Childhood Headache

Rachel Howells
 Learning Outcomes
By the end of this session, you should be
able to
 Differentiate primary from secondary
headache
 Recognise and manage common primary
headaches
 Epidemiology
Preschool
1/3 will have had a headache
Migraine headache 0-7% of population

Schoolchildren
70% have ≥ 1 headache a year
Peak at 90% at age 12-13
Prevalence of recurrent headache 20-30%
Case 1
 Case 1
15 year old girl
 Frontal headache, down neck and
shoulders
 2 months
 Start as soon as she rises from bed, and
relieved by lying down
 Missing school for 6 weeks
Primary or Secondary?
 Case 1
Further history
 Spinal surgery 3 months ago
 Epidural anaesthesia

Examination
 Normal
 Low pressure headache
Possible dural tap
Management
 Encourage mobilising
 Many spontaneously resolve within 3-4
months
 Short-term: Caffeine
 Long-term: Epidural blood patch
Primary vs Secondary
Headache
Primary vs Secondary Headache

 10% of headaches seen in a

specialist neurology / headache clinic
are secondary in origin
 Population prevalence of organic
disease is likely to be lower
 Secondary Headache Types

Altered Intracranial Pressure

Raised ICP
Low Pressure Headaches
Vascular
Subarachnoid Headache (eg AVM)
Dissection
Drugs Vasculitis
Drug effect
Analgesia induced headache

Central (thalamic) pain Local

Trigeminal neuralgia Dental Abscess
Cluster headaches Sinusitis
Post head injury
 How to identify a
secondary headache
 How to identify a
secondary headache

History

Examination

Brain Imaging
Indications that a headache
is secondary to altered
intracranial pressure
 Indications
1. Timing of headache
2. Postural manoeuvres
3. Associated symptoms
 Timing of Headache

Morning but from sleep, Morning but

before rising after getting up

Raised Low Pressure

Intracranial Pressure Headache
 Postural Manoeuvres

Getting up relieves
Lying down
headache
relieves headache
Coughing and straining
exacerbates it

Low Pressure
Raised Headache or
Intracranial Pressure Sinusitis
 Associated Symptoms
Frontal headache Frontal headache
Associations Associations
Morning vomiting Pain / parasthesiae
Other neurology across shoulders*
Confusion Blocked nose, facial pain¤

Low Pressure
Raised
Headache* or
Intracranial Pressure
Sinusitis¤
Case 2
 Case 2
16 year old girl seen in OPD
 Frontal headache
 There when she wakes, gets better when
she gets up
 No nausea or other neurological
symptoms

4 months, not getting any worse

 Primary or Secondary?
Is this raised or low intracranial pressure?
 Case 2 continued
Past History – nil
Examination
 Enlarged blind spots on confrontation
 No other alteration of visual fields
 Papilloedema

 No ataxia, long tract signs

What diagnoses need to be
considered?
 Causes of Raised Intracranial
Pressure
Hydrocephalus
Tumour obstructing CSF pathways
Obstruction to CSF re-absorption
(post haemorrhage or meningitis) Idiopathic (Benign)
Congenital (eg aqueduct stenosis) Intracranial
Hypertension
Cerebral oedema
Inflammation (ADEM, stroke)
Infection (meningitis etc)
CO2 retention (obstructive sleep apnoea)
Metabolic (DKA, other)
Idiopathic Intracranial Hypertension

Raised intracranial pressure

in the absence of space occupying lesion
or obstruction to CSF flow

Aetiology unknown
 Adolescent girls
 Obesity, drugs, steroid withdrawal
 Visual loss (10%) may be permanent and
is only indication for treatment
 Indications
1. Timing of headache
2. Postural manoeuvres
3. Associated symptoms
Case 3
 Case 3
14 year old girl
 Headache since the evening before
 Single and worst headache ever
 Sudden onset

Vomited once at start

No history of head injury / prodrome
 Case 3
Examination
 Afebrile
 No meningism
 GCS 15

 Unilateral facial weakness with frontal

sparing
 Ipsilateral arm weakness with hyporeflexia
What diagnoses should you
entertain?
CT brain
 Case 3
CT shows haemorrhage around area of
left basal ganglia

Patient admits to using some cocaine at a

party with her 18 year-old sister
More information to help
you identify secondary
headache

History
 Timecourse
Migraine?

