OFFICIAL ABP TOPIC:

Understand the presentation, evaluation, and management of different types of headaches

BACKGROUND

Headache is a common pediatric complaint that often raises concern for both practitioners and parents. Primary headaches are idiopathic or genetic disorders without an underlying cause, while secondary headaches result from an identifiable etiology, such as increased intracranial pressure or infection. It is important for pediatricians to identify both types of headaches to guide appropriate evaluation and treatment.

COMMON PRESENTATIONS OF HEADACHE DISORDERS

PRIMARY HEADACHE DISORDERS

• Migraine
  • Recurring headaches, typically 1-4 hours with associated symptoms and wellness between episodes
  • Pulsating quality, moderate to severe pain, worse with physical activity
  • Frequently bilateral, frontal in children and unilateral, temporal in adults
  • Nausea, vomiting, photophobia, and phonophobia commonly associated
  • 20% of pediatric migraines are preceded by a neurologic aura, typically visual
• Tension-type headache
  • Common in children and adolescents
  • Pain typically milder than migraine
  • Bilateral, pressing/tightening quality, not aggravated by routine physical activity
  • No nausea/vomiting
  • Often triggered or exacerbated by stress, poor sleep, and muscular tension
• Chronic daily headache
  • Headache (tension-type and/or migraine) on ≥15 days/month for >3 months
  • Often complicated by medication overuse, which can perpetuate chronic headaches

SECONDARY HEADACHE DISORDERS

• Increased intracranial pressure: Progressive headache worse in the morning or with Valsalva. May have neurologic deficits, altered mental status, papilledema.
• Intracranial hemorrhage: Sudden-onset severe headache with rapid progression. Focal deficits, meningismus common.
• Meningitis/Encephalitis: Fever, meningismus, altered mental status concerning for CNS infection.
• Cerebral venous sinus thrombosis: Progressive headache with increased ICP signs, seizures, focal deficits. Risk factors include estrogen use, thrombophilia, head trauma, systemic illness.

EVALUATION OF HEADACHE DISORDERS

A detailed headache history is key for characterizing the headache type and distinguishing primary from secondary disorders. Important elements include duration, temporal pattern, location, quality, and any associated symptoms.

The physical exam should include a detailed neurological exam that assesses mental status, pupillary light reflexes, extraocular movements, visual fields, funduscopy, cranial nerve function, motor strength and symmetry, coordination and gait, deep tendon reflexes, and meningeal signs.

Red flags in the history and exam raise suspicion for serious secondary etiologies and warrant further investigation:

Algorithm for evaluating pediatric headaches

1. Perform focused headache history. Identify red flags (see table above).
2. Conduct thorough neurological examination with funduscopy.
3. If exam normal AND no red flags, diagnose clinically and treat based on headache type.
4. If red flags present OR exam abnormal:
   • Brain MRI (preferred) or head CT if emergent.
   • Consider adding MRV for suspected ICP or venous thrombosis.
   • LP for possible meningitis or idiopathic intracranial hypertension.
5. Refer to specialist for:
   • Abnormal neuroimaging
   • Focal deficits
   • Rapidly progressive symptoms
   • Treatment-refractory headaches

TREATMENT OF HEADACHE DISORDERS

Migraine

• Acute treatment:
  • Rest in a quiet, dark room, hydration
  • NSAIDs or acetaminophen taken early in attack
  • Triptan agents for incomplete relief with NSAIDs
• Lifestyle modification: Sleep hygiene, hydration, regular meals, limit caffeine, exercise, stress reduction, relaxation techniques
• Daily prophylactic medicationfor frequent (≥4/month) or disabling migraines:
  • Antihistamines: Cyproheptadine
  • Antidepressants: Amitriptyline, nortriptyline
  • Antiepileptics: Topiramate, valproate
  • Antihypertensives: Propranolol, verapamil

Tension-type headache

• Acute treatment: Rest, hydration, acetaminophen or NSAIDs
• Preventive strategies: Address lifestyle factors and sources of stress/anxiety, relaxation therapy, biofeedback; consider amitriptyline for frequent headaches

Chronic daily headache

• Identify and address exacerbating factors: medication overuse, sleep disturbance, caffeine excess, untreated mood disorders
• Consider supplements such as riboflavin, magnesium, melatonin, CoQ10
• Preventive medications: amitriptyline or topiramate
• Behavioral therapies: Biofeedback, relaxation, CBT
• Interventional procedures for refractory cases: Nerve blocks, botulinum toxin

Increased intracranial pressure

Treatment depends on the underlying etiology.

• Tumors: Surgical resection, radiation, chemotherapy.
• Hydrocephalus: CSF diversion (e.g., ventriculoperitoneal shunt).
• Idiopathic intracranial hypertension: Acetazolamide, topiramate, weight loss if obese. Optic nerve sheath fenestration for vision loss.

Intracranial hemorrhage

Achieve hemostasis, control ICP, prevent complications (e.g., vasospasm, hydrocephalus). May require surgical intervention.

Meningitis/Encephalitis

Prompt empiric antibiotics or antivirals. Supportive care.

Cerebral venous sinus thrombosis

Anticoagulation with heparin, even with intracranial hemorrhage. Duration depends on provoking factors.

REFERENCES

https://publications.aap.org/pediatricsinreview/article/41/4/159/35399/Headache-in-Children