|Year : 2015 | Volume
| Issue : 3 | Page : 142-149
Primary headaches in children
Ajay Kumar Pan, Anuradha Mitra, Subrata Ray, Amitava Rudra
Department of Anesthesiology, KPC Medical College and Hospital, Jadavpur, Kolkata, West Bengal, India
|Date of Web Publication||21-Sep-2015|
Dr. Anuradha Mitra
B1, Sourav Abasan, ED Block, Salt Lake, Kolkata - 700 091, West Bengal
Source of Support: None, Conflict of Interest: None
Headache is a widespread clinical problem; the prevalence is high in all age groups, from which children and teenagers are not spared. It has been reported that, as many as 75% of school-age children may experience headache infrequently, among them 10% have recurrent headaches. , The vast majority of headaches are primary and classified as migraine, tension-type headache (TTH), cluster headache, and other trigeminal autonomic cephalgias. The type of primary headaches could usually be diagnosed by a thorough and careful history taking, and physical examination. Once the diagnosis of migraine is established and appropriate reassurance provided, a balanced and individually tailored treatment plan can be instituted. The goal of treatment includes abortive or acute pain treatment, preventive long-term treatment, and biobehavioral therapy. Knowledge of precise impact of primary headaches on child's quality of life helps to design a proper comprehensive treatment plan.
Keywords: Children, headaches, primary
|How to cite this article:|
Pan AK, Mitra A, Ray S, Rudra A. Primary headaches in children. Indian J Pain 2015;29:142-9
| Introduction|| |
Headache is a universal affliction of humankind from which children and teenagers are not spared. Headaches can be divided into primary headache disorder, such as migraine, tension-type, chronic daily headache (CDH), cluster headache, and paroxysmal hemicranias in which there is no attributing etiology and the pain arises from intrinsic processes. Otherwise, the headache may result from secondary causes (a symptom of another disorder).
It has been reported that, as many as 75% of school-age children may experience headache infrequently, among them 10% have recurrent headaches. , The most common form of headaches in school children are primary headache (58.4%).  Headache disorders are associated with school absences, poor school performance, and decreased extracurricular activities. ,
The type of primary headaches could usually be diagnosed by a thorough and careful history taking, and physical examination. Taking the history requires sufficient time and patience and should be done with age-appropriate terminology. Questions need to be directed to both the child and parents. To reduce the impact on the activities of the patient, a treatment strategy, which incorporates acute treatments, preventive treatments, and biobehavioral therapies must be implemented.
The purpose of this article is to explore the symptoms of headache, appropriate evaluation, and managements of each type of a primary headache in children.
| Migraine|| |
Several definitions of pediatric migraine have been proposed by Vahlquist,  followed by Prensky and Sommer.  Internationally recognized criteria for evaluation and diagnosis of headache came after the publication of the first International Classification of Headache Disorders (ICHD) in 1988.  The second edition of the ICHD (ICHD-2, 2004)  has been recognized by World Health Organization and is used as the basis for headache diagnosis included in the International Classification of Diseases-10. ICHD-2 includes the following criteria or comments specific to pediatric migraine without aura:
- Attacks may last for 1-72 h.
- Migraine headache is commonly bilateral.
- Photophobia and phonophobia may be inferred from behavior.
Prevalence of migrainous headaches 1-3% (3-7 years), 4-11% (7-11 years), and 8-23% (11-15 years).  The gender ratio being boys > girls (3-7 years), boys = girls (7-11 years), and girls > boys (15 years). 
Symptoms of a migraine vary with the age of the child. In preschool children, migraine often consists of episodes of involving an ill, pale appearance, abdominal pain, vomiting, and the need to sleep. Pain may be expressed by irritability, crying, rocking or seeking a dark room in which to sleep. Five to ten-year-old patients with migraine tend to experience bilateral frontal, temporal or a retro-orbital headache with associated nausea, abdominal cramping, vomiting, photophobia, phonophobia, and need to sleep. Parents may describe these children as pale with dark circles under the eyes. Older children tend to present with a unilateral, temporal headache and the location and intensity of pain often change within or between attacks.
| Classification|| |
Migraine without aura
Migraine without aura is the most common form of a migraine in children. This is to be recurrent in nature. However, may limit the diagnosis in children as they may just be beginning to have headaches. Associated symptoms include (a) at least five headaches, (b) headache lasting for 4-72 h in untreated or unsuccessfully treated child, and (c) headaches should have two characteristics:
- Unilateral location or,
- Pulsating quality or,
- Moderate to severe pain cause avoidance of routine physical activity or,
- During headache patient should have at least one of the following  :
- Nausea and/or vomiting.