Single or first Recurrent severe headaches

severe headache One a month
Bleed? 2 years without progression

Headaches all day

on most days Headaches every few months
18 months then weeks
then days
TTH?
Now every day
Tumour?
Severe headaches all day for 12 days
2 months ago
None since Bleed?
 Timecourse

Single or first Recurrent severe headaches

severe headache One a month
2 years without progression

Headaches all day

on most days Headaches every few months
18 months then weeks
then days
Now every day

Severe headaches all day for 12 days

2 months ago
None since
Pointers in History: Summary
1. Timing of Headache
2. Postural manoeuvres
3. Symptoms associated with headache
4. Timecourse
Examination
 Purpose of Examination
 To support your clinical impression made
on history
 To rule out other differentials
 To adhere to many families expectations
 to be taken seriously
 to be able to support your view that nothing serious
is going on
 Essential elements of Examination

Conscious level Vision

Acuity
Fields including blind spot
Long tract signs Extraocular movements
Tone
Power Cerebellar signs
Reflexes Finger-nose test (eyes shut)
Tremor
Blood pressure Dysarthria
Gait Fundi
Bruit
Case 4
 Case 4

8 year old boy with 10 month history of

 Bi-temporal headache
 Throbbing
 Worse with movement / exercise
 Mother says looks pale and unwell

 Usually start in morning

 Last all day
 Case 4

No family history
Examination is normal
Primary or Secondary?
What is the most likely diagnosis?
Migraine without aura
 What causes migraine?
Migraine headache
 Nerve efferents – trigeminal,
vagal
 Meninges have pain fibres with
inputs from trigeminal complex
 Vasodilation of meningeal vessels

Why do some people get migraine

headaches?
 Genetic
 Abnormal inhibitory inputs to
trigeminal nerve complex Michael Creighton
Clinical Implications
Abnormal inhibition to
nociceptive parts of brain
 Abnormal response to
changes in environment eg
sleep, diet, smells
 Pain is exacerbated by
noise and light
 Headache relieved by sleep
in a dark room

Migraine symptoms
 Pain involves the face
(trigeminal)
Delia Malchert
 Throbbing pain (meningeal)
 Pallor and nausea (vagal)
 Migraine
Classification
 Migraine without aura (commonest)
 Migraine with aura

 Basilar migraine
 Ophthalmoplegic migraine
 Alternating hemiplegia
 Migraine
The diagnosis is a clinical one
Families can be reassured by
 Family history
 Longevity of symptoms
 Normal examination
 Addressing their underlying concerns
 Management
1. Explanation

 This is not a tumour

 Worst in second decade of life
 Most patients will get fewer headaches
as they get older
 Management
2. Treatment of attacks

 Analgesia as soon as an attack starts

 Ibuprofen works best (one RCT)
 May be supplemented by anti-emetic

 Patients over 12 may respond to im, oral

or nasal sanomigran (Imigran)
 Management
3. Prevention – control of environment

 ‘Sleep hygiene’ – regular sleep

 ‘Diet hygiene’ – avoid long breaks ± snack
before bed, avoid caffeine, low amine diet
 ‘Exercise hygiene’ – regular exercise,
maintain hydration
 Avoid stress – relaxation training, CBT
 Management
4. Prevention – pharmacological

No magic bullet, trial basis only

 Pizotifen
 Propanolol

 Feverfew
Case 5
 Case 5
10 year-old girl with 18 month history of
 Bilateral headache, mainly vertex
 Constant
 Comes on during day
 Not worsened by walking
 No aura or pallor / nausea

 5/7 days a week, most weeks of the year

 Case 5
 No family history
 Examination normal

 Local grammar school

 Predicted for A grades in 10 GSCEs
 No external sources of anxiety – stable
home, not being bullied
 Trying to keep going to school
 Case 5
 Alternating ibuprofen 400mg and
co-codamol for headaches
 ‘Nothing really works’
Primary or secondary?

What is the most likely diagnosis?

Chronic Tension-Type
Headache
How is the diagnosis
made?
 CTTH
 No features suggestive of organic disease
 Time of day
 Postural manoeuvres
 Associated symptoms
 Time course

 Not classifiable as migraine

 Examination normal
 Management
Explanation
Although not an organic disease, effects on
life can be significant (school etc)

Treat attacks
 Simple analgesia
 Avoid multiple drugs
 Feverfew / Levomenthol / TigerBalm
 Management
Prevention of attacks

 Sleep, diet, exercise hygiene

 Address anxiety (relaxation training, CBT)
 Maintain contact with school, try and
attend but manage workload
 What did you learn?
You should now be able to
 Differentiate primary from secondary
headache
 Recognise and manage common primary
headaches
 Migraine with / without aura
 Tension-type headache
Any questions?
Thank you for listening
Rachel Howells