CHRONIC HEADACHES
History
Tom is a 10-year-old boy referred to outpatients by his GP with a 2-year history of recurrent headaches. He describes the pain as being of gradual onset, frontal, right-sided and throbbing. He has not noticed any visual symptoms. He takes paracetamol but it is of limited value. The headache is often preceded or accompanied by nausea and vomiting. His mother has noticed that he becomes very pale and quiet. He takes himself off to bed and sleeps for several hours after which he is fine. The episodes can last up to 12 hours. In between episodes Tom is fit and well. He is happy at school and doing well but missed 10 days last term due to headaches. He takes part in numerous after-school activities and loves performing arts, especially dance. He was admitted with a minor head injury at the age of 7 having fallen off his bike. There is no other significant past medical history and he takes no regular medication. His mother suffered with migraine as a teenager.
Examination
Tom is a healthy, well-grown boy. His height and weight are both on the 75th centiles. His pulse is 68 beats/min and regular and his blood pressure 96/58 mmHg. Examination of the cardiovascular, respiratory and abdominal systems is normal. His cranial nerves are intact and fundoscopy is unremarkable. His peripheral nervous system is normal.
Questions
• What is the most likely diagnosis?
• What is the differential diagnosis?
• What investigations would you request?
• Is there any treatment that would reduce the frequency of these episodes?
Medicine
These are the characteristic features of common migraine – recurrent headache with symptom-free intervals, often unilateral, typically throbbing and accompanied by nausea and vomiting. Abdominal pain is often a feature. This is the commonest form of migraine in childhood and over 90 per cent have a family history. The diagnosis should be reconsidered if this is absent. Classic migraine has aura as an additional feature. Auras are usually visual and include small areas of visual loss in a visual field (scotoma) and brilliant white zigzag lines (fortification spectra). Headaches are common in children and their frequency increases with age. In young children, certainly pre-school, an organic cause is highly likely.
Differential diagnosis of chronic headaches
• Tension headaches – commonest of all, described as a ‘band’ or 'pressure’ and bilateral. Usually otherwise asymptomatic. May last weeks and tend to worsen as day progresses. Child is otherwise healthy
• Sinusitis – percussing over affected sinuses causes pain and discomfort
• Refractive errors – ensure vision has been checked recently
• Raised intracranial pressure – a brain tumour is most parents’ underlying worry. Unlike migraine and tension headaches, pain is worse when lying down. It is almost always accompanied by other abnormal symptoms, e.g. change in behaviour, or neurological signs, e.g. papilloedema
• Solvent or drug abuse
• Hypertension – blood pressure must be checked
A thorough history and examination are the mainstays in making a diagnosis in a child of this age and he probably needs no investigations. Obviously if there are focal neurological symptoms or signs (apart from visual aura), an MRI should be performed. Most children can lie still enough for this from about 7–8 years. Otherwise, sedation or a general anaesthetic is needed. The younger the child, the lower the threshold for scanning because an organic cause is more likely and they are poor at communicating the characteristics of their headache. His previous head injury is irrelevant and not an indication to scan. Prevention of migraine should focus on lifestyle changes. Reassurance that there is no serious intracranial pathology is often enough to improve symptoms. Keeping a diary is a simple way to try to identify any trigger factors, including, rarely, a specific food. Blanket exclusion diets should be avoided. Stress, tiredness and anxiety are the commonest precipitants. Problems at school, including bullying, should be explored. Relaxation and biofeedback techniques may help. Finally, if all else fails, school attendance is affected and the migraines are unacceptably intrusive, prevention with drugs may be considered. There are very few well-designed clinical trials, but drugs such as propranolol (contraindicated in asthma), pizotifen and some of the newer anticonvulsants (gabapentin or topiramate) may be effective. All have side-effects.
KEY POINTS
• Headaches in young children are more likely to be organic in origin and there is a lower threshold for scanning.
• Lifestyle changes, not drugs, should be the focus for the prevention of migraine.
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