This document discusses approaches to evaluating and treating headaches in children. It begins by outlining common causes of chronic and severe headaches in children, including tension-type headaches, cluster headaches, and migraines. It then provides details on evaluating patients with headaches and classifying different headache types based on international standards. The rest of the document elaborates on diagnostic criteria and treatment strategies for recurrent headache types like tension headaches, cluster headaches, and migraines. It describes treating acute migraine attacks with analgesics and triptans and providing migraine prophylaxis for frequent or disabling attacks.

1. APPROACH TO HEADACHE
Dr Surya Kumar

2. Headaches in ChildrenHeadaches in Children
ObjectiveObjective
 Learn the Causes of Headaches inLearn the Causes of Headaches in
Children.Children.
 Learn common causes of chronicLearn common causes of chronic
headache and common causes of severeheadache and common causes of severe
headache.headache.
 Learn to evaluate a patient withLearn to evaluate a patient with
headache.headache.
 Understand parental concerns.Understand parental concerns.

3. INTRODUCTION
 The term headache should encompass all
aches and pains located in the head, but in
practice its applications is restricted to
discomfort in the region of the cranial volt.
 Headache, or cephalalgia, is defined as
diffuse pain in various parts of the head, with
the pain not confined to the area of
distribution of a nerve
 Incidence of Chronic or recurrent headacheIncidence of Chronic or recurrent headache
40% by age 7 years.40% by age 7 years.
75% by age 15 years.75% by age 15 years.
 Accounts for 10% referrals to NeurologistAccounts for 10% referrals to Neurologist..

4. CLASSIFICATION
(International headache society)
1. Migraine:
•Migraine without aura.
•Migraine with aura.
•Ophthalmoplegic migraine.
•Retinal migraine.
2.Tension type headache
3.Cluster headache

5. 4.Miscellaneous headache not associated with
structural lesion:
Idiopathic stabbing headache.
Cold stimulus headache .
Benign cough headache .
Headache associated with sexual activity .
5.Headache associated with head trauma.
6.Headache associated with vascular disorder.
Acute ischaemic (CVD)
Intracranial haematoma .
SAH
Arteritis- Giant cell arteritis.
Venous thrombosis.
Arterial hypertension.
Classification contd..

6. 7. Headache associated with non vascular
intracranial disorder.
8. Headache associated with substances or their
withdrawal.
9. Headache associated with non
cephalic infection
10. Headache associated with
metabolic disorder.
11.Headache or facial pain associated
withdisorders of facial or cranial structures.
12.Cranial neuralgias ,nerve trunk
pain
13.Headache not classified

7. RECURRENT HEADACHE
TENSION TYPE HEADACHE.
CLUSTER HEADACHE.
MIGRAINE.

8. Case history 1Case history 1
 7 year old boy with history of frequent7 year old boy with history of frequent
headaches for the last 4 monthsheadaches for the last 4 months
 Not responding to paracetamole andNot responding to paracetamole and
Ibuprofen and CodeineIbuprofen and Codeine
 Not associated with vomitingNot associated with vomiting
 CNS , eye, ears, and systemic examinationCNS , eye, ears, and systemic examination
were normalwere normal
 Cranial CTCranial CT
 More anxietyMore anxiety

9. TENSION TYPE
HEADACHE
 The word "tension" implies that this typeThe word "tension" implies that this type
of headache can be attributed entirely toof headache can be attributed entirely to
tension or stress, which may maketension or stress, which may make
people with this type of headachepeople with this type of headache
reluctant to consult a physician.reluctant to consult a physician.

10. .. International Headache SocietyInternational Headache Society
diagnostic criteria for tension-typediagnostic criteria for tension-type
headacheheadache
 Primary diagnosisPrimary diagnosis
1.1. Headache hasHeadache has at leastat least two of the followingtwo of the following
characteristicscharacteristics::
Bilateral painBilateral pain
PressurePressure
Mild to moderate painMild to moderate pain
No increased pain with physical exertionNo increased pain with physical exertion
2.2. AndAnd no more than one of the following:no more than one of the following:
Sensitivity to lightSensitivity to light
Sensitivity to soundSensitivity to sound
3.3. AndAnd neither of the following*:neither of the following*:
NauseaNausea
VomitingVomiting
4.4. AndAnd duration of 30 minutes to 7 daysduration of 30 minutes to 7 days

11. Subdivision diagnosisSubdivision diagnosis
 1.1. Episodic (<15 days/mo)Episodic (<15 days/mo) oror chronic (chronic (>>1515
days/mo for >6 mo)days/mo for >6 mo)
2.2. Associated withAssociated with oror not associated withnot associated with
coexisting pericranial muscle tenderness**coexisting pericranial muscle tenderness**
 **Chronic tension-type headache may include oneChronic tension-type headache may include one
of these symptoms.of these symptoms.
 **Diagnosed by manual palpation or**Diagnosed by manual palpation or
electromyographic studies.electromyographic studies.
 Adapted from Headache Classification Committee of the InternationalAdapted from Headache Classification Committee of the International
Headache Society (2).Headache Society (2).

