Evaluating and Treating Children's Headaches

US Pharmacist. 2002;27(10) 

Introduction

Headache is one of the most common and wide-ranging disorders. In fact, the list of differential diagnoses for headache is one of the most extensive ever elucidated for a medical condition: 13 major categories and 129 subcategories.[1]

The term "primary headache" includes migraine, cluster, and tension headaches. "Secondary" headaches are caused by as many as 300 different identifiable pathological processes. Over 90% of headaches are primary.[2]

Headaches are relatively common in children and adolescents. The prevalence of severe recurrent headache in those under the age of 10 is almost 10 per 1,000; it is approximately 46 per 1,000 for those aged 10 to 17.[3,4] If the prevalence of headache of this severity exceeds 2.5%, it stands to reason that relatively minor headaches, which are unreported in most cases, are even more common. When children aged 15 and younger were surveyed about headache, 55% reported experiencing non-migraine headache (almost 7% reported frequent headache and nearly 4% had experienced migraine).[4]

Headaches cause an average of 3.3 missed school days per child each year.[4] Children with headaches may be forced to limit participation in social activities, family events, and school activities.[3] Additionally, when a child develops headache, there is an increased likelihood that he will experience headaches throughout adulthood.[3]

Children's headaches (e.g., migraine) exhibit no gender variation before puberty. In late adolescence, however, twice as many females report recurrent headaches.[4] When adolescents were asked about the frequency of their headaches in the previous month, 74% of girls and 56% of boys reported one or more.

Older headache taxonomies were ill-defined and vague, which made differential diagnoses of headache difficult. In 1988, the International Headache Society refined headache classification by eliciting data about the quality of pain and concurrent symptomatology.[3] Pediatric headache was not a specific subtype, but investigators eventually identified a type of chronic daily headache specific to children--one in which the child experiences simultaneous periodic migraine headache and chronic daily headache. Several well-known types of headache are also possible in children, such as postconcussion and migraine headaches.

When a child has a recurrent headache, certain etiologies are more likely than others. They include post- concussion headache, migraine, tension headache, sinusitis, intracranial mass, eye strain, caffeine withdrawal, pseudotumor cerebri, sleep disorders, hyperthyroidism, hypertension, and temporomandibular joint disease.[4,5] Cluster headaches are rare in children, since they typically manifest after the age of 20.

Minor head trauma is experienced by 2 million people each year.[6] At least 500,000 people require hospitalization as a result of the trauma. Forty-five percent of incidents are caused by auto accidents, and 30% by falls. Children are at high risk for falls, and often suffer headaches caused by minor head trauma. Approximately 30%-90% of patients with mild head injury will experience headache.[7] As many as 30%-50% will develop chronic headache.[5] Thus, if the pharmacist is approached by a parent requesting advice for a child's headache, it is prudent to ask if the child has had a recent fall. The headache typically begins within hours of the injury or the following day.[8] Additional symptoms that indicate post-traumatic headache include dizziness/vertigo, irritability or aggressive behavior without provocation, susceptibility to fatigue, anxiety, insomnia or disturbances of the sleep/wake cycle, and impaired concentration and memory.[5] The headache itself may last for 1-2 weeks, but these ancillary problems may persist for 18 months or, in some cases, as long as a lifetime.[8]

Many experts estimate that as many as 3% of pediatric patients experience migraine headache.[3] However, one survey revealed that 4% of male adolescents and 7% of female adolescents reported headache symptoms consistent with migraine, suggesting that the number may be somewhat higher.[4] Migraine exhibits a strong familial tendency; the pharmacist may inquire about a family history to help identify migraine in the pediatric patient. Migraine typically manifests as a throb on one side of the head lasting 6-8 hours, but may persist longer. Patients may also experience concomitant symptoms such as nausea, vomiting, phonophobia and photophobia.[8]

Identification of migraine triggers for a specific individual can be valuable in helping avoid further attacks. The list of potential triggers includes environmental factors (e.g., sunlight, loud noises, stagnant air, odors), foods (e.g., some cheeses, chocolate, food preservatives), lifestyle choices (e.g., changing one's sleep patterns, missing a meal), and psychosocial stress.[4]

Some patients notice a migraine prodrome beginning 24 hours before onset of the headache. The prodrome may include fluid retention and unpredictable alterations in energy level, mental alertness, and appetite.[5]

Many migraine sufferers may experience an aura 15-60 minutes before onset of pain, possibly as a result of ischemia.[5,8] Vision problems are common, beginning as a set of bright visual obstructions. Some patients describe the changes as geometric patterns (e.g., triangles) marching in from both edges of the visual field. The vision then becomes temporarily obscured. The onset of visual changes does not always signal a migraine, however. They may also occur alone.[8]

At least 40% of those who experience tension headaches report an onset prior to the age of 20.[9] Tension headache is characterized by a dull, vise-like pain.

Sinus infections are a frequent cause of headache, often occurring as sequelae of the common cold. Sinus headache is a dull, constant pressure.[5] Markers for infected sinuses include recent history of an upper respiratory infection, persistent frontal headache, facial pain, tenderness over the sinus, and a change in severity of pain depending on the position of the head.[4]

Parents of children with recurrent headaches often fear that their child has a brain tumor. Fortunately, this is seldom the case. While it is true that headache is often the first sign of a brain tumor and eventually develops in 70% of those with a brain tumor,[5] most children with tumors develop further abnormalities within 4 months. Clues to a tumor-induced headache are intermittency, seizures, worsening pain with exertion or positional changes, frequency at night or in the morning after awakening, pain that does not pulse but is a deep ache, and the effectiveness of analgesics to relieve the pain.[4,5]

Children are often prone to engage in activities such as prolonged reading, watching television, or viewing a computer screen. Excessive computer usage in children may be related to homework, but is more often a result of playing video games or surfing the Web. The pharmacist may ask about the child's recreational activities when inquiring about the nature of a headache. Ophthalmological headache is a dull frontal headache, often bilateral.

Caffeine addiction produces a constellation of adverse reactions; withdrawal from caffeine is also bothersome. Headache is the most common withdrawal symptom. When the patient is no longer subjected to the vasoconstrictor effect of caffeine, the patient experiences rebound vasodilation.[8] The pharmacist may inquire about caffeine use by the child (e.g., excessive soft drink consumption), and the possibility that within the past 24 hours the child has undergone recent withdrawal from caffeine use.

Signs that a headache may require physician referral are discussed in this month's patient leaflet. The parent should be urged to take the child to a physician if the history of the headache includes seizures, accelerating frequency, behavioral changes, reduced visual acuity, nausea or vomiting, frequent nighttime awakenings with headache, worsening severity, sensitivity to light, altered mental state, or changes in pain when waking, coughing, straining, or with changing the position of the head.[4] Neck stiffness, fever, or rash are warning signs which may signal systemic illness (e.g., meningitis, encephalitis, Lyme disease).[9,10]

Internal analgesics for headache are available in a wide variety of products and dosage forms. This month's patient leaflet describes therapeutic options. It also discusses several circumstances in which the patient should see a physician.

Remember, if you have questions, Consult Your Pharmacist.

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