Management of Headaches in ChildrenManagement of Headaches in Children

Dr Nagi G BarakatDr Nagi G Barakat

Consultant PaediatricianConsultant Paediatrician

UKUK

Types of HeadachesTypes of Headaches

AcuteAcute Acute recurrentAcute recurrent Chronic progressiveChronic progressive Chronic nonprogressiveChronic nonprogressive Cluster headacheCluster headache Epileptic headacheEpileptic headache Psychogenic Psychogenic MixedMixed

Acute HeadacheAcute Headache

It could be migraineIt could be migraine Cerebrovascular bleedCerebrovascular bleed(CT or MRI with contrast)(CT or MRI with contrast)

Trauma (CT)Trauma (CT) Meningitis (LP )Meningitis (LP ) Encephalitis (EEG and CT or MRI)Encephalitis (EEG and CT or MRI) Drugs (urine toxicology)Drugs (urine toxicology)

Acute recurrentAcute recurrent

Migraine headache Migraine headache Patients history (recurrent pattern)Patients history (recurrent pattern)

– Family historyFamily history– Visual auraVisual aura– NauseaNausea– Unilateral pain (throbbing)Unilateral pain (throbbing)– Gastrointestinal symptomsGastrointestinal symptoms– Exclude other causesExclude other causes

MigraineMigraine Hippocrates described migraineHippocrates described migraine Galen first used the term hemicraniaGalen first used the term hemicrania Incidence 1.2% -3.2% at age of 7 years , and 4%-Incidence 1.2% -3.2% at age of 7 years , and 4%-

19% by age of 15 years19% by age of 15 years More prevalent in femalesMore prevalent in females Have genetic componentHave genetic component 2.8 school days per year lost as result of migraine2.8 school days per year lost as result of migraine Children commonly have migraine without auraChildren commonly have migraine without aura Children not usually having unilateral headacheChildren not usually having unilateral headache Vasodilatation,vasoconstriction,oedema, and Vasodilatation,vasoconstriction,oedema, and

inflammation of cerebralinflammation of cerebral vessels produce painvessels produce pain

Causes of MigraineCauses of Migraine

The exact cause(s) of migraine headaches is The exact cause(s) of migraine headaches is unknownunknown

Some migraines are thought to be due a temporary Some migraines are thought to be due a temporary deficiency of the brain chemical serotonindeficiency of the brain chemical serotonin

» The most common triggers are alcohol, chocolate, cheese, The most common triggers are alcohol, chocolate, cheese, nuts, shellfish, Chinese food, sugar, and caffeine. nuts, shellfish, Chinese food, sugar, and caffeine.

Clinical features of migraine Clinical features of migraine attackattack

ProdromeProdrome (change in mood or activity level)(change in mood or activity level)

**AuraAura( occurring in 10-50% of paediatric migraine ( occurring in 10-50% of paediatric migraine attacks) Photopsia, scotoma, numbness, tingling, ataxia, attacks) Photopsia, scotoma, numbness, tingling, ataxia, dizziness, and vertigo.dizziness, and vertigo.

** Headache Headache( ( Barlow et al, 300 pts with juvenile migraine, Barlow et al, 300 pts with juvenile migraine, only 9% of attacks were children awakened from sleep by the onest of only 9% of attacks were children awakened from sleep by the onest of a migraine and only 4% of attacks did they begin on awakening)a migraine and only 4% of attacks did they begin on awakening)

ResolutionResolution( headache may last 1-4hrs, sleep and ( headache may last 1-4hrs, sleep and analgesic)analgesic)

PostdromePostdrome( Lethargy, anorexia and mood ( Lethargy, anorexia and mood disturbances)disturbances)

Types of migraine Types of migraine (HIS 1988)(HIS 1988)

Migraine with aura(Classical migraine) Migraine with aura(Classical migraine) It lasts from half an It lasts from half an hour to 48 hours. hour to 48 hours.

Migraine without aura (common migraine) Migraine without aura (common migraine) bilateral and bilateral and occurs in 60-85% of migrainous childrenoccurs in 60-85% of migrainous children

Chronic migraine:Chronic migraine: at least 15 days of every month for at least 2 at least 15 days of every month for at least 2 months. It may affect up to 4% of teenage girls and 2% of months. It may affect up to 4% of teenage girls and 2% of teenage boys. teenage boys.