- Photophobia and phonophobia.
Migraine persisting beyond 72 h is classified as a variant termed status migrainous. The quality of migraine pain is often, but not always, throbbing. This may be difficult to elicit in young children.
Migraine with aura
About 14-30% of children with migraine also experience a migraine with aura indicating focal or cortical or brainstem dysfunction.  The aura associated with migraine is a neurologic warning that a migraine is going to occur. In the common forms, this can be the start of a typical migraine or a headache without migraine, or it may even occur in isolation. For a typical aura, the aura needs to be visual, sensory or dysphasic.
The aura usually precedes the headache by <30 min and lasts for 5-20 min. The visual aura consists of spots, flashes, or lines of lights that flickers in one or both visual fields (photopsia). Migraine auras may also consist of brief episodes of unilateral or perioral numbness, unilateral weakness or even vertigo. Aura symptoms vary widely within and between attacks.
Rare varieties of auras include:
- Sensory auras: Occur unilaterally and described as a sensation of worms or insects crawling from hands to the face of the patient. Numbness is developed following this sensation.
- Dysphasic aura: Described as an inability or difficulty to respond verbally.
- Hemiplegic aura: An atypical aura including hemiplegia (transient unilateral true weakness). Hemiplegic aura may be familial. Weakness developed in these patients last only a few hours, however, may persist for days due to autosomal dominant disorder with mutation of genes.
| Migraine Variants|| |
Migraine variants are headaches that are accompanied or manifested by transient neurologic symptoms. For example:
- Familial hemiplegic migraine is an uncommon and genetically heterogeneous autosomal dominant subtype of a migraine with aura in which the aura consists of hemiparesis, aphasia, and visual field defects that precede the headache by 30-60 min. The headache is often contra lateral to the local deficits.
- Basilar type migraine is the most common type of complicated migraine variants and is estimated to represent 3-19% of all a migraine. ,, This is a subtype of migraine with aura. The onset of basilar type migraine is characterized by disturbances in function believed organizing from the brain stem, occipital cortex, and cerebellum. The onset of a basilar migraine tends to occur in younger children, with a mean age of 7 years. The important criteria consist of vertigo, visual disturbances in hemifields, bilateral sensory symptoms, and ataxia. History of a typical migraine exists in many families. Some parents experience basilar migraine attacks intermingled with typical migraine attacks.
- Acute confusional migraine, a rare type of migraine, lasting for 4-24 h, associated with agitation and aphasia commonly seen in juvenile migraineures.
- "Alice in Wonderland" syndrome, characterized by vivid or bizarre visual illusions and spatial distortion, which precede headaches. The children may describe their illusions as micropsia (objects appear smaller), macropsia (objects appear larger), metamorphopsia (objects such as faces and appear distorted), and teleopsia (objects appear far away).  These unusual visual symptomatology is best considered as migraine with aura.
| Migraine Equivalents || |
Migraine equivalents are recognized by periodic, paroxysmal syndromes without associated headache that are thought to be migrainous in etiology.  The following equivalents are presently recognized.
Cyclic vomiting syndrome
This migraine associated condition is characterized by recurrent periods of intense vomiting separated by symptom-free intervals. Many patients with cyclic vomiting have regular or cyclic patterns of illness. Symptoms usually have a rapid onset at night or in the early morning and last 6-48 h. Associated symptoms include abdominal pain, nausea, retching, anorexia, pallor, lethargy, photophobia, phonophobia, and headache. Migraine-associated cyclic vomiting syndrome usually begins when the patient is a toddler and resolves in adolescence or early adulthood; it rarely begins in adulthood. More females than males are affected by cyclic vomiting. Usually, a family history of migraines in the patients or siblings is present. Migraine-associated cyclic vomiting syndrome is a diagnosis of exclusion. Other causes of cyclic vomiting include gastrointestinal disorders (malrotation), neoplasm, urinary tract disorders, metabolic, and endocrine disorders.
Benign paroxysmal vertigo of children
Clinical features include in this type of a migraine:
- Young children are mostly sufferers usually found in aged 2-6 years.
- Brief episodes of unexplained unsteadiness make them off balancing and fall.
- Careful observation will reveal nystagmus within but not between attacks.
- Dizziness, headache, and nausea may be complained by older children.
