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The most common cause of headaches in children and adolescents are migraines
and stress-related headaches. Headaches can also be seen with fever, the flu,
and acute respiratory infections. This document reviews many of the less
frequently seen headaches that occur in children and adolescents. The order of
presentation of the different headache types discussed in this document is
consistent with the frequency with which these headaches types occur.
Post-traumatic headache
Head injuries account for a large number of emergency department visits by
children. Children and adolescents who are involved in motor vehicle accidents,
bicycle accidents, sports-related injuries, or child abuse may develop a
headache syndrome within minutes to days following the incident, even after what
would seem to be a trivial head injury.
Patients with post-traumatic headache often have other symptoms including
dizziness, vertigo, difficulty concentrating, memory disorders, depression,
altered school performance, behavior disorders and sleep alteration. This
collection of symptoms together with headache is commonly called postconcussion
syndrome. Importantly, the severity of the symptoms does not depend on the
severity of the head injury.
The headaches associated with the postconcussion syndrome can be similar to a
migraine headache (occurring intermittently with nausea or vomiting or daily), a
tension-type headache, or both.
Most patients who are hospitalized for a mild to moderate head injury receive
some form of neuroimaging -- either computed tomography (CT) or magnetic
resonance imaging (MRI). However, the absence of abnormality on MRI or CT does
not predict whether a patient will develop post-traumatic headaches or
postconcussion syndrome.
Following mild head injury, functional recovery generally occurs in the
following order: attention and concentration deficits usually resolve within 6
weeks; visual memory, imagination, and analytic capacity do not begin to resolve
for at least 6 weeks; verbal memory, abstraction, cognition and information
processing speed can take more than 12 weeks to recover. Although most children
have clinical improvement of their headache sequelae within several weeks, and
almost all within 3 to 6 months, some patients continue to experience headache
and the associated symptoms of postconcussion syndrome.
Post-traumatic headache treatment is symptomatic. The initial headache
symptoms and soft tissue injuries may be effectively treated with mild
analgesics and nonsteroidal anti-inflammatory drugs over the initial weeks. If
there is associated cervical soft tissue symptoms, a short course of physical
therapy might be of benefit. If more prominent headache symptomatology or
associated symptoms of anxiety, depression, or cognitive difficulties are
present, more aggressive intervention may be necessary. Post-traumatic headache
usually responds to the medications that are used for chronic headache and
chronic tension-type headache, although no specific medication or treatment
protocol has been found that will alter the underlying central nervous system
disturbance. Tricyclic antidepressants, such as amitriptyline or nortriptyline,
are often the medications of choice. To avoid rebound headaches, analgesic use
should be limited to no more than twice a week.
Patients who have migraine-like post-traumatic headaches may benefit from
triptans, with or without antiemetics. Some patients may respond to
dihydroergotamine, especially if there is a persistent, refractory headache
pattern. Nonpharmacologic therapies, such as counseling -- which is often
combined with biofeedback and stress management techniques -- can be quite
effective, even in children as young as 9 years of age. Regardless of treatment
approach, patients are encouraged to return to school and normal activities as
soon as possible.
Sinusitis
Many people think their headaches are due to sinusitis, but this isn’t
usually the case. Although headaches can be a symptom of sinusitis, sinusitis is
a distinct medical condition. Sinusitis is an inflammation and/or infection of
the sinuses. Some of the causes include allergies, smoke, and respiratory
infections. Sinusitis may have a sudden onset and be of short duration or can be
a chronic condition, characterized by at least four recurrences of sinusitis or
infection that last 12 weeks or longer.
Common symptoms of sinusitis include facial pain/pressure, nasal blockage and
discharge, and frontal headache. Other symptoms include fever, bad breath, and
fatigue.
The clinical diagnosis of sinusitis can be based on symptoms or, even better,
confirmed by nasal endoscopy or a CT scan of the sinuses. Treatments include
decongestants and antibiotics.
Exertional headaches
Exertional headaches are brought on by strenuous activities, such as
running, swimming, or weight lifting, as well as sexual activity. Exertional
headaches can occur during or after the activity and may be associated with
nausea and vomiting. The headaches may be brief and generalized or sharply
localized. Patients describe the pain as a "hammer-like blow to the
head." The pain may last from 15 minutes to 12 hours.
If headaches occur only with exertion and are not associated with neurologic
signs or symptoms, imaging studies may not be necessary. If neurologic signs and
symptoms are present, medical evaluation is needed.
