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Headaches in Children

Headaches are one of the most common pain disorders in childhood which negatively affect the child’s and the family’s quality of life. They are under recognized and undertreated mainly because children experience headaches differently than adults. Headache criteria are based on adult symptoms, so most young children are not recognized as having headaches because they don’t fulfill adult criteria.

Children who experience pain often can become sensitized to pain. When this happens, the nervous system actually interprets signals inappropriately. An example of this is when the brain interprets a sensation of pressure as pain. The signals which are supposed to tell the brain there is pressure against the body are saddled over to the pain pathway. So instead of being registered as a sensation of soft touch, deep pressure, hot, cold, tingling and so forth, the brain registers the information as pain. The other change that happens in the brain is that the threshold for what is felt as pain is lowered; therefore less of a signal is required before the child feels pain. This is a concern because without adequate headache criteria for children, a correct diagnosis and an early intervention is delayed. This can result in pain sensitization in the child and long term may result in  a higher likelihood of becoming an adult with chronic pain.

Infants can have headaches following complications around or during delivery. A long, difficult or fast delivery and particularly one where the infant is pulled or pushed out are reasons why an infant can have a headache and be irritable.  An acute cesarean section where the baby has descended in the canal and is pulled back up is traumatic for the head and neck. We understand an infant has a headache based on the history around delivery and their behavior. Holding their heads, scratching their face, pulling their hair and/or holding their eyes shut are common signs of a headache in an infant. Infants with difficulty feeding and sleeping may have a headache. Toddlers display headaches by head banging, holding their heads, turning away from light and/or seeking a quiet and dark room.

Pre-schoolers may have headaches of short duration which are usually experienced above the eyes. The quality is mostly pressing or tightening and they may cause problems with sleep.  Among boys, behavioral disorders may be a sign of or a precursor to headaches. In this age group headaches may not be the primary symptom, instead the child may experience vegetative symptoms. The child may have episodes of pallor and sweating, abdominal pain, vomiting and/or vertigo. This age group is particularly difficult to diagnose due to issues with communication.

School age children may still have short episodes of headaches which increase with increasing age. Headaches are often experienced like a band around the head or at the temples. By puberty headaches behave more like those we recognize in adults and are more easily classified and diagnosed. It is most common to get a first headache in adolescence, but headaches starting at a younger age are not uncommon. Risk factors for headaches in adolescence are chronic stress, physical inactivity, pain in the shoulders and neck, smoking, drinking alcohol, and coffee consumption.

The most common types of headaches are migraine headache, tension-type headache (spännings huvudvärk) and cervicogenic headache ( huvudvärk som härstämmer från nacken).

Migraine headache is due to a neurovascular reaction caused by inflammation and vasodilation. It is hereditary and frequently coexists with asthma and atopic disease.  It is primarily due to a chemical trigger, but stress and mechanical dysfunction of the neck can initiate and exacerbate it. This headache is classically experienced on one side of the head, though it may change place during an episode or from episode to episode. It is accompanied by nausea, vomiting, sensitivity to light and sound. Children with headache who vomit usually have migraine headaches. This headache becomes worse when you strain yourself, it is a pulsating headache which is relieved by sleep. This headache is relieved by a class of medications called triptans. Other common medications like paracetamol and ibuprofen do not completely relieve the headache.

Migraine headaches are the most common cause of severe recurrent headaches in children. The quality of life for these children and their families is compromised, with children often home not only with headaches but other sicknesses. It affects their social life and academic performance. Risk factors for developing a migraine headache are complications during pregnancy, prematurity, intracranial bleeding in childhood, meningitis and food allergy.

In younger children precursors to migraine include childhood periodic syndromes. These are primarily recurring episodes of vertigo, vomiting, abdominal pain. Studies are currently investigating whether colic is an early manifestation of migraine in some children. In older children some common symptoms of migraine include sensitivity to smells, dizziness, balance disturbances, anxiety and depression. Sleep disturbances are common with migraine headaches, including nightmares, snoring, grinding teeth and sleep talking. Poor sleep patterns are related to the onset and chronicity in migraine headaches. Other triggers for migraine headaches are fatigue, infection, stress, hormones, missing meals and bright flashing lights. Foods which can trigger a migraine include dairy products, citrus fruits, nitrites, food dyes and additives and artificial sweeteners. Other offending chemicals include allergenic proteins (cross allergens)LINK, sulfites, histamine, MSG and asthma medicine.

