Headaches: Less Frequent Types
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.
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 post-concussion syndrome.
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 without remission.
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 effects.
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 lower altitudes.
Ergotamine may be effective, but oxygen inhalation is especially effective. The disorder may be prevented with the use of acetazolamide, phenytoin, and dexamethasone.