HEADACHE AND FACIAL PAIN: PEDIATRIC PAIN: HEADACHES IN CHILDREN

Overview

Headaches have existed since the dawn of civilization, with reports of headaches dating back 25 to 30 centuries to the times of the ancient Egyptians; however, little emphasis was placed on the impact of headache disorders in children until 1873 when William Henry Day, a British pediatrician, included an entire chapter on head disorders in his book, Essays on Diseases in Children.1 Although health care providers have learned much about headaches since then, many of Dr. Day's impressions are applicable today, including his assertion that non-vascular headaches are most common and that many headache disorders in children are related to psychosocial stresses.

The potential impact of headaches on the everyday lives of children should not be underestimated. Headache disorders can be chronic, recurrent problems that interfere with usual childhood activities including school attendance. By age 6, more than 30 percent of children have reported having headaches and up to 75 percent of children suffer from this malady by age 15.2 Children miss more than one million days of school each year because of headaches.

Foremost in the minds of parents and health care providers is the fear that some underlying problem is responsible for the headache (eg, brain tumor). In most cases, no life-threatening problem is found to be the cause of the pain, but a thorough history and physical examination performed by a physician is necessary rule out potentially life-threatening problems. In one study of 74 children younger than 16 years of age admitted to a neurosurgical unit with brain tumors, researchers reported that 60 percent had headaches that occurred everyday, interfered with activities of daily living, and were not relieved by simple analgesics such as acetaminophen or ibuprofen.3 An average of 4.6 consultations occurred before a brain tumor was diagnosed — 19 percent had been previously diagnosed as migraine. This underscores the importance of having your child evaluated by a physician who is familiar with the appropriate work-up and treatment of pediatric headache disorders even though must are not related to life-threatening problems. Depending on training and experience, appropriate health care providers include pediatricians, neurologists or family practice physicians.

Many of the following symptoms may occur with migraine and other headache disorders, but also may suggest underlying pathology and the need for further diagnostic testing to rule out a brain tumor:

· Increased severity or frequency of headaches

· Morning headaches

· Headaches that awaken the child from sleep

· Constant or daily headaches

· No improvement with analgesics (acetaminophen, ibuprofen)

· Vomiting, especially if without nausea

· Alteration of pain with changes in position

· No family migraine history

· Changes in mental status

· Irritability

· Mood swings

· Appetite changes

· Changes in school performance

· Inability to concentrate

· Visual disturbances

· Gait problems

· Seizures

· Motor weakness

Most importantly, if an underlying reason is responsible for the headache (e.g., brain tumor), early diagnosis may help treatment success and improve a child's outcome.

Most recurrent headaches in children are due to one of several possible headache disorders. A thorough history and physical examination and, when indicated, diagnostic laboratory and radiologic studies help your child's physician arrive at a correct diagnosis. Depending on the diagnosis, the physician may prescribe specific therapies and medications to treat and prevent subsequent headaches. In many cases, these therapies will help lessen the severity and/or frequency of the child's headache.

Fast Facts

· Headaches can be a chronic, recurrent disorder that interferes with a child's daily activities, including school attendance, and can have a significant negative impact on daily life.

· Headaches are a common event in the lives of children — 31 percent of children report headaches by age six and 75 percent report headaches by age 15. Twenty-six percent of children ages seven to 16 years report having at least one headache per month.

· Headaches account for children missing one million school days per year.

· Children diagnosed with having migraine headaches miss 8.5 more days of school per year than children without migraines or those with tension-type headaches.

· Researchers estimate that 2 percent to 10 percentof the general population experience migraines.

· The number of children who experience headache (one episode or more per month) has increased 40 percent over the past 20 years.

· The risk of migraine in children is approximately 45 percent when one parent has migraine headaches and 70 percent when both parents have migraines.

· Motion sickness is observed in almost half of children with migraines. Other associated conditions include asthma or eczema.

