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Headache in children: Approach to evaluation and general management strategies

Headache in children: Approach to evaluation and general management strategies
Literature review current through: Jan 2024.
This topic last updated: Sep 19, 2022.

INTRODUCTION — Headache (commonly defined as pain located above the orbitomeatal line) is one of the most common complaints in children and adolescents. It is recognized as one of the top medical and neurologic contributors to the global burden of disease and is a leading cause of disability in adolescents and young adults (age 10 to 24 years) [1,2].

The prevalence of headache increases with age. Children who complain of headache usually are brought to medical attention by their caregivers due to missing school or social activity or concerns of an ominous etiology such as a brain tumor or other serious disease. The first steps in evaluation are a thorough history, physical, and neurologic examination. If these are abnormal or suspicious for a secondary etiology, then additional diagnostic testing is performed.

An overview of the causes, evaluation, and management of headache in children will be presented here. Emergency evaluation of headache in children, specific primary headache syndromes in children, and headache related to exertion are discussed separately:

(See "Emergency department approach to nontraumatic headache in children".)

(See "Types of migraine and related syndromes in children".)

(See "Pathophysiology, clinical features, and diagnosis of migraine in children".)

(See "Acute treatment of migraine in children".)

(See "Tension-type headache in children".)

(See "Exercise (exertional) headache".)

EPIDEMIOLOGY — Headaches are common in children and adolescents [3-5]. In a systematic review of 50 population-based studies, nearly 60 percent of children reported having had headaches over periods of time (ranging from one month to "lifetime") [5]. By age 18 years, more than 90 percent of adolescents report having had a headache [3].

Recurrent severe headaches also are common in children. In the United States, approximately 20 percent of children aged 4 to 18 years report having had notable recurrent headaches (including migraine) in the past 12 months [6]. The prevalence of recurrent headaches increases with age from 4.5 percent among children 4 to <6 years to 27.4 percent among children 16 to 18 years [6]. In a population-based study, 1.5 percent of middle school students (age 12 to 14 years) had "chronic daily headache" (15 headache days per month with chronic migraine and chronic tension-type headaches making up the majority, and chronic migraine most frequently presenting for evaluation) [7,8]. Other chronic daily headaches include new daily persistent headache and chronic posttraumatic headaches [9]. (See 'Migraine' below and "Chronic daily headache: Associated syndromes, evaluation, and management", section on 'Definition'.)

Before 12 years of age, the prevalence of headaches is similar among males and females (approximately 10 percent) [6]. After age 12 years, the prevalence is higher in females (approximately 28 to 36 percent versus 20 percent) [4,6]. In adults, the female to male ratio for migraine is approximately 3:1. Headaches occur more often in children who have a family history of headaches in first- or second-degree relatives [10-12].

The epidemiology of migraine and tension-type headaches in children is discussed separately. (See "Pathophysiology, clinical features, and diagnosis of migraine in children", section on 'Epidemiology' and "Tension-type headache in children", section on 'Epidemiology'.)

ETIOLOGY — Childhood headaches are rarely caused by a serious underlying disorder [13]. The most common headache etiologies vary depending upon the setting in which the child is evaluated.

Most children who present to pediatric emergency departments with acute headache have a viral illness or an upper respiratory infection as the symptomatic etiology of their headache. However, more serious conditions occasionally are diagnosed, and primary headaches, especially status migrainosus, also present to the emergency department [14-16]. As many as 90 percent of adults who have been diagnosed (self-diagnosed or diagnosed by a clinician) with recurrent sinus headaches actually have migraine headaches [17]. (See "Emergency department approach to nontraumatic headache in children", section on 'Causes'.)

In the primary care setting, primary headaches (table 1) and infectious etiologies are most common [18-20]. In a historical cohort of 48,575 children aged 5 to 17 years who were seen by primary care providers for complaint of headache, 19 percent were diagnosed with primary headache at the time of presentation, 1.1 percent were diagnosed with secondary headache, and 79.7 percent received no formal diagnosis (5.4 percent of these were diagnosed with primary headaches in the subsequent year) [20].

CLASSIFICATION — Headaches can be classified as primary (those in which the head pain is due to the headache condition itself (table 1)) and secondary (those in which the head pain is a symptom of an underlying condition).

Primary headaches and secondary headaches are not mutually exclusive; patients with a primary headache disorder can have a primary headache exacerbated by a secondary etiology.

The International Classification of Headache Disorders, 3rd edition (ICHD-3) provides detailed diagnostic criteria for primary headaches, secondary headaches, and facial pain disorders [9].

Primary headache — The most common primary headaches in children are migraine and tension-type headache (table 1). Trigeminal autonomic cephalalgias (including cluster headaches) are rare in children younger than 10 years and uncommon in older patients.

