The most common cause of headaches in children and adolescents
are migraines and stress-related headaches. Headaches can also be seen with
fever, the flu, and acute respiratory infections. This document reviews many of
the less frequently seen headaches that occur in children and adolescents. The
order of presentation of the different headache types discussed in this document
is consistent with the frequency with which these headaches types occur.
Head injuries account for a large number of emergency department
visits by children. Children and adolescents who are involved in motor vehicle
accidents, bicycle accidents, sports-related injuries, or child abuse may
develop a headache syndrome within minutes to days following the incident, even
after what would seem to be a trivial head injury.
Patients with post-traumatic headache often have other symptoms
including dizziness, vertigo, difficulty concentrating, memory disorders,
depression, altered school performance, behavior disorders and sleep alteration.
This collection of symptoms together with headache is commonly called
post-concussion syndrome. Importantly, the severity of the symptoms does not
depend on the severity of the head injury.
The headaches associated with the post-concussion syndrome can
be similar to a migraine headache (occurring intermittently with nausea or
vomiting or daily), a tension-type headache, or both.
Most patients who are hospitalized for a mild to moderate head
injury receive some form of neuroimaging – either computed tomography (CT) or
magnetic resonance imaging (MRI). However, the absence of abnormality on MRI or
CT does not predict whether a patient will develop post-traumatic headaches or
Following mild head injury, functional recovery generally occurs
in the following order: attention and concentration deficits usually resolve
within 6 weeks; visual memory, imagination, and analytic capacity do not begin
to resolve for at least 6 weeks; verbal memory, abstraction, cognition and
information processing speed can take more than 12 weeks to recover. Although
most children have clinical improvement of their headache sequelae within
several weeks, and almost all within 3 to 6 months, some patients continue to
experience headache and the associated symptoms of post-concussion syndrome.
Post-traumatic headache treatment is symptomatic. The initial
headache symptoms and soft tissue injuries may be effectively treated with mild
analgesics and nonsteroidal anti-inflammatory drugs over the initial weeks. If
there is associated cervical soft tissue symptoms, a short course of physical
therapy might be of benefit. If more prominent headache symptomatology or
associated symptoms of anxiety, depression, or cognitive difficulties are
present, more aggressive intervention may be necessary. Post-traumatic headache
usually responds to the medications that are used for chronic headache and
chronic tension-type headache, although no specific medication or treatment
protocol has been found that will alter the underlying central nervous system
disturbance. Tricyclic antidepressants, such as amitriptyline or nortriptyline,
are often the medications of choice. To avoid rebound headaches, analgesic use
should be limited to no more than two days a week.
Patients who have migraine-like post-traumatic headaches may
benefit from triptans, with or without antiemetics. Nonpharmacologic therapies,
such as counseling – which is often combined with biofeedback and stress
management techniques – can be quite effective, even in children as young as 9
years of age. Regardless of treatment approach, patients are encouraged to
return to school and normal activities as soon as possible.
Many people think their headaches are due to sinusitis, but this
isn’t usually the case. Although headaches can be a symptom of sinusitis,
sinusitis is a distinct medical condition. Sinusitis is an inflammation and/or
infection of the sinuses. Some of the causes include allergies, smoke,
respiratory infections and immune deficiency. Sinusitis may have a sudden onset
and be of short duration or can be a chronic condition, characterized by at
least four recurrences of sinusitis or infection that last 12 weeks or longer.
Common symptoms of sinusitis include facial pain/pressure, nasal
blockage and pus discharge, and frontal headache. Other symptoms include fever,
bad breath, and fatigue.
The clinical diagnosis of sinusitis can be based on symptoms or,
even better, confirmed by nasal endoscopy or a CT scan of the sinuses.
Treatments include decongestants and antibiotics.
Exertional headaches are brought on by strenuous activities,
such as running, swimming, or weight lifting, as well as sexual activity.
Exertional headaches can occur during or after the activity and may be
associated with nausea and vomiting. The headaches may be brief and generalized
or sharply localized. Patients describe the pain as a "hammer-like blow to the
head." The pain may last from 15 minutes to 12 hours.
If headaches occur only with exertion and are not associated
with neurologic signs or symptoms, imaging studies may not be necessary. If
neurologic signs and symptoms are present, medical evaluation is needed.
