Headache is one of the most common concerns reported by children. Recurrent headaches are reported in one-third to one-half of children and adolescents and occur daily or near daily in about 2% to 6% of young patients. Despite these numbers, usually after evaluation for secondary causes of headache is completed, most children with a primary headache syndrome are left untreated or under treated. Medication is often only a small part of the treatment plan, as thorough identification, education, and nonpharmacologic therapies show significant benefit.
Identification of a primary versus a secondary headache in a child is the first step. It can be difficult for parents and health professionals to accurately identify history details of a child's headache. The ability to describe the headache is limited by their developmental stage. Important clues can include paroxysmal events where the child appears unwell or pale, vomits, or bangs or holds his or her head. The primary goal of the interview is to eliminate any red flags for secondary headaches and to obtain enough information to make the diagnosis of a primary headache. It is important to determine the impact of the condition on school and extracurricular activities, including the number of school days missed in a given time period. Efforts should be made to determine additional stressors at school that contribute to recurrent headache. A thorough review of lifestyle practices, including caffeine intake, regularity of meals, sleep habits, and exercise, is important in identifying possible sources of modification. Lastly, the pediatric Migraine Disability Assessment Scale can be helpful in determining the impact of headaches on the child.
In addition to the standard neurologic examination, a comprehensive headache examination that evaluates for specific headache alterations is important. Depending on the child's age, measure head circumference to identify macrocephaly, which could be associated with hydrocephalus, and to look for obvious or hidden neurocutaneous stigmata. Remember to perform thorough ophthalmic examination is necessary to look for papilledema.
As per further testing, in most cases, neuroimaging is not necessary. The recommendation is to consider neuroimaging if there is an abnormality on the neurologic examination, a change in the character or frequency of preexisting headaches, recent onset of severe headache, associated features that suggest neurologic dysfunction, or coexistence of seizures. Imaging is not routine for patients with unchanging recurrent headaches and a normal examination. Head imaging in pediatrics often requires discussion about the radiation exposure with CT or the need for sedation with MRI. In nearly all cases MRI is the preferred methodology.
Pharmacological treatment is but only a small part of the treatment plan. Thorough identification of triggers, education, and nonpharmacologic therapies might also show significant benefit. The earlier the problem can be recognized and appropriately diagnosed and a treatment plan established, the greater the likelihood of a better lifelong outcome.
REFERENCE: CONTINUUM: Lifelong Learning in Neurology: August 2015 - Volume 21 - Issue 4, Headache