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Headache

Headache: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics

In most children, headache is not due toa serious cause. Diagnostic dilemma is to determine which childrenhave serious underlying pathology.

Principal Causes of Headache

1. Tension-typeheadache
2. Vascular headache
   1. Migraineheadache
      1. Migrainewith aura (classic migraine)
      2. Migraine without aura (common migraine)
      3. Complicated migraine
         1. Hemiplegicmigraine
         2. Ophthalmoplegic migraine
         3. Basilar artery migraine
         4. Confusional migraine
      4. Migraine variants
   2. Cluster headache
   3. Systemic infection
   4. Hypoxia
   5. Systemic hypertension
   6. Connective tissue diseases
3. Head trauma
4. Headache due to disorders of head andneck structures
   1. Head and neck disorders
   2. Ear, eye, and sinus disorders
   3. Mouth and jaw disorders
5. Intracranial infections
   1. Meningitis
   2. Encephalitis
   3. Brain abscess
6. Traction headache
   1. Braintumor
   2. Intracranial hemorrhage
   3. Disorders of cerebrospinal fluid pressure
7. Psychogenic

Clinical Features and Diagnosis

Tension-Type Headache

Most commontype of headache in adolescence but also occurs in childhood.

Usually dull in character, diffuse,and bilateral and may last hours or days.

Nausea and vomiting are unusual.

Precipitating factors include emotionalstress and fatigue.

Vascular Headache

Migraine Headache

Vascularheadaches that are periodic, throbbing, and usually unilateral.

Generalized headaches are more commonthan unilateral headaches in children.

Positive family history is found inmany cases.

Typical clinical features and positivefamily history are diagnostic.

Migraine with Aura (Classic Migraine)

Migraineheadaches that occur with aura are called classic migraine.

Not only does aura precede headache,but it can persist with headache. May consist of visual (scotomata,flashing lights, blurring), sensory (numbness, paresthesias), ormotor (mild aphasia) phenomena.

Headache usually lasts for a few hoursbut can persist for 1–2 days. Interrupts normal activity,and most children wish to lie down in quiet place until it goesaway. Noise, light, and activity make headache worse.

Migraine without Aura (Common Migraine)

Migraineheadaches that occur without aura are called common migraines.

In childhood they are more common thanclassic migraines.

Headache is bifrontal or bitemporaland is often associated with nausea, vomiting, and abdominal pain.

Positive family history for migraineis important diagnostic clue.

Complicated Migraine

Associationof migraine episode with transient neurologic disturbance.

Deficits are usually benign but mustbe distinguished from serious intracranial pathology; thus, headCT or MRI is often necessary.

Hemiplegic Migraine

Hemisensoryloss or hemiparesis followed by headache on contralateral side characterizeshemiplegic migraine, which can be familial.

Hemiplegia may persist after headacheresolves and lasts hours to days. Can recur and alternate from sideto side. Permanent deficit rarely occurs.

Ophthalmoplegic Migraine

Associationof recurrent, unilateral, periorbital headaches associated withthird nerve palsy is known as ophthalmoplegic migraine.

Headache may precede, accompany, orfollow ophthalmoplegia. Eyes appear "down and out," withdeficits in elevation and adduction. There also may be ptosis andmydriasis.

Headache may last a few hours, butophthalmoplegia can persist for days to weeks.

Basilar Artery Migraine

Often beginswith visual disturbance consisting of blurred vision, scotomata,or transient loss of vision. Nausea, vomiting, ataxia, vertigo,paresthesias, hemiparesis, quadraparesis, and impaired consciousnessalso can occur.

Occipital headache may precede, accompany,or follow neurologic deficits. Episode lasts usually 10–30mins.

Recurrent attacks with absence of residualneurologic deficits is general pattern.

Confusional Migraine

Headacheusually precedes episodes of confusion that last a few hours upto 1 day. Impaired memory and restless or combative behavior sometimesoccur.

There is often family history of migraineheadache.

Diagnosis is usually made retrospectively.

Migraine Variants

Migrainevariants refer to transient episodic neurologic dysfunction in individuals withmigraine or who later develop migraine.

Cyclic vomiting is episodic occurrenceof unexplained nausea, vomiting, and abdominal pain that may occur ± headache.

Paroxysmal torticollis consists ofrecurrent episodes of torticollis, which are associated with nausea,vomiting, and headache that may last from hours to days.

Benign paroxysmal vertigo is suddenonset of vertigo, lasting a few minutes, and usually occurring inchildren 2–6 yrs of age. Children are frightened and unableto stand but do not lose consciousness.

