.
  • Indications for investigation are the same as for adults. Unexplained deterioration in school work or headaches in the very young are additional causes for concern.
  • The rate of incidental abnormalities is higher - up to 20 per cent is quoted.
Click here for features of headache

Associated syndromes
The associations remain unclear but there is often a family history of migraine.

  • Cyclic vomiting - recurrent severe nausea and vomiting associated with pallor, lethargy and autonomic symptoms. Symptoms often begin in the middle of the night. Girls are affected more than boys. It begins at approximately five years of age and resolves by puberty. Migraine preventive therapy is effective in reducing frequency of attacks.
  • Abdominal migraine - more common in children aged 7 to 13 years with a family history of migraine. Recurrent, episodic attacks of abdominal pain lasting from one hour to three days. Abdominal pain has a dull character usually in a peri-umbilical location but can be more diffuse. Treatment is with conventional migraine preventive medication.
  • Benign paroxysmal vertigo of childhood - more commonly affects young children. Attacks begin suddenly, last minutes and may occur in clusters lasting days to weeks. Paroxysmal, recurrent, untriggered, attacks of severe vertigo and/or gait unsteadiness can occur without warning.

Headache in the elderly
Headache is less prevalent in the elderly and rarely develops after 50 years of age.

In patients over 50 developing a first migraine, 10 per cent will have an abnormality on imaging and should be investigated.

Triptans are unlicensed for patients over 65 but the benefits are often greater than potential risks, providing there are no vascular contraindications. An ECG may be advisable.

Headaches with higher prevalence in the elderly

  • Comorbidities and drug usage are more common, both can cause headache.
  • Space occupying lesions - increasing risk with age of primary and secondary tumour.
  • Temporal arteritis - can include jaw claudication and constitutional symptoms. Always consider in patients over the age of 50.
  • Neuralgia: trigeminal, post herpetic.
  • Systemic disease: anaemia, hypocalcaemia, hyponatremia, renal failure, hypoxia or hypercapnia.
  • Cerebral vascular disease: thrombotic and embolic stroke (headache in 20 per cent); intracerebral haemorrhage; subarachnoid haemorrhage.
  • Cervical spondylosis leading to cervicogenic headache.
  • Paget's disease.
  • Hypnic headache. Occurs only during the night, wakes from sleep and lasts up to three hours. Indometacin, caffeine and lithium are treatment options.
  • Dr Kernick is a GP in Exeter and RCGP headache champion
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