Paediatrics: Headache

Headache

Children with headache are commonly referred to general paediatricians.

·  Over 90% will have chronic childhood headache, with no identifiable physical cause.

·  Some have migraine.

·  Malignant brain tumours obstructing CSF flow, causing hydrocephalus and consequent headaches, are less common. These are almost always associated with focal signs on examination or a suggestive history, if present for more than 6wks.

Chronic, tension type headache

This form of headache is:

·  regular;

·  often frontal;

·  not associated with vomiting, paraesthesia, visual disturbance, or abnormality on examination (including BP).

History

The headache may be reported to be severe enough to take time off school, but with few objective signs of pain. A full history is important, not only to exclude migraine and symptoms of raised ICP, but also to elucidate stresses that may be causing the headache or gains the child may have from the behaviour. It should be assumed to be chronic if present for more than 6wks.

Treatment

·  Reassure the family that, with the thorough history and examination, migraine and tumours can be excluded.

·  It is inappropriate to perform either a CT or an MRI scan.

Sympathize with the family over the problem and suggest analgesia, but at best it is likely to make no difference. Therefore dosage and number of drugs should be reduced to the minimum acceptable. Encourage the child or young person to continue doing all the normal activities for somebody of their age. ‘I can’t take away the headache, but the more normal things you do and the fewer drugs you take, the less you will notice the pain’.

Raised ICP

This is a potent cause of headache and will be associated with either or both of the following:

·  Abnormal examination: in particular, heel–toe walking, finger–nose co-ordination, eye movements, and fundi (i.e. papilloedema).

·  Severe short history: vomiting, morning headache, visual disturbance.

Clinically, the main concern is a mass obstructing CSF flow, particularly a malignant posterior fossa tumour. Therefore the children need expert opinion on neuroimaging as soon as possible. MRI superior, but CT head is performed if MRI not immediately available.

However, the ICP can be raised without abnormality evident on CT scan. In some of these children there may be thrombosis of a cerebral sinus. Therefore, MRI and MRV are recommended.

A subgroup has raised pressure of unknown cause—idiopathic intrac-ranial hypertension, where the only sign on examination will be papil-loedema +/– reduced visual acuity, with normal cranial imaging, except for the lateral venous sinuses, which can look compressed.

Idiopathic intracranial hypertension (IIH)

IIH or benign IH or pseudotumour cerebri typically is associated with obe-sity, female sex, and adolescence. It is important to exclude secondary cases caused by:

·Drugs: steroid withdrawal; vitamin A; thyroid replacement; oral contraceptive pills; phenothiazines.

·Systemic disease: iron deficiency; Guillain–Barré syndrome; systemic lupus erythematosus.

·Endocrine changes: adrenal failure; hyperthyroidism; hypoparathyroidism; menarche; pregnancy; obesity.

·Head injury.

History

Early morning headache blurred or double vision, vomiting.

Examination and investigation

·General: check BP.

·Neurology: there may be ataxia.

·Eyes: papilloedema; scotoma on visual field testing.

·Imaging: normal.

·Lumbar puncture: raised ICP (>20cm CSF); normal CSF cell count, protein, and glucose.

Management

·Weight loss in the obese.

·Try and remove the causal medication.

·Diuretics: to reduce CSF formation (e.g. acetazolamide, furosemide).

·Steroids: may be effective, but can cause rebound problems when withdrawn.

·Serial lumbar punctures or surgical intervention.

Monitoring of eyes and visual fields: most patients without visual deficit do well, but some patients with eye problems may deteriorate.