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Childhood headache
R W Newton Arch. Dis. Child. Ed. Pract. 2008;93;105-111 doi:10.1136/adc.2007.124743
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References
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Childhood headache
R W Newton
Correspondence to: Dr R W Newton, Royal Manchester Childrens Hospital, Pendlebury, Manchester M27 4HA, UK; richard.newton797@ ntlworld.com Accepted 19 February 2008
Few adults have never had a headache yet the condition in childhood, particularly when recurrent, commonly causes irrational fear of serious illness among parents and primary care physicians, leading to referral to paediatric services.
2/3. The trigeminal innervation of pain-producing intracranial structures; activation of the peripheral branches of the ophthalmic branch of the trigeminal nerve
Large cerebral vessels, pial vessels, the venous sinuses and dura mater are all innervated by small diameter myelinated and unmyelinated neurones serving nociception. Moskowitz showed in rats that migraine pain may be a form of sterile neurogenic inflammation with plasma extravasation with mast cell degranulation and platelet aggregation.5 Cortical spreading depression may activate trigeminal neurones, particularly the ophthalmic division, release substance P and calcitonin gene-related peptide. This sterile inflammatory response may lead to allodynia (perceived pain from a normally non-painful stimulus) in the trigeminal area, sensitisation of thalamic neurones and an important central nervous system role.
Arch Dis Child Educ Pract Ed 2008;93:105111. doi:10.1136/adc.2007.124743
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Table 1 Suggested strict criteria to be applied for various headache types
Migraine without aura diagnostic criteria: A At least 5 attacks fulfilling criteria B to D B Headache attacks lasting 1 (4 in adults) to 72 hours (untreated or unsuccessfully treated) C Headache has at least two of the following characteristics: 1. Unilateral location 2. Pulsating quality 3. Moderate or severe pain intensity 4. Aggravation by or causing avoidance of routine physical activity (for example walking or climbing stairs) D During headache at least one of the following: 1. Nausea and/or vomiting 2. Photophobia and phonophobia E Not attributed to another disorder 1.2 Migraine with aura diagnostic criteria: A At least 2 attacks fulfilling criterion B B Migraine aura fulfilling criteria B and C for one of the sub-forms 1.2.1 to 1.2.6 C Not attributed to another disorder Tension type headache. The following alternative criteria may be applied to A.2.1 infrequent episodic tension headache: A.2.2 frequent episodic tension type headache and A.2.3 chronic tension type headache A Episodes, or headache, fulfilling criterion A in main definition set and criteria B to D below B Headache lasting 30 min to 7 days C At least 3 of the following characteristics: 1. Bilateral location 2. Pressing/tightening (non pulsating) quality 3. Mild or moderate intensity 4. Not aggravated by routine physical activity such as walking or climbing stairs D No nausea (anorexia may occur), vomiting, photophobia or phonophobia E Not attributed to another disorder
third and largest group had bilateral headaches (pulsating or pressing) with nausea and vomiting but few other symptoms. Classifications developed from adult practice may not always be helpful for the paediatrician. We should do our best to think this way clinically but the unclassified group is likely to be large and this has a bearing on the explanatory words we use (see below). Chronic daily headache. This is rare in my practice but has been reported in 0.9% of UK children2 and up to 4% in the USA.8 An impressive study of 7900 Taiwanese children aged 1214 years showed a prevalence of 2.4% in girls and 0.8% in boys where symptoms were being experienced at least 15 days a month with an average of two hours per day for more than three months.9 Almost 75% had chronic tension type headache and nearly 7% had chronic migraine. These families present a diagnostic and management challenge. We need to consider a spaceoccupying lesion and idiopathic intracranial hypertension. Shorter histories may make one think of a chronic lymphocytic meningitis. In my experience, however, probably the commonest formulation is that of illness behaviour, where the young person concerned is experiencing a physical symptom as an expression of some inner conflict or fear. Chronic analgesia over use may contribute to symptoms.
