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Headaches in Children

Chronic or recurrent headache is common in children, occurring in approximately 40% of children by 7 years of age and 75% of children by 15 years. Pain referred to the head can arise from the following structures: 1) intracranial or extracranial arteries, large intracranial veins, or venous sinuses; 2) cranial or spinal nerves; 3) basal meninges; 4) cranial and cervical muscles; and 5) extra- cranial structures such as the nasal cavity and sinuses, teeth, mucous membranes, skin, and subcutaneous tissues.

The neurogenic hypothesis proposes that afferent inputs to the brainstem result in a slowly spreading cortical neuronal depression that is followed by dilation and inflammation of the cranial vasculature innervated by the trigeminal nerve. Serotonin (5 hydroxytryptophan [5HT]) plays a complex role.

Clinical Evaluation

Headaches should be characterized as isolated acute, recurrent acute, chronic nonprogressive, or chronic progressive.

RECURRENT OR CHRONIC HEADACHES

History should exclude renal, cardiac, sinus, or dental disease or previous head trauma. A social and educational history is particularly important and may identify significant stresses. Finally, the past strategies of analgesic use should be clarified.

Examination

A complete physical examination should include measurement of growth parameters, head circumference, and blood pressure.

Investigations

If increased intracranial pressure or an intracranial lesion is suspected, a computed tomographic (CT) head scan should be performed. Such a scan will demonstrate nearly all structural causes of headache. Magnetic resonance imaging (MRI) occasionally may be required to diagnose subtle vascular abnormalities.

TABLE 2 -- Physical and Neurological Examination of the Child Who Has Headaches

FEATURE	SIGNIFICANCE
Growth parameters	Chronic illness may affect linear growth
	Hypothalamopituitary dysfunction may disturb growth
Head circumference	Increased intracranial pressure prior to fusion of the sutures may accelerate head growth
Skin	Evidence of trauma or a neurocutaneous disorder
Blood pressure	Hypertension
Neurologic examination	Signs of increased intracranial pressure
	Neurologic abnormality
Cranial bruits	May reflect an intracranial arteriovenous malformation

or hypothalamopituitary lesions.

Lumbar puncture may be helpful in assessing chronic headache if pseudotumor cerebri is being considered. However, lumbar puncture may result in herniation of the brain in patients who have obstructive hydrocephalus, an intracranial mass lesion, or cerebral edema. Consequently, any patient who has headache and requires a lumbar puncture should have neuroimaging performed prior to the procedure.

Causes of Headache

MIGRAINE

There may be a preceding aura, which usually involves visual phenomena. The older child typically describes unilateral or bilateral recurrent throbbing headache often associated with nausea or vomiting. The child often appears pale or has "dark rings under the eyes". Photophobia or phonophobia is common. Characteristically, the headache is relieved by sleep or by simple analgesics in adequate doses.

A family history of migraine is obtained in up to 80% of children who have migraine. A family history of motion and travel sickness also is common. It is helpful to have the parents describe their own headaches. Migraine episodes may be triggered by a variety of factors, including stress, lack of

TABLE 4 -- Potential Triggers of Migraine Headaches ^*

Emotional stress

Changes in behavior

--Missing a meal; hypoglycemia

--Sleeping more or less than normal

Environmental factors

--Bright or flickering light

--Loud noise

--Weather change

Foods and chemicals

--Chocolate

--Nuts, peanut butter

--Hot dogs, smoked meats, spiced meats

--Chinese food, soy sauce, monosodium glutamate

--Beef concentrates

--Cheese

--Cola drinks and other caffeine-containing beverages

--Oranges, bananas, plums, pineapples

--Aspartame

Drugs

--Atenolol, hydralazine, reserpine, nifedipine

--Cimetidine, H₂ -receptor blockers

--Oral contraceptives

--Nitrofurantoin

Stress is the most important precipitating factor.

Management and Therapy

MIGRAINE HEADACHE

Management of Acute Episodes

Oral promethazine (1 mg/kg up to 25 mg) often results in sleep and is generally effective. Intramuscular chlorpromazine (1 mg/kg) can be used for

Simple analgesics, such as acetaminophen, ibuprofen, or naproxen, may be effective if given in adequate dosage at the onset of the attack.

Sumatriptan, a selective 5-HT agonist, is an effective treatment for migraine. One subcutaneous dose of 6 mg has been reported to be effective and

Intravenous dihydroergotamine mesylate (DHE) is often effective when used with metoclopramide in the treatment of an intractable migraine headache. The metoclopramide can be given orally or intravenously prior to the DHE, which is administered over 3 minutes at a dose of

Prophylaxis

Migraine may be precipitated by a variety of factors, including stress, certain foods, lack of sleep, hormonal changes during the menstrual cycle, alcohol, and certain medications such as oral contraceptives. Elimination of these factors may influence the frequency or severity of the attacks.

TABLE 5 -- Drug Dosages in the Treatment of Migraine

Acute Episode
Simple analgesics
Acetaminophen	Initial dose of 20 mg/kg PO followed by 10 to 15 mg/kg q 4 h up to a maximum dose of 65 mg/kg per day (maximum, 3,000 mg/day)
Ibuprofen	1 to 12 years: 10 mg/kg PO q 4 to 6 h
	More than 12 years: 200 to 400 mg PO q 4 h; maximum dose, 1,200 mg/day
Naproxen	5 mg/kg PO q 12 h; maximum dose, 750 mg/day
Antiemetics
Promethazine	Initial dose of 1 mg/kg PO (maximum, 25 mg); can be repeated at doses of 0.25 to 1 mg/kg q 4 to 6 h
Metoclopramide	0.1 to 0.2 mg/kg PO (maximum, 10 mg)
Chlorpromazine	1 mg/kg IM for severe attacks
Other Drugs
Sumatriptan	6 mg SC
Dihydroergotamine mesylate	0.5 to 1 mg IV over 3 min in children >10 y. Can be repeated q 8 h. Often used in combination with metoclopramide.
Prophylactic Agents
Amitriptyline	6- 12 years: 10 to 30 mg/day bid
	Adolescents: 10 to 50 mg/day tid
Propranolol	1 to 4 mg/kg per day; start at low dose and increase slowly
Riboflavin	400 mg/day as a single dose