Migraine — Migraine is a disease characterized by intermittent attacks of headache. Recognition that migraine is a disease in which headache is just one of the symptoms is important. (A person does not have a "migraine," but rather has a headache due to migraine.) An attack of migraine is characterized by recurrent episodes of head pain that are typically moderate to severe in intensity, lasting 2 to 72 hours if not treated, characterized by focal pain that is throbbing and worsens with activity or causes avoidance of activity [9]. It can be accompanied by nausea, vomiting, light sensitivity ("photophobia"), and sound sensitivity ("phonophobia") (table 2A). In children, particularly young children, the duration of headache is typically shorter than in adults, lengthening with age. Migraines in children are most often bilateral (bifrontal or bitemporal). Headaches that are occipital in location have an increased risk of a secondary cause (although migraine remains the most common cause of occipital headaches) and need to be investigated further. (See 'Worrisome findings' below.)

The clinical features, diagnosis, and management of migraine in children are discussed separately. (See "Pathophysiology, clinical features, and diagnosis of migraine in children" and "Preventive treatment of migraine in children" and "Acute treatment of migraine in children".)

Approximately 10 percent of children with migraine have associated auras that include visual, sensory, speech/language, motor, brainstem, or retinal symptoms (eg, scotoma), paresthesias, dysphasia, hemiplegia, weakness, ataxia, or confusion [21].

Chronic migraine is the most common chronic headache condition in children and adolescents. It is defined as headaches on 15 or more days per month, with at least eight having migraine features. Chronic migraine is a considerable problem in children. In a population-based study of middle school students (age 12 to 14 years), the overall prevalence was 1.5 percent [7]. Chronic migraine was more common in females than males (2.4 versus 0.8 percent).

Avoidance of medication overuse is an important step in the prevention of chronic migraine [22]. Medication overuse has been reported in 20 to 36 percent of adolescents with chronic headache and is an independent predictor of chronic migraine persistence [7,23-25]. Discussion of medication overuse is one of the key outcome metrics recommended by the American Academy of Neurology [26]. Major depression is another independent predictor of highly frequent headaches [25].

Episodic symptoms associated with migraine (formerly childhood periodic syndromes or migraine "variants") have been reported to include benign paroxysmal vertigo, cyclic vomiting, abdominal migraine, and colic. Benign torticollis (recurrent, often short-lived, and spontaneously recovering attacks of head tilt in infants) also has been proposed as a variant of migraine [27,28]. (See "Types of migraine and related syndromes in children", section on 'Episodic syndromes that may be associated with pediatric migraine' and "Acquired torticollis in children", section on 'Benign paroxysmal torticollis'.)

Tension-type headaches — Tension-type headaches (TTH) are characterized by headaches that are diffuse in location, non-throbbing, mild to moderate severity, and do not worsen with activity (although the child may not wish to participate in activity). They can last from 30 minutes to 7 days (table 2B). TTH may be associated with photophobia or phonophobia (but not both) but is not accompanied by nausea, vomiting, or aura [9].

Although TTH may share clinical features with migraine, the ICHD-3 specifies that migraine diagnosis takes priority over the diagnosis of TTH, so when in doubt between the two, the diagnosis of migraine, rather than "mixed headache disorder," should be made [9]. TTH in children are discussed separately. (See "Tension-type headache in children".)

Cluster headaches — Cluster headaches constitute the most common trigeminal autonomic cephalalgia. This group of headaches is characterized by trigeminal location and association with autonomic features. Cluster headaches are typically unilateral and frontal-periorbital in location (table 2C). The pain of cluster headaches is severe and lasts less than three hours, but multiple headaches occur in a very short period of time (hence "cluster"). Cluster headaches usually are associated with ipsilateral autonomic findings, including lacrimation, conjunctival injection, nasal congestion and/or rhinorrhea, facial and forehead sweating, eyelid edema, and miosis and/or ptosis [9].

Cluster headaches have been reported in children as young as three years of age, but they are rare in children younger than 10 years and uncommon in older patients. They become more apparent between the ages of 10 and 20 years, although they remain infrequent. Cluster headaches are discussed separately. (See "Cluster headache: Epidemiology, clinical features, and diagnosis", section on 'Clinical features'.)

Secondary headache — Secondary headaches are caused by an underlying condition. They usually develop in close temporal relationship to the underlying condition and usually successfully resolve with adequate treatment of the condition. Secondary headaches include exacerbation of primary headaches by an underlying condition [29].

