Pediatric Annals

Comprehensive Evaluation and Treatment of Recurrent Pediatric Headache

Mark Scott Smith, MD

Abstract

Recurrent pediatric headache is a common disorder that may affect approximately half of the population. A Swedish study reported 58.6% of school children experienced headache with 3.9% classified as migraine, 6.8% as frequent nonmigrainous headache, and 48% as infrequent nonmigrainous headache.1 Prior to adulthood, the incidence of headache increases with age. By age 15, approximately 55% of children and adolescents report having experienced nonmigrainous headache (6.8% frequendy) and 3.9% have had migraine.2 Before puberty, male and female children experience equal headache rates, but by late adolescence, girls are twice as likely as boys to complain of recurrent headache. In a recent survey, 56% of adolescent boys and 74% of adolescent girls reported at least one headache in the previous month. Approximately 4% of the boys and 7% of the girls described headaches with characteristics consistent with migraine.2 Although some studies suggest a decrease in headache activity with the onset of adolescence, long-term follow-up studies suggest that the majority will continue to experience recurrent headaches as adolescents3 and adults.4

Data from the 1988 National Health Interview Survey indicates that frequent or severe headache has a prevalence of 25.3 per 1000 population for children and adolescents younger than 18 years.5 The reported range was 9.9 per 1000 for children younger than 10 years and 45.8 per 1000 for those from 10 to 17 years of age. In this survey, frequent or severe headache followed allergy, otitis media, asthma, and eczema in order of prevalence. Headache was reported to be more frequently bothersome than any other childhood chronic condition. Furthermore, symptom intensity was reported as "a great deal of bother" in 57% of those who reported headache. The average number of school days missed per year due to headache symptoms was 3.3, compared with 4-6 days for asthma and 3.4 days for seizures.

Table

Ideally, baseline symptom recording prior to the institution of treatment provides the best information for subsequent evaluation of treatment success. More commonly, the clinical situation does not allow for the collection of baseline data, and the clinician must rely on historical data. In general, such data are inaccurate, particularly if only global ratings (eg, "how bad is your headache activity now") are obtained. A 2-week symptom recall period may provide more accurate information when the clinician reviews each headache with the patient and parents.

After establishing reported baseline data, the patient and parents should be instructed in a method of prospective symptom recording. Minimally, a record of symptom frequency and average intensity (eg, rated on a scale from 0 to 10) should be obtained. More sophisticated attempts at headache data collection may be attempted, and many different pain scales have been proposed for use with children and adolescents including facial expression pictures, colors, descriptive words, Likert-type scales, and visual analog scales.14 In addition to the frequency, intensity, and duration of headache pain, ongoing recording of medication use, functional disability (eg, school days missed), and recognition of precipitating factors should be recorded.

Prior to the prescription of a definite treatment plan, it is important to review previous treatment attempts for efficacy and possible negative effects. Often, the dismissal of previous treatment as ineffective is inappropriate due to factors such as inadequate dosage or length of treatment. Another important factor to assess prior to prescription of treatment is the patient's spontaneous and preferred coping mechanisms for headache. Reinforcement of these techniques and their incorporation into a treatment regimen may enhance therapeutic success.

Pharmacotherapy may be valuable in recurrent pediatric headache, but is rarely the sole important factor in successful treatment. Any treatment program should begin with attention to basic hygienic factors…

Recurrent pediatric headache is a common disorder that may affect approximately half of the population. A Swedish study reported 58.6% of school children experienced headache with 3.9% classified as migraine, 6.8% as frequent nonmigrainous headache, and 48% as infrequent nonmigrainous headache.1 Prior to adulthood, the incidence of headache increases with age. By age 15, approximately 55% of children and adolescents report having experienced nonmigrainous headache (6.8% frequendy) and 3.9% have had migraine.2 Before puberty, male and female children experience equal headache rates, but by late adolescence, girls are twice as likely as boys to complain of recurrent headache. In a recent survey, 56% of adolescent boys and 74% of adolescent girls reported at least one headache in the previous month. Approximately 4% of the boys and 7% of the girls described headaches with characteristics consistent with migraine.2 Although some studies suggest a decrease in headache activity with the onset of adolescence, long-term follow-up studies suggest that the majority will continue to experience recurrent headaches as adolescents3 and adults.4

Data from the 1988 National Health Interview Survey indicates that frequent or severe headache has a prevalence of 25.3 per 1000 population for children and adolescents younger than 18 years.5 The reported range was 9.9 per 1000 for children younger than 10 years and 45.8 per 1000 for those from 10 to 17 years of age. In this survey, frequent or severe headache followed allergy, otitis media, asthma, and eczema in order of prevalence. Headache was reported to be more frequently bothersome than any other childhood chronic condition. Furthermore, symptom intensity was reported as "a great deal of bother" in 57% of those who reported headache. The average number of school days missed per year due to headache symptoms was 3.3, compared with 4-6 days for asthma and 3.4 days for seizures.