· No definite study exists linking the occurrence of migraine with anxiety, depression or psychiatric problems.

Myths & Misconceptions

Myth: Hardworking, high-achieving people — "type A" personalities — are more likely to suffer recurring headaches than others.
Reality: Everyone gets headaches, even children. Headaches are no more prevalent among people with so-called "type A" personalities.

Myth: Children who get headaches all the time are simply trying to avoid school or chores.
Reality: Recurring headaches are a real problem for an estimated 60 million to 80 million adults and children. While headaches may interfere with school, work or relationships, most people do their best to lead normal, active lives.

Myth: "Headaches are a part of life and my child should just suffer them."
Reality: While everyone gets a headache from time to time, chronic, persistent headaches are not the norm. Once diagnosed, various treatment options are available to manage all types of chronic headaches.

Myth: Headaches are caused by brain injury or damage.
Reality: Headache patients' brains are hypersensitive to all kinds of stimulation, even thoughts. Such events, including head injuries, changes in the weather, internal hormone changes, etc., trigger a cascade of chemical changes that cause inflamed blood vessels and neurological symptoms, including pain.

Myth: It's possible to cure chronic headaches once and for all.
Reality: Unfortunately, most people who get recurring headaches are likely to keep getting them. This means treatment focuses on "managing," rather than "curing," the headache.

Myth: There are no good treatments for chronic headaches.
Reality: No one headache treatment will work for everyone. It may take a thorough medical work-up and working closely with your health care team to find the treatment option that will work best for you.

Headache Types in Children

All types of headaches cause pain, and regardless of the type or cause, the pain can range from mild to severe to incapacitating. The number of headaches a child has and the length of pain vary from child to child and headache type. Headache types include primary, ordinary and secondary.

· Primary headaches. Primary headaches are classified as such because the pain or headache is the primary symptom related to a disturbance of the brain or the blood vessels within the brain. Primary headaches include migraine, tension, cluster and ordinary headaches (a mild form of either migraine or tension headache).

· Ordinary headaches. Ordinary headaches are the most common form of headache. We all experience ordinary headaches at some point in our lives. They usually are easily treated with simple analgesics (eg, acetaminophen, non-steroidal anti-inflammatory drugs [NSAIDs] like ibuprofen). This type of headache does not significantly interfere with daily activities, has no associated symptoms, produces mild pain, lasts a few hours, and does not recur at regular intervals.

· Secondary headaches. Secondary headaches are related an underlying problem like a sinus infection or brain tumor. There are hundreds of causes for secondary headaches including head trauma, dental problems, hypertension, carbon monoxide poisoning and viral illnesses.

Headaches may be further classified as:

· Acute

· Acute, recurrent

· Chronic, progressive

· Chronic, non-progressive.4

· Acute: An acute headache is a one-time event where severe pain occurs suddenly and without warning. Possible causes of an acute headache include ordinary headache; the first time the child experiences a migraine, in which case the headache will recur and become an acute, recurrent headache; tension headache, or a wide range of systemic illnesses some of which may be life-threatening and require immediate medical attention (eg, infections of the central nervous system, toxins such as carbon monoxide, high blood pressure or a brain tumor).

· Acute, recurrent. Acute, recurrent headaches are characterized by severe pain that occurs suddenly, lasts several hours, and occurs at regular intervals with pain-free periods in between. This type of headache does not increase in intensity or frequency over time. Migraines and tension-type headaches are included in this group.

· Chronic progressive. Chronic progressive headaches become more painful and more frequent over time. When accompanied by other signs and symptoms such as nausea, vomiting or findings on physical examination, a problem such as a brain tumor may be present. Chronic, non-progressive headaches occur at regular intervals (daily) or are constant. They do not increase in severity. There are no associated clinical signs or symptoms.

It is important to determine what type of headache your child is experiencing because treatment options vary depending on the headache. Following are criteria set by the International Headache Society for determining if your child's headache is a migraine or tension headache.