Conditions that may cause secondary headache in children include [29]:

Acute febrile illness (eg, influenza, upper respiratory infection, sinusitis) (see "The common cold in children: Clinical features and diagnosis" and "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis")

Such infections are the most common cause of secondary headache in children [14,15]. However, recurrent rhinosinusitis is one of the most common misdiagnoses for headaches, with the majority actually being a primary headache and usually migraine

Posttraumatic headaches; acute posttraumatic headaches usually resolve within seven to ten days (see "Intracranial epidural hematoma in children", section on 'Clinical features' and "Intracranial subdural hematoma in children: Epidemiology, anatomy, and pathophysiology")

Medications (given the frequency of headache as a complaint, "headache" is listed on nearly every medication as a potential side effect)

Medication overuse headache; frequent overuse of analgesic medication is one of the most common causes of secondary chronic headache

Acute and severe systemic hypertension (may cause headache or be a response to increased intracranial pressure) (see "Evaluation of hypertension in children and adolescents", section on 'Initial evaluation')

Acute or chronic meningitis (see "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Clinical features' and "Viral meningitis in children: Clinical features and diagnosis", section on 'Clinical features')

Brain tumor (see "Clinical manifestations and diagnosis of central nervous system tumors in children", section on 'Clinical manifestations')

Idiopathic intracranial hypertension (see "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis")

Hydrocephalus (see "Hydrocephalus in children: Clinical features and diagnosis", section on 'Clinical features')

Intracranial hemorrhage (typically presents as sudden severe unilateral headache)

Headache attributed to visual refractive error is included as a type of secondary headache in the ICHD-3 [9]. However, in contrast to the secondary causes of headache listed above, definitive evidence that visual refractive errors cause headaches in children is lacking [30].

CLINICAL PRESENTATION — Young children may express pain differently than older children and adolescents and often are able to attenuate or ignore pain through play [31,32]. Headache pain may not be apparent to caregivers of younger children, who react by crying, rocking, or hiding, or altered activity level. Chronic pain may be associated with anxiety, depression, and behavior problems and affect the child's ability to eat, sleep, or play. Older children are better able to perceive, localize, and remember pain. Emotional, behavioral, and personality factors become more important as the child enters adolescence.

The variability in presentation in children of different ages may lead to difficulty when applying the standard headache diagnostic criteria (eg, International Classification of Headache Disorders, 3rd edition [ICHD-3]) [9].

EVALUATION — The evaluation of headache in children includes a thorough history (table 3), physical examination (table 4), and neurologic examination with particular attention to the clinical features suggestive of intracranial infection or space-occupying lesion (table 5). If the initial evaluation is suspicious for secondary headache, additional diagnostic testing is necessary. The neurologic examination is the most sensitive indicator of needing further evaluation, including neuroimaging. The headache pattern may help to suggest the etiology. (See 'Headache pattern' below.)

Headache history — The headache history provides most of the necessary diagnostic information in the evaluation of childhood headaches (table 3). A thorough history helps to focus the physical examination and prevent unnecessary investigation and neuroimaging.

The history of headache for a child should initially be obtained from the child and confirmed by the caregivers. In young children, caregiver observation of behavior can support the diagnostic criteria. Asking young children to "draw the headache" may assist in the diagnosis when the child is not able to express the headache characteristics in words. Children, adolescents, and young adults may be prone to the childhood periodic syndromes/episodic syndromes associated with headache. This includes motion sickness, sleep walking, sleep talking, night terrors, unexplained fevers, recurrent abdominal pain, and episodes of anxiety. Motion sickness precipitated by reading in a car is a common feature in migraine sufferers [33,34].

A diary in which the quality, location, severity, timing, precipitating and palliating factors, and associated features of the headache are recorded prospectively may be a useful adjunct if the child is willing and able to complete on a daily basis. A diary is not subject to recall error, may reveal a pattern that is typical for a certain type of headache, and provides important diagnostic information for children who are unwilling or unable to provide sufficient detail during the office interview [35,36].

Headache pattern — Determining if a headache is new or represents a recurrent problem is useful in differentiating primary from secondary headaches. Most primary headaches are episodic headaches that may transform to more frequent headaches (chronification). Asking about all headaches, not just the one that is being brought to attention, can help identify this pattern. An acute change in an underlying recurrent, episodic headache disorder is a potentially concerning pattern.

Physical examination — Important aspects of the physical examination in a child with headache are described in the table (table 4) [37].

The physical examination, including the funduscopic examination, is usually normal in children with primary headaches (eg, migraine, tension-type headache). (See "Pathophysiology, clinical features, and diagnosis of migraine in children", section on 'Diagnosis' and "Tension-type headache in children", section on 'Examination'.)

Although the physical examination is also typically normal in secondary headaches, when the physical or especially the neurologic examination is abnormal, secondary headaches must be considered and the examination findings may provide clues to the underlying diagnosis (eg, fever and nuchal rigidity in a child with meningitis). Abnormal funduscopic examination requires additional evaluation, as indicated by the findings from the history and physical examination. In most cases of brain tumor-induced headache, some aspect of the neurologic examination is abnormal.

Worrisome findings — Predictors for intracranial pathology (ie, space-occupying lesion or central nervous system infection) have been identified in small observational studies (table 5) [38-43]. It is particularly important to ask about and look for these symptoms and signs of increased intracranial pressure, intracranial infection, and progressive neurologic disease. Worrisome findings are an indication for further evaluation and/or neuroimaging. (See "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)

Neuroimaging — Neuroimaging studies may detect a variety of disorders that cause secondary headache, including congenital malformations, hydrocephalus, intracranial infections and their sequelae, trauma and its sequelae, neoplasms, vascular disorders (such as arteriovenous malformations), and intracranial thrombosis. However, most children who present to primary care have signs and symptoms consistent with primary or uncharacterized headaches and do not require neuroimaging [20].