Treatment of these headaches should be conservative. In many patients,
headaches disappear spontaneously. Indomethacin can be used chronically and/or
prior to specific activities. If indomethacin is taken chronically, monitoring
for side effects is mandatory.
Temporomandibular Joint Disorder (TMJ)
TMJ as a cause of headache is relatively uncommon in children and
adolescents. Children with TMJ disorders usually complain of a dull aching pain
that occurs just below the ear on one or both sides of the face. The pain is
usually localized but may expand to the temple, toward the middle of the face,
or across the top and front of the skull. The pain is usually aggravated by
chewing. Patients frequently describe clicking and locking of their jaw. Upon
examination, there may be tenderness over the jaw, and joint slipping may be
felt upon opening and closing the mouth. In addition, patients often cannot open
their mouths widely.
The cause of TMJ disorders is not clear, but the symptoms are thought to
arise from either stress or problems with the muscles of the jaw and/or with the
parts of the joint itself. Possible causes include:
- Injury
- Stress, which can cause a person to tighten facial and jaw
muscles or clench the teeth
- Grinding or clenching the teeth, which puts a lot of pressure
on the TMJ
- Presence of osteoarthritis or rheumatoid arthritis in the TMJ
Treatment for TMJ disorder usually begins with a combination of any of the
following: anti-inflammatory drugs, muscle relaxants, mouth splints,
biofeedback, and counseling. The need for surgery in children and adolescents is
rare.
Cluster Headaches
There are two types of cluster headaches: chronic and episodic. Patients with episodic cluster headaches --
which account for 80 to 90 percent of
cluster headaches -- report frequent headaches over a period of 1 to 3 months,
followed by a period of remission. This period of remission may last from months
to years. Chronic cluster headaches, which account for 10 to 20 percent
of cluster headaches, are headaches that occur continuously for a year or longer
without remission.
Cluster headaches are rare in children (age under 10) and uncommon in teens.
They primarily affect men in their 30s. Typically 2 to 10 headaches occur each
day. The headaches last from 10 minutes to 3 hours; the average length of attack
is 45 minutes. The headaches occur both during the waking hours and during
sleep. A common feature of these headaches is that they can occur at exactly the
same time each night.
The headache pain is severe, is usually isolated around one eye or one side
of the head (and never switches sides), and is associated with eye tearing,
runny nose, and nasal stuffiness. A drooping upper eyelid and constriction of
the pupil of the eye may also occur.
Most patients with cluster headache cannot lie down or rest during the
attack. Alcohol has been shown to trigger attacks, especially once the headache
cycle has begun. The cause of cluster headaches remains unclear.
In the acute phase of an attack, patients have benefited from oxygen,
ergotamine tartrate, or the triptan medications. Chronic prophylactic
medications have included verapamil, lithium, and prednisone.
Cyclic Migraine
Cyclic migraine, as its name implies, is a form of migraine that occurs in
cycles. This type of headache has also been incorrectly called cluster migraine.
Cyclic migraine is not a form of cluster headache.
Headache cycles range from 1 to 6 weeks in length. During the cycles,
headaches can occur daily or several times per week. In between the migraine
headaches, there may be a constant low-intensity headache. The headache cycles
are followed by headache-free intervals lasting weeks to months in duration.
Most patients who experience this type of headache are female. The disorder
may begin in the first or second decade of life and more than 50 percent of
patients have a positive family history of migraine.
In the absence of neurologic symptoms or signs, an underlying cause is seldom
found.
Treatment options for cyclic migraine have included lithium carbonate and
indomethacin. Standard antimigraine therapy may be ineffective for cyclic
migraine.
Chronic Paroxysmal Hemicrania
Chronic paroxysmal hemicrania is identified by the occurrence of multiple
daily attacks, usually five per day, which last from 5 to 30 minutes in
duration. The pain usually occurs on one side of the head and rarely alternate
sides.
The pain is described as severe, and autonomic phenomenon (eye tearing, eye
redness, eyelid edema, nasal congestion, runny nose) and other symptoms may be
present. The pain is most frequently localized to the eye or forehead above the
eye on one side of the head. The headache may be brought on by head movement.
Chronic paroxysmal hemicrania has also been called atypical cluster headache.
The disorder is usually seen in females and has only rarely been described in
children. The general physical and neurologic examinations between attacks are
completely normal.
This disorder responds dramatically to indomethacin. When indomethacin is
discontinued, the headaches reappear in several days.
