Headache in children Dr Nagi Giumma Barakat

Introduction
Headache is one of the commonest neurological symptoms in children and young people who are referred to doctors. Headache refers to pain involving the orbits, forehead, scalp and temples but not the face or neck(1). The primary headache includes chronic or recurrent headache and migraine. The prevalence of chronic or recurrent headaches in children occurs in 60-69% by the age of 7-9 years and 75% by the age of 15 years (2). The prevalence of migraine in children is up to 28% of older teenagers (2). The most serious cause of secondary headache is brain tumour and the prevalence of brain tumours in children is 3 per 100,000 per annum (2).
Headache in general can occur as a result of vasodilatation, oedema, vasoconstriction, and inflammation of cerebral vessels which all can produce pain. Any delay in managing headache will create anxiety and stress for both the parents and the child, so it is important to seek help from a specialist at an early opportunity.
The two important elements in diagnosing any type of headache are history and examination.
Patient History
History is usually taken from the parents and the child or adolescent. It usually takes place in the clinic and needs an extra 10 minutes of time to perform a full examination, taking care not to miss a fundi examination if you are familiar with it, otherwise this should be done in all secondary suspected headaches at some stage. Sometimes giving the patient a questionnaire to complete it about the headache before they see you is a good idea
Box Number 1
The points to be covered in history are:
Ask both parent and child to describe the events, what happen first thing ?
Encourage them to use a diary to record the location, severity (1-10 scale) and any precipitating factors such as exercise, anxiety, stress, cheese, dark chocolate, homework;
When the headaches started and how often they happen, if there is any aura or accompanying symptoms.
Headache characteristics eg. squeezing band around the head or stabbing or just pounding and dullness. Any patterns and how often it is happening – per day or week or month
How long it takes to recover, is it getting longer or more frequent or more intense
Is the headache affecting your daily social life or education or sleep?
Is your headache provoked by cold or hot environment?
What time do you go to bed and wake up? Do you get a headache on waking up or during sleep?
Do you have any weakness, numbness or feeling sick or vomiting before, during and after the headache?
Do you get any warning signs or see or hear anything before the headache (abdominal pain, flashing lights in your eyes, lump in your throat or other signs)? . Any changes in your test or smell during the headache or feeling sick
Do you see shape or flashes or stars when headache started?
What treatment have you received which is the most effective?
Have you had any recent head injuries or trauma which required you to go to hospital?
Any deterioration in school work, absences from school, or behavioural changes?
Any family issues, bullying at school or other emotional events happen recently?
Does anyone in the family have the same or any other conditions?
Clinical examination
This should be a general and systemic examination and fundi examination should be done for all types of headaches.
Look at the skin
Record weight, height and head circumference
Listen for cranial bruits
Blood pressure must be done on first visit
Detailed CNS and systemic examination (optic disc, eye movements, motor asymmetry, coordination, gait, tone, power and reflexes)
Box 2

Types of headache
There is primary headache which is acute, acute recurrent, chronic non-progressive, chronic recurrent, cluster headache or mixed. There is also secondary headache which means there must be a cause which could include chronic progressive, epileptic and psychogenic headache(2).
Primary headache
Migraine with/without aura (3):
Headaches characterised by periodic episodes of headache that are accompanied by nausea, vomiting relieved by sleep
Autonomic symptoms accompanying migraines include photophobia, phonophobia, nausea, and vomiting.   (IHS criteria I and II) (3)
Tension type headaches:
Headaches due to fatigue or emotional stress
Throbbing quality in a band-like distribution
Mild to moderate lasting 30 minutes to several days
Not exasperated by routine physical activity nor are they accompanied by nausea and vomiting. (IHS criteria III)
Cluster type headaches: 
Rare in children, having a greater prevalence in male adolescents
Characterised by recurrent, unilateral peri-orbital, extreme non-throbbing deep pain radiating into the same side of the face and lasting less than 3 hours.
Migraine (hemicrania) This will be covered fully in next paper
Chronic progressive headache- will be covered in third paper
This is a secondary headache which can always be picked up from history and clinical examination which include Brain Tumour-(space occupying lesions and Benign increased intracranial pressure (Pseudo-tumour cerebri)
Chronic non progressive (Tension headache)- Box 3
This is the commonest type of headache you will see in your clinic after migraine. It is more prevalent in teenagers and varies in intensity, frequency and presentation. It is important not to label it as psychogenic and support is needed. It is also important to recognise it early on teenagers tend to self-medicate themselves and this may continue for many years (1).
The simplest definition of CDH is more than 15 headache days per month. In the International Classification of Headache Disorders, Second Edition (ICHD-II), several types of CDH have been identified (3). It can also be related to the tension headache which usually occurs towards the end of the day on most days and very often does not respond to analgesia and may cause rebound headache. The child or teenager is frequently absent from school and you may find one member of the family has the same. It often responds to relaxation therapy and behavioural intervention. It is very important to do a systematic review and have a therapeutic plan which should include lifestyle, stress and anxiety management, school attendance diary and behavioural issues. (refer to box no3)

