Paediatric medicine - Headache in childhood

Dr Dan Hindley looks at a range of the causes that lie behind persistent headaches in children.

Parents often fear a brain tumour when their child complains of a headache. While childhood headache is common, brain tumours are rare.

Most childhood headache is recurrent, unexplained and shows no physical signs once fever or trauma is excluded.1

Consultations with children are usually constructive and often reassurance is sufficient to defuse concerns and make the symptom manageable.

Visual acuity, BP and urine should be checked and height, weight and head circumference monitored.

Have a low threshold for neuroimaging, for some it can be reassuring

It is worth remembering that a visual aura followed by headache and vomiting can sometimes be caused by benign occipital epilepsy. However, most recurrent headache in childhood is primary rather than secondary, with migraine and tension headache being common causes.

Migraine
There have been many classifications of headache, mainly to provide definitions for research.

Hockaday's assertion that 'children with recurrent, paroxysmal headache may have migraine if there is full return to normal mental and physical health between attacks and if other causes of headache have been excluded' is suitable.1

Classical (with aura) and common (no aura but other symptoms apart from headache) migraines can be managed similarly. The patient should undergo a full clinical assessment, which will also reassure them. Have a low threshold for neuroimaging if there is significant family anxiety. MRI scans are safe and for some a normal scan is therapeutic.

Triggers such as exercise, fasting, poor sleep patterns or stress are more common than the well-known foods (cheese, orange juice or chocolate).

Simple analgesia (paracetamol or ibuprofen) given early in an attack and at adequate dosage are often sufficient. Prescription of concomitant antiemetics for childhood migraine is rarely necessary. Neither are combination preparations.

The use of compound analgesic preparations with low-dosage codeine often gives opiate side-effects without any significant additional relief of pain.

Triptans have been helpful. Fewer children are now prescribed long-term prophylaxis for migraine because alternative drugs are available for acute use. There is little published evidence of a substantial benefit for most of the triptans in childhood migraine, except perhaps sumatriptan nasal spray.

If the migraine is intrusive and the above measures fail, regular preventive treatment should be given. Pizotifen is the most commonly used drug in children. However, in a double-blind placebo controlled trial pizotifen had no impact on the number or duration of migraines but caused drowsiness, constipation and weight gain. In three clinical trials for propranolol, one showed a benefit but two did not.2

Tension
Tension headaches are dull in quality, poorly localised, 'crushing' or 'band like' and not associated with other symptoms. They can be episodic or can evolve into chronic daily headaches.

Reassurance and simple analgesia can help. Relaxation therapy and treatment of mood disturbance are often helpful if symptoms persist.

Intracranial lesion
Most GPs will be familiar with the warning signs of a progressive space-occupying intracranial lesion (see box). Any of these red flag symptoms or signs should lead to referral and neuroimaging. To reduce the delay in making a diagnosis imaging can be requested on the basis of suggestive symptoms in the absence of signs.

One study had useful results. Of 72 children with headache as a symptom, 68 had abnormal finding from neurologic or ocular examination at diagnosis. Signs developed in two weeks in 51 per cent, two months in 75 per cent and in all by six months.4

This suggests that a child with recent-onset headaches should be examined carefully; and that a long symptom history without physical signs can be reassuring.

  • Dr Hindley is a consultant paediatrician in Bolton, Lancashire

Red flag symptoms
Space-occupying lesions

  • Recurrent headache with vomiting in a previously well child.
  • Accelerating frequency/and or severity of headaches.
  • Headaches causing night waking or worse on waking.
  • Child unwell between headaches eg, lethargy, behavioural, speech or cognitive change.
  • Physical signs especially cranial nerve/ocular palsies and papilloedema.

References

1. Definitions, clinical features, and diagnosis of childhood migraine. In: Hockaday JM. Migraine in childhood. London: Butterworths, 1988.

2. Managing migraine in children. Drug Ther Bull 2004; 42: 25-8.

3. Lakshmi CV, Singhi P, Malhi P, Ray M. Topiramate in the prophylaxis of pediatric migraine: a double blind placebo controlled trial. J Child Neurol 2007; 22(7): 829-35.

4. Honig PJ, Charney EB. Children with brain tumour headaches. Am J Dis Child 1982; 136: 121-4.

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