12.  Synonym:
Raeder’s syndrome, Histamine cephalalgia, Red
migraine, paroxysmal nocturnal cephalagia.
 Age – 20 to 50 yrs.
 Sex – men are affected 7 to 8 times more than
women.
 The pain begins without warnings & reaches a
crescendo within 5 minutes. Each attack last for
30 min to 2 hours.
1 – 3 short-lived attacks/day over a 4 – 8 weeks
period, followed by a pain free interval that
average one year.
CLUSTER HEADACHE

13. CLUSTER HEADACHE
  Almost always the same orbit is involved
during attacks.
  The pain is excruciating in intensity &
deep, non-fluctuating and explosive in
quality.
  Associated with - homolateral
lacrimation, red eye, miosis, lid ptosis, nasal
stuffiness & nausea.
  Onset is nocturnal is about 50% of the
cases & then pain usually awakens the
patients within 2 hours of falling asleep.

14. Diagnostic Criteria for ClusterDiagnostic Criteria for Cluster
HeadacheHeadache
A At least five attacks fulfilling criteria B through DA At least five attacks fulfilling criteria B through D
B Severe unilateral orbital, supraorbital and/orB Severe unilateral orbital, supraorbital and/or
temporal pain lasting 15 to 180 minutes (untreated)temporal pain lasting 15 to 180 minutes (untreated)
C .Headache associated with at least one of theC .Headache associated with at least one of the
following signs on the pain side:following signs on the pain side:
ConjunctivalConjunctival
injectioninjection
LacrimationLacrimation
Nasal congestionNasal congestion
RhinorrheaRhinorrhea
Forehead and facialForehead and facial
sweatingsweating
MiosisMiosis
PtosisPtosis
Eyelid edemaEyelid edema
D. Frequency of attacks: one attack every otherD. Frequency of attacks: one attack every other
day to eight attacksday to eight attacks

15. Contd..
 Treatment:
• Inhalation of 100% O2 for 10 – 15 minutes.
• Intranasal lidocaine/sumatriptane.
Prophylaxis
Ergotamine
Prednisolone
Verapamil
Lithium –
Methysergide.

CLUSTER HEADACHE

16. Case history 2Case history 2
 A 10 year old boy with history of headache for 4A 10 year old boy with history of headache for 4
weeksweeks
 Started as funny feeling inside his abdomenStarted as funny feeling inside his abdomen
 Pain round the right eyePain round the right eye
 Pain spread all over his headPain spread all over his head
 VomitVomit
 PhotophobiaPhotophobia
 Fatigue, lethargic and want to sleepFatigue, lethargic and want to sleep

17. MIGRAINE
Periodic, commonly unilateral, often pulsatile headache,
begins in childhood, adolescence, or early adult life & recur
with diminishing frequency during advancing years.
Associated with nausea, vomiting and/or other symptoms
of neurological dysfunction of varying admixture.
 The attacks cease during pregnancy in 75-80% of women.

18. Migraine: contd.
Some patients link their attacks to certain dietary
items – chocolate, cheese, fatty foods, orange,
tomatoes, onions.
 In others headache are consistently induced by –
exposure to glare or other strong sensory stimuli
– worry.
Sudden jarring of the head.
Rapid change in barometric pressure.
Lack of sleep.

19. Migraine with aura:
 Premonitory symptoms:
Changes in mood (surge of energy & feeling of well
being), appetite (hunger or anorexia).
 Aura:
Visual disturbance – Unformed flashes of white or
multicoloured light (Photopsia), An enlarging blind spot
with a shimmering edge (scintillating scotoma), formation
of dazzling zigzag lines-, (fortification spectra), blurred or
cloudy vision.
Sensory disturbance – Numbness & tingling of the lips
face & hand.
Motor disturbance – Weakness of an arm or leg, mild
aphasia or dysarthria.

