Headaches are common in children, increasing in incidence from early childhood to adolescence. They account for 0.7% to 1.3% of all pediatric emergency department visits.[1]Kan L, Nagelberg J, Maytal J. Headaches in a pediatric emergency department: etiology, imaging, and treatment. Headache. 2000 Jan;40(1):25-9.
http://www.ncbi.nlm.nih.gov/pubmed/10759899?tool=bestpractice.com
[2]Burton LJ, Quinn B, Pratt-Cheney JL, et al. Headache etiology in a pediatric emergency department. Pediatr Emerg Care. 1997 Feb;13(1):1-4.
http://www.ncbi.nlm.nih.gov/pubmed/9061724?tool=bestpractice.com
Headaches may be classified as primary or secondary.[3]Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211.
https://www.ichd-3.org
http://www.ncbi.nlm.nih.gov/pubmed/29368949?tool=bestpractice.com
Primary headaches include migraine, tension-type, cluster, as well as the new daily persistent headache. Secondary headaches are symptomatic of an underlying intracranial or medical condition that requires treatment. The initial evaluation of acute headache aims to determine whether there is a secondary cause for headache that requires urgent intervention.
Clinical classification
Headache may be classified in terms of time course.
Acute headache
A single episode of headache pain without prior headaches.
May represent the first or an unusually severe form of primary headache.
May suggest a new acute secondary cause for headache that, therefore, requires evaluation.
Acute recurrent headache
Stereotyped headaches separated by headache-free periods.
Most suggestive of a primary headache disorder, especially if the pattern has persisted for a long period.
May also occur in secondary headache, as with intermittent elevation in intracranial pressure.
Chronic progressive headache
A gradual increase in headache.
Suggestive of an expanding intracranial lesion.
Of children with brain tumors, 62% have headache prior to diagnosis, and 98% have at least one neurologic symptom or abnormality on examination.[4]The Childhood Brain Tumor Consortium. The epidemiology of headache among children with brain tumor: headache in children with brain tumors. J Neurooncol. 1991 Feb;10(1):31-46.
http://www.ncbi.nlm.nih.gov/pubmed/2022972?tool=bestpractice.com
The most common symptoms include nausea or vomiting, difficulty walking, visual symptoms, focal weakness, or personality change.[4]The Childhood Brain Tumor Consortium. The epidemiology of headache among children with brain tumor: headache in children with brain tumors. J Neurooncol. 1991 Feb;10(1):31-46.
http://www.ncbi.nlm.nih.gov/pubmed/2022972?tool=bestpractice.com
The most common signs include optic nerve edema, abnormal eye movements, ataxia, abnormal reflexes, and visual field or acuity defects.[4]The Childhood Brain Tumor Consortium. The epidemiology of headache among children with brain tumor: headache in children with brain tumors. J Neurooncol. 1991 Feb;10(1):31-46.
http://www.ncbi.nlm.nih.gov/pubmed/2022972?tool=bestpractice.com
Chronic nonprogressive headache
Migraine diagnostic criteria
Diagnosis of migraine without aura requires:[3]Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211.
https://www.ichd-3.org
http://www.ncbi.nlm.nih.gov/pubmed/29368949?tool=bestpractice.com
[5]Hershey AD. Current approaches to the diagnosis and management of paediatric
migraine. Lancet Neurol. 2010 Feb;9(2):190-204.
http://www.ncbi.nlm.nih.gov/pubmed/20129168?tool=bestpractice.com
A: At least 5 attacks fulfilling criteria B-D
B: Headache attacks lasting 2 to 72 hours (when untreated or unsuccessfully treated) (note: compared with 4 to 72 hours in adults)
C: Headache having at least 2 of the following characteristics:
Unilateral location, may be bilateral, frontotemporal*
Pulsing quality
Moderate or severe pain intensity
Aggravation by or causing avoidance of routine physical activity (e.g., walking, climbing stairs)
D: During the headache, at least 1 of the following:
E: Not attributable to another disorder.
*The ICHD-3 classification notes that migraine headache in children and adolescents (aged under 18 years) is more often bilateral than is the case in adults; unilateral pain usually emerges in late adolescence or early adult life. Migraine headache is usually frontotemporal. Occipital headache in children is rare and calls for diagnostic caution.[3]Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211.
https://www.ichd-3.org
http://www.ncbi.nlm.nih.gov/pubmed/29368949?tool=bestpractice.com
Diagnosis of migraine with aura requires:
A: At least 2 attacks fulfilling the criteria B and C
B: 1 or more of the following fully reversible aura symptoms**:
C: At least 3 of the following 6 characteristics:
1. At least 1 aura symptom spreads gradually over 5 minutes
2. Two or more aura symptoms occur in succession
3. Each individual aura symptom lasts 5-60 minutes
4. At least 1 aura symptom is unilateral
5. At least 1 aura symptom is positive
6. The aura is accompanied, or followed within 60 minutes, by headache
D: Not attributable to another disorder.
**The ICHD-3 classification notes that in children and adolescents, less typical bilateral visual symptoms occur that may represent an aura.[3]Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211.
https://www.ichd-3.org
http://www.ncbi.nlm.nih.gov/pubmed/29368949?tool=bestpractice.com
Log in or subscribe to access all of BMJ Best Practice