Indications — Decisions regarding neuroimaging in children with headaches should be made on a case-by-case basis [44].

Children with an abnormal neurologic examination, children younger than six years, or children who have features worrisome for a pathologic intracranial process (table 5) generally should undergo neuroimaging with magnetic resonance imaging (MRI) (see 'Which imaging study?' below). Neuroimaging also is indicated for severe headache in a child with an underlying disease that predisposes to intracranial pathology (eg, immune deficiency, sickle cell disease, neurofibromatosis, history of neoplasm, coagulopathy, hypertension) [43-45]. Although occipital headaches are classically considered to be a worrisome feature, two small observational studies question whether neuroimaging is necessary in children with occipital headaches and no other worrisome features [46,47]. Pending verification of these results in larger studies, we continue to consider occipital headaches a worrisome feature.

Neuroimaging for children with acute head trauma, suspected infection (eg, sinusitis, meningitis, encephalitis), or other obvious cause is discussed in greater detail separately. (See "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Diagnosis' and "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Neuroimaging' and "Acute viral encephalitis in children: Clinical manifestations and diagnosis", section on 'Neuroimaging'.)

Neuroimaging of children with headaches in the absence of neurologic abnormalities on examination and/or symptoms of neurologic abnormalities on history has a low yield of clinically significant findings (0.9 to 1.2 percent) [43,48,49]. Neuroimaging of such children may detect incidental findings that require additional evaluation or follow-up [45,48,50-52]. Other potential adverse effects of neuroimaging include radiation exposure, exposure to anesthesia if sedation is required, and false reassurance from an inadequate study [44].

Most children who present to primary care with headaches have primary or uncharacterized headaches and do not require neuroimaging [20]. Neuroimaging generally is not indicated for children with a history of recurrent, episodic headaches that have persisted for greater than six months and who have no signs or symptoms of neurologic dysfunction or increased intracranial pressure [43,44]. Headache features and frequency may vary with time, so the full history must be utilized to guide neuroimaging decision making. Neuroimaging also is usually not indicated for children with migraine who lack neurologic abnormalities. However, it may be difficult to differentiate early migraine episodes from headache secondary to a space-occupying lesion because the International Classification of Headache Disorders (ICHD) criteria for migraine will not have been met, as five headache episodes are required (table 2A) [43].

The yield of neuroimaging in detecting clinically significant intracranial abnormalities in children without neurologic abnormalities is extremely low. In a systematic review of six studies in which 605 of 1275 children with recurrent headaches underwent neuroimaging, imaging abnormalities were found in 97 children (16 percent) [38,43,53-57]. However, in 79 of these children, the abnormalities did not require further intervention. Among the remaining 18 children, 14 had lesions requiring surgery (10 tumors, three vascular malformations, one arachnoid cyst with mass effect), and four had lesions that required medical treatment. All of the children who had surgically treatable lesions had abnormal findings on neurologic examination, including papilledema, abnormal eye movements, or motor or gait dysfunction.

Our indications for neuroimaging in children with headache are consistent with the guidelines from the American Academy of Neurology (AAN), the American College of Radiology, and the multidisciplinary United States Headache Consortium [43-45].

Timing — The level of urgency is determined by the status of the patient and the speed with which the situation is evolving [18]. Urgent neuroimaging is reserved for patients with signs of increased intracranial pressure and/or focal neurologic examination with concern for a space-occupying lesion (eg, brain tumor or brain abscess) or intracranial hemorrhage. (See 'Which imaging study?' below.)

Which imaging study? — Brain MRI is usually preferred. Head computed tomography (CT) is performed if MRI is not available or imaging is needed immediately (eg, suspected acute hemorrhage, rapid diagnosis of space-occupying lesion). MRI with gadolinium or CT with contrast should be performed if the clinician suspects an inflammatory cause or breakdown of the blood-brain barrier (eg, abscess or tumor).

MRI is usually preferred in nonacute situations (or if there is persistent concern despite a normal head CT scan) because it minimizes radiation exposure and is more sensitive than CT [58]. MRI demonstrates sellar lesions, craniocervical junction lesions, posterior fossa lesions, white matter abnormalities, and congenital anomalies more reliably than does CT. However, in young children, MRI may require sedation, which CT usually does not.

MR angiography or CT angiography may be indicated if subarachnoid blood or parenchymal blood is identified on initial MRI, CT, or lumbar puncture [45]. (See 'Lumbar puncture' below.)

Laboratory evaluation — Laboratory testing rarely is helpful in the evaluation of childhood headache and is predominantly used to differentiate causes of secondary headache [36,43,59]. The AAN practice parameter indicates that the evidence is insufficient to support any recommendation regarding the value of routine laboratory studies or lumbar puncture in the evaluation of recurrent headache in children [43].

