A rigorous diagnostic framework can be useful for treating headaches in children
A rigorous diagnostic framework can be useful for treating headaches in children
Paediatric headache is a common neurological presentation in general practice. More than one in five children have reported chronic daily headache at some stage in childhood, but these presentations often go under-diagnosed and untreated.
From a low 3% to 8% for under the age of three, the childhood headache presentations rise to a significant 37% to 51% in seven-year-old children. While most chronic daily headaches in children are benign, it’s worth keeping in mind that many children later found to have significant intracranial pathology have a history that started solely with headaches. This makes childhood headaches challenging, and a diagnostic framework is useful to assist GPs to work through the possible causes.
The management of paediatric migraine is aimed at reducing the number of headaches and minimising the impact on normal activities. A two-pronged approach – to stop the acute attack and to prevent frequent headaches – is appropriate for most cases.
The case study below outlines the initial evaluation of paediatric headache, the tools to help differentiate between primary and secondary headaches, and the role of neuroimaging in the systematic approach to diagnosis. Treatment of acute migraine will be discussed with particular reference to the use of triptans and the options for preventative therapy.
CASE STUDY
John is a 10-year-old boy in year four. He has been having headaches for the last three months, worse in the afternoon, lasting for up to 48 hours. He describes the headaches as located over his forehead and severe enough for him to have missed two weeks of school in the last term.
His mother Joan is concerned about the headaches and worried she may soon lose her job if she keeps taking sick leave to stay home with John. She has brought her own mother Cheryl with her today to the consultation. Cheryl has a long history of headaches herself , which have been diagnosed as migraines by her own GP.
RED FLAGS
A recent onset of severe childhood headache is a troubling presentation. Like all doctors with limited consultation time, I start my history-taking with a focus on the red flags.
A genuine headache unrelieved by analgesics
This is in contrast to a headache in a child who has been able to continue the usual daily activities despite claiming that the headache is unrelieved by analgesia.
Children with brain tumours may have no objective neurological signs in the first three to four months of their illness.
Headaches that wake the child up from sleep or are present immediately on awakening
This is in contrast to the child whose first complaint of headache is at the breakfast table or on the way to school.
The specifics of headaches
Occipital headaches are unusual. Headaches much worse with coughing are a sign of raised intracranial pressure, especially if this brings on the headache. In preschool children below the age of six, distressing headaches have a higher rate of pathology than older children.
Papilloedema
Carefully check the ocular fundus for signs of papilloedema, which can also occur in so-called “benign intracranial hypertension”.
Change in Glasgow Coma score
While this is listed here as a red flag, children with delirium or reduced consciousness usually present directly to an Emergency Department.
Other red flags
- Declining school performance
- Altered personality or behaviour
- Loss of motor skills
- Seizures
- Abnormal neurological examination
Most children with intracranial tumours have abnormal signs by three to four months after the start of the headaches.
WHAT NOW?
Any one of the red flags listed above is a cause for concern and requires specialist referral.
The urgency of specialist referral is dictated by the possible causes of acute severe headache, including:
Subarachnoid haemorrhage
The usual presentation includes an acute severe headache with a reduced level of consciousness and a rapid progression of symptoms. Neck stiffness is usually present. The possibility of subarachnoid haemorrhage is an indication for an urgent head CT scan and a transfer to an Emergency Department.
Migraine
Migraine is the most common differential diagnosis of subarachnoid haemorrhage.
Meningitis
Despite childhood immunisation, meningitis presentations are frequent and should be included in differential diagnosis of severe headache. Meningitis is accompanied by fever, a universal sign in meningitis presentations.
Acutely raised intracranial pressure
An acute rise in intracranial pressure is usually due to obstructive hydrocephalus, with an intracranial tumour as the most common cause.
Psychological headaches
Once acute intracranial pathology has been excluded, psychological headaches call for the application of art rather than the science of medicine. Children presenting with severe psychological headache often have a history of significant personal and family trauma, which requires psychological management. A GP also needs to consider mandatory reporting if history indicates abuse or neglect of the child.
BEFORE REFERRAL
- Measure and record the head circumference and growth parameters
- Measure and record the blood pressure
- Observe the gait carefully. The younger the child, the more likely they are to present with an ataxic gait when infra-tentorial pathology is present
- Perform an ENT examination, being careful to check sinuses and teeth
WHICH INVESTIGATION?
Having established the clinical urgency for investigating, imaging should be considered for childhood headaches, keeping in mind the accessibility of the imaging services.
- MRI is now the investigation of choice, but may not be available for children on weekends or out of hours, even at large adult teaching hospitals. There’s no exposure to radiation with MRI, but general anaesthetic is usually required for children below the age of six.
- CT scan will pick up tumours, raised intracranial pressure and bleeding. The radiation exposure with a CT scan is considerable and equivalent to around three-and-a-half years’ worth of background radiation, depending on the local CT scanner and the protocol for use. By comparison, a chest X-ray confers around one day’s worth of background radiation exposure.
- EEG is helpful only in the investigation of headache with seizures. In childhood headaches, EEGs reports will often describe non-specific abnormalities, especially if reported by a non-paediatric neurologist.
STATISTICS AND DIAGNOSES
Forty percent of children with headache will have tension headache
Classically these are diffuse and non-throbbing. Activity is usually unaffected even though the headaches are present on most days, and may have been present for some months.
Twenty-three percent in this group will have migraine
The migraine headache usually has associated symptoms such as a throbbing quality, nausea or vomiting, and may be unilateral.
In children with migraine, there are recurrent attacks of headache, separated by symptom-free intervals. “Classical” migraine in children is uncommon. Only about 10% will describe an “aura”. More than two-thirds of children diagnosed with migraine have a family history of migraine, and only 6% will have a cause found on detailed investigation.
MIGRAINE TREATMENT
Minimising all sensory stimulation in a quiet, well-ventilated room is mandatory.
Ibuprofen is the drug of choice, though paracetamol is possibly just as effective. Aspirin should be avoided for children under 12 years.
Prochlorperazine is the antiemetic of choice if vomiting is a problem. The use of prochlorperazine needs to be balanced against the theoretical concern of dystonic reactions. Ondansetron is a more expensive non-PBS alternative for migraine.
For those children who don’t improve with the three treatment steps above, sumatriptan nasal spray is the most commonly used option.
Opioids are not recommended in the management of childhood headaches.
MIGRAINE PROPHYLAXIS
Propranolol is the first-line option for prophylaxis, but asthma must be excluded before prescribing. Pizotifen, even though widely used, may not be as effective as previously thought. Recent studies indicated that the placebo effect may be as high as 50%. Second-line options include topiramate, valproate or amitryptyline. I have never used any of these in childhood migraine because first-line drugs are usually effective. For children with migraine unresponsive to the above treatment, the diagnosis needs a review.
PROGNOSIS FOR MIGRAINE
Half of children with migraine are free of attacks by age 13, but many tend to relapse in adolescence. By age 25, only 23% are completely migraine-free. When followed up at age 50, half of children with childhood migraines will still suffer from ongoing headaches.
A specialist referral is advised for all cases where diagnostic uncertainty remains, as well as for all cases of severe headache unresponsive to treatment and first-line migraine prophylaxis.
A second opinion should also be sought for unusual migraine variants (such as hemiplegic migraine, basilar migraine, and confusional migraine) and for chronic daily headache of more than 15 days per month, over three months or longer.
Dr Andrew McDonald is Associate Professor at UWS and UNSW and a former NSW member of parliament
References:
Calvert, S. “Investigation and treatment of headaches and migraines in children and adolescents” from proceedings of 2015 RACP Congress, Cairns, Australia
