Headache

The Problem

“My child is having headaches.”

Common Causes

Migraine

Tension headache

Other Causes

Eyestrain (uncommon cause of headache)

Accommodation difficulty

High refractive error

Increased intracranial pressure

Tumor

Hydrocephalus

Idiopathic intracranial hypertension

KEY FINDINGS

History

Migraine

Usually fairly severe headache

Child stops activities to lie down or go to school nurse Nausea/vomiting

Prodromal visual symptoms

Sparkling colors, jagged lines, visual field changes Family history

Tension headache

Often situational (e.g., during school) Less severe symptoms

Do not stop activities

Eyestrain

Eye fatigue or double vision Worse when reading

Increased intracranial pressure Progressive symptoms, more constant Headache may awaken child from sleep Nausea, vomiting

Double vision

Transient episodes of vision loss

Examination

Migraine Normal vision

Normal examination

If seen during headache, may have visual field changes

Eyestrain

Visual acuity usually normal Increased intracranial pressure

Bulging fontanelle in infant (too young to complain of headache)

Papilledema

Possible sixth nerve palsy Other cranial nerve palsies

WHAT SHOULD YOU DO?

Headaches are a fairly frequent complaint in children, and most are not a serious problem. However, they may be an early symptom of serious disorders such as an intracranial tumor or idiopathic intracranial hyperten-

sion. A careful history and examination are necessary to determine whether additional testing or referral to a pediatric ophthalmologist or neurologist is indicated. If the history is consistent with migraine or tension headache and the examination is otherwise normal, symptomatic treatment may be all that is necessary. If the

130 ■ Section 2: Symptoms

history or examination suggests the possibility of increased intracranial pressure, then imaging studies and referral to a pediatric neurologist are indicated.

The eyes themselves are rarely the cause of headache, but an ophthalmological examination may be necessary to rule out this possibility.

What Shouldn’t Be Missed

Migraine headaches are not uncommon in children. They may present with an initial complaint of abnormal visual phenomenon (prodrome). Recognition of migraines is important both for treatment and to avoid unnecessary testing. Less commonly, headaches may result from intracranial tumors or other serious disorders. The presence of papilledema indicates the need for prompt evaluation.

COMMON CAUSES

1.Migraine headache. Migraine headaches are more common in children than is often recognized.These may present with specific complaints of eye pain, which may be retroor periorbital. Classic migraines are accompanied by prodromal syndromes, which are often visual, such as sparkling lights, jagged lines, or visual field defects (Figure 22–1). Most patients develop headaches in association with these phenomena, but the abnormal visual sensations sometimes occur without the headache (acephalgic migraine). The features of the headache, normal eye examination after the symptoms resolve, and the presence of a family history of migraines help in establishing a diagnosis.

2.Tension headache. Tension headaches also occur in children, but are less severe. Patients

FIGURE 22–1 ■ Jagged lines. A form of visual prodrome that patients may describe in association with migraine headaches.

typically do not specifically complain of eye pain. The headaches tend to occur in specific situations, such as while at school.

3.Eyestrain. Eye problems rarely cause headaches, but an ophthalmological examination may be necessary if a diagnosis cannot be established. Patients with uncorrected refractive errors may squint chronically in an attempt to improve vision through a pinhole effect. Spectacle correction should resolve this problem. Occasionally, patients may have difficultly with accommodation (focusing of the lens at near) or convergence, which may cause complaints of eye fatigue or strain, particularly with reading.

4.Increased intracranial pressure. Headaches are a common symptom of increased intracranial pressure, which may occur for a variety of reasons. The visual acuity is usually normal unless the pressure is markedly elevated or prolonged to the point that optic nerve damage occurs. Etiologies include intracranial space-occupying lesions, hydrocephalus, and idiopathic intracranial hypertension (pseudotumor cerebri).

