Headaches in Children
Headaches are a common complaint in children and can be a source of significant anxiety for both the child and their parents. While most headaches are benign, a small number are caused by serious underlying conditions. The key to a successful assessment is a detailed history and physical examination to identify any red flags that would prompt further investigation.
Classification
Headaches in children are classified as either primary or secondary.
Primary Headaches: These are not caused by an underlying medical condition.
Migraine: A common cause of episodic headaches, often with a pulsating quality and associated symptoms like nausea, vomiting, or visual aura.
Tension-type Headache: A frequent cause of headaches, often described as a constant, dull ache on both sides of the head.
Secondary Headaches: These are caused by another medical condition.
Intracranial: Raised intracranial pressure (ICP), meningitis, encephalitis, brain tumours, or a shunt malfunction.
Extracranial: Headaches caused by eye problems, sinusitis, or dental issues.
Clinical Assessment
History
A detailed history is the most important part of the assessment.
Headache Characteristics: Ask about the onset (sudden or gradual), duration, and frequency of the headaches.
Pain Description: Ask the child to describe the location and type of pain. A pulsating headache suggests a migraine, while a dull ache suggests a tension headache.
Associated Symptoms: Enquire about symptoms such as nausea, vomiting, visual changes, or neurological symptoms like pins and needles or weakness.
Triggers: Ask about potential triggers, such as stress, lack of sleep, or certain foods.
Impact on Life: Assess the impact on daily activities, such as school attendance.
Examination
Vital Signs: Check the child’s blood pressure.
Neurological Examination: Perform a full neurological examination, including an assessment for meningism (neck stiffness, photophobia) and signs of raised intracranial pressure.
Fundoscopy: An ophthalmoscopic examination is crucial to look for papilloedema, a key sign of raised ICP.
Red Flags
The presence of a red flag warrants urgent investigation and specialist referral to rule out a serious cause.
Sudden onset: A sudden, severe “thunderclap” headache is a medical emergency.
Age: A child under the age of 4 years with a new headache should be thoroughly investigated.
Progression: A headache that is getting progressively worse or is a new type of headache is a red flag.
Associated Symptoms: Headaches associated with a new neurological deficit, such as a squint, ataxia, or loss of balance.
Nocturnal Headache: A headache that wakes a child from sleep or is present on waking, especially if associated with vomiting, suggests raised ICP.
Other Contexts: Headaches in a child with a history of malignancy, immunosuppression, or recent head trauma.
Investigations and Management
Investigations: Most children with headaches will not require any investigations. An urgent CT or MRI brain scan is indicated if a red flag is present. A lumbar puncture may be required if meningitis or encephalitis is suspected.
Management: For primary headaches, management is usually conservative.
Migraine: Acute management involves simple analgesics like paracetamol or ibuprofen. In severe cases, triptans may be used.
Tension-type Headache: Reassurance, stress management, and simple analgesics are the mainstays of treatment.
Psychosocial Factors: Address any underlying psychosocial factors at school or home.