Dr Jonathan Derrick and Dr Amit Bali
Are headaches giving you a headache? Patients and their families can be understandably worried by headaches – and their impact is massive (quality of life can be affected as much as with cancer). They are also a common presentation encountered by paediatricians, A+E and GP’s, but what is the best approach to them? In this article I will cover the different classifications, some top tips, red flags and the basics of management. Hopefully once you have read this there will be serene calm…
Much of the headache assessment is about ruling out secondary causes and, of course, the elephant in the room, a brain tumour. On one hand, these are rarer than primary causes of headache, but on the other hand, the consequences of missing the latter is what scares most professionals. Thankfully, following a simple but thorough approach will allow you to reassure a family (and yourself) that you are not missing anything, and means you can set up a plan that makes a positive difference.
To understand how to assess and manage headaches, first you need to understand their classification. The ICHD-3 (International Classification of Headache Disorders) is the agreed, up-to-date place to go when you are trying to decide how to categorise the headache – so bookmark that link!
Broadly speaking, headaches can be classified as either
- Primary (Not due to any underlying cause, though there may be multiple triggers)
- Secondary (This may be a malignancy, infection or another cause)
Common diagnoses in primary headaches in children may be tension type headaches (TTH), migraine, and medication overuse headaches.
Top tip: It is important to appreciate that a patient can experience more than one headache type.
So, we have covered the basics… Next up, what do you want to definitely not miss and what is a worrying feature? Any of the below are concerning and suggest that there may be an underlying secondary cause. Time to get on speed dial to your friendly local paediatrician…
- Acute severe
- Focal neurology
- Early morning headache or vomiting
- Age < 3 years
- Hypertension (If your worried try going manual…)
At risk groups
- Compromised immunity (At risk of some funky bugs…)
- Age under 20 and a history of malignancy
- A history of malignancy known to metastasise to the brain
- Vomiting without other cause
The good old-fashioned history is king when it comes to headaches, so put away those blood tubes and request cards (maybe you are lucky enough to work somewhere paperless!!). Time is always tight but a detailed history is most likely to reveal the diagnosis so it’s worth putting the time into. Below are some of the suggested questions to cover.
How many different types of headache are there?
Overuse of painkillers can be common, alongside a different initial headache type, so you should take separate histories for each one – but start with the type that is most concerning to the patient.
Sometimes it is tricky to build up an accurate picture if you only have 15 minutes (or less!) for a consultation, so headache diaries can help. They can help both you as the clinician and the patient to get a clearer idea of the patterns and trends to their headaches. However, they do take effort and need to be kept up for a suggested minimum of 8 weeks.
Top tip: Explain to the patient why you would like a headache diary and what you can hope to get from it.
Try to include
- Frequency, duration and severity of headaches
- Any associated symptoms
- All prescribed and over the counter medications taken to relive headaches
- Possible precipitants
- Relationship to periods, in an adolescent girl
Asking someone to bring back a headache diary often results in nothing being brought at the next appointment! It is far better to give something the family can fill in, such as in this example below.
You may think that examination, adds very little to getting to the bottom of headaches, as it is usually normal. HOWEVER, headaches due to a secondary cause will often have abnormal findings, especially a space-occupying lesion. It can also be helpful if medications are to be used so you know a baseline (Especially BP).
Things you should always do include:
- Optic Fundi (May show papilledema and therefore raised ICP)
- Blood Pressure (Rarely the cause but preventer medication may affect blood pressure)
- Examination of head and neck for muscle tenderness (Common in tension type headaches)
- Head Circumference (In young children, should also be plotted on centile chart)
- ENT examination (this includes a quick look for a dental cause)
A full neurological examination should of course be performed especially if there are any concerning features in the history suggestive of e.g.
- Gait difficulties
- Abnormal or asymmetrical tone
- Presence of clonus
- Diplopia/Dysdiadokokinesis/Nystagmus/Intention Tremor/Scanning Dysarthria/Co-ordination difficulty
- Cranial nerve abnormality
To image or not…
Often there is a lot of pressure on clinicians to request neuroimaging from themselves and patients/relatives. Sadly, the re-assurance of a normal scan is short lived. If you’re not sure it is indicated then seek advice from colleagues or specialists. MRI indeed means no radiation exposure but it is a finite resource, and younger children may require sedation and/or general anaesthetic, so it is not without risk. That, along with the anxiety that accompanies the ordering any investigation, means neuroimaging should be only be used when clinically indicated, and not ‘for reassurance’. As a useful rule of thumb, the longer a patient has had headaches, without the presence of red flags, and now a normal examination, the less likely you are to be missing anything that would show up on a scan.
Impact of headaches
Headaches can be very tough on patients and their whole family. They can cause a significant amount of distress. It is useful to try to get an objective measure of how headaches are impacting them. But what tools are out there? Look no further than the PedMidas score! (Disclaimer, I have no financial benefit or interest in PedMidas or the Cincinnati children hospital..!)
Headaches can have a major impact on education and a useful ‘Schools Policy’ has been produced by the RCGP, RCN and Headache UK.
Sooo, now we know what we are dealing with but what should we try to do about it?
Conservative – This doesn’t mean do nothing
Children often respond to conservative treatment and this should be the initial approach. Re-assurance of parents and or carers is important and also identification and/or moderation of possible precipitants and triggers. In fact, without properly doing this, any escalation in treatment is not just not warranted, but it is less likely to be successful. A patient or family may offer a specific trigger they have noticed, but it is vital to always ask about: sleep (duration for age and quality), screen use (not within 1-2 hours of sleep), hunger, dehydration, anxiety/stress. No real dietary triggers have been identified in studies of young people except caffeine – remember to ask about energy drinks!
Safety net & provide information
Luckily, the Headsmart website is a great resource for concerned families, and also a fantastic safety-netting resource, as it outlines what to look out for in terms of red flags. Another useful website, for those who have been classified as having migraine, is the Migraine Trust.
Children not responding to trigger avoidance and simple analgesics taken early with or without anti-emetics should be referred to a paediatrician with an interest in headaches or neurologist.
Drug Therapy – Try to avoid it in children!
Most headaches can be managed very well by their GP without any specialist input. If headaches are not responding to simple medications and conservative treatment, it is time to refer to paediatrics.
Below is the general drug therapy that a paediatrician or paediatric neurologist might commence.
Acute treatment should start as soon as possible from the onset of an attack. Always try simple pain killers alone first, such as paracetamol or ibuprofen. For patients with migraine, a useful next agent to trial for acute attacks, can be a triptan. (E.g Sumatriptan)
Prophylaxis (For severe attacks significantly affecting quality of life, even when triggers are optimised)
Propanolol – evidence in migraine (Contra-indicated in asthma)
Topiramate – evidence in migraine
Pizotifen (Note however that no study has actually shown benefit over placebo, but some clinicians claim is useful in some patients. This may be more that it is generally well tolerated!)
Psychological therapies such as relaxation therapy, stress reduction and coping strategies can have a great benefit if there are co-existent anxiety and or stress. Drug therapy is unlikely to be successful if these are not also addressed.
It is important to act with empathy and kindness and sometimes there are a multitude of factors that may be contributing to headaches. Addressing these underlying causes if they are present is important. Referrals may have to be made to other services and specialities or back to primary care.
Headaches are common
The majority are primary in nature
Know your red flags in headaches
The history is key and neuro-imaging is rarely required
Simple measures, listening and signposting is the mainstay of treatment
Dr Jonathan Derrick, Paediatric ST1, Royal London Hospital, supervised by Dr Amit Bali, Paediatric Consultant with special interest in Paediatric Neurology