The child with a headache

Headaches are common in children and the practice nurse will see many patients with headaches. Most headaches, whilst unpleasant, are not serious. Is this true in children, too? Do their headaches have the same causes as in adults? When should we be worried? We examine the common, as well as the rare but more serious, causes of headache in children

WHAT IS A HEADACHE?

Headaches mean different things to different people, and children are not always very good at describing where their pain is.

A headache is pain anywhere in the head – so this includes the top and back of the head but also the forehead, the cheekbones and face, the temporo-mandibular joint (TMJ) and the back of the neck.

Headaches can arise from the muscles and joints of the face, head and neck - including the scalp, neck and upper back, from the skull and from inside the skull – mainly the surface coverings of the brain.

DIAGNOSING HEADACHE

The secret to diagnosis in headache is a mixture of:

• Pattern recognition (we match a set of described symptoms to the list of conditions we know about)
• Deduction (we listen to symptoms and rule out those that ‘don’t fit’ until were left with the ones that do)
• Observation (we observe and examine the child to decide whether the findings support our diagnosis)
• Common sense (we add some understanding of which things are common and likely and which are rare and less likely).

This is, of course, the process that we used in all consultations. In children it is complicated by difficulty getting a clear history because children may not be able to describe the headache clearly, and the story may have been told to an adult several times and have been changed by the adult’s ideas, concerns and expectations

When consulting with children we can manage some of these difficulties through the use of non-technical language, a mixture of open and closed questions and touch and pointing. Being interested in and engaged with the child and taking as much of the history as you can from them will help.

Parents are often concerned that acute headaches represent meningitis (particularly in a poorly child) and brain tumour.

To manage this anxiety you need a confident manner, making it clear that you have time to listen to the story and are interested in it, so that you are able to get a clear story from the child as well as hearing the parent’s concerns. (Box 1 – Taking the history)

Examination is also important. We may see and feel things that support our diagnosis. Patients and parents are reassured by examination, and without it your diagnosis and explanation will not carry the same weight.

COMMON CAUSES OF HEADACHE IN CHILDREN^1,2

The most common causes of headache in poorly children are referred headaches secondary to swollen glands and inflamed muscles in the neck. However, the most important diagnosis to exclude is meningitis/meningoencephalitis.

The most common causes of chronic or recurrent headache are tension headaches, migraines and tiredness. Brain tumours are – thankfully – rare.

EXAMINATION

General examination^3,4

Examination will be tailored by the age of the child and the history:

Observe the child: well, poorly or very sick? Well hydrated? Jaundiced or pale?

Basic observations: demeanour, temperature, pulse.

Blood pressure: we don’t often do this in children and it is probably not an essential initial part of the examination of a child with a headache in primary care. However if you have concerns about intracranial causes or if the child is very sick then diastolic blood pressure must be checked.

Rash: if there is a rash look at it early. The classical rash of meningococcal disease is purpuric and does not blanch. The first appearance may be a tiny area. It is usually associated with fever and often with vomiting (although see under meningitis below)

Examination of the head and neck

Pupils: Equal and reacting to light and accommodation

Fundoscopy: Fundoscopy does not often yield useful signs in headache. You are looking, in particular, for papilloedema, which is rarely seen in headache, particularly not without other signs. However, if there is any suspicion of intracranial cause of headache then fundoscopy to exclude papilloedema is essential.

Examination of ears and throat: Tonsillitis and pharyngitis are very common causes of headache in children.

Cervical lymph nodes: Palpation of cervical lymph glands may show lymphadenopathy which is a common cause of headache.

Examining for neck stiffness: A stiff neck is not one that the patient cannot bend, it is one that the clinician cannot bend even if the patient tries to relax.

To properly examine for neck stiffness you need to

• Go behind the patient
• Ask them to relax whilst you move their head forwards and back or up and down
• Take their head between your hands and bend the neck gently till the chin is on the chest, then come up again. Do this gently and ask the child to relax.

Once you have done this a few times you will know how this should feel. Genuine neck stiffness associated with meningism feels very different. The neck feels stiff and you cannot bend it. The child can usually overcome this and put their chin on their chest so the ability to do so does not rule out neck stiffness.