20. Migraine Variants:
 Ophtlamoplegic migraine :
Recurrent unilateral associated with weakness of the
extra ocular muscle – A transient 3rd or 6th nerve palsy.
More common in children.
 Retinal migraine:
Headache associated with monocular blindness due to
retinal or ant. optic nerve ischaemia.
 Basilar migraine:
The patient first develop total blindness which is
accompanied by admixture of – vertigo, ataxia,
dysarthria, tinnitus, & distal or perioral paresthesia.
The neurological symptoms are followed by throbbing
occipital headache.

21.  Hemiplegic migraine:
 Childhood periodic syndrome:
Instead of complaining of headache, the child appears
limp & pale & complains of abdominal pain. Vomiting is
more common than in the adult..
 Complicated migraine:
Migraine with dramatic transient focal neurologic
features. Or, migraine attack that leaves a persisting
residual neurologic deficit.
 Status migrainosus:
Migraine patient who lapses into a condition of daily or
virtually continuous migraine.

22. Modified Diagnostic Criteria for Migraine
Episodic attacks of headache lasting 4-72hr
With two of the following symptoms:
•Unilateral pains
•Throbbing/pulsating
•Aggravation on movement.
•Pain of moderate or severe intensity.
And one of the following symptoms:
•Nausea or vomiting.
•Photophobia or Phonophobia.

23.  Diagnostic Criteria for MigraineDiagnostic Criteria for Migraine Migraine without auraMigraine without aura
 At least five attacks fulfilling criteria B through DAt least five attacks fulfilling criteria B through D
 Headache lasting 4 to 72 hours (untreated or unsuccessfully treated)Headache lasting 4 to 72 hours (untreated or unsuccessfully treated)
 At least two of the following pain characteristics:At least two of the following pain characteristics:
 Unilateral locationUnilateral location
 Pulsating qualityPulsating quality
 Moderate or severe intensityModerate or severe intensity
 Aggravation by walking stairs or similar physical activityAggravation by walking stairs or similar physical activity
 During headache, at least one of the following:During headache, at least one of the following:
 Nausea and/or vomitingNausea and/or vomiting
 Photophobia and phonophobiaPhotophobia and phonophobia
 Migraine with auraMigraine with aura
 At least two attacks fulfilling criterion BAt least two attacks fulfilling criterion B
 At least three of the following characteristics:At least three of the following characteristics:
 One or more fully reversible aura symptoms indicating focal cerebral corticalOne or more fully reversible aura symptoms indicating focal cerebral cortical
and/or brain-stem dysfunctionand/or brain-stem dysfunction
 At least one aura symptom develops gradually over more than 4 minutes, or twoAt least one aura symptom develops gradually over more than 4 minutes, or two
or more symptoms occur in succession.or more symptoms occur in succession.
 No aura symptom lasts more than 60 minutes; if more than one aura symptom isNo aura symptom lasts more than 60 minutes; if more than one aura symptom is
present, accepted duration is proportionally increased.present, accepted duration is proportionally increased.
 Headache follows aura, with a free interval of less than 60 minutes (headacheHeadache follows aura, with a free interval of less than 60 minutes (headache
may also begin before or simultaneously with aura).may also begin before or simultaneously with aura).

24. B. Pharmacologic therapy:
Staged approach to migraine
pharmacotherapy:
StageStage DiagnosisDiagnosis TherapiesTherapies
MildMild • Occasional throbbingOccasional throbbing
headache (less than oneheadache (less than one
attack per month)attack per month)
• No major impairment ofNo major impairment of
functioningfunctioning..
• Control of migraineControl of migraine
attacks –attacks –
ModerateModerate • Some impairment of function.Some impairment of function.
• Moderate or severeModerate or severe
headache (1-3 attacks perheadache (1-3 attacks per
month)month)
• Nausea commonNausea common
• Control of migraineControl of migraine
attacks –attacks –
SevereSevere • Severe headache (>3 attacksSevere headache (>3 attacks
per month)per month)
• Marked nausea and/orMarked nausea and/or
vomiting.vomiting.
• Significant functionalSignificant functional
impairment.impairment.
• Control of migraineControl of migraine
attacksattacks
• ProphylacticProphylactic
medicationmedication

25. Control of acute migraine attacks:
The drugs should be taken as soon as the headache
component of the attack is recognized.
Drugs used in the control of migraine attacks are
 Analgesics
 Combination analgesics
5HT agonist (Oral, Nasal, SC, IM, or IV)
Dopamine antagonists (Oral, IM or IV).

26. The vast majority of migraine attacks can be treated solely
with mild analgesics such as –
•Acetaminophen –
•Aspirin -
• Other NSAIDs –
Ibuprofen –
Naproxen.
Indomethacin -.
Combination analgesics:
•The combination of Acetaminophen, Aspirin & Caffeine has
been approved for use by the FDA for the treatment of mild
to moderate migraine.
•The combination of Acetaminophen, Dichloral phenazone
& Isometheptene has been classified by the FDA as
“possibly” effective in the treatment of migraine.

