Dr Deirdre Peake - Consultant Paediatric Neurologist talks to us about childhood headaches
Headaches are a common problem in childhood and it is estimated that ¼ of adolescents suffer weekly headache and 2/3 of the childhood population report one or more headache in the past year. Dr Deirdre Peake fills us in on this problem that affects many children.
Headaches are a common problem in childhood and it is estimated that ¼ of adolescents suffer weekly headache and 2/3 of the childhood population report one or more headache in the past year.
The repercussions of suffering from childhood headache are significant with recent studies showing that these children have significant school absence and a quality of life worse than those who have other long-term conditions such as asthma or diabetes (Kernick D, Campbell, Cephalagia 2008)
We acknowledge that there is an unmet need for these patients in whom there is often significant parental and professional anxiety about brain tumours, inadequate training to classify and treat headaches and often ineffective treatment options prescribed ( Kernick D, Reinhold D, J Headache Pain 2007).
Most headaches are primary in nature but there is an anxiety surrounding the delayed diagnosis of these tumours in the UK in comparison to other countries (50% cases are diagnosed within 12-13 weeks in UK (5-6 weeks in other countries). This has lead to the “Headsmart campaign” www.headsmart.org.uk
Nearly all headaches seen by GPs and Paediatricians are primary headaches. Primary headache disorder in children include migraine (with or without aura); complicated migraine (hemiplegic, basilar, confusional); migraine variants or equivalents (cyclic vomiting, paroxysmal vertigo, paroxysmal torticollis, ocular migraine, abdominal migraine); and tension type headaches (episodic or chronic) (Silverboard 2001).
Secondary headaches are rare in non acute setting.
Key points on secondary headaches
- Tumours 33% of children with brain tumours have headache.
- 88% of tumour related headaches are associated with other clinical features.
- “Headsmart be brain tumour aware” highlights clinical signs and age related symptoms for identifying brain tumours: www.headsmart.org.uk
Migraine in children
Migraine is common in children. The inheritance is multifactorial and complex. Predispositions to attacks are triggered by environmental factors, and emotional/ psychological stressors.
Migraine without aura is the most common recurrent primary headache disorder in children. The International Headache Society (HIS) has recently revised the criteria for paediatric migraine without aura (Table 1) (Lewis 2004) as migraines in children may differ to those in adults, in that they are of shorter duration and are more often bilateral. As a result they can go unrecognised and thus may be under-treated (Billinghurst 2005).
An 8 year old boy presented with headaches for 5 months
- 1-2 attacks per month, Attacks last 12 hours, Pain is severe enough to sop activities, Headache is throbbing and mainly in the front of the head
Triggers: none. Aura: none. Associated: loss of appetite, nausea, light and noise intolerance
Diagnosis: Migraine without aura
Table 1: International Headache Society classification: Criteria for paediatric migraine without aura.
| || |
≥ 5 attacks fulfilling features Bto D
Headache attack lasting 1 to 72 hours
|C||At least 1 of the following|
- Nausea or vomiting
- Photophobia/ phonophobia
6 year old girl with headache for 6 months
- 1 attack last – 12 hours, Pain stop activities, Throbbing pain, Mainly unilateral
- Warning symptoms - Zigzag signs
Lasts 5 – 10 mins. Associated symptoms: Loss of appetite, Nausea, Light and noise intolerance
Relieving factors: rest, sleep, Paracetomol. Examination normal
Diagnosis: Migraine with typical aura
Table 2: International Headache Society classification: Criteria for paediatric migraine with aura.
| || |
At least 2 attacks fulfilling B
At least 3 of the following 4 characteristics
- One or more fully reversible aura symptoms indication focal cerebral cortical – and/or brain stem dysfunction
- aura develops gradually over 5 mins
- No aura symptom lasts more than 60 mins
Headache follows aura within 60 mins
Treatment: treatment includes management of the acute attack and prevention.
Early intervention is important with rest and avoidance of aggravating factors. Pain relief (ibuprofen or Paracetomol) should be given early, at the right dose, via the right route and an anti emetic considered.
Prevention includes lifestyle modifications such as regular meals and sleep, regular exercise and rest, the avoidance of caffeine and adequate hydration. Triggers are important to identify and avoids as appropriate. Many different classes of drugs have been used in the past for migraine prophylaxis including; anti-epileptics, antihistamines, anti-depressants, calcium channel blockers, beta-blockers and alpha-agonists.In practice Pizotifen and Propranolol should be used as first line preventatives in children. They have been show to be very effective in adults, have few side-effects and good safety records. Second line preventatives are Valproate, Topiramate and Amitryptiline. Carbamazepine is ineffective.
Neuroimaging: 3 recommendations made:
- Obtaining a neuroimaging study on a routine basis is not indicated in children with recurrent headaches and a normal neurological examination.
- Neuroimaging should be considered in children with an abnormal neurological examination, the coexistence of seizures, or both.
- Neuroimaging should be considered in children in whom there are historical features to suggest the recent onset of severe headache, change in type of headache, or If there are associated features that suggest neurological dysfunction.
- Find out more about Dr Deirdre Peak - Click here
- If your child suffers from headaches and you would like to book an appointment - Click here
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