Turn the head from side to side. Ask if any of the neck movements hurt? Tender neck muscles are not meningism, but can lead to headache.

The jaw: Feel over the jaw joint as the child opens and closes their mouth. Is there pain there? Does it click? TMJ problems often cause pain on biting and chewing.

OTHER CAUSES OF HEADACHE IN CHILDREN

Tension headache⁴

Tension headaches are common in children, particularly older children. They arise from tightness in the muscles of the shoulders and neck, which then are passed on to the muscles of the scalp. Underlying causes include poor posture at desks and at computers, sitting at laptops late at night, poor sleeping positions (classically with too many pillows). Stress and anxiety also cause tension headaches.

Tension headache is typically

• Felt at the front of the head like a tight or pressing band
• Bilateral/symmetrical
• Not pulsating
• Not made worse by physical activity
• Worse at the end of the day
• Not associated with visual disturbance (children often describe blurring but this is a poor localising sign. Diplopia may occur occasionally and should be checked but is often a sign of tiredness and ‘eye strain’)
• Can be of any duration from minutes to days

Treatment is aimed at treating the cause. Simple painkillers can help but may turn the tension headache into a medication headache. Warm wheat bags on the neck, drinking plenty, reducing the number of pillows and addressing seating position for reading and working are helpful. Young children playing musical instruments may get tension headache from hours of practice, and need to address their posture with their music teacher.

Medication headache and chronic daily headache (CDH)³

These are slightly different. Medication headache arises from taking continuous painkillers for head pain, sometimes over as short a period as 2-3 days. It is thought to be caused by an ‘upregulation’ of pain receptors in response to painkiller use, and is only a feature of head pain, not of pain elsewhere.

CDH is a term used for headaches that occur on most days for 15 days or more. They often begin as tension headaches or migraines, but they then are often perpetuated by medication use and become medication headaches. It is essential to stop using the painkillers to get rid of the headache, but it can take some time and patients may need some convincing, even though their painkillers aren’t really working. Children, like adults, get chronic daily headache, and support and help are needed to get rid of them.

Migraine¹

Cephalic migraine is unusual under the age of two years but increasingly common beyond this – under-12s are more likely to experience migraine without aura. Abdominal migraine often precedes its onset. There is often a positive family history. Typical features of migraine include:

• One sided
• Throbbing
• Causes nausea and incapacity
• Dislike of light is common
• Can vary from mild to extremely severe
• Aura occurs in about 1 in 3 children. This is a visual or other transient neurological disturbance occurring before the headache rather than during it, is usually one sided, and lasts up to an hour.
• Children are often pale and unwell
• Anorexia and vomiting are common
• Headache duration is usually between an hour and three days although ‘back to back’ migraines can occur

Migraine is often not relieved by oral medication due to the associated gastric stasis, which prevents absorption.

Typical triggers include stress, tiredness, hunger and specific foods including caffeine and chocolate.

Treatment should both address the triggers and the pain. If simple painkillers don’t work then migraine preventers can sometimes be the answer.

Eye strain and visual acuity problems²

Eye strain and problems with vision can cause headaches. The child may always have been short sighted/long sighted/astigmatic and the headache may only really appear when pressure of schoolwork and homework mean that the eyes are really put to the test. Headaches are typically worse at the end of the day and relate to periods of working and reading. They may resemble tension headaches but may also be felt behind the eyes. Children may say they have tired, watery or dry eyes and blurry vision and may be sensitive to light.

If visual acuity problems are suspected children should be referred to an optometrist for refractive eye testing.

Computer vision syndrome

This kind of eye strain is typically seen in the older child who is working had for exams or spending long hours in front of the computer screen. Video and computer games are the most common culprits for eye strain in children. Children would rather keep on playing than complain about the symptoms they are feeling. Using the computer for hours without taking into account the tiredness of their eyes increases the likelihood of this occurring.

Tiredness

Tiredness headaches are essentially a combination of tension headaches and eye strain, and show features of both.

Secondary to mood disturbance

This is again more likely in older children. Signs of altered affect should prompt questioning about mood and feelings.