Lumbar puncture — Lumbar puncture (LP) generally should be performed in children in whom intracranial infection, subarachnoid hemorrhage, or idiopathic intracranial hypertension (pseudotumor cerebri) is suspected. Neuroimaging typically is performed before LP because LP is contraindicated in patients with space-occupying lesions. However, in patients in whom bacterial meningitis is suspected, the risks of delaying the LP and administration of antibiotics while awaiting neuroimaging must be considered. (See "Lumbar puncture in children", section on 'Indications' and "Lumbar puncture in children", section on 'Contraindications'.)

Patients in whom idiopathic intracranial hypertension is suspected may require reassurance or sedation before undergoing the lumbar puncture because an accurate opening pressure measurement is crucial to the diagnosis. Inadequate technique (eg, Valsalva, straining, crying) can cause artifactually high opening pressure measurements. (See "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis", section on 'Lumbar puncture'.)

Other tests — Other tests should be performed as indicated to evaluate suspected underlying medical conditions. These tests should be tailored to evaluate conditions suggested by information from the history and examination. Examples include [18]:

Complete blood count with differential and erythrocyte sedimentation rate (if infection, anemia, vasculitis, or malignancy is suspected)

Serum or urine toxicology screens (if acute or chronic intoxication is suspected)

Thyroid function tests (if thyroid dysfunction is suspected) (see "Acquired hypothyroidism in childhood and adolescence", section on 'Diagnosis' and "Clinical manifestations and diagnosis of Graves disease in children and adolescents", section on 'Diagnostic evaluation')

Electroencephalography — Electroencephalography is not recommended in the routine evaluation of a child with recurrent headaches and typically has no role to play [43]. It is unlikely to be useful in determining the cause of headache or in distinguishing migraine from other types of headache.

DIAGNOSIS — The diagnosis of primary headache disorders is made clinically, based upon the International Classification of Headache Disorders, 3rd edition [9]:

Migraine (table 2A) (see 'Migraine' above)

Tension-type headache (table 2B) (see 'Tension-type headaches' above)

Trigeminal autonomic cephalalgias, including cluster headaches (table 2C) (see 'Cluster headaches' above)

The diagnosis of a chronic headache is also made clinically in children with headache on more than 15 days a month for more than three months in the absence of detectable organic pathology and is based on the predominant headache features with chronic migraine trumping chronic tension-type headache [8]. (See 'Migraine' above.)

The diagnosis of secondary headaches depends upon identification of the underlying condition. (See 'Secondary headache' above.)

MANAGEMENT — The management of recurrent and chronic headache in children and adolescents depends upon the underlying etiology. The management of migraine and tension-type headaches is discussed separately. (See "Acute treatment of migraine in children" and "Tension-type headache in children", section on 'Treatment'.)

Some management components of recurrent headache disorders include [60-63]:

Providing realistic expectations (ie, the frequency and severity of the headaches may decrease over weeks to months of therapy, but the headaches may continue to occur) (see 'Outcome' below)

Return to school for children who have been absent; if necessary, they can go to the school nurse or office once daily for 15 minutes when headache pain peaks

Avoidance of headache triggers (eg, dietary triggers, caffeine, lack of sleep, inadequate hydration, overuse of electronic devices)

Daily exercise for 20 to 30 minutes

Addressing comorbid sleep problems (eg, delayed sleep onset, frequent night waking), mood problems, and/or anxiety

Additional nonpharmacologic approaches may be beneficial. Cognitive behavioral therapy and biofeedback-assisted relaxation therapy including guided imagery, progressive muscle relaxation, and deep breathing have some evidence of benefit, while other treatments, including physical therapy, acupuncture, hypnosis, meditation, and massage, may be helpful but are unproven [61,64-66].

The use of acute medications is a key component of treatment and should include early recognition and addressing barriers to treatment, use of multimechanism care when primary acute medication is incompletely effective and avoidance of medication overuse. Preventive medications may be necessary for children with headaches that occur more than four times per month or headaches that adversely affect the child's activities [61].

When medication overuse is identified (>15 days per month of over-the-counter medication or >10 days per month of prescription medication) discontinuation of all analgesic medications is indicated.

Several devices have been approved by the US Food and Drug Administration for the acute and preventive treatment of headaches due to migraine. These devices, which provide mild electrical stimulation to the face, head, or upper arm, offer the additional benefit of allowing the patient to have an increased locus of control, while avoiding the need to swallow medications.

Acute and preventive agents (eg, calcitonin gene-related peptide monoclonal antibodies, gepants, ditans) have been approved for adults and are under study in children and adolescents. The use of these agents in adults is discussed separately. (See "Preventive treatment of episodic migraine in adults", section on 'CGRP antagonists' and "Estrogen-associated migraine headache, including menstrual migraine".)

