Headache Disorders

Headache Basics & Types - Kiddo Head Pains

• Headache (cephalgia): Pain in head/upper neck. Common in children.
• Types:
  • Primary: No underlying cause. E.g., Migraine, Tension-Type Headache (TTH).
  • Secondary: Due to pathology. E.g., Infection, tumor, ↑ICP.
• ⚠️ Red Flags (SNOOPP):
  • Systemic: Fever, weight loss, immunosuppression.
  • Neurologic: Focal deficits, papilledema, altered mental status, seizures.
  • Onset: Sudden (thunderclap), new in child <5 yrs, or recent significant change.
  • Occipital: Especially if isolated and in young children.
  • Pattern: Progressive, wakes from sleep, worse with Valsalva/cough, postural aggravation.
  • 📌 SNOOPP helps screen for serious underlying causes.

⭐ Migraine is the most common cause of recurrent headaches in children.

Pediatric Migraine - Little Brain Storms

• Common primary headache; ~7-10% child prevalence.
• Clinical (vs. Adults):
  • Shorter: 1-72 hrs.
  • Often bilateral (frontal/temporal).
  • Prominent GI: Nausea, vomiting, abdominal pain.
  • Aura: Visual (common), sensory.
• Diagnosis: ICHD-3 (≥5 attacks).
• Variants: Abdominal Migraine, Cyclical Vomiting (CVS), Benign Paroxysmal Vertigo (BPV).
• Management:
  • Acute: Ibuprofen (10 mg/kg); Sumatriptan (age-specific).
  • Prophylaxis: Topiramate, Propranolol (frequent/disabling).
  • Non-pharm: Trigger avoidance, lifestyle.

⭐ Pediatric migraine attacks are often shorter (1-72h), bilateral, with prominent GI symptoms; aura may be atypical (e.g., confusion).

Other Headaches & Red Flags - Danger Signals

• Tension-Type Headache (TTH):

  • Most common primary headache.
  • Bilateral, non-pulsating, "band-like" pressure.
  • Mild-moderate intensity. Not worsened by routine activity.
  • No nausea/vomiting; photophobia OR phonophobia (not both).
  • Rx: NSAIDs, Paracetamol. Prophylaxis: Amitriptyline.

• Headache Red Flags (Danger Signals) 📌 SNOOP + 3 P's:

  • Systemic symptoms (fever, weight loss) or risk factors (cancer, HIV).
  • Neurologic signs/symptoms (focal deficits, altered mental status, seizures).
  • Onset: Sudden ("thunderclap"), or new/progressive in child < 5 yrs.
  • Occipital location (posterior fossa tumor risk).
  • Papilledema (check fundus!).
  • Pattern change (↑frequency/severity, awakens from sleep).
  • Precipitated by Valsalva/cough/exertion, or Postural trigger.

⭐ > Occipital headache in a child is a red flag for a posterior fossa tumor until proven otherwise.

Headache Management - Kid-Friendly Relief

• Non-Pharmacological First! (Pillar of management)
  • Lifestyle: Regular sleep, hydration, balanced diet, identify & avoid triggers.
  • Stress reduction: Relaxation techniques, CBT, biofeedback.
• Acute (Abortive) Therapy: (Step-up approach)
  • Mild: Rest, paracetamol (15 mg/kg), ibuprofen (10 mg/kg).
  • Migraine (Mod-Severe): If simple analgesics fail or severe onset.
    • Triptans: Sumatriptan Nasal Spray (>12y), Rizatriptan ODT (>6y), Almotriptan tabs (>12y).
    • Antiemetics: Ondansetron, Domperidone (⚠️ QT risk).
• Prophylactic (Preventive) Therapy:
  • Indications: ≥4 headache days/month, prolonged attacks, significant disability, or abortive therapy failure/overuse.
  • Meds: Propranolol, Topiramate (⚠️ cognitive effects), Amitriptyline, Flunarizine. Cyproheptadine (esp. <7y, appetite stimulant).

⭐ In children >12 years with acute moderate-to-severe migraine, sumatriptan nasal spray (10-20 mg) is a preferred first-line specific therapy if NSAIDs are insufficient.

High‑Yield Points - ⚡ Biggest Takeaways

• Migraine in children: often bilateral, shorter duration; positive family history common. Aura may occur.
• Tension-type headache (TTH): typically bilateral, "band-like" pressure, not worsened by routine activity.
• Key Red Flags: sudden severe onset, neurological deficits, papilledema, persistent morning vomiting, age <5.
• Acute treatment: ibuprofen or paracetamol. Sumatriptan (nasal/oral) for adolescent migraines.
• Consider prophylaxis (e.g., propranolol, topiramate) for frequent or disabling migraines.
• Medication Overuse Headache (MOH): identify early; caused by frequent analgesic/triptan use.