Migraine Without Aura (Formerly Called A Common Migraine)

The child must have experienced at least five attacks meeting the following criteria:

· Headache lasts from four to 72 hours — duration decreased to two hours in children less than 15 years old

· Two of the following characteristics

o Unilateral (meaning on one side of the head)

o Pulsating

o Moderate to severe intensity

o Aggravated by physical activity (becomes worse with physical activity)

· Associated problems with the headache

o Nausea or vomiting

o Photophobia or phonophobia (abnormal sensitivity to light or sound)5

Migraine With Aura (Formerly Called a Classic Migraine)

An aura is a sensation of light or warmth that is caused by the nervous system and may precede a migraine. Visual changes are the most common aspect of an aura and may include flashing lights, double vision, partial vision loss, zig-zag lines or size distortions. The aura also may cause tingling in an arm or leg or a peculiar smell; weakness in an arm or leg or an inability to speak; or even abdominal pain.

The child must have experienced at least two attacks meeting the following criteria:

· One or more reversible auras

· Gradual development of the aura over more than four minutes

· No aura lasts more than 60 minutes

· Headache follows the aura within 60 minutes5

Migraines occur equally in boys and in girls. Approximately 30 percent of migraines in children are migraines with aura. Boys typically experience migraine at a younger age than girls — migraine with aura occurring at 5 years in boys and 12 to 13 years in girls and migraine without aura occurring at 10 to 11 years in boys and 14 to 17 years in girls.

Tension-type Headache

The child must have experienced at least 10 previous episodes with:

· Headache lasting 30 minutes to seven days

· Two of the following characteristics

o Bilateral location (meaning on both sides of the head)

o Non-pulsatile, pressing (tightening) quality

o Mild to moderate intensity

o No aggravation by physical activity (headache does not become worse with physical activity)

· No associated nausea, vomiting and no photophobia or phonophobia (abnormal sensitivity to light or sound)5

How Headache Pain Occurs

The brain and the membranes covering the brain, called meninges, have no pain fibers. Headache pain comes from the nerves in the blood vessels inside the brain and outside the skull and the muscles of the head and neck. Migraine pain typically is related to the nerves in blood vessels while tension type headaches are related to the muscles in the head and neck. Although the exact cause has not been determined, the pain and other symptoms (eg, nausea, tingling, sensitivity to light and sound) that occur during migraine headaches are related to changes in blood flow to structures within the brain. The changes in blood flow, in turn, affect nerve cells within the central nervous system. Both blood flow changes and affected nerve cells alter the concentration of several different chemicals (eg, nitric oxide, serotonin, substance P) in the central nervous system. Current research suggests that serotonin concentrations are low between migraine attacks and increase significantly during migraine headaches, although the exact chemicals (neurotransmitters) responsible for migraines are not delineated. Medications that alter serotonin play a crucial role in the treatment of migraine.

Treatment Options

Effective treatment for childhood headache begins with an accurate diagnosis of the condition. A physician will conduct a thorough history and physical examination on your child, which may include measuring the blood pressure in your child's arms and legs. Your child's physician may conduct further tests based on his or her findings during the history and physical examination. One way to help your child's physician accurately diagnose what type of headache he or she is experiencing is to keep a headache diary. A headache diary should include information about:

· How often the headaches occur (eg, once a month, every week, every other day)

· How long the headaches last

· How intense or severe the headaches are

· Factors that might lead to the headache, such as certain foods and environmental factors like stress and lack of sleep

· The child's response or lack of response to the treatments tried at home

Treatment options include simple analgesics, which are pain medications that help control pain, or prophylactic medications, which are medications taken daily that may help prevent headaches. Your child's physician may recommend giving the child simple analgesics when he or she complains of headache. Although many of these medications including acetaminophen (Tylenol) and ibuprofen (Advil) are available over-the-counter, they are often effective in treating pain and should not be underestimated.6 There are different ways of administering analgesics, including suppository forms of acetaminophen when headaches are accompanied by nausea and vomiting that prevent a child from taking an oral form of the medication. In one research study, 54 percent of patients reported relief from acetaminophen while 68 percent reported relief from ibuprofen.7

