1. Childhood Headache
Rachel Howells

2. Learning Outcomes By the end of this session, you should be able to
Differentiate primary from secondary headache
Recognise and manage common primary headaches

3. Epidemiology Preschool 1/3 will have had a headache
Migraine headache 0-7% of population
Schoolchildren
70% have ≥ 1 headache a year
Peak at 90% at age 12-13
Prevalence of recurrent headache 20-30%

4. Case 1

5. Case 1 15 year old girl Frontal headache, down neck and shoulders
2 months
Start as soon as she rises from bed, and relieved by lying down
Missing school for 6 weeks

6. Primary or Secondary?

7. Case 1 Further history Spinal surgery 3 months ago
Epidural anaesthesia
Examination
Normal

8. Low pressure headache Possible dural tap Management
Encourage mobilising
Many spontaneously resolve within 3-4 months
Short-term: Caffeine
Long-term: Epidural blood patch

9. Primary vs Secondary Headache

10. Primary vs Secondary Headache
10% of headaches seen in a specialist neurology / headache clinic are secondary in origin
Population prevalence of organic disease is likely to be lower

11. Secondary Headache Types
Altered Intracranial Pressure
Raised ICP
Low Pressure Headaches
Vascular
Subarachnoid Headache (eg AVM)
Dissection
Vasculitis
Drugs
Drug effect
Analgesia induced headache
Central (thalamic) pain
Trigeminal neuralgia
Cluster headaches
Local
Dental Abscess
Sinusitis
Post head injury

12. How to identify a secondary headache

13. How to identify a secondary headache
History
Examination
Brain Imaging

14. Indications that a headache is secondary to altered intracranial pressure

15. Indications
Timing of headache
Postural manoeuvres
Associated symptoms

16. Intracranial Pressure
Timing of Headache
Morning but from sleep,
before rising
Raised
Intracranial Pressure
Morning but
after getting up
Low Pressure
Headache

17. Postural Manoeuvres Getting up relieves Lying down headache
Coughing and straining
exacerbates it
Raised
Intracranial Pressure
Lying down
relieves headache
Low Pressure
Headache or
Sinusitis

18. Associated Symptoms Frontal headache Associations Morning vomiting
Other neurology
Confusion
Raised
Intracranial Pressure
Frontal headache
Associations
Pain / parasthesiae
across shoulders*
Blocked nose, facial pain¤
Low Pressure
Headache* or
Sinusitis¤

19. Case 2

20. Case 2 16 year old girl seen in OPD Frontal headache
There when she wakes, gets better when she gets up
No nausea or other neurological symptoms
4 months, not getting any worse

21. Is this raised or low intracranial pressure?
Primary or Secondary?
Is this raised or low intracranial pressure?

22. Case 2 continued Past History – nil Examination
Enlarged blind spots on confrontation
No other alteration of visual fields
Papilloedema
No ataxia, long tract signs

23. What diagnoses need to be considered?

24. Causes of Raised Intracranial Pressure
Hydrocephalus
Tumour obstructing CSF pathways
Obstruction to CSF re-absorption
(post haemorrhage or meningitis)
Congenital (eg aqueduct stenosis)
Idiopathic (Benign)
Intracranial
Hypertension
Cerebral oedema
Inflammation (ADEM, stroke)
Infection (meningitis etc)
CO2 retention (obstructive sleep apnoea)
Metabolic (DKA, other)

25. Idiopathic Intracranial Hypertension
Raised intracranial pressure
in the absence of space occupying lesion
or obstruction to CSF flow
Aetiology unknown
Adolescent girls
Obesity, drugs, steroid withdrawal
Visual loss (10%) may be permanent and is only indication for treatment

26. Indications
Timing of headache
Postural manoeuvres
Associated symptoms

27. Case 3

28. Case 3 14 year old girl Headache since the evening before
Single and worst headache ever
Sudden onset
Vomited once at start
No history of head injury / prodrome

29. Case 3 Examination Afebrile No meningism GCS 15
Unilateral facial weakness with frontal sparing
Ipsilateral arm weakness with hyporeflexia

30. What diagnoses should you entertain?

31. CT brain

32. Case 3 CT shows haemorrhage around area of left basal ganglia
Patient admits to using some cocaine at a party with her 18 year-old sister

33. More information to help you identify secondary headache
History

34. Timecourse Migraine? Single or first Recurrent severe headaches
One a month
2 years without progression
Bleed?
Headaches all day
on most days
18 months
Headaches every few months
then weeks
then days
Now every day
TTH?
Tumour?
Severe headaches all day for 12 days
2 months ago
None since
Bleed?