APPROACH TO THE PATIENT

Headaches are fairly common in children, and the pediatrician must decide which patients require only symptomatic care and which require further evaluation. Primary ocular problems only rarely cause headaches, but an ophthalmological evaluation may be indicated if a diagnosis cannot be established.

History

A careful history is very helpful in the evaluation of patients with headaches. Often a presumptive diagnosis can be identified based on the history alone. Occasional mild headaches that resolve without treatment usually do not require any further evaluation other than a screening examination (see below).

The history in migraine headaches can be variable, but certain features are common. The pain is usually fairly severe. If a child stops normal activities because of a headache, particularly while doing enjoyable activities, then migraine is the most likely diagnosis. The pain in migraine may occur in any location on the head, including the retroor periorbital area, and the child may complain of specific eye pain. Migraines are frequently accompanied by nausea and vomiting, which can also occur in patients with increased intracranial pressure. The presence of prodromal visual symptoms, such as sparkling colored lights (scintillat-

ing scotomas), jagged lines (Figure 22–1), or visual field defects, which resolve either as the headache begins or after the headache subsides, is almost pathognomonic for migraine. Most patients with migraines have a positive family history.

Eye problems are infrequently the cause of headaches, but specific historical information may suggest this possibility. Patients with uncorrected refractive errors may complain of decreased vision, but it is important to recognize that children with refractive errors may not realize that they do not see as well as others. Therefore, decreased vision is often first noticed by teachers or family members, when the child is unable to read something at a distance that others can. Difficulty with accommodation or convergence may cause complaints of eyestrain or eye fatigue, which is worse during reading.

Symptoms of increased intracranial pressure are initially often similar to those of headache, particularly migraine, but certain features help differentiate the two. The headaches with increased intracranial pressure tend to be chronic, rather than episodic. The presence of progressively worsening symptoms is very concerning for an enlarging intracranial lesion. Headaches due to increased intracranial pressure may awaken the child from sleep, which would be unusual with migraine. Patients with idiopathic intracranial hypertension may have symptoms of horizontal diplopia due to sixth nerve palsy and may also experience brief (few seconds) episodes of visual loss (transient visual obscurations). The visual field defects that may occur with migraines last longer (30–60 minutes) and resolve after the headache.

Examination

Patients who present for evaluation of headache should undergo a thorough neurological examination. The eye examination should include assessment of visual acuity, pupil reactions, confrontation visual fields, and ocular motility. The direct ophthalmoscope should be used to check for papilledema (Figure 22–2).

CHAPTER 22 Headache ■ 131

FIGURE 22–2 ■ Marked papilledema in a patient with idiopathic intracranial hypertension.

By the time patients with migraines are evaluated, the headaches have usually resolved and the examination is normal. If they happen to be seen during the headache, visual field defects or other visual abnormalities might be documented.

PLAN

A decision regarding management and further evaluation of headaches depends on consideration of all the factors above (Table 22–1). If papilledema is present, urgent referral for neuroimaging and pediatric neurological consultation is indicated. If the examination is normal, including the absence of papilledema, then the history may help determine an appropriate course of action. If the specific headache features are typical of migraine, and particularly if there is a positive family history, additional tests may not be necessary. If the history is less clear, neuroimaging may be considered. If the examination is normal except for decreased visual acuity, or if the patient has specific complaints of

eyestrain that are worse with reading, referral to a pediatric ophthalmologist is warranted.

WHAT SHOULDN’T BE MISSED

Headaches are fairly common in children, and usually are not severe. However, very serious disorders, such as intracranial tumors, may present initially with headaches. The presence of papilledema on examination indicates the need for urgent evaluation (Figure 22–3).

When to Refer

■Any patient with a headache and papilledema should be referred promptly for neuroimaging and neurological consultation

■Patients with headache and other neurological abnormalities (e.g., cranial nerve palsy) should be referred promptly

■Patients with specific complaints of eyestrain, especially if worse when reading, should be referred to a pediatric ophthalmologist