07 Jul Pediatric Headaches
Headaches are one of the most common ailments in childhood and adolescents. Headaches occur in up to 75% of children before the age of 15. Most of these headaches are minor and infrequent. Unfortunately headaches can become severe and lead to missed school, missed social events and a general decrease in quality of life. Headaches that cause at least one missed school day per month occur in as many as 25% of children 5 – 18 year olds. There is some evidence that pediatric and adolescent headaches are increasing in prevalence. So the bottom line is that headaches can really be “that bad” and often are.
What is a headache? Quite simply a headache is pain in the head, but what hurts in the head? Well, it is not the brain. Although the brain interprets the sensory nerve signals as pain it does not have any pain sensing nerves. The structures inside the skull that do have sensory nerves include the tissues lining the brain and the blood vessels in those tissues. More often headaches come from pain in structures outside of the skull including skin, muscles, blood vessels, soft tissue of scalp, face, sinuses, eyes, and eye muscles.
When headaches happen in our children our biggest concern is that there is something that is potentially life threatening happening. Luckily according to the National Headache Foundation less than 5% of pediatric headaches are due to an underlying serious illness or trauma. The evaluation of headache relies in collecting a thorough history and physical examination of the child. This evaluation can then guide if anything further needs to be investigated.
Headaches can be divided into three categories based on frequency, the acute headache (first or worst ever), the recurrent or intermittent headache, and the chronic headaches (continuous or near continuous headaches). The acute headache is often the first or worst headache that a patient has had. While this may be the first attack of episodic or recurrent headaches, serious or potentially life-threatening underlying conditions must be ruled out. First headaches can rarely be diagnosed as migraine.
Recurrent episodic headaches are those headaches that exhibit complete recovery between episodes. Luckily in adolescents recurrent headaches are often tension type headaches but vascular headaches are quite common as well. The symptoms of a tension type headache often include band-like pressure across the forehead occasionally associated with neck or shoulder pain. These headaches often better in the morning and worsen as the day progresses. Vascular headaches: also known as migraines and migraine variants account for the remainder of primary recurrent headaches. These headaches are exceedingly common, but contrary to popular belief need not be particularly severe. Migraine headache patterns can vary over time for an individual, and vary enormously between individuals.
Chronic headaches may be variable in severity, but are continuous since onset. Once they start they are always there. This type of headache deserves some more attention. These fall into a few categories. First is the Transformed Migraine or Medication Overuse Headache. These are caused by a rebound headache from the over use of either over the counter (OTC) or prescribed breakthrough headache medication. Any child taking medication for headache more than twice a week is at risk for developing this type of headache. Post-Traumatic headaches can also fall into this chronic headache classification. Headaches associated with chronic illness or increased pressure in the head are often continuous in nature. Chronic headaches deserve a very thorough history and physical.
In evaluation of chronic or recurrent headaches history is (nearly) everything and physical exam is the rest. Laboratory testing and imaging rarely help in the absence of suggestive history or physical findings. So what do we look for in the history? We look at pattern and chronology of pain, preceding and accompanying symptoms (visual changes, numbness, weakness, confusion), other associated illnesses, symptoms, risk factors, medications (prescribed, OTC, vitamins, BCPs), substance use/abuse, mood, behavior, school phobia, secondary gains, and family history.
As part of the history collecting a list of precipitating factors is very useful (and keeping a diary). These precipitants may include foods (chocolate, nuts, cola, cheeses, others), food additives (nitrates, nitrites, MSG, caffeine), physical stimulants (temperature changes, bright light, strobes, exercise, sexual activity, odors), poor sleep patterns, any medications including birth control pills, minor analgesics, vitamins, supplements, alcohol, street drugs or any other systemic symptoms or illness
A complete physical examination for signs and symptoms of systemic disease or etiology of headaches is essential. This examination must include an exam of the back of the eye for increased pressure inside the skull. Lastly a careful and complete neurological examination, searching for signs suggesting a neurological problem.
Further testing is rarely necessary. A CT scan or MRI is indicated only if there are abnormalities found on neurological examination, increased head pressure is suspected from the eye exam or an increase in head size, or headache pattern suggests an intracranial lesion (daily morning headache). EEG is generally not useful in the evaluation of headache and sinus films are indicated only with other symptoms suggesting sinus disease. One must take some caution in diagnosing migraines as there are a few rare metabolic disorders that may masquerade as migraines.