- The attacks may appear in cluster and resolve with sleep.
- Long-term sufferers often develop migraine as they mature.
This type of migraine equivalent includes the following features:
- Recurrent episodes of midline epigastric abdominal pain.
- The pain of moderate to severe in intensity and associated with vasomotor symptoms (e.g., flushing, pallor). Moreover, pain is also associated with nausea and vomiting.
- Usually, patients are well between the attacks.
- An abdominal migraine may alternate with a typical migraine and can lead to a typical migraine as the child matures.
| Chronic Daily Headache|| |
Many adolescents report the experience of headache virtually every day, during waking hour. This type of headache is known as CDH. In this disorder, the diagnosis is based on the presence of headache for greater than or equal to 15 headache days in a month, over a period of three consecutive months, with no underlying organic pathology. The headache lasts for more than 4 h a day. This headache disorder tends to affect teenagers and also can occur in preteens. It can occur up to 4% of young women and up to 25% of young men. ,, In middle school, 0.8% of boys and 2% of girls acknowledge daily headaches. The quality of life of patients with CDH is significantly affected. The headache can cause school absence, affect after-school activities, and result in family discord. Therefore, early diagnosis and management of CDH is essential. 
CDH can be defined under four different categories based upon symptoms. These include transformed or chronic migraine, chronic TTH, new daily persistent headache, and hemicrania continua. Many teen patients with CDH have a past history of episodic migraine. This frequent headache syndrome drew more attention following the landmark publication of Mathew et al., where they described an evolutional pattern of migraine from episodic to daily or near daily headache.  The transformation of episodic to a chronic migraine may occur over a period of weeks to months. Approximately, a quarter of teenagers with CDH will have no significant past headache history.
New persistent daily headache (NPDH) is a new subtype of CDH first described by Vanst.  One-third of the patients of NPDH develops the disease with a flu-like illness. This has raised the possibility of infection as an etiology of NPDH.  A smaller number of patients will have a history of TTHs prior to their CDH. Uncommon in children, hemicrania continua represented a cluster variant with daily unilateral pain with conjunctival injection, lacrimation, rhinorrhea, and occasionally ptosis. The key feature of hemicrania continua is responsiveness to indomethacin.
CDH is a multi-symptom complex:
- Majority of the patients suffered from disruption of sleep.
- Complain of dizziness in the morning, which is associated with feeling weak, unsteady, and with blurry or loss of vision.
- Syncope or near syncope for several minutes after standing.
- Mood problems and anxiety also frequently co-exist with CDH.  The mood problems may precede or follow the onset of headache.
- Frequent comorbid symptoms without additional etiology are:
- Nonspecific abdominal pain.
- Back pain.
- Neck pain.
- Diffuse muscle and joint pain.
There are important environmental factors that play a role in CDHs. Most patients will do better in the summer time and frequently have a worsening of their headaches at the start of the school years, and school absence can be a significant problem.
| Tension-type Headache|| |
TTH and migraine are the two most common type of headache in children and adolescents. Tension-type may be hard to differentiate from a migraine in children as some of the symptoms overlap. However, a headache diary is a useful method for the differentiation of headache types. Epidemiological data on TTH in young subjects have become available only in the last decade and suggest prevalence rates of between 10% and 24%.  TTHs are generally described by the patient as bilateral, pressing, or tightening quality on cranium or suboccipital region. The headache is mild to moderate in intensity and usually not aggravated by the physical activity.
The ICHD, second edition (ICDH-II) sub-classifies TTH as infrequent episodic (<12 times/year), frequent episodic (1-15 times/month), and chronic (more than 15 headaches/month or 180 days/year). Associated symptoms are absent or limited to out of photophobia or phonophobia in chronic TTH. Either photophobia or phonophobia may be present that lasts for minutes to days but not both. The duration of headache can be 30 min-7 days. However, in few children, associated symptoms such as tiredness sleep disturbances and light headedness may occur with episodic TTH. More than 50% with chronic TTH have had predisposing physical or emotional stress factor. , In children, a connection seems possible between TTH and psychological stress, psychiatric disorders, muscular stress. TTH may progress into CDH.
| Cluster Headache|| |
Cluster headache (CH) is the most painful of the primary headaches. The prevalence of childhood and adolescence onset is approximately 0.1%.  Childhood onset at ages between 5 years and 19 years. CH may be episodic or chronic and attacks that lasts for weeks or even months. CH is characterized with circadian rhythmicity, severe unilateral orbital pain, which lasts for 15-180 min with a sense of restlessness, ipsilateral conjunctival injection, lacrimation, nasal congestion, miosis, or ptosis. The sex ratio is approximately (M:F 3:1). Children may experience thrashing about or emotional outbursts secondary to the severe pain.