Cluster Headache

Form ofvascular headache that may be transmitted as autosomal-dominanttrait in some cases.

Onset is usually in children >10yrs of age.

Headaches are intense, unilateral,and periorbital in location. Occur 2–10 times/day,lasting from 10 mins to a few hours, and never switch sides.

Headaches are usually episodic, occurringfor 1–3 mos at a time with remissions that last monthsto years.

Systemic Infection

Any systemic infection, usually viral orbacterial, may produce fever and headache.

Hypoxia

Can cause vasodilatation of cerebral arteriesand produce headache. Frequent causes include high altitude, carbonmonoxide poisoning, and chronic lung disease (most commonly cysticfibrosis).

Systemic Hypertension

When severe, may cause headache, which canbe dull or throbbing. BP should be measured in anyone who complainsof persistent severe headache.

Connective Tissue Diseases

Systemic lupus erythematosus may cause cerebralvasculitis and headache.

Head Trauma

Minor headtrauma can produce bruising, soft-tissue swelling, and mild headache. Whiplashinjuries produce neck pain, stiffness, and often occipital headache.

Concussion-associated headache generallylasts for a few days.

Postconcussion syndrome is unusualin childhood but may last for months or years. Besides headache,dizziness, irritability, insomnia, memory loss, and learning difficultiesalso may occur.

Headache Due to Disorders of Head and Neck Structures

Headache often occurs with various disordersinvolving head and neck region. History, physical exam, and appropriateradiographs are usually diagnostic.

Head and Neck Disorders

Other causesof cranial headache include osteomyelitis of skull and cervicalspine disorders (congenital anomalies, fracture, bone tumor, juvenilerheumatoid arthritis).

See section Head Trauma.

Ear, Eye, and Sinus Disorders

Acute otitismedia can produce headache, but earache and fever are major manifestations.

Hyperopia and astigmatism are occasionallyassociated with sustained contraction of extraocular, frontal, andtemporal muscles, which can cause frontal headache.

Acute glaucoma is characterized byincrease in intraocular pressure and steady pain in eye region,which may radiate to forehead.

Eye strain is another cause of ocularpain and headache.

In young children, headache from sinusdisease is uncommon. In older children, acute and chronic sinusitiscan cause frontal headache along with tenderness over involved sinus.Maxillary and ethmoid sinuses are most commonly involved. Pain isusually dull, aching, and nonthrobbing.

Mouth and Jaw Disorders

Dental caries, malocclusion, and temporomandibularjoint dysfunction sometimes cause pain in frontal and temporal areasas well as jaw pain.

Intracranial Infections

Headachewith meningitis or encephalitis is usually acute, constant, generalized,and associated with fever.

Brain abscess may produce headacheif abscess is large enough to cause traction and displacement ofintracranial structures. Associated findings include fever, vomiting,seizures, papilledema, hemiparesis, and alteration in consciousness.CT and MRI are usually diagnostic.

See Chap.3, Alteration in Consciousness.

Traction Headache

Pain-sensitive intracranial structures includecerebral and dural arteries and large cerebral veins and venoussinuses. Traction on these structures produces headache.

Brain Tumor

Headachesin children with brain tumors may be throbbing or nonthrobbing.

Although pain-free intervals sometimesoccur, these headaches are usually persistent and become more intense.

Also common for these headaches toawaken children from sleep and to occur upon awakening in morning.

Vomiting, lassitude, visual disturbance,ataxia, seizures, personality change, neck stiffness, papilledema,and alteration in consciousness can be manifestations of brain tumor.

Response to analgesics is unreliableindicator for presence of tumor.

CT or MRI locate and define extentof tumor. Histologic diagnosis is definitive.

Table25.1 lists common brain tumors and their locations.

Table 25.1. Anatomic Location of Common Intracranial Neoplasms

Location	Neoplasm
Cerebral hemispheres	Astrocytoma
Lateral ventricle and fourth ventricles	Ependymoma
	Choroid plexus papilloma
Third ventricle	Ependymoma
	Craniopharyngioma
Thalamus	Astrocytoma
Hypothalamus	Astrocytoma
	Glioma
Pituitary	Adenoma
Pineal area	Germ cell tumors
Optic pathway	Glioma
	Craniopharyngioma
Posterior fossa
Cerebellum	Astrocytoma
	Ependymoma
	Medulloblastoma
Brainstem	Glioma

Intracranial Hemorrhage

Acute onsetof severe headache that persists can signify presence of intracranialhemorrhage. Besides head trauma, causes of intracranial hemorrhageinclude spontaneous bleeding from ruptured arteriovenous malformationor cerebral aneurysm.

