Although migraines and stress-related tension-type headaches are the most commonly seen headache types in children and adolescents, other headache types can occur too. This article reviews some of the lesser known headaches that occur in children. Consider seeing a pediatric headache specialist for these less common headache types.

What is a post-traumatic headache/post-concussion syndrome?

Head injuries account for a large number of emergency department visits by children. These head injuries often result from falls, motor vehicle accidents, bicycle accidents, sports-related injuries, or child abuse. However, even a minor head injury can cause a post-traumatic headache.

Besides the headache itself, other symptoms seen with this headache type include dizziness, spinning sensation (vertigo), difficulty concentrating, memory problems, depression, changes in school performance, behavior problems, and changes in sleep pattern. This collection of symptoms together with headache is commonly called post-concussion syndrome. The headache can take minutes to days to develop after the incident.

Computed tomography (CT) or magnetic resonance imaging (MRI) are often performed in patients with a mild to moderate head injury.

Recovery from mild head injury usually occurs in the following order: attention and concentration problems usually improve first (within 6 weeks); memory of objects, imagination, and problem solving begin to improve after 6 weeks; memory of words/language, idea generation, understanding information and speed of understanding can take more than 12 weeks to recover. Although most children’s headaches improve within weeks – and almost all within 3 to 6 months – some children continue to have headaches and related symptoms.

Treatment is based on symptoms. Mild pain relievers (analgesics) and nonsteroidal anti-inflammatory drugs (NSAIDs), taken for 2 to 3 weeks, are helpful for mild headache symptoms. If relief is not achieved after 4 weeks, seek the help of a headache specialist.

Physical therapy may benefit those who have neck injuries. If the headache is more severe or occurs with symptoms of anxiety, depression, or mental difficulties (learning, recognizing, remembering, thinking, understanding), further evaluation and prescription medications may be needed. Tricyclic antidepressants, such as amitriptyline or nortriptyline, are often used. Taking analgesic medication for a long period of time can cause a headache (called a rebound headache). For this reason, do not take analgesic medications more than two days a week.

Children who have migraine-like post-traumatic headaches may benefit from triptans, with or without anti-nausea drugs (antiemetics). Non-drug treatments, such as counseling, biofeedback, and stress management can be helpful, even in children as young as 9 years of age. Especially important is to get 8 hours of sleep a night, drink six 8-oz glasses of water day, eat three healthy meals a day (especially don’t skip breakfast), limit the use of over-the-counter medications – 2 days/week or less, and exercise 30 minutes/3 times week. During recovery, avoid contact sports and avoid a second impact/concussion. Children should return to school and normal activities as soon as possible.

What are exertional headaches?

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 occur with nausea and vomiting. Patients describe the pain as a “hammer-like blow to the head.” The pain may last from 15 minutes to 12 hours.

In many children, exertional headaches disappear on their own without treatment. Children should over-hydrate before participating in cross country, running or other very exertion activities. Nonsteroidal anti-inflammatory drugs can be used long term and/or 2 hours before strenuous activities. If exertional headaches continue to occur, seek the advice of a headache specialist.

What is occipital neuralgia?

Occipital neuralgia includes pain felt 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, the 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 prone to injuries from head and neck movement, such as persons involved in automobile accidents.

Neck area tenderness, limited range of head-neck motion, and decreased feeling at the back of the head are seen during physical exam. Imaging of the base of the brain/neck area may be abnormal.

Treatment depends on the severity of the problem and may include use of a soft neck collar, analgesics, muscle relaxants, local injections, physical therapy, massage, and on rare occasions, surgery. This headache should be managed by a headache specialist.

What is an ice cream headache?

An “ice cream headache” is the nickname that is given to headaches that are brought on by consuming cold foods or beverages. The headache pain lasts for less than 5 minutes and is felt in the middle of the forehead. To prevent this headache, avoid quickly swallowing cold foods and drinks. This headache is more common in patients who have migraines, but can also occur in migraine-free patients. The pain lasts a short period of time and only rarely requires treatment.

What is a cough headache?

Cough headache is sometimes grouped with “sneezing headache” and “laughing headache.” These headaches are all brought on by exertion – that is to say, coughing, sneezing, and laughing. A cough headache is felt on both sides if the head, occurs suddenly, and lasts less than 1 minute. Treatment for these headache is to prevent the cough by treating its triggers. The most common triggers of cough in children are chronic bronchitis, asthma, and cystic fibrosis.

What is an ice pick headache?

Ice pick headache is described as sharp, and/or jabbing pain that occurs either once or several times a day and lasts only seconds. This headache is also nicknamed the “jabs and jolts” or “stabs and jabs” headache. The pain is most often felt around one eye or the temple area, recurs in the same place, or may move to other places on the same side of the head or the opposite side. Ice pick headaches are not common in the young children but become more common in adolescents. This headache disappears on its own or can be treated with indomethacin.

What is an altitude headache?

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 symptoms including lung swelling (called pulmonary edema) and brain swelling (called 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 throbbing throughout all areas of the head and is made worse by exertion, coughing, and lying down. The headache usually appears from 6 to 96 hours after arriving at high altitudes.

During examination, patients may have retinal bleeding (hemorrhages), swelling of the optic nerve (papilledema), and confusion. Descending to lower altitudes relieves the headache.

Ergotamine may be effective, but giving oxygen is especially effective. Altitude headache may be prevented with acetazolamide, phenytoin, or dexamethasone.

What are cluster headaches?

There are two types of cluster headaches: chronic and episodic. Eighty to 90% of cluster headaches are episodic. These headaches occur often over 1 to 3 months, followed by a headache-free period (called remission) that may last from months to years. The remaining 10 to 20% of cluster headaches are chronic cluster headaches. These headaches occur for a year or longer without periods of remission.

Cluster headaches are rare in children under age 10 and are uncommon in teens. They primarily affect men in their 30s. For those who do get cluster headaches, 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 occurs 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 early phase of an attack, treatments include oxygen, steroids, or the triptan medications. Long-term treatment to prevent cluster headaches includes verapamil, lithium, and steroids. These headaches should be managed by a headache specialist.

What is chronic paroxysmal hemicrania?

Chronic paroxysmal hemicranias, also called atypical cluster headache, consists of multiple daily attacks. The typical patient experiences about five headaches per day, which last from 5 to 30 minutes.

The pain is described as severe and occurs around the eye or forehead above the eye. The pain is usually isolated to one side of the head and rarely changes side from one attack to another. Other symptoms may include eye tearing, eye redness, eyelid swelling (edema), nasal congestion, runny nose. The headache may be brought on by head movement.

Chronic paroxysmal hemicrania is usually seen in females and is not commonly reported in children. Results of general physical and neurologic exams are completely normal between attacks.

This headache disorder responds well to indomethacin. When indomethacin is stopped, the headaches reappear in several days. Long-term treatment with indomethacin requires careful monitoring for side effects.

What is hemicrania continua?

Hemicrania continua is a constant, moderately intense, one-sided headache that consists of episodes of more intense pain that occurs several times a day. The pain is felt in the front part of one side of the head (and the pain does not switch sides) and is not associated with nausea. Other symptoms may include eye tearing, eye redness, eyelid swelling, nasal congestion, runny nose. The headache is not brought on by any particular event and the cause is not clear. Most of the affected patients are female.

Hemicrania continua is very rare in children and adolescents.

Indomethacin is the treatment option of choice. Chronic treatment with indomethacin requires careful monitoring for side effects. This headache type should be managed by a headache specialist.

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