HOW COMMON ARE HEADACHES IN CHILDREN?
Headache is a common complaint in children. Up to 1/3 of children will have complained of headache by their seventh birthday and about 2/3 of them by age fourteen years. The commonest causes of occasional headaches include illness with fever and a minor blow on the head.
ARE ALL HEADACHES THE SAME?
Headaches may be due to some underlying disease affecting the brain or the structures in the skull, face (eyes, ears, teeth & gums) and neck and are classified as secondary headaches. In many instances however, no underlying disease process is found and these headaches are classified as primary headaches. There are different types of primary headache which are identified by certain clinical characteristics. Two common examples of primary headache are migraine & tension headache.
MIGRAINE is one of commonest types of primary headache in children, occurring in around 10% of children aged 5-15 years. More boys than girls have migraine below age 12 years but girls predominate thereafter.
A migraine headache is usually of moderate or severe intensity, is located in the front or at the side(s) of the head, and is pulsating or throbbing in character. It is commonly associated with nausea, vomiting and dislike for light or noise and may be accompanied by visual symptoms (blurred vision; double vision), dizziness, and tummyache. The headache may last for some hours and is often relieved by rest or sleep. Young children often have difficulty describing the nature of the pain and commonly complain of headache for shorter periods. Triggers of migraine include psycho-social stress (at school; at home), lack of sleep, noise, bright light, overexertion, hunger, dehydration, minor injury to the head, menstruation, and certain foods or drinks (e.g. fermented cheese; caffeine). Many children with migraine also suffer from allergic disorders (asthma, allergic rhinitis, eczema) & motion sickness.
TENSION TYPE HEADACHE is another common form of primary headache in childhood but tends to be commoner in older children and adolescents and affects more girls than boys. The headache is usually mild to moderate in intensity, located in the front or all over the head and is pressure-like or tight in quality. It tends to come on in the latter part of the day, may wax and wane and may sometimes last for a whole day. It is not associated with nausea, vomiting, or dislike for light and noise. Psycho-social stress is a common trigger. Migraine and tension type headache may co-exist.
SEVERITY OF HEADACHE
Severity of headache may be quantified by
Asking the child to give a score between one and ten, with the most severe pain scored as ten.
Asking the child to choose a cartoon face with the mildest headache showing the child to be smiling and the worst headache showing him to be very sad with eyes and mouth turned down and to be shedding tears.
Asking the child to draw a picture of herself while having a headache. This drawing may show that she is having a pretty bad headache!
Generally speaking, a bad headache usually causes a child to stop playing.
COMMON MYTHS ABOUT HEADACHE
Headache is often due to an eye problem: Refractive errors (eye defects that can be corrected by glasses) are uncommon causes of recurrent headache.
Headache is due to a “sinus problem”: The term “sinus problem” usually refers to allergic rhinitis or hay fever. As noted above, allergic disorders often co-exist with, but do not cause migraine.
Most headaches are just “ordinary headaches”: There is no such thing as an ordinary headache. Headaches are either due to some underlying disease or can be identified as one of the types of primary headache.
HEADACHE MAY BE CAUSED BY
(a) Head injury
(b) Inflammation of the covering & substance of the brain (meningitis; encephalitis) or of structures in the head (sinuses, orbits of the eyes, teeth and gums)
(c) Bleeding into the spaces around the brain or into the substance of the brain
(d) Blood clots in the arteries supplying, or veins draining blood from, the brain
(e) Brain tumor
(f) Epileptic seizures
(g) Hydrocephalus which is an accumulation of cerebrospinal fluid (CSF) caused by obstruction to flow between the points of production and absorption of CSF
Many of these conditions will cause a rise in pressure inside the skull (intracranial pressure), which will in turn cause headache. Headache due to raised intracranial pressure is typically continual and severe in intensity; is made worse by coughing, sneezing, straining or lying down and is often associated with vomiting in the early morning or late at night.
DIAGNOSIS OF HEADACHE
The underlying cause of headache is determined by
(a) Taking a thorough clinical history
(b) Doing a complete physical examination
(c) Carrying out diagnostic procedures such as brain imaging, when these are indicated. If the history fulfils the diagnostic criteria for migraine and the physical examination is normal, brain imaging is usually unnecessary.
TREATMENT OF ACUTE HEADACHE
Appropriate treatment if underlying disease has been detected e.g. antibiotics for meningitis
Prescription of Acetaminophen or Ibuprofen at the onset of headache for relief of pain
Prescription of a drug of the triptan family (e.g. Sumatriptan) to abort a migraine headache
Prescription of drugs to alleviate nausea (e.g. dimenhydrinate), which is a frequent accompaniment of a migraine headache
MANAGEMENT OF MIGRAINE
Keep a headache diary: this helps to identify triggers and document headache frequency and severity.
Regularize the child’s activities of daily living (bedtime, meals, homework, play)
Avoid known triggers
Alleviate stress e.g. early identification and appropriate management of academic difficulty; development of realistic expectations for academic achievement; maintenance of marital harmony
PREVENTION OF MIGRAINE HEADACHE
Children with migraine should
- drink sufficient water to prevent dehydration
- get sufficient and regular sleep
- eat balanced meals at proper times
- exercise regularly
- reduce excess of activities
Children with frequent severe migraine headaches that interfere with daily life activities may obtain relief from
- Drugs such as antihistamines, anti-epileptic drugs and anti-depressants, taken over a long period of time.
- Physical treatments such as progressive muscle relaxation, biofeedback, guided imagery and hypnosis. Most of these treatments however require special expertise and equipment as well as a sufficient level of comprehension on the part of the child.
- Psychological evaluation and counselling.
OUTLOOK FOR MIGRAINE HEADACHES
About half of the persons who have migraine will eventually stop having headache while the remainder will have some alleviation of headaches over time.
MANAGEMENT OF TENSION HEADACHES
- Alleviate stress
- Physical treatments like those mentioned for migraine
- Psychological evaluation & counselling