Treatment of these headaches should be conservative. In many
patients, headaches disappear spontaneously. Long-acting nonsteroidal
anti-inflammatory drugs, such as indomethacin, can be used chronically and/or
prior to specific activities. If indomethacin is taken chronically, monitoring
for side effects is mandatory.
Temporomandibular Joint Disorder (TMJ)
TMJ as a cause of headache is relatively uncommon in children
and adolescents. Children with TMJ disorders usually complain of a dull aching
pain that occurs just below the ear on one or both sides of the face. The pain
is usually localized but may expand to the temple, toward the middle of the
face, or across the top and front of the skull. The pain is usually aggravated
by chewing. Patients frequently describe clicking and locking of their jaw. Upon
examination, there may be tenderness over the jaw, and joint slipping may be
felt upon opening and closing the mouth. In addition, patients often cannot open
their mouths widely.
The cause of TMJ disorders is not clear, but the symptoms are
thought to arise from either stress or problems with the muscles of the jaw
and/or with the parts of the joint itself. Possible causes include:
- Stress, which can cause a person to tighten facial and jaw muscles or
clench the teeth
- Grinding or clenching the teeth, gum chewing, lip biting, which put a
lot of pressure on the TMJ
- Presence of osteoarthritis or rheumatoid arthritis in the TMJ
Treatment for TMJ disorder usually begins with a combination of
any of the following: anti-inflammatory drugs, muscle relaxants, mouth splints,
biofeedback, and counseling. The need for surgery in children and adolescents is rare.
There are two types of cluster headaches: chronic and episodic.
Patients with episodic cluster headaches – which account for 80 to 90%
of cluster headaches – report frequent headaches over a period of 1 to 3
months, followed by a period of remission. This period of remission may last
from months to years. Chronic cluster headaches, which account for 10 to 20% of
cluster headaches, are headaches that occur continuously for a year or longer
Cluster headaches are rare in children (age under
10) and uncommon in teens. They primarily affect men in their 30s. Typically 2
to 10 headaches occur each day. The headaches last from 10 minutes to 3 hours;
the average length of attack is 45 minutes. The headaches occur both during the
waking hours and during sleep. A common feature of these headaches is that they
can occur at exactly the same time each night.
The headache pain is severe, is usually isolated around one eye
or one side of the head (and never switches sides), and is associated with eye
tearing, runny nose, and nasal stuffiness. A drooping upper eyelid and
constriction of the pupil of the eye may also occur.
Most patients with cluster headache cannot lie down or rest
during the attack. Alcohol has been shown to trigger attacks, especially once
the headache cycle has begun. The cause of cluster headaches remains unclear.
In the acute phase of an attack, patients have benefitted from
oxygen, ergotamine tartrate, steroids, or the triptan medications. Chronic
prophylactic medications have included verapamil, lithium, and steroids.
Cyclic migraine, as its name implies, is a rare form of migraine
that occurs in cycles. This type of headache has also been incorrectly called
cluster migraine. Cyclic migraine is not a form of cluster headache.
Headache cycles range from 1 to 6 weeks in length. During the
cycles, headaches can occur daily or several times per week. In between the
migraine headaches, there may be a constant low-intensity headache. The headache
cycles are followed by headache-free intervals lasting weeks to months in duration.
Most patients who experience this type of headache are female.
The disorder may begin in the first or second decade of life and more than 50%
of patients have a positive family history of migraine.
In the absence of neurologic symptoms or signs, an underlying
cause is seldom found.
The first treatment options for cyclic migraine include lithium
carbonate followed by indomethacin. Standard antimigraine therapy may be
ineffective for cyclic migraine.
Chronic Paroxysmal Hemicrania
Chronic paroxysmal hemicrania is identified by the occurrence of
multiple daily attacks, usually five per day, which last from 5 to 30 minutes in
duration. The pain usually occurs on one side of the head and rarely alternate sides.
The pain is described as severe and autonomic phenomenon (eye
tearing, eye redness, eyelid edema, nasal congestion, runny nose) and other
symptoms may be present. The pain is most frequently localized to the eye or
forehead above the eye on one side of the head. The headache may be brought on
by head movement.
Chronic paroxysmal hemicrania has also been called atypical
cluster headache. The disorder is usually seen in females and is not commonly
reported in children. The general physical and neurologic examinations between
attacks are completely normal.