Headache is intense and throbbing andmay be associated with neck stiffness, photophobia, retinal hemorrhages,seizures, and alteration in consciousness.

CT or MRI shows hemorrhage, whereasconventional angiography definitively demonstrates vascular malformation.

Disorders of Cerebrospinal Fluid Pressure

Headacheas well as vomiting, lassitude, ataxia, and papilledema can occurwith increased intracranial pressure.

Common causes include infection (meningitis,encephalitis), mass lesion (tumor, intracranial hemorrhage), andhydrocephalus from CSF pathway obstruction.

Less common cause of increased intracranialpressure is idiopathic intracranial hypertension (pseudotumor cerebri).

Most commonmanifestations are headache, vomiting, and diplopia. Aside from papilledemaand abducens nerve palsy, neurologic exam is normal. CSF analysisand brain imaging are also normal.

More common causes include otitis media,head trauma, drugs (vitamin A, oral contraceptives, tetracycline,corticosteroid withdrawal), and vitamin A and D deficiencies.

Headache may occasionally develop afterlumbar puncture and usually worsens with sitting up and improveson lying down. May be result of CSF leak, which can sometimes bedemonstrated by MRI.

Psychogenic

Common inchildren from about 6 yrs of age through adolescence.

Can be caused by anxiety, depression,school phobia, hypochondriasis, or conversion reaction.

Can be severe and last for days.

Diagnosis is based on history and physicalexam.

Diagnostic Approach

Most commoncauses of headache in otherwise well children are tension-type andmigraine headaches.

In ill children, most common causeis viral or bacterial infection.

History and physical exam are diagnosticin most cases.

In every child with significant headache,careful neurologic exam including funduscopic exam should be performedand BP should be measured.

When history and physical exam arenormal, other tests rarely reveal presence of significant organicdisease.

Although less common, headaches sometimesare associated with life-threatening illnesses (e.g., meningitis,encephalitis, brain abscess, and brain tumor). Besides history,physical exam, and lumbar puncture for suspected meningitis or encephalitis,CT and MRI are most important diagnostic tools. If increased intracranialpressure is suspected, CT should be performed before lumbar puncture.Cerebral angiography is useful for demonstrating cerebral aneurysmor arteriovenous malformation.

References

1. Aicardi J. Diseases of the nervous systemin childhood, 2nd ed. London: Mac Keith Press, 1998.
2. Ball WS Jr, ed. Pediatric neuroradiology. Philadelphia:Lippincott-Raven, 1997.
3. Barlow CF. Headaches and brain tumors. Am J Dis Child1983;136:99–100.
4. Fenichel GM. Clinical pediatric neurology: a signsand symptoms approach, 4th ed. Philadelphia: WB Saunders, 2001.
5. Gascon G, Barlow C. Juvenile migraine, presenting asan acute confusional state. Pediatrics 1970;45:628–635.
6. Honig PJ, Charney EB. Children with brain tumor headaches.Am J Dis Child 1982;136:121–124.
7. King C. Headache. In: Fleisher GR, Ludwig S, eds. Textbookof pediatric emergency medicine, 4th ed. Philadelphia: LippincottWilliams & Wilkins, 2000:459–465.
8. Online Mendelian Inheritance in Man (OMIM). McKusick-NathansInstitute for Genetic Medicine, Johns Hopkins University (Baltimore,MD) and National Center for Biotechnology Information, NationalLibrary of Medicine (Bethesda, MD), 2000. World Wide Web URL: http://www.ncbi.nlm.nih.gov/omim.
9. Rothner AD. Classification, pathogenesis, evaluation,and management of headaches in children and adolescents. Curr OpinPediatr 1992;4:949–956.
10. Rothner AD. Headaches. In: Swaiman KF, Ashwal S, ed.Pediatric neurology: principles & practice, 3rd ed. St.Louis: CV Mosby, 1999:747–758.
11. Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
12. Shinner S, D'Souza BJ. The diagnosis and managementof headaches in childhood. Pediatr Clin North Am 1981;136:121–134.
13. Singer HS, Rowe S. Chronic recurrent headaches in children.Pediatr Ann 1992;21:369–373.
14. Swaiman KF, Ashwal S. Pediatric neurology: principles & practice,3rd ed. St. Louis: CV Mosby, 1999.

Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

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More About This Book: Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics Authors: Paul S. Bellet Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 0-78172-899-1

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