Headaches

R51

DESCRIPTION

Headache is the most common pain syndrome in children of all ages. Recurrent headaches are a common health problem and can be:

  • primary, e.g. migraine, or
  • secondary/symptomatic, e.g. raised intracranial pressure.

The actual perception of headache varies according to age and is influenced by factors such as experience, memory and cultural environment.

International Classification of Headache Disorders (ICHD)
Migraine (without aura)

Five or more headaches lasting 1–48 hours (duration in children is often shorter, lasting a few hours only) fulfilling at least 2 of the following:

  • bilateral or unilateral, frontal or parietal in location,
  • pulsating in character,
  • moderate or severe,
  • aggravated by routine activity,
  • nausea and/or vomiting plus photophobia and/or phonophobia during headache.

Migraine (with aura)

At least 2 attacks fulfilling at least 3 of the following:

  • one or more reversible aura symptoms,
  • at least one aura developing over > 4 minutes or 2 or more successive symptoms,
  • no aura lasting > 1 hour,
  • headache follows aura in less than 1 hour.

Episodic tension-type headache

At least 10 prior episodes, occurring less than 15 times per month and lasting 30 minutes to 7 days with at least 2 of the following:

  • pressing or tightening quality,
  • mild or moderate intensity,
  • bilateral location,
  • no aggravation by routine physical activity,
  • no nausea, vomiting, photophobia or phonophobia.

Cluster headache

  • Severe unilateral sharp headache associated with conjunctival injection and lacrimation.
  • Rare in childhood.

Paroxysmal Hemicrania Continua

  • Cluster headache of shorter duration.

Each of the above can occur in combination in any patient, i.e. mixed/comorbid headache.
Headaches can also be sub-classified according to temporal patterns, i.e. acute, acute recurrent, chronic progressive/non-progressive, episodic or constant.

DIAGNOSTIC CRITERIA

  • Exclude secondary causes of headache, e.g. raised intracranial pressure.
  • Red flags in childhood headaches:
    • change in pattern (e.g. “worst headache ever”),
    • progressive course over time,
    • age younger than 3 years,
    • nocturnal/wakes child from sleep,
    • early morning vomiting,
    • ataxia,
    • focal neurological signs,
    • alteration of level of consciousness.

GENERAL AND SUPPORTIVE MEASURES

  • Environmental and lifestyle changes, e.g. avoid precipitants such as bright lights, sleep deprivation and certain foods, excessive video games.
  • Adequate hydration.
  • Avoid skipping meals, excessive caffeine ingestion.
  • Regular exercise.
  • Stress alleviation and coping skills training where possible.
  • Headache diary and identify possible triggers.

MEDICINE TREATMENT

Treat non-migraine headaches with analgesics.

  • Paracetamol, oral, 15 mg/kg/dose 6 hourly as required.

For migraine:

  • Ibuprofen, oral, 10 mg/kg/dose, 6 hourly.

Persistent vomiting and not tolerating oral feeds:

  • Metoclopramide, oral, 0.15–0.3 mg/kg as a single dose.

OR

  • Metoclopramide, IM/IV, 0.1 mg/kg as a single dose.

Migraine prophylaxis

Indicated when headaches occur frequently, impacting on the child’s activity and requiring substantial relief medication.
Treat for six months then review.

  • Propranolol, oral, 0.5–3 mg/kg/day in 2–3 divided doses.
    • Contraindicated in asthma and heart block.
    • Avoid in diabetes and depression.

In children who are unable to take propranolol, e.g. asthma:

  • Topiramate, oral, 1–3 mg/kg/day in 1–2 doses. (Specialist initiated).
    • Starting dose: 0.5 mg/kg/day.
    • Titrate dose slowly every 1–2 weeks.
    • Reinforce behavioural management before considering topiramate.

REFERRAL

  • Secondary intracranial cause suspected.
  • Failure to respond to first-line treatment.
  • No response to treatment.