Treatment strategies for migraine:
Three approaches avoid triggers, treat headaches early and completely and lastly prevention. To avoid triggers they must first be identified. Keeping a detailed diary of headaches, diet, activity, medication for at least 5-6 headache cycles is often necessary. This strategy is worth a try for all migraine patients. Once complete, families can try such strategies as sun protection (sunglasses, brimmed hat), avoiding strobe conditions, avoiding MSG, nitrates, nitrites, minimize or wean daily caffeine intake, and stabilize sleep patterns (same bedtime and wake-up hours daily)
The acute management of migraine for infrequent attacks hinges on taking the appropriate medication as soon as you realize the headache is starting. For many patient medications such as ibuprofen when taken at the first signs of a headache are very effective. Migraine specific medications such and sumatriptan (Initrex) are also much more effective when taken at the very onset of a migraine headache. Medication for nausea is often necessary in addition to pain medication. Lastly resting in a quite dim room and encouraging sleep can be quite helpful.
There is growing evidence that at the cause of recurrent vascular headaches lies in irritability in certain structures in the brain. This irritability then leads to increase sensitivity causing migraines to be trigged more frequently. Preventative therapies for migraine, chronic daily headache, and migraine variants focus on decreasing this central nervous system irritability. This treatment can include medication, cognitive and behavioral therapy, other complementary therapies and an emphasis on a return to normal daily living.
Medications such as beta blockers, tricyclic antidepressants, anti-histamines (cyproheptadine), and anti-seizure medication have been shown to decrease the frequency of migraine headaches in young patients. The use of such medication is often started simultaneously with abortive medications. It is very important to limit or withdraw any overused analgesics as they can perpetuate the headaches.
In addition to medications there are a few supplements and herbal products that have been shown to treat or reduce headache frequency. Co-enzyme Q10 and Magnesium supplementation have been shown to reduce headache frequency. Few herbal regimens have been proven to be effective for headache therapy. Feverfew has the best evidence of effectiveness and is generally considered safe. Peppermint, Ginkgo Biloba, Butterbur, Valerian, Passionflower, Cayenne, and Willow have some positive findings but conflicting results. Please be advised that supplements and herbs can interact with migraine medication and have side effects of their own so please consult your healthcare provider before starting any new remedies on your own.
Cognitive therapy is the modification of an individual’s beliefs, expectations and coping abilities. This is essential to chronic headache therapy and includes education, trigger identification and avoidance, stress management and relaxation. The education for chronic headache focuses on reframing the pain. Rather than focus on the “cause” discuss the cause as known, in terms of pain mechanisms. For example the pain is resulting from a neural signaling problem rather than a tumor or illness. Techniques such as distraction, guided imagery (imagining specific imagery designed to increase self efficacy), relaxation (controlled deep breathing, progressive muscle relaxation), and hypnotherapy (a state of awareness marked by heightened concentration through which suggestions are accepted that allow the use of natural skills to optimal levels) have all been demonstrated to significantly reduce headache severity and frequency in children and adolescents. Biofeedback is a therapy that couples relaxation therapy with technology that can measure a child’s level of relaxation and then display that information. Biofeedback has been shown to be effective in the treatment of adolescent headaches but it is unclear if it provides a significant improvement over relaxation therapy alone.
Behavior therapy is used to identify behaviors in a child and their primary caregivers that either trigger headaches or reinforce pain behavior. The goal is then to stop or decrease all of the identified behaviors. For many families the use of a reward system can be highly effective. Recovering from chronic headaches is difficult and rewards can be very motivating. Behaviors that promote positive functioning and coping are rewarded and negative and reinforcing behaviors are not. There is also good evidence that children with chronic headaches benefit from individual or group therapy. These therapies are helpful to address changing meaning of pain, teach active coping strategies targeting increased self-efficacy, support normal developmental trajectory and independence and facilitate emotion based communication and active problem solving with family, teachers, and peers.
Physical therapy has been shown to be effective especially for tension headaches. There is evidence for positive effect in migraine as well especially when coupled with relaxation therapy. Complementary therapies such as acupuncture and massage have both been demonstrated to be effective and well tolerated in the treatment of chronic headache and migraine in adolescents. These therapies often require 6 – 10 treatments for optimal results. There is data on the positive effect of Chiropractic manipulation, and Osteopathic manipulation but more data is needed. There is currently little or no data on Homeopathy and Restriction diets
To sum up, headaches in children are common and can significantly interfere with a child’s life. Very few headaches are secondary to serious illness. Young people get both migraines and tension type headaches. There are many treatment options that have been shown to be effective and most are even more effective when used in combination. Children and teens do not need to suffer from chronic or recurrent headaches. Please contact your healthcare provider if your child’s life is at all impacted by headaches.
References available upon request