Children and Headache

Headache in Children and Adolescents – a Frequent Symptom

Headache is a frequent symptom in children and adolescents, many cases not being seen by doctors.  Studies have shown that prevalence increases from preschool age (3-8%) to mid-adolescence (57-82%).  One of the recommendations of a recent World Health Organization report ‘Headache Disorders and Public Health’ was ‘to raise the priority of effective treatment and prevention of headache in children’.

Headache is one of the main reasons children miss school.  Missing school can affect a child’s overall education and ability to ‘fit in’ to school environment and curriculum. In most cases the headache can be diagnosed quickly and treated effectively. Avoiding missed meals, dehydration, and tiredness or over excitement, common headache triggers, may prevent some headaches.

Some headaches can cause significant pain and disability.  Most headaches are benign but the seriousness of the causes of some headaches gives the symptom a feared reputation.  Headache in association with fever, significant drowsiness or other symptoms may be a sign of a serious illness and should be referred to a doctor.

Types of Headache

Headaches can be classified as primary (occur on their own and not resulting from another health problem) and secondary (resulting from another health problem).

The most common primary headaches are migraine and tension-type headaches.  Prevalence of migraine in community studies of children is 4-10%.  Both migraine and tension-type headache are common in children with a family history of headache.  Distinguishing features of migraine and tension-type headaches are:

 

Migraine

Tension-type

Headache is severe

Headache is mild to moderate

Headache may affect one or both sides of the head

Headache affects both sides of the head

Short duration (30 mins to several hours)

Can last from 30 minutes to days or even weeks

Aura symptoms may be present (may be described as flickering lights, zigzag lines or loss of part of the visual field, usually occurring just before or during the headache)

No aura symptoms

Nausea and Vomiting

Nausea and vomiting uncommon

Pallor

No pallor

Usually history of headache in parents 
Attack relieved by sleep 

 

The most common cause of new secondary headaches (no previous attacks) in children seen by doctors is infection such as sinusitis or middle-ear infection. Other rare secondary headaches include head injuries or concussion, blood vessel problems, medication side effects, brain tumours, cervical spine injury, ocular inflammation, meningitis and encephalitis.

Headaches that are continuous are called chronic daily headaches.  It is rare that recurring headaches are due to an underlying disorder. However, should any of the following also affect your child please consult a doctor:

  • An unaccountable increase in the frequency, severity or duration of the headaches
  • An extremely severe headache
  • A headache with symptoms different to previous headache.
  • Headaches accompanied by fever or a stiff neck
  • Headaches that wake a child from sleep
  • Headaches preceded by an injury
  • Early morning vomiting without nausea
  • Personality changes
  • Recent school failure
  • Failure to grow or attain normal developmental goals.

Migraine in Children and Adolescents

One of the hardest things for parents is to see their child in pain.  But sadly children can suffer from migraine too. Recent studies have shown that 3-7% of children suffer from migraine, 25% having their first attack before the age of 6, and 57% between 6 and 10.  Migraine usually runs in families.  In the children studied 77.5% of family members were also affected by migraine.  Migraine becomes more common with increasing age, being twice as common in mid-teens as under 10.  In childhood there is no gender difference but from adolescence, migraine is more common in girls than boys.   There is thought to be a link to hormone levels.

Triggers

Just as with adults, migraine in children is triggered by a combination of factors. Many adult triggers are also applicable to children and children are often aware of relevant triggers themselves: typically lack of sleep, exercise, delayed or missed meals, worries about home or school, or excitement such as children’s parties. Other important triggers that can easily be overlooked include parental conflicts or bullying, inadequate nutrition particularly during the teenage growth spurt, constipation, food intolerance or allergy, travel, minor blows to the head in the playground or playing sport, dehydration, environmental conditions such as odours, loud noises and bright light, and food allergies including MSG.

Diagnosis

Diagnosis can be difficult as children may have trouble explaining their symptoms. These are similar to those of adults but the headache may be less pronounced with other symptoms (such as nausea, stomach cramping, sensitivity to light and sound, and diarrhoea) are more common. Children tend to have migraine on both sides of the head, while adults are usually confined to one.  Migraine attacks in children are often shorter than in adults, as brief as 1-2 hours in duration.  In a study, Professor James Lance found that initial migraine attacks were experienced at 10 years or younger by about 20 per cent of patients. The youngest patient he can remember was a baby of 3 months whose mother recalled episodes where the child cried, held his head, and vomited. When the child was old enough it became clear that these episodes had all the hallmarks of migraine.

Treatment

Non-drug treatments are usually tried first.  This may involve changes to a child’s diet, posture, schedule and learning relaxation techniques.  Treating an attack may involve sleep, rest in a quite darkened room and using a hot or cold pack (whichever the child prefers).  The chances of an attack may be reduced by:

  • Maintaining regular life style factors such as drinking enough fluids (4-8 glasses per day) and having regular meal times with nutritious, freshly cooked or raw foods
  • Avoidance of foods known to be triggers such as caffeine, present in cola drinks
  • Maintaining regular bedtime routines with 8-10 hours sleep per night
  • Balance between school, recreational and sporting activities, avoiding overcrowded schedules and stressful situations
  • Avoidance of long hours of TV watching or computer game playing
  • Encouraging a positive self-image despite headache – not letting parental anxiety and concern allow the child to identify himself or herself as a helpless and impaired patient unable to live a normal life- keep regular routines as much as possible and reinforce and encourage normal activities
  • Talking to counsellors or other children with migraines to assist the child to understand the headaches and make him or her feel more comfortable in dealing with them and explaining them to friends etc
  • Ensuring child’s school and teachers are aware of condition and treatment plan
  • Ensuring any medication is taken as directed
  • Counselling if headaches seem linked to anxiety or depression
  • Keeping a headache diary where the child can record times and places the headaches occur; thoughts, behaviours or events that occur with the headaches; food consumed; and sleep patterns- information compiled from the diary can help the child avoid triggers and will assist the medical practitioner
  • Regular follow-up appointments with the child’s doctor to evaluate treatment.
    Over-the-counter and prescription medications are available but parents should consult the child’s doctor before starting any form of treatment.

Tension-type Headache in Children and Adolescents

Tension-type headache is the most widespread headache disorder, onset often being in the teenage years.  Tension-type headache in children and adolescents may be hard to differentiate from migraine as some symptoms overlap (see previous table of differences).  Tension-type headache is not necessarily caused by muscle tension or anxiety but may include tightness in the muscles of the head and neck.  Tension-type headaches can be chronic (occur for 15 days/month or more) or episodic (less than 15 days/month).

Tension-type headache in children and adolescents has been little studied.  There have been few clinical trials involving treatments but the tricyclics such as amitriptyline or the anti-convulsant sodium valproate are often effective.

References

Migraine and other headaches, 2000 ed, Professor James Lance
Understanding Migraine and other Headaches, 2002 ed, Dr Anne MacGregor
Headache in Children and Adolescents 2001 Paul Winner & A. David Rothner
Migraine in Children, A Parent’s Guide Mayo Clinic www.mayohealth.org
Rhonda’s Migraine Page, www.migrainepage.com
Childhood & Adolescent Headache, Drs J.Heywood & I. Hopkins, Australian Doctor 24.11. Cephalalgia 2000. 20(6), 573-579; 1999 Dec;19 Suppl 25:57-9.

 




Prepared by Louise Alexander, PhC, Grad Dip Comm Mngt, Former National Director of the Brain Foundation. Reviewed by Professor James Lance, AO, CBE, MD, Hon DSc, FRCP, FRACP, FAA, Consulting Neurologist, and author, “Migraine and Other Headaches”