Table

TABLE 1International Headache Society Classification 1988

TABLE 1

International Headache Society Classification 1988

While it is apparent that recurrent pediatric headache causes significant functional disability, it is likely that the majority of children and adolescents with recurrent headache do not seek medical care.2 Although not systematically investigated in children and adolescents, a recent study of college undergraduates found a relationship among headache frequency, length of headache history, and treatment-seeking behavior.6 It is probable that many children and their parents do not identify recurrent headaches as distinct from the usual human condition and thus do not seek treatment.

HEADACHE CLASSIFICATION

In an effort to standardize diagnostic criteria for headache disorders, the International Headache Society published guidelines in 1988.7 Although subject to continued modest criticism and revision, these guidelines form a useful framework for classifying recurrent pediatric headache. Many types of headache, neuralgia, and facial pain have been described, but the most common types of headache in childhood and adolescence are migraine with or without aura and tension-type headache. Table 1 provides a comparison of migraine without aura and tension-type headache.

Migraine with aura (classical migraine) presents with recurrent self-limited episodes of neurological symptoms localized to the cortex or brain stem that are commonly followed by the migraine symptoms listed in Table 1. The most common neurological symptoms (auras) are scotomata, blurred vision, flashing lights, vertigo, and paresthesias. Although poorly documented, premonitory symptoms such as hyperactivity, depression, craving special foods, or repetitive yawning may precede the migraine attack by 1 to 2 days. Less common forms of complex migraine include symptoms of perceptual distortion, hemiplegia, ophthalmoplegia, vertigo, and basilar artery dysfunction.

Tension-type headache is less well characterized in children and adolescents than migraine. This type of headache is rare in young children and becomes much more common during adolescence. Although a disorder of pericranial muscles may be present in many individuals with tension-type headache, it may be absent in others. Psychosocial stress appears to be a major factor in tension- type headache at all ages. A particularly difficult management problem exists with chronic daily headache. These individuals may report symptoms consistent with both migraine and tensiontype headache, and some controversy exists regarding their possible evolution from migraine or overuse of analgesic medications. Regardless of their etiology, it appears that children and adolescents with chronic daily headaches have higher rates of concurrent psychiatric diagnoses and greater functional disability than children with other types of headache.8

CLINICAL EVALUATION

The evaluation of recurrent pediatric headache should begin with a detailed clinical history, family history, and review of systems. Useful areas to address when taking the headache history include:

* type of headache (Table 1),

* aura or premonitory symptoms,

* age at onset and subsequent course,

* frequency, intensity, and duration in the past month,

* seasonality/school-related,

* exacerbating and ameliorating factors,

* school missed/limitation of activities,

* medication/other treatment efficacy,

* spontaneous self-coping techniques, and

* family history of headache/role model.

Clinical observation of recurrent pediatric headache suggests that many factors are involved in the exacerbation of headache activity. There is a strong genetic predisposition for migraine, and a positive family history can be obtained in the majority of these patients. It is equally clear that various environmental, behavioral, and psychosocial variables may singly or in combination precipitate a headache. Environmental factors commonly reported to precipitate migraine include exposure to sunlight, loud noise, stagnant air, various odors, and certain foods. The suggestion that the majority of pediatric migraine is related to food allergy seems unlikely. On the other hand, particular foods (eg, certain cheeses, chocolate, and food preservatives) appear to exacerbate migraine in some individuals. Changes in sleep pattern (particularly hypersomnia), missed meals, and psychosocial stress are commonly associated with increased headache activity.

Table

TABLE 2Indications for Neurofmaglng In Recurrent Pediatric Headache

TABLE 2

Indications for Neurofmaglng In Recurrent Pediatric Headache

In the diagnostic evaluation of recurrent pediatric headache, particular attention should be paid to blood pressure, the optic fundi, pericranial muscles, cranial bruits, sinuses, teeth, temporomandibular joints, thyroid gland, integument, and neurological functioning. The differential diagnosis of recurrent pediatric headache includes sinusitis, intracranial mass, pseudotumor cerebri, sleep disorders, hyperthyroidism, hypertension, and temporomandibular joint dysfunction. Although frequently the first concern of parents, decreased visual acuity is rarely a cause of recurrent headache. Of particular importance is the determination that an intracranial process is not responsible for the headaches. While headache may be the initial presenting symptom of brain tumor, additional signs and symptoms appear within 4 months in a majority of pediatric patients.9 The headache associated with a brain tumor may mimick other headache syndromes, but it is characteristically nonpulsatile, deeply aching, and intermittent. These headaches are usually worse with exertion and change in position, are relieved by analgesics, and commonly occur nocturnally or in the early morning upon arising.10