| Paroxysmal Hemicrania|| |
Paroxysmal hemicrania is a rare headache with a prevalence of 0.02%.  Relatively few pediatric cases have been reported in the literature. Children as young as 3 years of age have reportedly been diagnosed with the disorder. , Headache is characterized by intense attacks of periodic pain lasting only 5-30 min. The attacks occur up to dozens of times/day.
| Managements of Primary Headaches in Children|| |
Once the diagnosis of a migraine is established, and appropriate reassurance provided a balanced and individually tailored treatment plan can be instituted. The decisions regarding the most appropriate therapeutic plan depend on: 
- An acute treatment.
The strategy should be developed for stopping a headache attack on a consistent basis with a return to function.
- A preventive treatment.
The strategy should be considered when the headaches are frequent (1/week or more) and disabling.
Therapy should be started, including a discussion of adherence, elimination of barriers to treatment, and healthy habit management. 
The most common reported participants of attacks in children are:
- School-related stress. 
- Weather changes or environmental factors (hot, humid weather, noise, and smoke). 
- Prolonged fasting. 
- Lack of sleep or prolonged sleep. 
- Minor head trauma during playing of football 
- Menstrual period in adolescent girls. 
Intermittent or "symptomatic" analgesics are a mainstay for treatment of infrequent, intense episodes of migraine. Symptomatic therapy requires early administration of the analgesic, rest and sleep in a quiet dark room. Administration of oral medication is limited because of nausea and vomiting. Only sumatriptan in the nasal spray form (5-20 mg) has demonstrated efficacy in adolescents. ,, For younger children (<12 years of age), ibuprofen (7.5-10 mg/kg), and paracetamol (15 mg/kg)  have demonstrated efficacy and safety for the acute treatment of migraine. Previously, antiemetics were used for acute treatment of nausea and vomiting. However, recently, it has been identified that their effectiveness in headache treatment is related to their antagonism of dopaminergic neurotransmission. Therefore, antiemesis with prochlorperazine and Metoclopramide have excellent efficacy to relieve a migrainous headache that is unresponsive to the nonsteroidal anti-inflammatory drugs and triptans. The goal of the primary acute medication should be headache relief within 1 h with a return to function in 10 out of 10 headaches.
Many children experience such severe or frequent attacks which interfere with activities of daily living to justify the daily use of preventive agents. Daily prophylactic medications may not only reduce attack frequency and severity, but may also enhance the effectiveness of symptomatic medications, lifestyle modifications must be put into place to regulate sleep, establish routines including exercise, and identify any precipitating factors or aggravating influences, eliminating as many as possible (e.g., caffeine, stress, and missed meals). Other treatment options include psychological support or counseling, stress management.
Pharmacologic and nonpharmacologic therapy of a pediatric and adolescent migraine
- Acute treatment.
- Promethazine (0.25-1 mg/kg/dose; every 4-6 h; maximum 15-25 mg),
- Metoclopramide (0.1-0.15 mg/kg/dose; every 6 h; maximum 10 mg).
- Paracetamol (15 mg/kg/dose),
- Ibuprofen (7.5-10 mg/kg/dose).
- 5-hydroxytryptamine agonists.
- Sumatriptan (oral: 25 mg; nasal spray: 10 mg; Subcutaneous: 6 mg).
- Tricyclic antidepressant.
Amitriptyline (10 mg/kg/day)
Gabapentin (900-1800 mg divided BID)
- β-adrenergic blocker.
Propranolol (10-20 mg TID). This agent is contraindicated in asthma and depression
Cyproheptadine (0.2-0.4 mg/kg divided BID).
- Nonpharmacologic therapy.
- Patient education.
- Regular sports.
- Regular sleep schedule.
- Avoid missing meals.
- Eliminate precipitating factors.
| Chronic Daily Headache|| |
CDH is difficult to control. There are often no immediate answers or easy ways to the treatment and resolution of the pain. The cornerstones of the therapy are education, preventive medications, and attention to environmental trigger factors. To limit frustration, it is useful to spend adequate time with the patient and family discussing medications, when not to use pain relievers, the role of nonmedical approaches (biofeedback or physical therapy). The majority of children with CDH have a chronic migraine or chronic migrainous headache features, a modification of standard migraine therapy is appropriate, but the emphasis must be placed on preventive measures rather than analgesic or abortive strategies.
