Headache in Children

Aka: Headache in Children, Headaches in Children, Cephalgia in Children, Pediatric Headache

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II. Epidemiology

  1. Incidence of Headache
    1. Age 7 years or older: 33% (frequent in 2.5%)
    2. Age 15 years or older: 50% (frequent in 15%)
  2. Gender predominance
    1. Before Puberty: Boys
    2. After Puberty: Girls
  3. Headaches in teens presenting to Emergency Department (all serious causes had neurologic findings)
    1. Upper respiratory tract infection with fever: 55%
    2. Primary Headache syndrome (Migraine or Tension Headache): 18%
    3. Viral Meningitis: 7%
    4. Brain Tumor: 2.5%
    5. Post-ictal Headache following Seizure: 2%
    6. Postconcussive: 2%
    7. Ventricular shunt malfunction: 2%
    8. Undetermined cause: 7%
    9. Lewis (2000) Headache 40:200-3 [PubMed]

III. Causes: Primary Headaches

  1. Common primary Headaches in Children
    1. Migraine Headache
      1. See Migraine Headache Triggers
      2. See Tyramine-Vasoactive Amines
    2. Tension Headache
  2. Uncommon primary Headaches in Children
    1. Young Children
      1. Hemiplegic Migraine Headache
      2. Ophthalmoplegic Migraine
    2. Older Child, Adolescent and Young adult
      1. Temporomandibular Joint Disorder
      2. Basilar Migraine Headache (female adolescents)
      3. Paroxysmal Hemicrania
        1. Similar to Cluster Headache without Lacrimation
      4. Cluster Headache (rare in children)
      5. Occipital Neuralgia

IV. Causes: Secondary Headaches

  1. Head and neck infections
    1. Upper Respiratory Infection
    2. Acute Sinusitis
    3. Pharyngitis
    4. Dental Infections
  2. Intracranial Infections
    1. Meningitis
    2. Encephalitis
    3. Intracranial Abscess
      1. Cyanotic heart disease
      2. Immunocompromised
      3. Untreated Sinusitis (e.g. Periorbital Cellulitis)
  3. Intracranial Cause
    1. Hydrocephalus
    2. Cavernous Sinus Thrombosis
    3. Intracranial Tumor
      1. Rare cause of Headache in Children (3 in 100,000)
      2. See red flags below
    4. Nontraumatic Intracranial Hemorrhage
      1. See Subarachnoid Hemorrhage
      2. Presentations
        1. Headache with Vomiting
        2. Seizures
        3. Hemiparesis
        4. Glasgow Coma Scale <15
      3. Types
        1. Arteriovenous Malformations
        2. Hematologic disorder (Thrombocytopenia, Hemophilia, Sickle Cell Anemia)
        3. Intracranial Aneurysms
  4. Miscellaneous Causes
    1. See Medication Causes of Headache
    2. Temperomandibular joint dysfunction
    3. Carbon Monoxide Poisoning
    4. Lead Poisoning
    5. Hypertension
      1. See Hypertension Causes in Children
      2. See Hypertensive Crisis
      3. Hypertensive Encephalopathy
        1. Presents with Headache and diastolic Blood Pressure >95th percentile
        2. May be accompanied by Seizures or Vision change
        3. Causes
          1. Renal disease (most common)
          2. Aortic Coarctation
          3. Hyperthyroidism
          4. Pheochromocytoma
          5. Neuroblastoma
          6. Wilms Tumor

V. Red Flags: Intracranial Tumor or mass

  1. Predictors of space occupying lesion
    1. Headache worse with lying down or on awakening
    2. No Family History of Migraine Headache
    3. No visual symptoms
    4. Headache duration <6 months
    5. Vomiting
    6. Confusion
    7. Neurologic Exam abnormalities
    8. Medina (1997) Radiology 202: 819-324 [PubMed]
  2. Headaches are present in 62% of children with Intracranial Mass and 99% have accompanying neurologic findings
    1. History
      1. Vomiting (>72%)
      2. Personality or speech problems, or problems in school (>81%)
      3. Weight loss (>66%)
      4. Difficulty walking for age over 2 years (>77%)
      5. Upper extremity weakness (>63%)
      6. Seizures (>6%)
      7. Diplopia in age over 4 years (>60%)
    2. Exam
      1. Lethargy or confusion (>72%)
      2. Papilledema (>65%)
      3. Head Tilt (>50%)
    3. References
      1. (1991) J Neuro-Oncol 10:31-46 [PubMed]

VI. Evaluation

  1. See Headache History
  2. See Headache Examination
  3. See Headache Diagnostic Testing
  4. Consider Organic Headache
    1. Evaluate Headache Red Flags
  5. Headache Timing
    1. Acute Headache
      1. Acute Generalized Headache
      2. Acute Localized Headache
      3. Acute Recurrent Headache
    2. Chronic Headache
      1. Chronic Progressive Headache
      2. Chronic Non-Progressive Headache

VII. Diagnosis: Migraine Headache in older children and teens

  1. See Migraine Headache Diagnostic Criteria
  2. Migraine Headache may be diagnosed based on classic presentation with normal exam
  3. Family History increases likelihood of Migraine Headache

VIII. Management

  1. See Headache General Measures
  2. Treat specific Headache type
    1. See Migraine Headache Management in Children

IX. References

  1. Fuchs and Yamamoto (2012) APLS, Jones and Bartlett, Burlington, p. 184-6
  2. Lewis (2002) Am Fam Physician 65(4):625-32 [PubMed]
  3. Winner (1997) Postgrad Med 101(5):81-90 [PubMed]

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