INDICATIONS FOR REFERRAL — Primary care providers can usually manage children and adolescents with acute, recurrent, episodic, and chronic headaches. Indications for referral may include [18,67]:

Secondary headache requiring specialist management (eg, space-occupying lesions, idiopathic intracranial hypertension)

Headaches associated with mood disturbance or anxiety

Uncertain diagnosis

Headaches refractory to primary care management

Very frequent headaches unresponsive to typical therapy (ie, chronic migraine or chronic tension-type headaches)

The need for more intensive management that can only be provided by a multidisciplinary headache program

OUTCOME — Headache that begins in childhood often changes in its characteristics with time and may remit or improve. In one study, 100 children and adolescents with headache were seen eight years after the initial visit [68]. Remission occurred in 44 percent of children with tension headache and in 28 percent of children with migraine. Migraine without aura persisted in the same form in 44 percent and became episodic tension headache in 26 percent. Episodic tension headache persisted in the same form in 26 percent and changed to migraine without aura in 11 percent. Psychiatric comorbidity at the initial visit was associated with worsening or unchanged clinical status at follow-up [69].

In another long-term study of 103 children with chronic headache (>15 headaches per month), frequent headaches persisted in 25 percent at two years and 12 percent at eight years [70]. Early onset was associated with a protracted disease course.

RESOURCES

The American Migraine Foundation provides information and resources for patients and providers.

The American Headache Society provides resources for clinicians.

The National Headache Foundation provides information and resources for patients and providers.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

Basics topic (see "Patient education: Headaches in children (The Basics)" and "Patient education: Migraines in children (The Basics)")

Beyond the Basics topic (see "Patient education: Headache in children (Beyond the Basics)")

SUMMARY

Epidemiology – Approximately 20 percent of children aged 4 to 18 years have had frequent or severe headaches in the past 12 months. (See 'Epidemiology' above.)

Etiology – Headache in children and adolescents may be due to a primary headache disorder (ie, migraine, tension-type headache, trigeminal autonomic cephalalgias (table 1)) or secondary to an underlying medical condition.

Secondary headaches usually are related to fever or infection (eg, upper respiratory infection, influenza) but may be due to central nervous system infection or space-occupying lesion. (See 'Etiology' above.)

Evaluation

The evaluation of headache in children includes a thorough history (table 3), physical examination (table 4), and neurologic examination, with particular emphasis on clinical features suggestive of intracranial pathology (table 5). The headache pattern helps to determine the etiology. (See 'Evaluation' above.)

Neuroimaging should be performed in children with headache and neurologic signs or symptoms suggestive of intracranial pathology (table 5). Brain MRI is usually preferred. Head CT is performed if MRI is not available or imaging is needed immediately (eg, suspected acute hemorrhage, rapid diagnosis of space-occupying lesion). MRI with gadolinium or CT with contrast should be performed if the clinician suspects an inflammatory cause or breakdown of the blood-brain barrier (eg, abscess, tumor). (See 'Neuroimaging' above.)

Routine laboratory evaluation usually is not necessary for children with recurrent or chronic headaches. The laboratory evaluation for secondary headache should be tailored to evaluate conditions suggested by information from the history and examination. (See 'Laboratory evaluation' above.)

Diagnosis – The diagnosis of primary headache disorders is made clinically, based upon the criteria of the International Classification of Headache Disorders (table 2A-C). The diagnosis of chronic headache also is made clinically (headache on >15 days per month for >3 months in the absence of detectable organic pathology). The diagnosis of secondary headaches depends upon identification of the underlying condition. (See 'Diagnosis' above.)

Management – The treatment of recurrent and chronic headaches requires a systematic approach over several months through which the child returns to normal activities of daily living. It is critical to address excessive school absence and overuse of over-the-counter analgesic medications. (See 'Management' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Andrew G Lee, MD, who contributed to an earlier version of this topic review.

