Headache in childhood

Abstract

Childhood headache is not an uncommon problem in clinical practice. From an aetiological perspective, headache is divided into primary and secondary. The distinction between the two should be the first step in the evaluation process, which in turn dictates the subsequent investigations, when needed, and management. A headache that has a progressive course or unusual features in association with additional symptoms suggestive of an intracranial pathology or abnormal neurological signs should always prompt consideration for neuroimaging. However, this has to be balanced with the need for not to over-investigate. Recognition of the different subtypes of primary and secondary headaches is facilitated by the use of the latest editions of the International Classification of Headache Disorders (ICHD). This system, however, is primarily based on data extrapolated from adult studies making it applicable for childhood somewhat less sensitive and specific. Acute management of headache in a previously well child should include an initial clinical assessment to exclude potential secondary causes. Early use of simple analgesics, a triptan and an antiemetic either solely or in combination is needed in the management of migraine exacerbations. Frequent migraine attacks that negatively impact the child’s quality of life warrant treatment with a suitable prophylactic drug for a period of few months whilst triggering and maintaining factors are eliminated as much as possible. Drug treatment of tension-type headache is usually unsatisfactory and thus coping strategies may be more appropriate. The possibility of medication-overuse headache should be considered and reviewed regularly during initial and follow-up visits.