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Approach to headaches in children.

Headache is a common problem in childhood - up to 25% of schoolchildren suffer from chronic, recurrent headaches. Although primary headaches are far more common than those with a secondary cause, it is the latter that result in the most anxiety for families. (1) A logical approach to investigating and managing headaches is needed.

Classification

According to the International Classification of Headache Disorders, 2nd ed., headaches are divided into those with primary and those with secondary causes. Primary headaches occur independently of any other medical condition, while secondary headaches are directly attributed to an underlying medical cause. (2)

History

A detailed history is vital to identify the characteristics of the headache and to exclude secondary causes. Pertinent questions that need to be answered are set out in Table I. (1)
Table I. Pertinent questions when evaluating a child with headache

Question Clinical Likely Management pointer
 features diagnosis

When did the Acute, Local cause Not pathological,
headache non-progressive analgesics
start?
 Acute, evolving Possible brain Refer, neuro-imaging
 tumour
 Chronic Migraine Non-pharmacological
 and pharmacological
 approaches
 Tension-type Analgesics
 headache

What is the Intermittent Migraine Non-pharmacological
pattern of and pharmacological
headache? approaches
 Worsening Intracranial Refer, neuro-imaging
 pathology
 Chronic, Tension-type Analgesics
 non-progressive headache

What is the Daily to few Tension-type Analgesics
headache times a week headache
frequency?
 Weekly to Migraine Non-pharmacological
 monthly and pharmacological
 approaches
 Clusters of few Cluster Analgesics
 times a headache
 week for a few
 weeks, long
 asymptomatic
 periods

Do the Night or early Migraine Non-pharmacological
headaches morning and pharmacological
occur at a approaches
specific
time?
 Raised Refer, neuro-imaging
 intracranial
 pressure

Is an aura or Present Migraine Non-pharmacological
prodrome and pharmacological
present? approaches
 Intracranial Refer, neuro-imaging
 pathology

Where is the Unilateral Secondary Refer, neuro-imaging
pain? persistent cause
 Bifrontal Migraine Non-pharmacological
 and pharmacological
 approaches
 Diffuse Tension-type Analgesics
 headache

Are there any Intermittent Migraine Non-pharmacological
associated nausea, vomiting, and pharmacological
symptoms? photophobia approaches
 Persistent Intracranial Refer, neuro-imaging
 nausea, vomiting, pathology
 photophobia

Are there any Relief with Migraine, Non-pharmacological
aggravating analgesics tension-type and pharmacological
or relieving headache approaches
factors?
 Relief with Migraine Non-pharmacological
 sleep and pharmacological
 approaches
 Worsened by Migraine Non-pharmacological
 light, noise, and pharmacological
 activity approaches
 Worsened by lying Raised Refer, neuro-imaging
 down intracranial
 pressure


Examination

The general examination should include vital signs, including blood pressure and temperature. Meningitis should be excluded in all children with pyrexia. The skin must be examined for features of neurocutaneous syndromes. An increased head circumference may be a reflection of chronically raised intracranial pressure. Exclusion of other non-neurological causes entails examination of the ears, nose and throat (ENT), sinuses, teeth, temperomandibular joint and cervical spine. It is useful to evaluate visual acuity by means of a Snellen's chart to exclude refractive errors that may cause headache.

In addition to measuring the head circumference, clues in the neurological examination that indicate a secondary cause would include depressed or altered level of consciousness, meningism, papilloedema (useful in older children to confirm raised intracranial pressure) and focal signs, including cranial nerve palsies and hemiparesis. Headache associated with papilloedema and an abducens palsy as the only abnormal neurological finding is a common presentation of benign intracranial hypertension.

In the majority of children presenting with headache the neurological examination will be completely normal.

Investigations

Investigations should be guided by the history and clinical findings. Most headaches are idiopathic in nature. Brain tumour is a rare cause of headache in children - the incidence is 3 - 5 per 100000, and of these only 10% will present with headache as the only symptom. Therefore, for every child with a brain tumour presenting with headache as the only feature, there are at least 50 000 children with recurrent headache. (2) Investigating all children with chronic headache and a normal neurological examination by computed tomography (CT) scanning of the brain is therefore not a feasible option. Neuro-imaging is nevertheless indicated in certain situations (Table II). Magnetic resonance imaging (MRI) is the neuro-imaging of choice, but in resource-limited settings CT is the logical alternative.