  1. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396:1204.
  2. Leonardi M, Grazzi L, D'Amico D, et al. Global Burden of Headache Disorders in Children and Adolescents 2007-2017. Int J Environ Res Public Health 2020; 18.
  3. Barea LM, Tannhauser M, Rotta NT. An epidemiologic study of headache among children and adolescents of southern Brazil. Cephalalgia 1996; 16:545.
  4. Zwart JA, Dyb G, Holmen TL, et al. The prevalence of migraine and tension-type headaches among adolescents in Norway. The Nord-Trøndelag Health Study (Head-HUNT-Youth), a large population-based epidemiological study. Cephalalgia 2004; 24:373.
  5. Abu-Arafeh I, Razak S, Sivaraman B, Graham C. Prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies. Dev Med Child Neurol 2010; 52:1088.
  6. Lateef TM, Merikangas KR, He J, et al. Headache in a national sample of American children: prevalence and comorbidity. J Child Neurol 2009; 24:536.
  7. Wang SJ, Fuh JL, Lu SR, Juang KD. Chronic daily headache in adolescents: prevalence, impact, and medication overuse. Neurology 2006; 66:193.
  8. Dodick DW. Clinical practice. Chronic daily headache. N Engl J Med 2006; 354:158.
  9. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018; 38:1.
  10. Aromaa M, Rautava P, Sillanpää M, et al. Familial occurrence of headache. Cephalalgia 1999; 19 Suppl 25:49.
  11. Russell MB, Ostergaard S, Bendtsen L, Olesen J. Familial occurrence of chronic tension-type headache. Cephalalgia 1999; 19:207.
  12. Anttila P, Metsähonkala L, Sillanpää M. School start and occurrence of headache. Pediatrics 1999; 103:e80.
  13. Abu-Arafeh I, Macleod S. Serious neurological disorders in children with chronic headache. Arch Dis Child 2005; 90:937.
  14. Kan L, Nagelberg J, Maytal J. Headaches in a pediatric emergency department: etiology, imaging, and treatment. Headache 2000; 40:25.
  15. Burton LJ, Quinn B, Pratt-Cheney JL, Pourani M. Headache etiology in a pediatric emergency department. Pediatr Emerg Care 1997; 13:1.
  16. Zhou AZ, Marin JR, Hickey RW, Ramgopal S. Serious Diagnoses for Headaches After ED Discharge. Pediatrics 2020; 146.
  17. Cady RK, Schreiber CP. Sinus headache or migraine? Considerations in making a differential diagnosis. Neurology 2002; 58:S10.
  18. Strasburger VC, Brown RT, Braverman PK, et al. Headache. In: Adolescent Medicine A Handbook for Primary Care, Lippincott Williams & Wilkins, Philadelphia 2006. p.25.
  19. van der Wouden JC, van der Pas P, Bruijnzeels MA, et al. Headache in children in Dutch general practice. Cephalalgia 1999; 19:147.
  20. Kernick D, Stapley S, Campbell J, Hamilton W. What happens to new-onset headache in children that present to primary care? A case-cohort study using electronic primary care records. Cephalalgia 2009; 29:1311.
  21. Slater SK, Powers SW, O'Brien HL. Migraine in children: presentation, disability and response to treatment. Curr Opin Pediatr 2018; 30:775.
  22. Hershey AD, Lipton RB. Adolescents get as well as they give: population perspectives on chronic daily headaches. Neurology 2006; 66:160.
  23. Cuvellier JC, Couttenier F, Joriot-Chekaf S, Vallée L. Chronic daily headache in French children and adolescents. Pediatr Neurol 2008; 38:93.
  24. Dyb G, Holmen TL, Zwart JA. Analgesic overuse among adolescents with headache: the Head-HUNT-Youth Study. Neurology 2006; 66:198.
  25. Wang SJ, Fuh JL, Lu SR, Juang KD. Outcomes and predictors of chronic daily headache in adolescents: a 2-year longitudinal study. Neurology 2007; 68:591.
  26. Robbins MS, Victorio MCC, Bailey M, et al. Quality Improvement in Neurology: Headache Quality Measurement Set. Headache 2021; 61:219.
  27. Cohen HA, Nussinovitch M, Ashkenasi A, et al. Benign paroxysmal torticollis in infancy. Pediatr Neurol 1993; 9:488.
  28. Hanukoglu A, Somekh E, Fried D. Benign paroxysmal torticollis in infancy. Clin Pediatr (Phila) 1984; 23:272.
  29. Lewis DW, Koch T. Headache evaluation in children and adolescents: when to worry? When to scan? Pediatr Ann 2010; 39:399.
  30. Roth Z, Pandolfo KR, Simon J, Zobal-Ratner J. Headache and refractive errors in children. J Pediatr Ophthalmol Strabismus 2014; 51:177.
  31. Rothner AD. The evaluation of headaches in children and adolescents. Semin Pediatr Neurol 1995; 2:109.
  32. Schechter NL. Recurrent pains in children: an overview and an approach. Pediatr Clin North Am 1984; 31:949.
  33. Aromaa M, Sillanpää ML, Rautava P, Helenius H. Childhood headache at school entry: a controlled clinical study. Neurology 1998; 50:1729.
  34. Welborn CA. Pediatric migraine. Emerg Med Clin North Am 1997; 15:625.
  35. van den Brink M, Bandell-Hoekstra EN, Abu-Saad HH. The occurrence of recall bias in pediatric headache: a comparison of questionnaire and diary data. Headache 2001; 41:11.
  36. Singh BV, Roach ES. Diagnosis and management of headache in children. Pediatr Rev 1998; 19:132.