It is usually post-traumatic and can happen for up to 6-8 weeks following a head injury or any traumatic incident and has a dizzy-like character (HIS diagnostic criteria V) (3)
Neuroimaging can be done for high priority cases as follow:
Chronic progressive headache with papilloedema,
neurocutaneous syndromes (NF or TS or others),
age younger than 7 years,
positive neurological signs or symptoms or behavioural changes with headache,
headache waking them at night,
trauma or head injury,
waking up with headache with some neurological signs, and
sudden severe headache.

Management of the headache

Box no 4

Box no 5
Approaches when treating headache
Headaches which do not interfere or preventing usual activities do not need treatment, can be managed without medication by stopping doing that activities.
Preventive therapy can be used if the headache interferes with daily activities, or if headaches are recurrent and cause the loss of more than 7 days per month of school.
Bio-behavioural therapy is important and can make an important contribution when managing chronic or recurrent headaches. Additional factors can contribute to the exacerbation of headaches which includes co-morbid disorders and pubertal changes.
Cluster headaches can be treated with verapamil by a specialist and paroxysmal hemicranial headaches can be treated by indomethacin and should be combined with ranitidine or omeprazole.

Medications proved to be safe in the paediatric age group (11)
Abortive treatment
Acute headache (11)

Anti-emetics such as:
Cyclizine- can be given oral, perrectum, subcutaneous and intravenous
Domperidone- oral or perrectum
Prochlorperazine- Oral, perrectum or intramuscular
The oral triptans (used more in migraines attacks) such as sumatriptan succinate, and zolmitriptan and the nasal spray formulations of sumatriptan and zolmitriptan;
Subcutaneous sumatriptan and parenteral dihydroergotamine have also been used with limitation in children due to side effects.
Prophylactic medications
Are good for recurrent non-progressive headaches occurring 3-4 times per month. Migraine with or without aura is the commonest in this group which may need prophylactic medication as below:
Propranolol (Avoid in asthmatic patients)- should be twice daily only
Pizotifen (sandomigran)- maximum 1.5mg (0.5mg am and 1mg pm), 12-18 years 1.5mg-3mg at night and maximum 4.5mg per day
Topiramate (topamax-anticonvulsant) (effective for daily chronic headache and migraine with or without aura if others failed)- 2-18years- 0.5mg/kg- up to 10mg/kg once per day- review side effects (9)
Flunarizine (calcium channel blocker)- maximum 10mg once daily for ages (10)
Amitriptyline( TCA), up to 11 years 10-20mg at night and >12yeras 25-50mg at night
Gabapentin- up 12 years, 10-20mg/kg there times per day. >12 years 300mg , three times per day
Sodium Valproate- all ages, start 10mg/kg twice per day and up to 40mg/kg if no response
Riboflavin (vitamin B6) – all ages, 50-10mg/kg twice daily
Calcium channel blocking (nifedipine, cyproheptadine)— by neurologist
Antidepressants amitriptyline hydrochloride and nortriptyline hydrochloride- as above
Antihistaminic agent cyprohepatine hydrochloride or other anti-emetic in combination with above if there is nausea or excessive vomiting

Bio-behavioural approaches

The lifestyle issues should be addressed and this can be helpful in the management of headaches which do not respond to medication or only partially respond. In this case, the patient should be advised to do as follows:
participate in all activities and play between headaches
get plenty of sleep, around 8-10 hours of sleep per 24hrs
relaxation e.g. listening to softly played music, swimming, taking a warm bath
exercise but not too vigorous nor excessive. Stop if a headache starts and rest in a quiet, dark place
Drink plenty of fluids, preferably water, and reduce intake of caffeinated drinks
Avoid precipitating factors in migraine which can be done on the basis of exclusion, one by one.