35. Timecourse Single or first Recurrent severe headaches severe headache
One a month
2 years without progression
Headaches all day
on most days
18 months
Headaches every few months
then weeks
then days
Now every day
Severe headaches all day for 12 days
2 months ago
None since

36. Pointers in History: Summary
Timing of Headache
Postural manoeuvres
Symptoms associated with headache
Timecourse

37. Examination

38. Purpose of Examination
To support your clinical impression made on history
To rule out other differentials
To adhere to many families expectations
to be taken seriously
to be able to support your view that nothing serious is going on

39. Essential elements of Examination
Conscious level
Vision
Acuity
Fields including blind spot
Extraocular movements
Long tract signs
Tone
Power
Reflexes
Cerebellar signs
Finger-nose test (eyes shut)
Tremor
Dysarthria
Gait
Blood pressure
Fundi
Bruit

40. Case 4

41. Case 4 8 year old boy with 10 month history of Bi-temporal headache
Throbbing
Worse with movement / exercise
Mother says looks pale and unwell
Usually start in morning
Last all day

42. Case 4
No family history
Examination is normal

43. What is the most likely diagnosis?
Primary or Secondary?
What is the most likely diagnosis?

44. Migraine without aura

45. What causes migraine? Migraine headache
Nerve efferents – trigeminal, vagal
Meninges have pain fibres with inputs from trigeminal complex
Vasodilation of meningeal vessels
Why do some people get migraine headaches?
Genetic
Abnormal inhibitory inputs to trigeminal nerve complex
Michael Creighton

46. Clinical Implications
Abnormal inhibition to nociceptive parts of brain
Abnormal response to changes in environment eg sleep, diet, smells
Pain is exacerbated by noise and light
Headache relieved by sleep in a dark room
Migraine symptoms
Pain involves the face (trigeminal)
Throbbing pain (meningeal)
Pallor and nausea (vagal)
Delia Malchert

47. Migraine Classification Migraine without aura (commonest)
Migraine with aura
Basilar migraine
Ophthalmoplegic migraine
Alternating hemiplegia

48. Migraine The diagnosis is a clinical one Families can be reassured by
Family history
Longevity of symptoms
Normal examination
Addressing their underlying concerns

49. Management Explanation This is not a tumour
Worst in second decade of life
Most patients will get fewer headaches as they get older

50. Management 2. Treatment of attacks
Analgesia as soon as an attack starts
Ibuprofen works best (one RCT)
May be supplemented by anti-emetic
Patients over 12 may respond to im, oral or nasal sanomigran (Imigran)

51. Management 3. Prevention – control of environment
‘Sleep hygiene’ – regular sleep
‘Diet hygiene’ – avoid long breaks ± snack before bed, avoid caffeine, low amine diet
‘Exercise hygiene’ – regular exercise, maintain hydration
Avoid stress – relaxation training, CBT

52. Management 4. Prevention – pharmacological
No magic bullet, trial basis only
Pizotifen
Propanolol
Feverfew

53. Case 5

54. Case 5 10 year-old girl with 18 month history of
Bilateral headache, mainly vertex
Constant
Comes on during day
Not worsened by walking
No aura or pallor / nausea
5/7 days a week, most weeks of the year

55. Case 5 No family history Examination normal Local grammar school
Predicted for A grades in 10 GSCEs
No external sources of anxiety – stable home, not being bullied
Trying to keep going to school

56. Case 5 Alternating ibuprofen 400mg and co-codamol for headaches
‘Nothing really works’

57. What is the most likely diagnosis?
Primary or secondary?
What is the most likely diagnosis?

58. Chronic Tension-Type Headache

59. How is the diagnosis made?

60. CTTH No features suggestive of organic disease
Time of day
Postural manoeuvres
Associated symptoms
Time course
Not classifiable as migraine
Examination normal

61. Management Explanation
Although not an organic disease, effects on life can be significant (school etc)
Treat attacks
Simple analgesia
Avoid multiple drugs
Feverfew / Levomenthol / TigerBalm

62. Management Prevention of attacks Sleep, diet, exercise hygiene
Address anxiety (relaxation training, CBT)
Maintain contact with school, try and attend but manage workload

63. What did you learn? You should now be able to
Differentiate primary from secondary headache
Recognise and manage common primary headaches
Migraine with / without aura
Tension-type headache

64. Any questions?

65. Thank you for listening
Rachel Howells