Management of Headache in Kids

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SCIENCE
Management of Headache in Kids
Key Take-Away: 

Headache is the most common form of pain. Headaches are often related to stress, depression or anxiety. Non-pharmacological approach is the first line approach to manage headaches of all types. Keeping track on headache patterns and precipitating can be helpful.

Occurrence of headache is very common nowadays, even in kids. Parents usually consider these headaches as a severe problem in kids. Physical examination by doctor is preferred, that help decide whether neuro-imaging is required or not. Mostly, based on the diagnostic reports, treatment of headache is initiated. 

Types of headache in childhood:

Headaches in fever: These headaches are common in viral infections like sinusitis, otitis media or intracranial infection may also cause headache.

Sudden onset of severe headache:

In these cases, immediate diagnosis and treatment is required because these headaches may indicate the serious inherent pathologies like meningitis, encephalitis, intracranial bleed, acute hypertension, acute elevation of intracranial pressure and the first attack of migraine.

Migraine: Chronic continuous headaches may be due to migraine which is often characterized by associated nausea, vomiting, photophobia, throbbing unilateral headaches.

Migraine without aura is characterized by:

  • At least 5 attacks fulfilling below criteria
  • Lasts for 4-72 hrs.
  • Accompanied by at least two of enlisted symptoms- unilateral, pulsating, moderate/severe pain, aggravation by/avoidance of physical activity
  • Accompanied by either nausea/vomiting, or photo/phonophobia or all
  • Not attributed to any other disorder

Migraine with aura is characterized by:

 At least 2 attacks fulfilling the below criteria

1. Aura (at least 1 of the following fully reversible neurological symptoms)

- Visual symptoms (positive e.g. flickering lights or negative e.g. loss of vision)

- Sensory symptoms (positive e.g. pins and needles or negative e.g. numbness)

2. Dysphasic speech  

Tension Headaches

In tension type headaches, “band-like” pain which starts step by step and is in diffused form. There can also be a phase with no symptoms. Usually, child's daily activities are not interrupted by these headaches.

Mixed migraine and tension headaches

Some children may have a clear history of more than one type of headache. Migraine and tension headaches are the two common types of headaches that may occur together in childhood.

Cluster headaches

These occur in series and are very uncommon during childhood. Headaches which lasts from few minutes or few hours are also followed by symptom-free periods after the attack. Pain is mostly around one eye and may spreads to the other side of the face as well. Contralateral autonomic findings may occur in older children.

Raised intracranial pressure

Expanding intracranial lesions and benign intracranial hypertension causes headaches which occur on waking and are provoked by coughing, sneezing and straining at stool. The headaches which are associated with these conditions are progressive with the frequency and severity which increases over the time.  Benign intracranial hypertension is diagnosed after a normal CT or MRI scan in a child with papilloedema by measuring the opening pressure at lumbar puncture.

Headaches associated with trauma

Headaches may occur acutely following the trauma or as a part of a post-concussion syndrome.

Analgesic headaches

These rarely occur in childhood. The headaches occur daily in childhood and disappear within a few weeks after the withdrawal of medication.

Management:

Non-pharmacological approaches will remain the first line approach to manage headaches of all types. Keeping track on headache patterns and precipitating can be helpful. Headache precipitants vary for each child and results in over-tiredness, missed meals, changes in physical activity, hormonal changes, bright lights, food and stress.

Other non-pharmacological approaches include appropriate sleep hygiene, regular physical activity, limiting caffeine intake, relaxation techniques, biofeedback and self-hypnosis. Behavioral therapies such as relaxation techniques and biofeedback, have demonstrated the efficacy in the treatment of pediatric headache.

Symptomatic and prophylactic medications fall under pharmacological approaches to headache treatment. Non-prescription analgesics are effective for acute headache relief in most patients if taken in appropriate doses. In pediatric migraine management, ibuprofen has been shown to be safe and effective.

Serotonin receptor agonists (triptans) have become the mainstay of treating adult migraine and are an option for children with severe migraine. Prophylactic medications should also be considered when headaches pose an impact on activities and school attendance and causes functional disability. Various tools are available for evaluating the headache-related disability and quality of life which can provide better measures of the true impact of headaches.

Mostly medications which are effective in adults with headache, also fail to demonstrate a significant therapeutic response in children. However, beta-blockers are contraindicated in children with reactive airway disease, diabetes, orthostatic hypotension and cardiac conditions associated with bradycardia. Athletic children may find beta-blockers intolerable because of limitation of physical stamina.

Various other medicines have a 'time-honored' place in the treatment of childhood headaches. Without any controlled trials to support, cyproheptadine is an antihistamine with calcium channel blocking and antiserotonergic properties, which is commonly used for pediatric migraine prophylaxis. Side effects from this are weight gain and sedation. Drugs like topiramate, valproate, lamotrigine and gabapentin are also beneficial in pediatric migraine management.

References:

1.The optimal management of headaches in children and adolescents, Joanne acperskiMarielle A. KabboucheHope L. O’BrienJessica L. Weberding, 

2.The Treatment of Migraine Headaches in Children and Adolescents, Michelle Brenner, Donald Lewis, J Pediatr Pharmacol Ther. 2008 Jan-Mar; 13(1): 17–24.

3.The evaluation and management of paediatric headaches, JM Dooley, Paediatr Child Health. 2009 Jan; 14(1): 24–30.

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