Medication overuse (4 &5)
This is very common among teenagers and young adults who suffer from a primary headache (1). Overuse of medication can transfer migraine without aura and tension headache into chronic daily headache. Rebound headache can follow medication overuse, especially with opiates, triptans, aspirin or other NSAID and paracetamol over-use for more than 2 weeks either by themselves or in combination with each other.
It is not due to tissue damage but in pathology pathways (4). It is important to withdraw abruptly all what they use and give them clear instructions on how to use medication to maximum dosage over 24hrs and no more than 2 days per week use these medication (4).
It may get worse before it gets better and changing lifestyle is very important. Psychological support may be needed in these cases and approaching with cautions rather saying, it is tension headache and to relax.
Avoid using Triptans in hemiplegic migraine, basal artery migraine and ophthalmoplegic migraine as it may cause vasoconstriction (5).
Conclusion
Headache is one of the commonest neurological referrals to a paediatrician and GPs. It is important to get the diagnosis right for each type of headache. Knowledge about managing various types of headaches is very important. There are only a few evidence-based studies in treating headaches in children. It is depends most of the time on personal experience, colleagues’ experience and some reported cases. It is important to take a detailed history and full examination with fundi examination at all times and blood pressure should be measured as well. All treatment and choice of medication depends on the correct diagnosis. Using neuro-imaging for all patients is not the right approach and should only be used in secondary headache or when there is a red flag.
All resources available should be used to help children, young adults and their parents and no one should be told this is a tension headache which will get better. Chronic headache needs a multidisciplinary approach and referral to a headache clinic is the ideal approach.
The overuse of headache medication should be spotted early on to prevent it from continuing and adolescents and young adults should be made aware of this. Involving a psychologist as early as possible is advisable. A multidisciplinary approach is important in chronic and recurrent headaches rather than working alone. Any delay in managing headache will create anxiety and stress for parents and considerable discomfort for the child; seeking help from a specialist at an earlier stage will help to minimize all this.
There is excellent reviews of headache in children which you can learn a lot. (6,7,8, 9,10)

REFERENCES

1- Whitehouse WP, Agrwal S, Management of childern and yung people with headache. Arch.dis.child educ Pract Ed 2017;102:58-65.
2- http://learn.pediatrics.ubc.ca/body-systems/nervous-syste/approach-to-a-child-with-a-headache/
3- https://www.ichd-3.org
4- Me Bigale et el, Transformed Migraine and Medication Overuse in a Tertiary Headache Centre — Clinical Characteristics and Treatment Outcomes. published june 2014
5- https://cks.nice.org.uk/headache-medication-overuse#!topicsummary
6- Newton RW. Childhood headache. Arch.dis.child educ Pract Ed 2008:98:105-11.
7- Abu-Arafeh I. Diagnosis and management of headache in children and adolescents , Prog Neurol Psychiatry 2014;18:16-20.
8- Children’s Headache Training (CHaT), hit://www.bpna.org.uk/headache (accessed 4 November 2017- London)
9- Buch ML. Use of Topiramate in preventing pediatric migraine. Pediatr Pharmacother 2013;19:1-4
10- Mohamed Bp, Goadsby PJ, Prabhakar P. Safety and efficecy of Flunarazine in childhood migraine: 11 years experience, with emphasis on its effect in hemiplegic migraine. Dev Med Child Neural 2012;54:274-7.
11- BNF and BNF for children. https://www.medicinescomplete.com/aboiutsubscribe.htm (Feb 2017)

The Author: Dr Nagi Giumma Barakat ( MBBCH, MRCPCH, MSc epilepsy, CCST, FRCPCH, CASLAT9Med. Edu), PET
Consultant paediatrician/neurology- Cromwell Hospital
Honorary consultant paediatrician – IPP- Great Ormond Street Hospital-
UK

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