Posted by Bob P (129.65.106.172) on June 06, 2001 at 07:59:20:
In Reply to: My daughter's headaches? posted by Michelle on June 05, 2001 at 23:21:15:
Maybe some of this will help identify your daughter's headaches. My heart goes out to you and her.
Also want to thank Trip for all the links. This is some of the fruit that the Liaison Committee has been producing. Good job!
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Chapter 7: Special Patient Considerations
Seymour Diamond, MD
[Diagnosing and Managing Headaches © 1998 PCI]
Headaches in Children
Headache is a common complaint of children and adolescents. The headache may be due to a variety of causes, including migraine and tension-type headaches, as well as organic origins. As with adults, the physician must evaluate the physical and emotional factors that may impact on the headaches. The treating physician must also be aware of the various issues that influence therapy selection. In managing children with headache, the physician must be concerned with reassuring the parents about diagnosis and treatment.
Frequency of headache occurrence in children has been astonishing to patients and physicians alike. In Bille's classic epidemiological study of children in a Swedish community, 15.5% of the subjects had experienced a migraine attack before age 15. Another 15% of the children had experienced daily or almost-daily, tension-type headaches before age 15. The study by Linet's group in Washington County, Maryland, revealed that 56% of boys and 74% of girls between ages 12 and 17 had suffered from a headache within the month prior to the telephone interview.
Classification of headache in children is the same as that of adults. The headache history is the primary tool in determining the child's diagnosis. In the history, the interviewer should address questions about:
The mother's pregnancy, the labor and delivery of the child
The child's growth and development
Episodes of serious infection (meningitis, encephalitis) and trauma.
A computed tomography (CT) scan or magnetic resonance imaging (MRI) should be considered for patients with recent onset headaches or in patients who have noted a recent change in headache pattern. Electroencephalograms (EEGs) have long been considered essential in the workup of the child with headache problems. However, this test usually will not provide any significant data. Many children with systemic illness will present with a generalized headache. Obtaining vital signs are important in the initial evaluation to rule out febrile headache. Sinusitis may occur in conjunction with allergies or upper respiratory infections. Headache associated with acute sinusitis is characterized by:
Fever
Focal tenderness over the affected sinus
Elevated white blood count
Elevated sedimentation rate.
Subacute or chronic sinusitis may or may not be associated with respiratory symptoms, and the patient may be afebrile. Sinus x-rays may be necessary to confirm the diagnosis. Complications associated with sinusitis are:
Brain abscess
Orbital cellulitis
Meningitis.
Treatment measures include:
Antibiotics
Decongestants
Surgical drainage, if required.
Encephalitis and meningitis should be ruled out in the patient with:
Recent onset headache
Fever
Lethargy
Nuchal rigidity
Other central nervous system (CNS) symptoms.
Appropriate laboratory testing should be undertaken immediately. Urgent, aggressive antibiotic therapy is required in these patients.
Some children will experience headaches due to ophthalmic causes, including:
Astigmatism
Refractive errors
Eye strain
Squint.
Eye strain should be considered if the headache is:
Localized to the frontal area
Triggered by watching television, reading or doing school work
Relieved by stopping a given activity.
These patients should undergo an ophthalmological examination.
Exertional headache in children may be related to a specific athletic activity, such as weight-lifting or running. This headache may occur once or may be recurrent. The headache is described as:
Generalized
Severe
Throbbing
Lasting from a few minutes to hours.
The neurologic examination is usually negative. However, if abnormalities are observed, further studies (CT scan, MRI) may be indicated. Indomethacin may be prescribed if the headaches are frequent and severe.
Trauma can be a frequent cause of headache in children. Similar to adults, the degree of pain may not be indicative of the degree of injury. During the initial evaluation, skull fracture or significant brain injury should be ruled out. Neuroimaging is an essential element in the workup. In the presence of subdural hematoma and the history provided by the patient and/or parents is negative for trauma, the physician may be confronting a child abuse case. Headache due to subdural hematoma is often accompanied by seizures and other focal neurological deficits. The treatment of these brain lesions is discussed in Chapter 3, Headaches Due to Organic Causes.
In children as with adults, headache due to brain tumor may be nonspecific in location. Exertion and positional changes may increase the severity of the headache. Tumors due to intracranial lesions are also discussed in Chapter 3.
Some headaches associated with hydrocephalus may not manifest until adolescence. For example, congenital abnormalities such as compensated aqueductal stenosis may not cause any symptoms until the patient has reached adolescence. Physical examination usually demonstrates:
Macrocephaly
Papilledema
Sixth nerve palsy.
Neuroimaging will confirm the diagnosis. As noted in Chapter 3, shunting is usually necessary.
The typical patient with pseudotumor cerebri is usually an obese female in her teens or early twenties. This disorder is due to increased intracranial pressure without any evidence of obstruction to the cerebrospinal fluid (CSF). The usual causes of the disorder are:
Menstrual irregularity
Obesity
Chronic otitis
Medications, such as steroids.
As discussed in Chapter 3, the most evident signs are:
Headache
Papilledema
Sixth nerve palsy.
Visual field testing may reveal an enlarged blind spot. Neuroimaging is usually negative and lumbar puncture will disclose increased pressure with normal CSF elements. Treatment consists of removing adequate amounts of CSF to normalize the pressure. Diuretics may also be used.