This disorder responds dramatically to indomethacin. When
indomethacin is discontinued, the headaches reappear in several days. Also,
chronic treatment with indomethacin requires careful monitoring for side
Hemicrania continua is a constant, moderately intense, one-sided
headache that is characterized by episodes of more intense pain that occurs
several times a day. The pain is localized to the front part of one side of the
head (and the pain does not switch sides) and is not associated with nausea.
Autonomic symptoms (eye tearing, eye redness, eyelid edema, nasal congestion,
runny nose) may be present. The headache is not brought on by any particular
event and the cause is not clear. Most of the affected patients are female.
Headaches typically begin during adolescence and there is
usually no family history of headache.
Indomethacin is the treatment option of choice. Chronic
treatment with indomethacin requires careful monitoring for side effects.
Occipital neuralgia includes pain experienced at the back of the
head, often starting at the upper neck or base of the skull. It may occur on one
or both sides of the head. Pain can be infrequent, can occur several times per
day, or can be constant. The pain is described as jabbing or throbbing.
Pain may radiate to the front of the head or to the eye. In
addition, patients report that their scalp is sensitive to the touch. At times,
pain can be brought on by movement, especially an overextension of the head.
Other symptoms may include dizziness and, rarely, nausea and vomiting.
Occipital neuralgia is often seen in athletes – particularly
weight lifters, wrestlers, and football players – and others, such as persons
involved in automobile accidents and those who incur extension and flexion injuries.
Physical examination may reveal cervical area tenderness, range
of motion limitation, and decreased sensation at the back of the head.
Radiographic imaging at the brain-cervical vertebrae junction may reveal abnormalities.
Treatment depends on the severity of the problem and may include
use of a soft cervical collar, analgesics, muscle relaxants, local injections,
physical therapy, massage, and on rare occasions, surgery.
Ice Cream Headache
An "ice cream headache" is the nickname that is given to
headaches that are cold induced. The International Headache Society criteria
defines this headache as pain that develops during the ingestion of cold food or
drink that lasts for less than 5 minutes and is felt in the middle of the
forehead. The headache is prevented by avoiding rapid swallowing of cold food
and drink. This type of headache occurs more frequently in patients who have
migraine, but it can also occur in migraine-free patients. It has been suggested
that the pain is referred from the palate or teeth via the trigeminal nerve. The
pain is self-limited and only rarely requires treatment.
Cough headache is considered by some to be a form of exertional
headache and is sometimes grouped together with other headaches described as
"sneezing headache" and "laughing headache." The International Headache Society
defines cough headache as a headache that is felt in both sides if the head,
which is of sudden onset, that lasts less than 1 minute, is brought on by
coughing, and can be prevented by avoiding coughing. The most common triggers of
cough in children are chronic bronchitis, asthma, and cystic fibrosis. Treatment
for these headache triggers (but not this type of headache itself) may be indicated.
Ice Pick Headache
Ice pick headache refers to a type of headache pain that is
described as momentary (lasting seconds), sharp, and/or jabbing that occurs
either once or several times a day at irregular intervals. It has also been
nicknamed the "jabs and jolts" or "stabs and jabs" headache. The pain
is most often felt around one eye or the temple area and it recurs in the same place or
may move to other places on the same side of the head or the opposite side.
These headaches are more likely in patients with migraine or cluster headaches.
It is uncommon in the pediatric and adolescent population. This type of headache
disappears spontaneously in many cases or can be successfully treated with indomethacin.
Chronic facial pain is uncommon in children and adolescents. It
is more commonly seen in older individuals. Facial pain, when it occurs
suddenly, is usually related to sinusitis, dental disorders, or facial trauma.
Patients presenting with facial pain require a thorough evaluation. Stress and
psychological factors are prominent causes.
This headache is especially common in individuals who climb
mountains and ski at high altitudes. It may be seen in acute mountain sickness
along with other primary symptoms of pulmonary edema and cerebral edema. The
headache is seen at high altitudes (above 8,000 feet and with increasing
frequency as elevation increases) and is usually associated with low oxygen levels.
The headache is described as generalized and throbbing and is
aggravated by exertion, coughing, and lying down. The headache usually appears
from 6 to 96 hours after arriving at high altitudes.
On examination, patients may have retinal hemorrhages,
papilledema, and confusion. Relief of headache is obtained by descending to
Ergotamine may be effective, but oxygen inhalation is especially
effective. The disorder may be prevented with the use of acetazolamide,
phenytoin, and dexamethasone.
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