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are associated with at least one of the following, all of which must be ipsilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, myosis, ptosis, or eyelid oedema. In chronic paroxysmal hemicrania the episodes show pain with a similar characteristic but they tend to be shorter lasting and more frequent. The bouts may occur at the same time each day with a striking therapeutic response to indomethacin.12
CLINICAL ASSESSMENT
Before each consultation children and their families should be encouraged to write down their main concerns.13 After identifying what is worrying the family most, the childs pain should be assessed: site, duration, frequency, character, relieving and exacerbating factors for each headache type and record any associated symptoms. Ask about duration of symptoms and any recent change in behaviour, personality or educational performance. Red flag features14 identify the need to investigate further (see box 1). Be careful with language. Waters15 drew attention to the fact that the word throbbing in general parlance often means very severe rather than pulsatile and many people conceptualise the head to have five sides rather than two (top, front, back, left and right), so it is better to sit back and then clarify than lead children and their families with specific questions.
PHYSICAL EXAMINATION
Carry out a quick neurological examination (see box 2). In particular look at stature, visual fields and cranial bruits. Note any Fogs test asymmetry that could represent hemisphere dysfunction; check the blood pressure.
MANAGEMENT
The single most important thing for families is an explanation of childhood headache that makes sense. Try to teach some simple biology (see box 3 for a suggested approach). The importance of explaining things in this way is that you alter family expectation. For about 50% the tendency to recurrent headache will be life long,16 with good and bad spells. So make it clear that your intention is not to rid them of the problem but to allow them to adjust to it and live life successfully in spite of it, minimising the inconvenience of the episodes when they arise.
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Box 2 Hints for a quick neurological examination
Cranial nerves: c Pupillary reaction to light and accommodation (II, III) and view optic fundi (II) c Eye movements (III, IV, VI) c Bite and waggle jaw from side to side (V) c Screw up eyes and show teeth (VII) Say agh (IX) c Shrug shoulders (XI) c Put out tongue (XII) c Temporal visual fields (rare to have nasal field defect without temporal field defect) c Visual/hearing acuity when indicated by history. Then, patterns of movement: is it central nervous system (CNS) or neuromuscular (weakness)? If it is CNS, is it pyramidal, extrapyramidal, or cerebellar? c Hold arms outstretched c Finger-nose test c Alternating movement c Touch each finger in turn c Walk: look for toe-heel (or heel-toe?) gait-width of base/asymmetry-waddle of proximal weakness? c Fogs test c Gowers sign. Note: Routine sensory testing is unnecessary unless the history has a sensory component or there are motor signs. Supplementary tasks: c Reflexes/plantar response (if indicated) c Neurocutaneous features c Dysmorphism c Signs of a storage disorder: visceromegaly; heart murmur; skeletal signs of storage
given the great overlap of symptoms between children and in the same child over a period. Hence the modern term tension-type headache (with previously misleading terms tension or tension-like headache discarded).
psychiatric disturbance of some sort. It is commonly believed that stressors bring them on (see most simple analgesia advertisements). In effect they are yet another paroxysmal headache type whose pathophysiology is yet to be defined. It is likely that the pathophysiological substrate for migraine and tension-type headache are the same
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placebo-controlled studies showed a beneficial effect on the primary outcome measure headache frequency. They were for the drugs propranolol and flunarizine. Nimodipine, timolol, papavarine, pizotifen, trazodone, L-5HTP, clonadine, metachlopromide and domperidone showed no efficacy in the reduction of frequency of attacks. Studies on ciproheptadine, phenobarbitone, phenytoin, amitriptyline, metoprolol and piracetam were excluded for various reasons. The findings from a Drug and Therapeutics Bulletin, Managing migraine in children21 are summarised beside recent Cochrane reviews all with study populations largely incorporating adults.
decision-making process. Once remission is induced it is good to withdraw therapy within the next six weeks or so.