Complicated migraine (hemiplegic migraine, Complicated migraine (hemiplegic migraine, ophthalmoplegic migraine,confusional migraine, Basilar ophthalmoplegic migraine,confusional migraine, Basilar artery migraineartery migraine

Atypical forms of migraineAtypical forms of migraine– Cyclic vomitingCyclic vomiting– Recurrent abdominal painRecurrent abdominal pain

Abdominal migraineAbdominal migraine

1.1. The child may have recurrent bouts of The child may have recurrent bouts of generalized stomach pain with nausea and generalized stomach pain with nausea and vomitingvomiting

2.2. No headache is present. After several No headache is present. After several hours, the child can sleep and later feel hours, the child can sleep and later feel better.better.

3.3. Abdominal migraine may alternate with Abdominal migraine may alternate with typical migraine and usually leads to typical migraine and usually leads to typical migraine as the child maturestypical migraine as the child matures

Chronic non-progressiveChronic non-progressive Tension- Tension-Type HeadacheType Headache

This is the most common type of primary headache in This is the most common type of primary headache in children, children,

Emotional factors are the most likely cause. Emotional factors are the most likely cause. The pain is described as diffuse, sometimes like a tight The pain is described as diffuse, sometimes like a tight

band around the headband around the head Is usually not associated with nausea or vomiting.Is usually not associated with nausea or vomiting. These headaches are almost always related to stressful These headaches are almost always related to stressful

situations at school, competition, family friction or situations at school, competition, family friction or excessive demands by parents. excessive demands by parents.

Discussion with the child and parents is required to Discussion with the child and parents is required to determine whether anxiety or depression may be presentdetermine whether anxiety or depression may be present

Chronic non-progressiveChronic non-progressiveTension headacheTension headache

(2)(2)– At the end of the day on every day most daysAt the end of the day on every day most days– Often not responding to analgesia and may cause Often not responding to analgesia and may cause

rebound headacherebound headache– Frequent school absenceFrequent school absence– More in femalesMore in females– Often respond to relaxation therapy and behavioural Often respond to relaxation therapy and behavioural

interventionintervention– Systematic review is importantSystematic review is important– Therapeutic plan Therapeutic plan (check life style, school attendance (check life style, school attendance

mandatory,counselling, behaviour and stress therapy and mandatory,counselling, behaviour and stress therapy and biofeedback is important)biofeedback is important)

Chronic progressiveChronic progressive Daily headache with increase in severity and Daily headache with increase in severity and

frequencyfrequency Intercranial pathology should be suspectedIntercranial pathology should be suspected Not responding to analgesiaNot responding to analgesia May or may not associated with neurological May or may not associated with neurological

symptom and signssymptom and signs May or may not associated with behavioural May or may not associated with behavioural

problemsproblems Need investigations including neuroimaging in most Need investigations including neuroimaging in most

of patientsof patients Benign intracranial hypertension should be Benign intracranial hypertension should be

consideredconsidered

Brain TumourBrain Tumour Uncommon in school-age childrenUncommon in school-age children Incidence is 0.003%Incidence is 0.003% AdditionalAdditional neurological symptoms and signs on neurological symptoms and signs on

examinationexamination Honig and Charney( 72 children with brain tumourHonig and Charney( 72 children with brain tumour

– 94% with abnormal neurological examination94% with abnormal neurological examination– 85% with abnormalities on CNS examination within 2 months of 85% with abnormalities on CNS examination within 2 months of

presentationpresentation» Childhood brain Tumour consortiumChildhood brain Tumour consortium

3291 children with brain tumour3291 children with brain tumour Headaches at time of diagnosis in 58% of Headaches at time of diagnosis in 58% of

Supratontorial and 70% of InfratontorialSupratontorial and 70% of Infratontorial 99% of children with headaches and brain tumour 99% of children with headaches and brain tumour

had at least 1 abnormal neurological symptom and had at least 1 abnormal neurological symptom and 98% had at least 1 abnormal neurological sign98% had at least 1 abnormal neurological sign

Bilateral optic nerve Bilateral optic nerve swelling(Papilloedema)swelling(Papilloedema)

No enlargement of blind spot on visual fields

AstrocytomaAstrocytoma

MedulloblastomaMedulloblastoma