Indications for cranial computed tomography or magnetic resonance imaging are listed in Table 2. Electroencephalograms (EEG) are mildly abnormal in up to a third of normal children and may show epileptiform discharges in as many as 9% of pediatric migraine patients.11 Therefore, the EEG is rarely useful in the routine evaluation of recurrent pediatric headache. However, the sudden onset of headache of brief duration associated with obtundation or prolonged confusion is an indication for an EEG. Radiographic evidence of sinusitis has been reported in as many as 10% of patients with recurrent pediatric headache,12 but routine sinus radiography probably is not indicated in most cases. On the other hand, the patient with persistent frontal headache, facial pain, sinus tenderness, or positional change in intensity requires further evaluation for sinusitis.

While psychosocial stress is one of many factors that may precipitate migraine, it appears to be the major factor in tension headache. In general, studies in adults have shown that tension headache patients are more likely to have psychological problems (particularly anxiety and depression) than either migraine or healthy control subjects.13 There are scant data on the psychological status of children and adolescents with tension-type headache, but the incidence increases dramatically after puberty. Therefore, it is likely that the role of psychological factors is similar in adolescents and adults. Additionally, headache frequency (but not necessarily intensity) appears to correlate with the amount of psychosocial distress. An adolescent with daily persistent tension- type headache is very likely to have a significant underlying psychosocial problem. Likewise, because typical migraine occurs only occasionally, frequent migraine headaches strongly suggest the existence of a significant psychosocial component or an inappropriate diagnosis of migraine.

Because psychosocial factors are commonly involved in recurrent pediatric headache, particular emphasis should be placed on this part of the evaluation. Role models for headache or other pain behavior should be sought. Previous attempts at treatment and attitudes toward self-control should be discussed. The use of screening questionnaires for anxiety and depression may be useful. Table 3 lists important aspects of the psychosocial history in recurrent pediatric headache.

TREATMENT

Separate articles in this issue of Pediatrie Annah address specific pharmacotherapy and behavioral treatment of recurrent pediatric headache. The selection of behavioral or pharmacologic therapy will be determined by headache history and patient and parent preference. Treatment credibility, expectation that it will result in symptom improvement, and motivation to pursue compliance will affect both behavioral and drug therapy. Regardless of which type of therapy is selected, the following recommendations are appropriate.

Table

TABLE 3Psychosocial History in Recurrent Pediatric Headache

TABLE 3

Psychosocial History in Recurrent Pediatric Headache

Ideally, baseline symptom recording prior to the institution of treatment provides the best information for subsequent evaluation of treatment success. More commonly, the clinical situation does not allow for the collection of baseline data, and the clinician must rely on historical data. In general, such data are inaccurate, particularly if only global ratings (eg, "how bad is your headache activity now") are obtained. A 2-week symptom recall period may provide more accurate information when the clinician reviews each headache with the patient and parents.

After establishing reported baseline data, the patient and parents should be instructed in a method of prospective symptom recording. Minimally, a record of symptom frequency and average intensity (eg, rated on a scale from 0 to 10) should be obtained. More sophisticated attempts at headache data collection may be attempted, and many different pain scales have been proposed for use with children and adolescents including facial expression pictures, colors, descriptive words, Likert-type scales, and visual analog scales.14 In addition to the frequency, intensity, and duration of headache pain, ongoing recording of medication use, functional disability (eg, school days missed), and recognition of precipitating factors should be recorded.

Prior to the prescription of a definite treatment plan, it is important to review previous treatment attempts for efficacy and possible negative effects. Often, the dismissal of previous treatment as ineffective is inappropriate due to factors such as inadequate dosage or length of treatment. Another important factor to assess prior to prescription of treatment is the patient's spontaneous and preferred coping mechanisms for headache. Reinforcement of these techniques and their incorporation into a treatment regimen may enhance therapeutic success.

Pharmacotherapy may be valuable in recurrent pediatric headache, but is rarely the sole important factor in successful treatment. Any treatment program should begin with attention to basic hygienic factors such as adequate sleep, nutrition, and physical activity. Psychosocial factors actually may precipitate or augment recurrent pediatric headache. It is important to identify these factors, remove them if possible, and arrange for the provision of mental health services. At times, it is appropriate for the primary care clinician to provide such psychosocial support (eg, the academically stressed child). In the presence of a psychiatric condition or a dysfunctional psychosocial situation, referral to a mental health specialist is most appropriate. If successful referral to a mental health specialist is accomplished, it is important that the primary clinician continue to follow the headache activity and monitor the overall therapeutic intervention.