The onset of migraine often occurs in childhood. However, it may not manifest as a headache. Migraine is an autosomal dominant disorder with higher predominance in females. Prior to puberty, migraine is more prevalent in males. The clinical features of migraine in children are:
Paroxysmal headaches
Relief after sleep
Nausea, vomiting and abdominal pain
Throbbing, pounding quality
Unilateral headache.
A positive family history is reported by 69% of children with migraine. Migraine without aura is more common in children as an aura is only reported by 17%. Several triggers have been identified in children with migraine:
Anxiety
Minor head trauma
Exercise
Menses
Travel
Diet (chocolate, pizza, cola beverages).
In children with migraine, the premonitory symptoms are similar to those of adult migraineurs:
Pallor
Malaise
Fatigue
Irritability.
These symptoms are usually followed by frontal headache, nausea and vomiting. During an acute migraine attack, the pediatric patient will often go to their room complaining of photo- and phonophobia. The child expresses a need to sleep, and the attack usually resolves in 2 to 6 hours. In children with migraine with aura, the prodromal symptoms are similar to those of an adult with this disorder.
In treating the child with migraine, certain factors will impact on the selection of agents in both the abortive and prophylactic therapies:
Age of the patient
Size of the patient
Frequency of the attacks
Severity of the attacks.
In children under age 14 with infrequent attacks, pain relieving measures should be employed, including:
Non-habituating analgesics
Antiemetics
Sedatives.
For those patients experiencing more frequent attacks, prophylactic therapy with cyproheptadine (Periactin) or propranolol (Inderal) may be indicated. Children have demonstrated excellent responses to cyproheptadine in doses of 4 mg to 8 mg per bedtime. The major side effects of this drug are sedation and increased appetite. Propranolol has also been used successfully in children and adolescents with migraine. The side effect profile appears to be less with younger patients. It is contraindicated in patients with asthma. Depending on the size of the patient, the usual dose is 80 mg to 160 mg daily. Attempts are made after 6 months to gradually taper and then discontinue the drug.
Some children will present with complicated migraine, that is migraine associated with neurological manifestations. These patients should be evaluated for possible arteriovenous malformations (AVMs), tumor or aneurysm. Neuroimaging is essential in these patients. To establish the diagnosis, the physician should determine a family history of similar headaches. The types of complicated migraine occurring in children include:
Hemiplegic
Ophthalmoplegic
Basilar artery migraine.
Adolescents experiencing an acute attack of basilar artery migraine may be suspected of using street drugs. The patient may present with a variety of symptoms which may be alarming to the treating physician:
Episodes of altered consciousness
Agitation
Receptive or expressive aphasia
Occipital headache
Nausea and vomiting
Vertigo
Tinnitus
Facial weakness.
The diagnosis can be established by determining a previous history of migraine or a family history of similar attacks. Neurological symptoms usually disappear within 6 hours. Prophylactic agents used with other forms of migraine are indicated for these patients.
As stated previously, migraine in children may not manifest as headaches but rather as acephalic variants. In young children between the ages of 2 and 6 years, episodes of paroxysmal vertigo may occur. These episodes are brief and sudden, and the child is not able to maintain posture due to the vertigo. Due to the sudden onset and difficulty in walking, the child and the parents are quite alarmed. These attacks abate within a few minutes but are recurrent. Organic causes should be ruled out and the parents reassured about these symptoms. Cyproheptadine may be used successfully in these patients.
At a later age, migraine patients will provide a history of cyclic vomiting during childhood. These episodes of cyclic vomiting are associated with abdominal pain and are paroxysmal, similar to migraine attacks. The physician should rule out structural gastrointestinal etiologies and determine if there is a family history of migraine. Prophylactic agents used in migraine may be beneficial in these cases, including in the absence of headache attacks.
Cluster headaches rarely occur in children, although it may present as early as age 8. In adolescents, the initial onset of cluster may occur. Male predominance is evident in cluster headaches. Treatment would be similar to that of adult cluster patients.
Tension-type headaches do occur regularly in children. These headaches may be described as:
Diffuse pain
Band-like sensation (occasionally)
Not usually associated with nausea and vomiting
May be associated with muscle spasm and tenderness at the neck.
These headaches are not always related to stressful situations. It is essential that a careful inventory of the patient's family, social and school relationships is included in the initial history.
Chronic, tension-type headaches do present in adolescents. These headaches rarely occur in children under age 10. The frequency of these headaches varies from a daily pattern to several times per week or several brief headaches in a day. As with adults, the location and character of the headache vary. Nausea and vomiting may be associated with these headaches. The headaches are usually related to some type of emotional problems. Frequent school absences are typical, and certain questions should be addressed during the initial interview:
Family history of similar headaches
Parental absence from home (separation, divorce)
Substance abuse by family members
Over- or underachievement
Significant school problems
Previous emotional problems.
As part of the workup, psychological testing is indicated, such as the Minnesota Multiphasic Personality Inventory (MMPI). Intelligence and achievement tests may also be indicated in children presenting with school difficulties. The adolescent with chronic, tension-type headaches requires a multifaceted treatment approach with medical, psychological and pharmacological modalities. Treatment modalities include:
Family counseling
Individual counseling
Antidepressants
Biofeedback.
Acute pain may be relieved by simple analgesics, and habituating drugs should be avoided. Children with headaches have demonstrated excellent response to biofeedback training. These young patients are more open to learning new techniques, enjoy using the instrumentation, and have not yet adapted a chronic pain pattern into their daily lives.