Although simple analgesics are effective in most children with migraine headaches, some may need additional therapies. Some medications used to treat migraine headaches specifically work to reverse blood flow changes that are thought to cause migraine headaches. These medications generally are more effective if they are taken soon after the migraine begins (eg, during the aura phase if your child experiences aura). These medications should be used only as directed by your child's physician. Additional agents include the ergotamine derivatives (dihydroergotamine) that cause constriction of the dilated intracranial vessels. Dihydroergotamine can be taken via nasal spray, injection or dissolved underneath the tongue. More recently, the serotonin1 receptor agonist, sumatriptan (Imitrex) has been introduced to relieve pain related to migraine. This medication is available as a nasal spray, injection or tablet. These types of medications may have adverse side effects, including increased blood pressure. Rare adverse effects of all of these medications include increased blood pressure, decreased blood supply to the heart or other vascular issues.

Children who experience recurrent migraine headaches may be given medications to prevent headaches (prophylactic medication). Such medications include beta adrenergic antagonists such as propranolol, calcium channel blockers such as flunarizine or nifedipine, and antidepressants When you and your physician decide to treat your child's headaches in this manner, it is critical that you both closely monitor your child's reaction to such medications to limit the incidence of adverse effects.

Conclusions

· The potential impact of headaches on the everyday lives of children should not be underestimated. Headache disorders can be chronic, recurrent problems that interfere with usual childhood activities including school attendance.

· Foremost in the minds of parents and health care providers is the fear that some underlying problem is responsible for the headache (eg, brain tumor), but in most cases, no life-threatening problem is found to be the cause of the pain,

· All types of headaches cause pain, and regardless of the type or cause, the pain can range from mild to severe to incapacitating. The number of headaches a child has and the length of pain vary from child to child and headache type.

· Effective treatment for childhood headache begins with an accurate diagnosis of the condition. One way to help your child's physician accurately diagnose what type of headache he or she is experiencing is to keep a headache diary that includes information about:

o How often the headaches occur (eg, once a month, every week, every other day

o How long the headaches last

o How intense or severe the headaches are

o Factors that might lead to the headache, such as certain foods and environmental factors like stress and lack of sleep

o The child's response or lack of response to the treatments tried at home

Treatment options include simple analgesics, which are pain medications that help control pain, such as acetaminophen (Tylenol) and ibuprofen (Advil) or prophylactic medications, which are medications taken daily that may help prevent headaches. Some medications used to treat migraine headaches specifically work to reverse blood flow changes that are thought to cause migraine headaches. These medications generally are more effective if they are taken soon after the migraine begins (eg, during the aura phase if your child experiences aura) and are usually prescription medications prescribed by your child's physician.

References

1. Prensky AL, Sommers D. Diagnosis and treatment of migraine in children. Neurology 1976;29:506-510.

2. Sallanpaa M. Prevalence of migraine and other headache in Finnish children starting school. Headache 1976;16:288-290.

3. Edgeworth J, Bullock P, Bailey A, et al. Why are brain tumors still being missed. Arch Dis Child 1996;74:148-151.

4. Rothner AD. Headaches in children: a review. Headache 1978;18:169-174.

5. International Headache Society: Classification and diagnostic criteria for headache disorders, cranial neuralgia, and facial pain. Cephalgia 1988;8:1-96.

6. Weak analgesics and non-steroidal anti-inflammatory agents in the management of children with acute pain. Pediatr Clin North Am 2000;47:527-544.

7. Hamalainen ML, Hoppu K, Valkeila E, et al. Ibuprofen or acetaminophen for the acute treatment of migraine in children: A double-blind, randomized, placebo-controlled, crossover study. Neurology 1997;48:103-107.