Secondary to diet

Poor diet may lead to low energy levels, tiredness and swings in blood sugar. The modern version of the poor diet is over-reliant on sugars, processed food and fizzy drinks. There may be a lack of fibre, and over consumption of salt and additives. It’s very difficult to know which aspect of this sort of diet most causes headache, but anything that reduces physical condition or leads to sudden swings in blood sugar levels makes tiredness-related tension headache more likely.

Children with eating disorders may also present with headaches.

In anorexia this may be a consequence of hunger, tiredness and low blood sugar. In bulimia it may relate to parotitis due to frequent chewing of food, to muscle strain related to purging, or to swings in blood sugar related to binging and vomiting (causing swings in insulin levels and blood sugar) and electrolyte changes due to vomiting and laxative misuse.

Intracranial causes⁴

Intracranial causes of headache are rare, but it is important to be alert to the signs and symptoms of serious disease. (Box 2)

The brain itself does not feel pain, although the surface structures including blood vessels and meninges are very sensitive.

Intracranial disease causes headache by one of two mechanisms:

• Raised intracranial pressure
• Irritation of meningeal structures

Raised intracranial pressure classically causes a chronic, steadily increasing headache that is worse in the morning and present on waking up (and sitting up). As it gets worse it causes nausea, and may cause some double vision. It may not be severe headache – at least not at first. Causes include brain tumour, brain infection, congenital abnormalities and bleeding due to head injury. Papilloedema (swelling of the optic nerve head) is a classical but very late sign, and there may be no positive examination findings.

Meningeal irritation is caused by infection or by bleeding. It classically causes a severe headache with photophobia and neck stiffness. It can cause fitting and permanent nerve damage. Meningitis may be bacterial or viral, fungal or protozoan. The presence of a purpuric rash suggests septicaemia is also present.

Causes relating to other head structures

A good history should reveal the primary site of the cause of the pain.

Neck pain: muscle pull, torticollis. e.g. due to awkward sleeping position, pulling the deep tendons of the neck during sport or a fall, or whiplash injury from a road traffic accident.

Ocular causes: pain from the eye can cause headache, usually in and around the eye. Causes of painful red eye such as episcleritis are not common in children.

Ear causes: in otitis media the pain is usually obviously in the ears, but the pain of otitis externa may be felt in the face and jaw.

Dental problems may cause headache but the cause is usually obvious from the history.

Temporomandibular joint problems, including teeth grinding, cause pain, often around the jaw and in the cheeks. If due to grinding, an aching pain in the face is present on waking up.

Sinusitis: older children may develop sinusitis – it typically follows a cold and causes frontal headache that is worse on leaning forwards, sometimes with pain in the teeth. The frontal sinuses are not developed in young children, who don’t get acute and chronic sinus disease.

Systemic causes

Headache may also be a presenting feature of systemic disturbance such as dehydration, diabetes, thyroid disease, heat stroke/sunburn and any acute systemic illness.

These causes are not always obvious. The initial onset of diabetes in children is often insidious until it turns into ketoacidosis. There may be a history of weight loss, thirst and polyuria (the latter considered normal by the child in view of the former). Children are dehydrated and breath may smell of pear drops.

It is important to put systemic disease through your diagnostic sieve when examining the child with a headache and consider underlying metabolic disturbance.

SUMMARY

Headache is common in children, and while it is not usually serious there are some serious conditions that need to be excluded. A careful history and focussed examination allow the practice nurse to narrow the differential diagnosis down to the most likely causes. A clear explanation, management plan and a sensible safety net will then allow the child and parent to leave feeling reassured.

Most headaches are not serious, and most serious headaches present with clear symptoms and signs, which will be detected by a thorough approach. If in doubt, ask for help.

REFERENCES

1. Patient.co.uk Migraine in children (Professional reference) Dec 2011 http://www.patient.co.uk/doctor/migraine-in-children

2. Eye strain in children http://optometrist.com.au/detecting-eye-strain-children/

3. Mayo Clinic. Headaches in Children: http://www.mayoclinic.org/diseases-conditions/headaches-in-children/basics/definition/con-20034478

4. Lissauer T, Clayden G. Illustrated Textbook of Paediatrics 3rd edition. Oxford: Mosby; 2007