Headaches are a common complaint in the pediatric office practice. Although headaches are usually not associated with serious medical conditions but a careful clinical assessment is needed as, at times, headaches may be harbingers of sinister conditions which we cannot afford to miss. Acute symptomatic headaches are the commonest headache type in children- i.e. headaches associated with viral fevers, URIs, Malaria, Typhoid, various other nonspecific illnesses etc. On the other hand acute symptomatic headaches associated with CNS conditions like- Meningitis, Meningo-encephalitis, Space Occupying lesion(SOLs) etc are much less common but need a high index of suspicion. Another common but less recognized form of headaches in children are the Primary headaches- Migraine, Tension type headache and the less common cranial neuralgias.
The good strategy to evaluate headaches involves a detailed history regarding its onset, duration, trigger factors, behaviour of the child during the headache episodes and the relieving factors. Examination in a case of headache should focus on the following
- focal neurological deficits-Motor deficits, Co-ordination difficulty, basic confrontation test to rule out major visual field defects are important.
- Blood pressure measurement
- Fundus examination (by pediatritian or ophthalmologist) is a must in every case of headache. One should remember that presence of minor refractory errors is not a cause of headaches
Neuroimaging is commonly overused and even abused to “investigate” headaches. Clinical indications of neuro-imaging are- Presence of focal neurological deficits on examination, Papilodema on fundus exam, very young child >3yr old, VP shunt in situ, new onset headache(less than 6 months onset) with relentless worsening quality or very severe – thunderclap headache. Headache for more than 6 months duration are unlikely to be associated with significant findings on neuroimaging.
These are common in children but are often missed.
Migraine can be recognized with its episodic quality and the child remaining well in between attacks. It is associated with at least two of the following-
- Photophobia or phonophobia –ie worsening of headache with light or sound and/or preferring to be in dark and silent surroundings during headache.
- Nausea and/or vomiting during some of the headache episodes
- Fronto-temporal location of headaches with pulsatile/ hammering quality
- Family history of similar headaches(a careful history is needed as parents usually deny significant headaches).
- Migraines are usually associated with child avoiding daily activity like playing, watching TV etc during the headache period.
Migraines with frequency of 4 or more per month or frequent disruptions in the daily routine, do need daily medication. Acute pain medications are important in all migrainous headaches irrespective of frequency. NSAIDs like Naproxen/Ibuprofen are effective options especially if used soon after the onset of headache. Specific drugs triptans- sumatriptans/zolmitriptan are also effective alternatives especially in the severe migraine headaches. In the long term, parental understanding of migraine is important to bring about lifestyle changes.
Tension type headaches
These are also episodic with a characterless quality. None of the characters of migraine are present in this type of headache i.e
- generalized all over the head
- absence of photo/phonophobia
- no nausea/vomiting.
Thus tension type headaches present with generalized aching/heaviness/tightness. Psychogenic factors should be actively looked for in children with all headaches but this is especially true in this group. Amitriptyline is the only drug with any proof of efficacy in tension type headaches.
Lifestyle that encourage overall wellbeing and a headache free existence-
- Literally means to clean out ones sleep routines.
- Kids follow what their parents do and a regular sleep regime needs to be followed by the entire family for it to stick.
- Regular sleep rituals (changing into night wear, brushing ones teeth, reading a story etc )
- Shutting down all electronic entertainment avenues at least 1 hour before sleep time.
- Having a sacrosanct sleep time/schedule including fixed sleeping and waking up timing which are followed on weekends as well.
The various types of electronic screens (televisions, mobiles devices etc) have started to take up more and more of our waking hours. Children as young as a few months are being “entertained” and screens are also being used as “babysitters”. This is a worrying trend. Excessive use of screens can be quite harmful for young children where there is a clear link with poor social and language skills and even autistic features. The only strategy that works to get children off these is to replace them with alternative entertainment which gives them opportunity to interact socially eg- going to the park to play, joining a an activity of interest (like a dance class). Restricting screen time to no more than 1 hour per day goes a long way in reducing and preventing headaches, additionally this time is spent in more fruitful activities with their peers which helps build social skills that will help them throughout their life.
Living in a warm country, fluid intake is very important. Children need to be encouraged to consume adequate fluids as they are too “busy” to remember drinking water throughout the day. Adequate fluid intake improve overall health and prevent and reduce headaches as well. Having secure and clean washrooms in schools also goes a long way in keeping children, especially girls, confident to consume enough water during their school hours, as they do not dread their trips to the loo.
Regular physical activity is also important for one’s overall health and prevent headaches. Children need to be encouraged to have a daily outdoor play schedule that helps them build a health body that lasts a full lifetime but also healthy and long lasting friendships.