Hemicrania Continua
Hemicrania continua is a steady, moderately intense headache that is
characterized by episodes of more intense pain that occurs several times a day.
The pain is localized to the front part of one side of the head and is not
associated with nausea. Autonomic symptoms (eye tearing, eye redness, eyelid
edema, nasal congestion, runny nose) may be present. The headache is not brought
on by any particular event and the cause is not clear. Most of the affected
patients are female.
Headaches typically begin during adolescence and there is usually no family
history of headache.
Indomethacin is the treatment option of choice. Chronic treatment with
indomethacin requires careful monitoring for side effects.
Occipital Neuralgia
Occipital neuralgia includes pain experienced at the back of the head, often
starting at the upper neck or base of the skull. It may occur on one or both
sides of the head. Pain can be infrequent, can occur several times per day, or
can be constant. The pain is described as jabbing or throbbing.
Pain may radiate to the front of the head or to the eye. In addition,
patients report that their scalp is sensitive to the touch. At times, pain can
be brought on by movement, especially an overextension of the head. Other
symptoms may include dizziness and, rarely, nausea and vomiting.
Occipital neuralgia is often seen in athletes -- particularly weight lifters,
wrestlers, and football players -- and others, such as persons involved in
automobile accidents and those who incur extension and flexion injuries.
Physical examination may reveal cervical area tenderness, range of motion
limitation, and decreased sensation at the back of the head. Radiographic
imaging at the brain-cervical vertebrae junction may reveal abnormalities.
Treatment depends on the severity of the problem and may include use of a
soft cervical collar, analgesics, muscle relaxants, local injections, and on
rare occasions, surgery.
Ice Cream Headache
An "ice cream headache" is the nickname that is given to headaches
that are cold induced. The International Headache Society criteria defines this
headache as pain that develops during the ingestion of cold food or drink that
lasts for less than 5 minutes and is felt in the middle of the forehead. The
headache is prevented by avoiding rapid swallowing of cold food and drink. This
type of headache occurs more frequently in patients who have migraine, but it
can also occur in migraine-free patients. It has been suggested that the pain is
referred from the palate or teeth via the trigeminal nerve. The pain is
self-limited and only rarely requires treatment.
Cough Headache
Cough headache is considered by some to be a form of exertional headache and
is sometimes grouped together with other headaches described as "sneezing
headache" and "laughing headache." The International Headache
Society defines cough headache as a headache that is felt in both sides if the
head, that is of sudden onset, that lasts less than 1 minute, is brought on by
coughing, and can be prevented by avoiding coughing. The most common triggers of
cough in children are chronic bronchitis, asthma, and cystic fibrosis. Treatment
for these headache triggers (but not this type of headache itself) may be
indicated.
Ice Pick Headache
Ice pick headache refers to a type of headache pain that is described as
momentary, sharp, and/or jabbing that occurs either once or several times a day
at irregular intervals. It has also been nicknamed the "jabs and
jolts" or "stabs and jabs" headache. The pain is most often felt
around one eye or the temple area and it recurs in the same place or may move to
other places on the same side of the head or the opposite side. These headaches
are more likely in patients with migraine or cluster headaches. It is uncommon
in the pediatric and adolescent population. This type of headache disappears
spontaneously in many cases or can be successfully treated with indomethacin.
Facial Pain
Chronic facial pain is uncommon in children and adolescents. It is more
commonly seen in older individuals. Facial pain, when it occurs suddenly, is
usually related to sinusitis, dental disorders, or facial trauma. Patients
presenting with facial pain require a thorough evaluation. Stress and
psychologic factors are prominent causes.
Altitude Headache
This headache is especially common in individuals who climb mountains and ski
at high altitudes. It may be seen in acute mountain sickness along with other
primary symptoms of pulmonary edema and cerebral edema. The headache is seen at
high altitudes (above 8,000 feet and with increasing frequency as elevation
increases) and is usually associated with low oxygen levels.
The headache is described as generalized and throbbing and is aggravated by
exertion, coughing, and lying down. The headache usually appears from 6 to 96
hours after arriving at high altitudes.
On examination, patients may have retinal hemorrhages, papilledema, and
confusion. Relief of headache is obtained by descending to lower altitudes.
Ergotamine may be effective, but oxygen inhalation is especially effective.
The disorder may be prevented with the use of acetazolamide, phenytoin, and
dexamethasone.
This information is not intended to replace the medical advice of your doctor
or health care provider. Please consult your health care provider for advice
about a specific medical condition.
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