Headaches are common during childhood and become increasingly more frequent during the teenage years. The prevalence of headache rises steadily from one-third of children during the elementary school years and to more than one-half of adolescents by the high school years. Recurring or episodic patterns of headache, such as tension-type or migraine, occur in about 5% of 7-year-olds and increase to about 15% of 15-year-olds. Curiously, before puberty, boys are affected more frequently than girls, but after puberty, headaches occur two to three times more frequently in girls.
As a consequence, “headache” is a common chief complaint in primary care offices. Because headache can be caused by a variety of processes (from the primary entities, such as migraine or tension-type, to secondary causes, such as brain tumors, idiopathic intracranial hypertension, chronic meningitis, hydrocephalus, drug intoxications, sinusitis, or acute febrile illnesses, such as influenza), it is essential to have a systematic approach to the child or adolescent who presents to our offices with headache.
The “headache” evaluation includes a thorough medical history, followed by methodical physical examination, with measurement of vital signs, and is completed by the neurological examination. The diagnosis of primary headache disorders, such as migraine and tension-type, rests principally on clinical criteria established by the International Headache Society (available online at www.ihs-klassifikation.de/en/). Clues to the presence and identification of secondary causes of headache are revealed through this systematic process of history and physical. Whether or not it is necessary for any other diagnostic testing (magnetic resonance imaging, or MRI; computerized tomography, CT; or electroencephalogram, or EEG) to be performed depends upon information, or concerns, revealed during the history and physical.
This issue of Pediatric Annals is intended to serve as a toolbox for primary care physicians when evaluating a child with the complaint of headache. Once the headache diagnosis is determined, the most appropriate treatment plan can be formulated from the variety of treatment options discussed later in this issue of Pediatric Annals.
The issue begins with a strategy to evaluate and diagnose the cause of the pain (see page 399). When do we need to worry, and when do we scan?
Because migraine is such a common problem, two articles (pages 408 and 416) focus particular attention to the clinical spectrum of migraine and its treatment options. It must be emphasized that migraine is a chronic, progressive, debilitating disorder that affects the lives of millions of individuals. The origins of the disability can be traced into childhood and adolescence for the majority of adult migraine sufferers. Pediatricians stand in a pivotal position to provide accurate diagnosis and to begin aggressive treatment interventions during childhood and adolescence and, thereby, prevent decades of suffering and diminished quality of life that are directly attributable to migraine. This intervention has as much effect on the patient’s overall well being as providing immunizations and weight management.
One of the most difficult subsets of headache patients are those with chronic daily headache. Drs. Mack and Gladstein review this challenging condition, providing a categorization system and a management scheme (see page 424).
The articles that follow include an overview of “secondary” headaches (see page 431), with a focus on headache as a symptom of systemic illness, and include common entities, such as idiopathic intracranial hypertension (pseudotumor cerebri), a condition that is becoming more common as obesity becomes more prevalent among children.
Because migraine is not the only primary headache, there is a separate article (see page 440) covering the common problem of tension-type, and the rarer entities, such as the trigeminal autonomic cephalalgias (ie, cluster headache) in children.
The authors of these articles are all pediatric headache experts who have dedicated their careers to caring for children and teens who suffer from headache and to sharing their knowledge and experience with others. I am truly indebted to each of them, and I hope the reader learns as much from these articles as I have.