27. 5HT agonist (Oral, Nasal, SC, IM, or IV):
Ergot derivatives –
Ergotamine & Dihydro ergotamine (DHE)
Ergot preparation can be taken – Orally,
Sublingually, Rectally, IM, IV, Inhalers.

28. Indications for migraine
prophylaxis
Attacks occur >2-4 times per month
Disability occurs > 3 days per month
Duration of attack > 48 h
Medications for acute attack are ineffective, C.I or
overused
Attacks produce prolonged aura or true migrainous
infarction
Patient preference

29. Duration of prophylactic therapy
The optimum duration of prophylactic therapy is uncertain
The approach is to treat for 6-12 months and then taper
over the course of several weeks.
Data are limited on the effectiveness of preventive agents
in children

30. DRUGS USED FOR PROPHYLAXIS OF MIGRAINEDRUGS USED FOR PROPHYLAXIS OF MIGRAINE
 Propranolol.Propranolol.
 Timolol.Timolol.
 Sodium valproateSodium valproate
 Methyserzide.Methyserzide.
These drugs are approved by FDA, USA.These drugs are approved by FDA, USA.
Others:Others:
 Amitryptyline, Nortryptilline.Amitryptyline, Nortryptilline.
 Phenelzine, Cyproheptadine.Phenelzine, Cyproheptadine.
Under research:Under research:
 GabapentineGabapentine
 TopiramateTopiramate

31. •Accurate history taking is fundamental
•Need for further investigation is
determined by red flag symptoms
•Or symptoms that do not corresponding
to a recognised primary headache pattern
DIAGNOSIS

32. HISTORY TAKING:
1.Age, sex, occupation:
 Migraine headache – more frequent in teenagers &
young adults, higher occurrence in female.
Cluster headache – almost exclusively in males.
Cranial arteritis – more frequently in late middle age & in
elderly.
2. Duration:
 Tension headache -often has long duration.
 Headache due to expanding of intracranial disease –
usually short duration.
 Headache due to meningeal cause – acute in onset.
 Migraine headache – recur over a long period of time,
with symptoms free interval between attacks

33. DIAGNOSTIC APPROACH: Contd..
3. Location of headache:
 As a general rule localized headache is of greater
significance than diffuse headache.
Tension headache – typically generalized, band
like or bioccipital.
Migraine with aura – often unilateral & frequently
more prominent interiorly.
 Migraine without aura – frequently bilateral.
 Cluster headache – invariably limited to the same
side of the head in any given attacks & usually
periorbital.

34. APPROACH: Contd
8. Frequency, duration & diurnal variation:
 Tension headache – often persist & may worsen as the day
progress.
 Migraine headache – the frequency is variable & unpredictable.
Although usual variation is from 4 - 72 hrs, they may persist for
days.
 Cluster headache – occur repetitively over a period of weeks or
months. Often there are 1 or 2 attacks daily. The headache
typically nocturnal & of brief duration (30 min to a few hours).
9. Family history:
 Migraine headache – strong family history.
 Cluster headache – are not familial.

35. Red flag for secondary headache - Silberstein SD et al
Flag Descriptios/example
Systemic symptoms or secondary
risk factors
Fever,W. Loss,or known cancer,HIV,
immunosupression or thrombotic risks
Nerological symptoms or
abnormal signs
Confusion,impaired alertness/drowsy,
persistent focal signs> 1 H
onset First and worst headache,sudden abrupt
from sleep, or progressively worsening
older New onset and progressive-Giant cell
arteritis
Previous headache history Significant change in features, freq. or
severity
Triggered headache By valsalva, exertion, sexual intercourse

36. When to scan a patient withWhen to scan a patient with
headacheheadache
 First or worst headache, particularly if of suddenFirst or worst headache, particularly if of sudden
onset.onset.
 Headache of increasing frequency or severity.Headache of increasing frequency or severity.
 Increased frequency of vomiting and headache onIncreased frequency of vomiting and headache on
waking.waking.
 Headache triggered by coughing, straining orHeadache triggered by coughing, straining or
postural changes.postural changes.
 Persistent physical symptoms or signs after attackPersistent physical symptoms or signs after attack
(neurological or endocrine)(neurological or endocrine)
 Meningism, confusion,impairment ofMeningism, confusion,impairment of
consciousness or seizures.consciousness or seizures.

37. ThanksThanks