In a separate interview, the clinician should discuss the management of observable pain behavior with the parents. It is important to be aware that reinforcement (eg, stroking or release from responsibilities) during actual headache episodes may be counterproductive to efforts to extinguish functional disability. It may be more therapeutic for the caring parent to respond in a concerned, brief, and reserved manner during headache episodes and increase the duration and intensity of positive social responses during pain-free intervals. The parents should be advised to promote normalization of the child's sleep, daytime activity, and meal times. School attendance should be valued as a vital activity for the developing child or adolescent and representative of personal responsibility (their "job").

In general, it is appropriate for the parent to delegate as much responsibility as possible to the patient for treatment compliance. With behavioral techniques that require the use of self-help skills, parental assumption of responsibility for treatment compliance is counterproductive to promoting selfmastery and control. If compliance with practice of a behavioral skill such as self-hypnosis becomes a focus of confrontation and control between parent and child, its efficacy is likely to be diminished. Therefore, a developmentally appropriate balance between patient autonomy and parental involvement must be achieved.

Noncompliance with prescribed treatment regiments is a common clinical problem. Explicit, detailed instructions should be given for all aspects of treatment, and a contract for compliance should be agreed on between provider and patient. It is often appropriate to cue compliance with daily activities (eg, relax muscles each time the class bell rings). Possible hindrances to compliance should be anticipated, and strategies for success should be developed with patient and parent participation.

Regular follow-up (not as needed) visits should be scheduled to monitor progress and adjust treatment as necessary. At each follow-up appointment, the clinician should review the headache history, perform a brief symptom-focused physical examination, and review pain diary recordings. In addition to evaluating headache reports, it is important to assess the level of functional disability (eg, school absenteeism). The prescription of chronic medications should be controlled carefully and reviewed frequently. Decisions to change treatment regimens should be made only in the presence of adequate symptom monitoring data.

SUMMARY

Continuity of care with a clinician who has established a therapeutic alliance is the most important aspect of recurrent pediatric headache management. The provider should assume a concerned and supportive manner that promotes self-esteem and selfmastery and control. Patient and family efforts to reduce functional disability and return to normal activities should be strongly reinforced. Treatment regimens should be reviewed for side effects, compliance, and perceived efficacy. Behavioral techniques should be reviewed in detail with opportunities for the clinician to "trouble shoot" any difficulties encountered by the patient. Periods of potentially increased stress (eg, transitions or loss) should be anticipated and managed prospectively. The clinician should periodically reassess possible psychosocial issues and make appropriate mental health referrals. In the long run, regular follow-up by the primary care clinician remains the most important factor in the successful management of recurrent pediatric headache.

REFERENCES

1. Bille B. Migraine in school children. Acta Pediatr Scand. 1962:51(suppl 163):S1-151.

2. Linet MS, Stewart WF. Colentano DD, Zieglet D, Sprecher M. An epidemiologic study of headache among adolescents and young adults. JAMA. 1989;261:2211-2216.

3. Sillanpaa M. Changes in the prevalence of migraine and other headaches during the first seven school years. Headache. 1983;23:15-19.

4. Bille B. Migraine in childhood and its prognosis. Cephalalgia. 1981;1:71-75.

5. Newacheck PW, Taylor WR. Childhood chronic illness: prevalence, severity, and impact. Am J Pubic Health, 1992;82:364-371.

6. Rokicki LA, Holroyd KA. Factors influencing treatment-seeking behavior in problem headache sufferers. Headache. 1994;34:429-434.

7. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia. 1988;8(suppl 7):12-34.

8. Holden EW, Gladstein J, Trulsen M, Wall B. Chronic dally headache in children and adolescents. Headache. 1994;34:508-514.

9. Honig PJ, Charney ER. Children with brain tumor headaches. Am J Dis Child. 1982;136:121-124.

10. Suwanwela N, Phanthumchinda K, Kaoropthum S. Headache in brain tumor: a cross-sectional study. Headache. 1994;34:435-438.

11. Barlow CF. Headaches and Migraine m Childhood. Philadelphia, Pa: Spastics International Medical Publications; 1984.

12. Faleck H, Rothner AD, Erenberg G, et al. Headache and subacute sinusitis in children and adolescents. Headache. 1988;28:96-98.

13. Andrasik F, Blanchard EB, Arena JG, Teders SJ, Teevan RC, Rodichok LD. Psychological functioning in headache sufferers. Prychosom Med. 1982;44:171-182.

14. McGrath PA. An assessment of children's pain: a review of behavioral, physiological and direct scaling techniques. Pain. 1987;31:147-176.

TABLE 1

International Headache Society Classification 1988

TABLE 2

Indications for Neurofmaglng In Recurrent Pediatric Headache

TABLE 3

Psychosocial History in Recurrent Pediatric Headache

10.3928/0090-4481-19950901-05

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