Table II. Indications for neuro-imaging in children with headache

1. Abnormal neurological examination (focal neurological signs, abnormal eye movements, ataxia, hemiparesis, papilloedema)

2. Headache characteristics, such as headache on awakening; headache always occurring on the same side of the head; headache with change of posture/sneezing/coughing; unusual location (occipital headaches); headache causing sleep interruption; worst headache of life, chronic-progressive pattern

3. Deterioration in school-work and personality change

4. Presence of ventriculoperitoneal shunt

5. Presence of neurocutaneous features

6. Headache in child under 3 years of age

Management of primary headache

The management of headaches in children demands a multidisciplinary approach involving the general practitioner or paediatrician, schoolteacher, dietician and psychologist. Additionally, input from the family is essential to ensure successful treatment of a condition as complex as childhood headache. Management comprises both pharmacological and non-pharmacological approaches. Keeping a headache diary is useful, as it provides information regarding the pattern and frequency of headaches and response to interventions. Important non-pharmacological strategies involve good sleep hygiene, regular exercise, decreasing the amount of caffeinated drinks and relaxation methods. Obtaining a history can be difficult in young children. (3), (4) Therefore, their drawings may be very useful in the diagnosis of headaches in children. In a large study, identification of elements of children's drawings enabled differentiation between migraine, tension-type headache and other headaches (Figs 1 and 2). (5) Diet may also play an important role in childhood headaches and is often ignored as a therapeutic option. Foodstuffs that can trigger headaches include cheese, chocolate, citrus fruits, monosodium glutamate, aspartame, ice-cream and alcohol. A headache and diet diary should be kept, and foods presumed to trigger attacks must then be excluded. However, eliminating all potential food triggers is generally not advised and a well-balanced diet is encouraged. (6)

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

The aim of acute pharmacological treatment is a rapid return to normal function with minimal side-effects. (7) Ibuprofen 10 mg/kg/ dose was shown to be superior to placebo (8), (9) and equivalent to acetaminophen 15 mg/ kg/dose in the management of migraine in children. (8) If non-steroidals are not effective, serotonin-receptor agonists are an option. Nasal sumatriptan 10 mg (20 - 39 kg) and 20 mg (>39 kg) has been shown to be effective in an 8 - 17-year age group, as was rizatriptan 5 mg (20 - 39 kg) and 10 mg (>39 kg) in this age group. (10), (11) Analgesic headache occurs when drugs given for the treatment of headache aggravate headache symptoms. The condition is recognised in children and may even be induced by mild analgesics such as paracetamol used in isolation. The diagnosis is confirmed when abrupt withdrawal of analgesic drugs leads to headache resolution. (12)

Prophylactic therapy should be reserved for children with frequent headaches that interfere with daily lifestyle and result in functional disability. Prospective, randomised, controlled trials evaluating preventive treatment in children with migraine are scanty. The few studies published are hampered by placebo response rates as high as 50%. Therapeutic options most often used include: amitriptyline 10 - 25 mg at night, sodium valproate 20 mg/kg/ day given as either a single dose or 2 divided doses, topiramate 1 - 4 mg/kg/day (100 - 200 mg/day) in 2 divided doses, propranolol 2 - 4 mg/kg/day (10 - 40 mg three times daily) and levetiracetam 20 - 40 mg/kg/day in 2 divided doses. These therapeutic options are based on small studies, and the definitive agent has yet to be identified.

References available at www.cmej.org.za

REGAN SOLOMONS, MB ChB, DCH (SA), MMed (Paed), Cert Paed Neur (SA)

Consultant Paediatric Neurologist, Tygerberg Children's Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University

JOHAN SCHOEMAN, MB ChB, MMed (Paed), FCPaed (SA), MD

Professor and Head, Paediatric Neurology, Tygerberg Children's Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University

RONALD VAN TOORN, MB ChB, MRCPCH (UK), FCPaed (SA), Cert Paed Neur (SA)

Consultant Paediatric Neurologist, Tygerberg Children's Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University

Correspondence to: R Solomons (regan@sun.ac.za)
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Author:Solomons, Regan; Schoeman, Johan; Van Toorn, Ronald
Publication:CME: Your SA Journal of CPD
Date:Jan 1, 2012
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