Headache

Headache in children is a common reason to attend a  doctors surgery or emergency department, and finding the cause can be challenging. Some children have frequent headaches and childhood migraines are surprisingly common. In this article we will be dealing more with headaches that are of sudden onset or part of an infectious illness. Migraine will be covered elsewhere but note the diagram shows the typical history of migraines.

 

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Headaches probably occur in all ages but clearly become recognisable when a child can communicate. Up to 40% of children will have suffered a headache by the time they are 7.  The severity of the headache will affect activity. So if the child is unable to function, is holding his or her head and appears quite distressed then prompt evaluation is needed. If the child is otherwise active, has good appetite and sleeps well, the chances of a serious cause is negligible. Other symptoms such as fever, lethargy, vomiting, or flu like illness will provide clues as to the possible cause and whether there is need for further investigation.

Interestingly nowhere in medical literature are headaches felt to be caused by poor vision or not enough fluids. But for some reason every child with headaches in encouraged to have their eyes checked and to ‘drink more fluids’. Perhaps the squinting of the child with poor vision may cause a tension type headache.

 Typical Headache patterns

The patterns of headache are presented diagrammatically below.  Benign headaches, that is headaches that are not due to a serious cause will have headache free periods. For example a headache due to migraine will have headache free periods. The most serious cause of headache is chronic progressive headache. In other words a persisting headache that is getting worse and there are no headache free periods.

recurrent

CNS tumour

headache infection

Common headaches

1. Headache associated with an illness 

This is common, usually associated with viruses such as influenza, or gastrointestinal illness. The headache can be the most significant symptom, and is frontal in position and can be distressing. The child will lessen activity, but may be able to watch television or lie on the couch. 

  • There will be other symptoms such as runny nose, cough, fever, and general flu like symptoms, or in gastrointestinal illnesses, vomiting and diarrhoea.
  • The headache will come and go and will respond to simple pain relief such as panadol or nurofen.
  • As the virus subsides so will the headache.
  • Sinus disease in older children can present has frontal headaches associated with fever, purulent nasal discharge and tenderness in the facial area. This may also occur with allergic rhinitis (old fashioned name hay fever), when this becomes infected
  • Toddlers will sometimes complain of headache, and the origin may be the middle ear. Usually a complication of a cold.

1. Other causes of recurrent headache

  • Tension-Type Headache  – These headaches are frequent, often occurring for months and are non progressive.(This means there intensity is not getting worse).  There are some headache free periods. Usually the child will function reasonably. There are often other ailments such as stomach pains and psychological factors such as anxiety and school related problems maybe contributory.  Management of these headaches involves the use of intermittent analgesics coupled with behavior interventions such as stress management.
  • Temporomandibular Joint Disorder –  This can present as headache, and includes jaw pain aggravated by eating, teeth clenching, or yawning. Patients may describe a clicking or locking of the jaw. Family members may describe bruxism, (teeth grinding). Examination reveals tenderness over the TMJ and limitation of mouth opening. Treatment includes use of non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxation techniques, and avoidance of provocative processes like gum chewing or eating hard candy. Major oral surgery is rarely necessary.
  • Some other causes – 
    • Hair ties, some (girls) children will develop a headache if their ponytail is ‘too tight’.
    • Hats – sometimes a tight or ill fitting hat can slowly cause a headache
    • Exercise – particularly on hot days can sometimes induce a nasty headache – Cooling, and placed in quiet atmosphere with plenty of fluids will help.

Rare serious causes of headaches

Rare serious causes of headache – these present has progressive headaches in an unwell child with other symptoms.  Note the charts on the right, the infectious cause will develop over a short period of time, whereas increased pressure due to a tumour or other cause will develop over days to weeks.

  • MeningitisInfection of the surface of the brain is called meningitis, and if bacterial is a medical emergency.
    • The child will have a severe headache, very high fever, and be so unwell, that walking and talking are virtually impossible. In addition the child will complain of eye discomfort in bright light (photophobia). Drowsiness, vomiting, slurred speech, disorientation and in serious cases a seizure may occur.
    • Diagnosis is with a lumbar puncture after a CT scan and treatment is intravenous antibiotics.
    • There are a number of bacteria that can cause this and immunisation currently covers some of the most common organisms
  • Central Nervous System tumour.Brain tumours are one of the most common concerns when parents seek advice about headaches, but the incidence is rare. It is often the main parental concern and doctors will be pressured to order scans to ‘rule them out’.
    • The headache will be slowly progressive, associated with night waking, vomiting, progressive drowsiness, sometimes difficulty walking and sometimes slurred speech. There maybe some localised ‘seizures’.  There will be no features of infection or inflammation.
    • Examination will sometimes show abnormalities in the nervous system, such as problems with eye movements, and visual fields, balance, and reflexes.
    • Despite the rarity of such tumours  many CT scans were done to ‘reassure’ parents.  This was an unnecessary dose of radiation. Nowadays in Australia medicare will fund MRI examination which is risk free.
  • Central Nervous System Haemorrhage.
    • This is usually termed subarachnoid haemorrhage. It occurs due to an aneurysm or vascular abnormality. This will occur in an older child or adolescent and the headache is very sudden, severe, associated with drowsiness, disorientation, inability to walk.

How do you manage a simple headaches? 

The most important aspect is to keep a diary of the headaches to establish if there is a pattern. Simple pharmacological medications such as ibuprofen and panadol are generally safe and effective for non specific acute or recurrent headaches. Sometimes placing the child in a quiet dark room to encourage sleep is useful. If the headache is mild and the child does not feel it is necessary to go to sleep then propped up (such as beanbag) whilst watching tv (distraction) may help. (Being propped up relaxes the muscles of head and neck and may help to ease the headache faster).

When is a Scan necessary ? 

Understandably concerns about sinister causes of headaches such as brain tumours or structural abnormalities are one of the main reasons for attending a medical appointment. However until recently the only scan was a CT scan which is an unacceptable radiation dose. So CT scans were only used when it was clear on history or examination that there was a concern about a sinister cause. Nowadays an MRI is a reasonable option as there is no radiation. Nevertheless they are expensive and sometimes difficult to organise but are risk free. Features that suggest a scan should be organised include

  • Chronic progressive headache
  • Abnormal neurological examination – such as slurred speech, eye symptoms or signs, problems with gait, reflexes, sensory disturbance
  • Increase in size of skull
  • Vomiting that is not explained by migrainous headaches that is chronic progressive
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