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Most children and teenagers experience headaches. In fact, up to as many as 80% of them may complain about having at least one headache in a month. While preadolescent boys outnumber girls in terms of those affected, girls surpass boys at the onset of puberty.
Headaches in children are mostly benign in nature and may be of several different types. The two most common types of headaches found in this population are migraines and tension headaches.
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Migraine headaches appear to have a genetic element – susceptibility often runs in families. They are severe, throbbing headaches that tend to occur only on one side of the head. They are characterized by symptoms, such as vomiting, nausea and sensitivity to noise and light. In contrast, tension headaches are dull headaches that affect both sides of the head and are due to stiffening of the neck or head muscles. They are frequently associated with stress, anxiety and depression.
Mixed headache syndromes represent a combination of migraine and tension headaches, whereas inflammatory and traction headaches occur due to illness or an increase in intracranial pressure.
In addition to these, headaches may also be classified by other parameters, such as their duration, onset and frequency. There are acute headaches that occur suddenly and resolve quickly. Furthermore, there are non-progressive chronic headaches, which are the most common in adolescents and tend to be associated with tension and stress. On the other hand, progressive chronic headaches worsen over time and may be indicative of a tumor, brain infection or other condition.
When evaluating headaches in children and teens, a physical and neurological examination must be conducted after taking a thorough medical history. The history is critical for generating enough information to make an accurate diagnosis.
Several key questions are necessary to acquire data on the onset of the headache, severity, character, frequency, prodromal symptoms, associated symptoms, relieving/exacerbating factors, potential triggers, known and existing medical conditions as well as any drugs being taken. Furthermore, a family history is also taken to establish if anyone else suffers or has suffered from headaches.
During the physical examination, the child’s vital signs are taken and particular attention is paid to the head and neck. Palpation of these regions is performed to check for specific signs, such as tenderness of the sinuses and stiffness of the neck.
The circumference of the head is also measured to check for signs of increased intracranial pressure. Extensive neurological examination is performed to check for any abnormalities in all areas, including mental status, eye movements, motor or sensory function, coordination and deep tendon reflexes.
Imaging studies like computed tomographic (CT) scans and magnetic resonance imaging (MRI) are indicated in patients who have abnormal neurological exam findings or a progressive chronic pattern of headache. Neither CT nor MRI are routinely suggested for patients with non-progressive patterns of headaches and if the role of neuroimaging in general is controversial.
A clear majority of studies evaluating the role of these procedures do not demonstrate any diagnostic abnormalities or non-pathologic incidental findings.
In the routine evaluation of headaches in children, electroencephalography (EEG) is mostly of limited use. With this said, patients who present with a history of seizures or alterations to their consciousness may require an EEG.
Patients who have fever and a stiff neck in addition to the headache should be checked for viral or bacterial meningitis. This is done via a lumbar puncture. Lumbar puncture with opening pressure measurement and ancillary tests are also recommended in cases where conditions like subarachnoid hemorrhage are suspected.