Consideration of comorbid condition is important regarding choice of pharmacologic agents.
- In patients with difficulty falling asleep, amitriptyline may provide dual benefits for a patient with difficulty falling asleep. Consideration needs to be given to follow electrocardiogram changes, as the drug may prolong the QT interval. Weight gain is a significant concern in some of the teenage patients.
- Topiramate may decrease appetite in patient with obesity. Topiramate may also result in mental clouding.
- Valproate stimulates the appetite in patients with low appetite.
Pain control at the time of headache is a very difficult problem for patients. Most patients report that pain relievers are not effective for all the time, 24 × 7 headache. The use of analgesic agents for children and adolescents with CDH is controversial. It is reasonable to discourage patients from trying to use analgesics to treat the all the time headache since this may result in analgesic overuse and a potential analgesic rebound headache. Medications implicated in this overuse syndrome include most over-the-counter analgesics, decongestants, opioids, benzodiazepines, ergotamine, and triptans. The key for effective use of analgesic includes catching the migraine component of the headache as soon as it starts, using an adequate dose, and avoiding overuse.
Nonpharmacologic Measures for chronic daily headache
Nonpharmacologic approaches to treating headaches are also very important. A variety of vitamins (e.g., riboflavin), minerals (e.g., magnesium), and herbal remedies (e.g., feverfew) have been attempted for the prevention of headaches. Unfortunately, none of these remedies have been thoroughly evaluated in children with CDHs.
Patients who experience chronic headache pain should consult a psychologist to get introduced to the techniques of relaxation therapy and biofeedback. Anxiety is highly prevalent in migraine patients. A psychologist, therefore, also is useful in addressing the issues of mood and anxiety.
Many patients have also been ill for months to years and have become physically "deconditioned." Starting a reconditioning exercise program (aerobic exercise) is very important. Patients should be encouraged to start slowly. The key is to slowly but persistently increase activity level. A physical therapy consultant can be useful in these situations.
Until today, the outcome of adolescence with CDH is poorly understood. No long-term follow-up data are available.
| Tension-type Headache|| |
Treatment of TTH requires acute treatment, either prophylaxis or nonpharmacologic therapy. Nonpharmacologic therapy is needed for all types of TTH. It is often suspected there may be underlying psychological stressors, and although it may be suspected by the parents, it cannot be confirmed in the child. Simple analgesic agents such as paracetamol and ibuprofen can be effective for acute treatment. A major concern is with the overuse of these types of medications. Amitriptyline has the most evidence of effective prevention of TTH.
Pharmacologic and nonpharmacologic therapy of a tension-type headache
- Acute treatment.
- Ibuprofen 10 mg/kg body weight.
- Paracetamol 15 mg/kg body weight.
- Flupertine 50-100 mg.
- Magnesium 300-400 mg.
- Amitriptyline 1 mg/kg body weight.
- Topiramate 50-100 mg.
- Nonpharmacologic therapy.
- Patient education.
- Relaxation therapy.
- Regular sports.
- Training programs.
| Cluster Headache|| |
Only about 5-10% of CH patients developed the disease in adolescence while the onset of CH in childhood is very rare.  Management of this CH is difficult. The most effective acute/symptomatic treatment includes: 
- Inhalation of oxygen (100%) with a flow of 8-10 L/min for 10-15 min through a nonrebreathing facemask.
- Sumatriptan (6 mg) subcutaneous injections, or intranasally (20 mg).
- Dihydroergotamine (0.5-1 mg) intravenous, intramuscular, or subcutaneously at the onset of headache.
For prophylactic treatment,  the efficacy of verapamil has been attributed to a possible stabilization of vascular tone.  Furthermore, sodium valproate, lithium carbonate, methyl sergide, and ergotamine tartrate could be used. ,,
| Conclusion|| |
Pain physicians should have the understanding of primary headaches in children. Children may be deprived of optimal treatment because physicians may lack knowledge about diagnosis and management of a migraine and other primary headaches. This article has explored the symptoms of headache, appropriate evaluation, and management of each type of a primary headache in children. Investigating tools have a limited role; diagnosis is based on clinical evaluation and understanding. Overlapping symptoms sometimes make it difficult to diagnose, and recurrence and refractoriness sometimes yield unsatisfactory outcome following treatment.
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Conflicts of interest
There are no conflicts of interest.
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