Headache in children and adolescents may occur due to primary or secondary causes.
The most common forms of primary headache are migraine and tension type headache. If there are neurological signs and/or unexpected neurological symptoms accompanying the headache, secondary headache causes must be excluded.
Migraine
General Information
• Migraine is the most important among vascular headaches. It is characterized by recurrent attacks of unilateral and throbbing headache, which can be confused with epilepsy.
It is one of the episodic syndromes.
• Hyperemia or pallor, mydriasis, photophobia, cyclic vomiting are the most important vasomotor changes. The type of migraine with vasomotor changes is called "epilepsy equivalents". EEG disorder can be detected in a child with migraine, but there is no specific finding.
• Migraine and tension headaches are the most common chronic recurrent headaches in both children and adults.
Migraine full criteria
Migraine Without Aura
1. Headache that persists for 4-72 hours (Untreated or unsuccessfully treated)
2. Headache with at least 2 of the following features:
A) One-sided
B) throbbing
C) moderate to severe
D) Aggression or avoidance with routine physical activity (such as walking)
3. At least one of the following is present during the headache:
A) Nausea, vomiting, or both
B) Photophobia or phonophobia
4. Findings cannot be explained by another disease
For diagnosis, at least 5 attacks meeting criteria 1-3 are required.
Migraine with Aura (Typical)
1. The aura includes at least one of the following without motor weakness:
A) Completely reversible visual symptoms
B) Completely reversible sensory symptoms
C) Completely reversible dysphasic speech disorder
2. Having at least two of the following:
A) At least one aura is unilateral
B) At least one aura symptom and/or 2 or more consecutive symptoms occurring gradually over 5 minutes
C) Your symptoms are less than 5 minutes; not take longer than 60 minutes
D) The onset of the headache during the aura or within 60 minutes after the aura
3. Findings cannot be explained by another disease
For diagnosis, at least 2 attacks meeting criteria 1-3 are required.
• The pain is usually throbbing and does not start suddenly. Intracranial hemorrhage and pheochromocytoma should be considered in sudden onset headaches.
• Classical migraine has an aura and in many cases the pain is bilateral.
• Aura may be absent in atypical forms. In patients with hemiplegic migraine, transient neurological deficit develops just before or together with the headache. Neurological deficit aphasia, hemiparesis,
It can be in the form of hemianopsia or third nerve palsy.
• Patients with basilar artery migraine have episodes of confusion, vomiting, vertigo, and vision loss indicating basilar artery occlusion. A family history of migraine helps distinguish this form from vascular malformations.
• Migraine attacks can be precipitated by stress, intake of certain foods and substances [chocolate, peanuts, tyramine (found in cheddar cheese, chicken liver and beer), nitrites and quinine].
Treatment of migraine in children
Acute Migraine
ACUTE MIGRAINE
Analgesics: Acetaminophen - Ibuprofen
Triptans :
- Rizatriptan (6-17 years)
- Almotriptan (12-17 years)
- Sumatriptan
prophylaxis
Calcium channel blockers: Flunarizine
Antihypertensive: Propranolol
Anticonvulsants: Valproate, Topiramate, Levetiracetam, Gabapentin
Antihistamines: Cyproheptadine
Antidepressants: Amitriptyline (the most commonly used agent for prophylaxis)
Coenzyme Q, Riboflavin, Mg, Onabotulinum in toxin A
can be used for prophylaxis.
Resistant Migraine
Prochlorperazine
metoclopramide
ketorolac
Valproate
Dihydroergotamine (IV or Nasal spray)
Tension Type Headache
It is the most common type of headache with migraine in children. There may or may not be stretching of the pericranial muscles during headache. Having at least 10 headache attacks lasting 30 minutes/ 7 days at diagnosis distinguishes it from secondary headache.
Central Nervous System Imaging and Causes of Headache Requiring Further Examination
• Abnormal neurological findings
• Abnormal or focal neurological signs or symptoms
Focal neurological symptoms and signs that occur during a headache (eg, complicated migraine)
Focal neurologic symptoms and signs (except for the classical visual symptoms of migraine) that occur during the aura and are always on the same side; persistence or recurrence of focal aura findings during the headache phase
• Seizures or very short auras ( <5 min)
• Unusual headaches in children
Atypical auras, including bacillary-type, hemiplegic
Trigeminal autonomic cephalalgia in cluster headache
Acute secondary headache (patients with known underlying disease)
• In all children younger than 6 years old or unable to express headache
• Having headache with cough
• Severe headache that wakes the child from sleep or wakes up in the morning
• Migrant or similar headache without a family history
• Hemiplegia
• Trigeminal autonomic cephalgia