  37. Linder SL. Understanding the comprehensive pediatric headache examination. Pediatr Ann 2005; 34:442.
  38. Medina LS, Pinter JD, Zurakowski D, et al. Children with headache: clinical predictors of surgical space-occupying lesions and the role of neuroimaging. Radiology 1997; 202:819.
  39. Lewis DW, Qureshi F. Acute headache in children and adolescents presenting to the emergency department. Headache 2000; 40:200.
  40. Abe T, Matsumoto K, Kuwazawa J, et al. Headache associated with pituitary adenomas. Headache 1998; 38:782.
  41. Pfund Z, Szapáry L, Jászberényi O, et al. Headache in intracranial tumors. Cephalalgia 1999; 19:787.
  42. Honig PJ, Charney EB. Children with brain tumor headaches. Distinguishing features. Am J Dis Child 1982; 136:121.
  43. Lewis DW, Ashwal S, Dahl G, et al. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002; 59:490.
  44. US Headache Consortium. Evidence-based guidelines in the primary care setting: Neuroimaging in patients with nonacute headache, 2000. www.aan.com/professionals/practice/pdfs/gl0088.pdf (Accessed on March 23, 2011).
  45. Expert Panel on Pediatric Imaging:, Hayes LL, Palasis S, et al. ACR Appropriateness Criteria® Headache-Child. J Am Coll Radiol 2018; 15:S78.
  46. Bear JJ, Gelfand AA, Goadsby PJ, Bass N. Occipital headaches and neuroimaging in children. Neurology 2017; 89:469.
  47. Genizi J, Khourieh-Matar A, Assaf N, et al. Occipital Headaches in Children: Are They a Red Flag? J Child Neurol 2017; 32:942.
  48. Sempere AP, Porta-Etessam J, Medrano V, et al. Neuroimaging in the evaluation of patients with non-acute headache. Cephalalgia 2005; 25:30.
  49. Rho YI, Chung HJ, Suh ES, et al. The role of neuroimaging in children and adolescents with recurrent headaches--multicenter study. Headache 2011; 51:403.
  50. Graf WD, Kayyali HR, Abdelmoity AT, et al. Incidental neuroimaging findings in nonacute headache. J Child Neurol 2010; 25:1182.
  51. Schwedt TJ, Guo Y, Rothner AD. "Benign" imaging abnormalities in children and adolescents with headache. Headache 2006; 46:387.
  52. Maher CO, Piatt JH Jr, Section on Neurologic Surgery, American Academy of Pediatrics. Incidental findings on brain and spine imaging in children. Pediatrics 2015; 135:e1084.
  53. Chu ML, Shinnar S. Headaches in children younger than 7 years of age. Arch Neurol 1992; 49:79.
  54. Maytal J, Bienkowski RS, Patel M, Eviatar L. The value of brain imaging in children with headaches. Pediatrics 1995; 96:413.
  55. Dooley JM, Camfield PR, O'Neill M, Vohra A. The value of CT scans for children with headaches. Can J Neurol Sci 1990; 17:309.
  56. Wöber-Bingöl C, Wöber C, Prayer D, et al. Magnetic resonance imaging for recurrent headache in childhood and adolescence. Headache 1996; 36:83.
  57. Lewis DW, Dorbad D. The utility of neuroimaging in the evaluation of children with migraine or chronic daily headache who have normal neurological examinations. Headache 2000; 40:629.
  58. Choosing Wisely. American Headache Society. Five things physicians and patients should question. www.choosingwisely.org/wp-content/uploads/2013/11/AHS-5things-List_112013.pdf (Accessed on December 08, 2013).
  59. Rothner AD. Headaches in children and adolescents. Child Adolesc Psychiatr Clin N Am 1999; 8:727.
  60. Mack KJ. An approach to children with chronic daily headache. Dev Med Child Neurol 2006; 48:997.
  61. Newton RW. Childhood headache. Arch Dis Child Educ Pract Ed 2008; 93:105.
  62. Fisher PG. Systematic approach needed in managing chronic headaches. AAP News 2006; 27:10.
  63. Taheri S. Effect of exclusion of frequently consumed dietary triggers in a cohort of children with chronic primary headache. Nutr Health 2017; 23:47.
  64. Fisher E, Law E, Dudeney J, et al. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev 2018; 9:CD003968.
  65. Thompson AP, Thompson DS, Jou H, Vohra S. Relaxation training for management of paediatric headache: A rapid review. Paediatr Child Health 2019; 24:103.
  66. Klausen SH, Rønde G, Tornøe B, Bjerregaard L. Nonpharmacological Interventions Addressing Pain, Sleep, and Quality of Life in Children and Adolescents with Primary Headache: A Systematic Review. J Pain Res 2019; 12:3437.
  67. Gladstein J, Mack KJ. Common presentations of chronic daily headache in adolescents. Pediatr Ann 2010; 39:424.
  68. Guidetti V, Galli F. Evolution of headache in childhood and adolescence: an 8-year follow-up. Cephalalgia 1998; 18:449.
  69. Guidetti V, Galli F, Fabrizi P, et al. Headache and psychiatric comorbidity: clinical aspects and outcome in an 8-year follow-up study. Cephalalgia 1998; 18:455.
  70. Wang SJ, Fuh JL, Lu SR. Chronic daily headache in adolescents: an 8-year follow-up study. Neurology 2009; 73:416.
Topic 2842 Version 30.0

References

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