Recurrent head pain is a prevalent neurological issue in children, commonly assessed by pediatric neurologists. Two common types are tension-type headaches and migraines. The International Headache Society offers diagnostic criteria in the International Classification of Headache Disorders, 3rd edition (ICHD-3).
Within this section, we will explore the following subjects:
- Causes of tension-type headaches and migraines in children
- Symptoms and characteristics of tension-type headaches and migraines
- Diagnostic criteria for tension-type headaches and migraines
- Treatment options for tension-type headaches and migraines in children
Headache Differentiation
The primary goal is to distinguish between primary and secondary headaches. Primary headaches include tension-type headaches, migraines, trigeminal autonomic cephalgias, and other less common conditions. Secondary headaches arise from underlying structural abnormalities.
Diagnosis and Evaluation
When diagnosing primary headaches, it’s crucial to consider factors such as pain location, duration, characteristics, lifestyle habits, and family medical history. Secondary headaches may present warning signs that necessitate further evaluation and testing.
Distinguishing Between Tension-Type Headaches and Migraines
It is essential to differentiate between tension-type headaches and migraines based on their distinct clinical features. Understanding these differences can help in proper diagnosis and management of the headaches. Below is a summary of the key features that set these two types of headaches apart:
| Features | Migraine | Tension-Type Headache |
|---|---|---|
| Frequency of attacks monthly | Five or more | Ten or more |
| Duration of the attack | Lasting from 2 to 72 hours | Shortest – 30 minutes, longest – 7 days |
| Location of pain | Usually on one side, sometimes on both sides | On both sides, predominantly |
| Type of pain | Throbbing | Feeling of pressure, not throbbing |
| Migraine aura | May occur | Absent |
| Intensity of pain | Moderate to severe | Mild to moderate |
| Worsened by regular physical activity | Yes | No |
| Additional symptoms include: | ||
| Feelings of nausea, tendency to vomit | May be present | Absent |
| Sensitivity to light, noise, or both | May be present | At most, sensitivity to one of these |
*According to a reference from the Neurol Clin in 2023, the diagnosis of migraine requires the presence of one to four accompanying features.
Tension-Type Headaches
Clinical manifestations of tension-type headaches often involve feelings of pressure or tightness in the head, varying durations of pain, and differing frequencies of headache episodes.
Migraine Headaches
Migraine is characterized by throbbing pain, experienced either on one side or both sides of the head, along with additional symptoms such as sensitivity to light, noise, or both. In some cases, migraine with aura may manifest with visual disturbances before the onset of the headache.
Chronic Headache and Related Phenomena
Chronic migraine and other sudden attacks can result in missed school days, necessitating appropriate treatment and care.
Headache Treatment
Treatment options for migraine encompass acute abortive therapies and ongoing preventive measures utilizing medications and adjustments in lifestyle.
Acute treatment: Initiating treatment promptly when the headache begins (or at the onset of aura) is crucial to prevent worsening. Treatment should not exceed three times a week to prevent overuse headaches.
Nonsteroidal anti-inflammatory drugs (NSAIDs): Typically, home treatment includes an appropriate dose of an NSAID (like ibuprofen or naproxen sodium, or acetaminophen with adequate fluids). A repeat dose may be taken if the headache persists after 3-4 hours.
Triptans: These medications are specifically designed for treating acute migraines and can be used up to six times a month. If significant pain persists after the initial dose, a second dose can be administered after 2 hours. However, they are not suitable for certain conditions.
Out of the seven types of triptans available, four are suitable for adolescents and one for children.
Ditans: Approved in 2019 for treating migraines in adults, these drugs target 5-HT1F receptors without causing vasoconstriction.
Nonpharmacologic treatment: The efficacy of nonpharmacologic approaches is increasingly being recognized in the pediatric population. The FDA has authorized four nonpharmacologic devices for use.
Emergency department (ED) and hospital treatment: In situations where home treatment fails, a visit to the ED may be necessary. Treatment usually involves the administration of fluid boluses, ketorolac, and a D2-receptor antagonist.
Sodium valproate or dihydroergotamine (DHE): These are effective in aborting headaches, with specific DHE treatment protocols available for inpatient care.
Preventive treatment: Making lifestyle modifications, engaging in cognitive-behavioral therapy, and using supplements can assist in preventing migraines. Medications such as amitriptyline are commonly prescribed for this purpose.
Sodium valproate, propranolol, verapamil, and botulinum toxin injections: These are proven preventive treatments suitable for both adults and children.
Cyproheptadine: This antihistamine is utilized as a preventive medication for headaches in young children.
Calcitonin gene-related peptide (CGRP)-receptor monoclonal antibodies and antagonists: A novel class of drugs used for preventing migraines in adults.
Idiopathic Intracranial Hypertension
Headaches commonly occur in idiopathic intracranial hypertension (IIH), which is characterized by elevated pressure within the skull, normal cerebrospinal fluid levels, and specific opening pressure.
Clinical Features
In IIH, headaches worsen when lying down, during the Valsalva maneuver, and upon waking up, accompanied by nausea, sensitivity to light, and visual disturbances.
Physical Examination
A key indicator of IIH is papilledema, graded using the Frisén scale.
Papilledema Grading System
The University of Iowa Health Care images depict different grades (I-V) of papilledema.
In children, detecting papilledema, especially grade I, can be challenging during funduscopic exams. For children suspected of IIH, early consultation with an ophthalmologist is recommended. Visual field problems are common in IIH, emphasizing the importance of bedside visual field assessments and formal testing by an eye specialist in older children. Cranial nerve abnormalities, particularly involving the sixth nerve, are frequent, although other nerve deficits can also be observed.
Diagnosing IIH involves procedures such as lumbar puncture, MRI, and MRV, with the exclusion of cerebral venous sinus thrombosis being vital. Specific criteria and findings must be met for an IIH diagnosis in cases where papilledema is not present.
Prompt recognition and treatment are essential to prevent vision loss in IIH patients. Discontinuation of certain medications and weight reduction are initial steps. Acetazolamide is typically the primary treatment choice for IIH, while Furosemide and Topiramate can serve as alternatives. In severe cases, consultation with a neurosurgeon may be necessary, and bariatric surgery is advised for obese IIH patients.
Research and Reviews
Numerous clinical trials and studies have demonstrated some improvement in visual function with various treatments. Guidelines from reputable professional associations provide guidance on the diagnosis and management of IIH.