Nutraceuticals are vitamins, minerals and herbs used to treat health problems. Research has shown effectiveness of certain products for the treatment of migraine headaches in children. These include D vitamin, riboflavin, magnesium, coenzyme Q10, feverfew and butterbur.

A prior injury to the neck or mechanical problems with the neck can initiate or exacerbate a migraine headache. In these headache sufferers, chiropractic treatment of the neck reduced the frequency, intensity and duration of the headache as well as decreased the intake of headache medication (Lynge, 2020). Looking at screens for extended periods of time is a strain on the neck, particularly whenthe head is tipped forward (look around at prople looking at their phones), raise the phone closer to the eyes so the neck is in a neutral position. Prolonged periods of time on the computer (tex gaming) is a strain on the eyes as well as the neck. This highlights the importance of ergonomics for children and adults who are prone to headaches.

The two following articles are recently published where Doctor Weber. The first describes how migraines in children present and develop over time. The second describes how common headache types present in childhood.

The changing phenotypes of migraine headache from infancy to adolescence

Differentiating headaches in children part II


References:

Weber S. 2021. Headaches in children: Part 2. The changing phenotypes of headaches in children. JCCP;20(2)1802-1813.

Weber S. 2021. Headaches in children: Part 1. The changing phenotypes of migraine headache in infants, children and adolescents. JCCP;20(1)1747-1756.

Lynge S, Dissing KB, Vach W, Christensen HW, Hestbaek L. Effectiveness of chiropractic manipulation versus sham manipulation for recurrent headaches in children aged 7-14 years – a randomised clinical trial. Chiropr Man Therap. 2021 Jan 7;29(1):1. doi: 10.1186/s12998-020-00360-3.

Bursztein C, Steinberg T, Sadeh A. 2006. Sleep, sleepiness and behavior problems in children with headache. J child Neurol;21:1012.

Bellini, Panunzi, Bruni, Guidetti,. 2013. Headache and sleep in children. Curr pain Headache Rep;17(6)335-9.

Sherwood M, Goldman R. 2014. Effectiveness of riboflavin in pediatric migraine prevention. Canadian Family Physician;60:244-46.

Hershey A. 2012. Pediatric Headache: update on recent research. Headache;52(2)327-32.

Maneyapanda S, Venkatasubramanian A. 2005. Relationship between significant perinatal events and migraine severity. Pediatrics;116(4)555-8.

Laimi K, Salminen J, Metsähonkala L, Vahlberg T, Mikkelsson M, Anttila P, Aromaa M, Rautava P, Suominen S, Liljeström M, Sillanpää M. 2007. Characteristics of neck pain associated with adolescent headache. Cephalalgia; 27, 1244–1254.

Gelfand A. 2013. Migraine and childhood periodic syndromes in children and adolescents. Cur opinion neurology;26(3)262-8.

Jacobs H, Gladstein J. 2012. Pediatric Headache: a clincial review. Headache;52(2)333-9.

Cuvellier, Lepine. 2010. Child hood periodic syndromes. Pediatric Neurology;421(1)1-11.

Rapoff M, Connely M, Bickel J, Powers S, Hershey A, Allen J, Karlson C, Litzenburg C, Belmont J. 2014. Headstrong intervention for pediatric migraine headache: a randomized clinical trial. J of Headache and Pain;15:12-19.

Shevel E, Spierings E. 2004. Cervical muscles in the pathogenesis of migraine headache. J headache Pain;5:12-4.

Cayir A, Turan M, Tan H. 2014. Effect of vitamin D therapy in addition to amitriptyline on migraine attacks in pediatric patients. Brazilian Journal of Medical and Biological Research;47(4)349-54.