Pizotifen
Pizotifen is a histamine (H1) and serotonin receptor antagonist licensed for migraine prevention in children aged over 2 years in doses up to 1.5 mg daily, usually in divided doses. Common unwanted effects of the drug include anti-muscarinic effects (dry mouth, constipation), increased appetite, weight gain and sleepiness. It is probably the drug most commonly used by UK paediatriciansbut here is no evidence to suggest it works! A randomised placebo-controlled crossover trial involving 47 children aged 714 years showed that Pizotifen (11.5 mg daily) did not reduce the number of episodes, the total or mean duration of episodes, or the duration of the longest episode.20 30
Propranolol
Propranolol is licensed for the prophylaxis of migraine in children at a dose of 20 mg two or three times a day in those under 12 years, and in a starting dose of 40 mg two or three times a day in the over 12s, but contraindicated in asthma. There are three trials comparing propranolol with placebo in childhood migraine. In a crossover trail propranolol (16120 mg daily divided into three doses) reduced the average frequency of episodes.31 However, in a second study there was no difference in headache frequency between propranolol (80120 mg daily) and placebo, and the average duration of headache progressively increased in children taking propranolol with a small decline on placebo.32 In a third trial propranolol (3 mg/daily for three months) showed no reduction in the number of migraine episodes compared with and placebo.33 Unwanted effects included bradycardia, hypotension, peripheral vasoconstriction, bronchospasm, gastrointestinal disturbances, tiredness, sleep disturbance and nightmares. A recent systematic review included 58 trials involving 5072 participants of all ages, many with poor methodology, showed propranolol is more effective than placebo in the short-term interval treatment of migraine, but that no longterm benefit is conferred.34
Opiodes
There are no published studies on the use of opiodes in childhood migraine, which should generally be avoided due to the risk of addiction. Unwanted effects include nausea, vomiting and constipation.
Anti-emetics
Metaclopromide should be avoided, particularly in young children, because of the risk of inducing a dystonic attack. Domperidone is only licensed in the UK for use following radiotherapy and chemotherapy but may be helpful (if it is retained). Prochlorperizine is available as a nasal spray or suppository.
Antiepileptic drugs
There is growing evidence that antiepileptic drugs help migraine prevention. In a systematic review of 23 papers with 2927 participants those treated with antiepileptic drugs were more than twice as likely to have migraine frequency reduced by 50% or more compared with placebo.35 Valproate and topiramate in particular were shown to be effective but acetazolamide, clonazepam, lamotrigine and vigabatrin were not superior to the placebo. More work is required on gabapentin. If symptoms warrant it, dosage can slowly be escalated to an initial target dose of 30 mg/kg/day
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Prophylactic therapy
Use this only as a last resort where frequent symptoms are becoming very intrusive in a young persons life and make them part of the
Arch Dis Child Educ Pract Ed 2008;93:105111. doi:10.1136/adc.2007.124743
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for valproate or 4 mg/kg/day for topiramate over a three-week period or so, stopping the escalation if episodes arrest. The treatment should be continued until remission has been sustained for about a sixweek period and then the drug might be tailed over six weeks. chocolate or cheese may trigger migraine at one time but a few weeks later may not induce the event. So, before condemning any child to a life without chocolate or cheese, it is wise to explain this fluctuating vulnerability and exclude a trigger only if it consistently acts as one over time. It is the counsel of perfection anyway to suggest that a young person should attempt to live a life free of heat, light, noise, excitement, lack of sleep, etc. Indeed a doctor may lose a lot of credibility in a young persons eyes by doing so. Our job is rather to raise these issues for the young person to consider and for them to take an informed decision.
Behavioural interventions
A meta-analysis of 17 studies (9 controlled, 2 randomised) involving a total of 292 children (aged 518 years) investigating a range of behavioural interventions suggested that thermal biofeedback, progressive muscle relaxation or a combination of the two was more effective at reducing headache than placebo or waiting list control conditions, and that biofeedback alone or in combination with progressive muscle relaxation was apparently more effective than all the other treatments.39 However, the studies were small (556 participants each) and only six were considered to carry good methodological quality. This comment was echoed in Melchart and colleagues40 systematic review of acupuncture for idiopathic headache which nonetheless suggested some benefit; Bronfort and colleagues review of non-invasive physical treatments for chronic/ recurrent headache showed a few non-invasive physical treatments may be effective as prophylactic treatments, including spinal manipulation for cervicogenic headache (rare in children), the use of pulsating electromagnetic fields and a combination of transcutaneous electrical nerve stimulation (TENS) and electrical neurotransmitter modulation).41 Again the methodology was poor and these results cannot be relied upon.
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LIFESTYLE ISSUES
The British National Formulary for Children suggests that we advocate the avoidance of common headache triggers: heat, light, noise, strong smells, lack of sleep, lack of water, lack of food (such as breakfast), excitement, travel, exercise and (infrequently) types of food. Taking the latter it is my experience that the brains propensity/vulnerability to migraineous phenomena fluctuatesprobably related to endogenous biorhythms. Thus,
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