Headaches in children – what you need to know and what you shouldn’t miss

What are the common causes of headaches in children?

Headaches are a very common complaint in children. About 30% of children experience recurrent headaches, and the tendency to experience headaches increases with age.
Headaches in children are a very common complaint/symptom, and can be the result of a variety of causes.
Often the cause is not dangerous and headaches can really be brought about by mild medical conditions, such as a response to a transient viral infection, a side effect to a drug, a mild migraine, and more.
However, in a small number of cases, headaches can have a significant cause that requires rapid diagnosis.

Headaches as part of a ‘current’ illness

It is important to understand – a scenario where a child has a fever of 38.5 degrees Celsius as well as headaches is very different to one where a 10-year-old wakes up with a headache at 4 am every morning.
Headaches, that are present as one of the symptoms in a ‘current’ illness (in medical terminology we refer to this as intercurrent illness), should be attributed to that illness, and should be managed by the primary healthcare provider. In fact, any ongoing, mild infection, can cause a temporary headache, but prior to categorizing an illness as a “mild infection” it is important to see a doctor to rule out a more significant infection that may involve the central nervous system and cause headaches.

What are the common causes of ongoing or recurrent headaches in children?

Headache syndromes are common in children. The most common headache syndrome is migraines, while the second most common one is stress (tension type headaches) and headaches secondary to the use of medications.

How else can headaches in children be classified?

An additional classification is the following:
Primary headaches – these are the result of a primary tendency for headaches, such as migrainesץ
Secondary headaches – this is the result of several pathological factors that require rapid diagnosis and prompt treatment. Some examples may include headaches secondary to head tumors, brain and meningeal infections, non-infectious inflammatory processes of the central nervous system, increased intracranial pressure and more.

So, what is the correct approach to headaches in children?

The most important part of correctly diagnosing headaches and their cause is thorough medical history taking. This helps us distinguish between primary and secondary headaches.
Taking a medical history, especially in young children or children with special needs that are unable to express that they are in pain, can be a challenging task, and it requires an understanding, and a deep familiarization of the different ways headaches can manifest in children in different ages, with varying degrees of development.
Following a good history, thorough physical examination, and a detailed neurological assessment, we can move on to the next step of diagnosing the possible cause/s and referring to the auxiliary tests that will help confirm the diagnosis and management.

It is important to characterize the headache

It is important to answer questions including when the headache started, in what kind of circumstances, how rapidly it progressed, how long it has lasted, any association to a trigger or specific triggering cause or relieving factor (a specific type of food, physical activity, sleep, etc.), how the headache affects the child’s activity levels and daily function (does the child continue playing with his toys or does he seem to be suffering a lot).

It is important to pay attention to risk factors, if present, depending on the individual case
The presence of significant underlying medical conditions in the child or family and the presence of significant accompanying symptoms such as fever, vomiting, altered consciousness, seizures, strabismus, postural imbalance, motoric weakness, sensory changes, changes to eating habits, and the presence of a family history of headaches or migraines.

Additional questions that need to be asked when a child complains of headaches
The age at which he/she started experiencing headaches – a child under the age of 6 who is experiencing headaches must undergo a medical assessment, as you will see below.

What are additional red flags that we should pay attention to?

– An acute headache, or the new onset of a headache in a child who has never experienced headaches before, and one that is affecting a child’s functioning requires a full medical assessment.
– Recurrent headaches, that have different characteristics (going from having a headache occasionally to progressively worsening headaches, that are increasing in frequency or intensity), require medical attention.
– Headaches secondary to a febrile illness, presenting together with vomiting with or without altered consciousness/seizures required medical attention.
– Headaches presenting with pain in a non-typical area such as the back of the head, require medical attention.
– A sudden headache in a child without any underlying history of headaches, presenting at a high intensity, with or without any additional symptoms, requires medical attention.

Are there certain signs and symptoms that typically present with headaches?

The presence of vomiting (for example in the middle of the night or early in the morning), confusion, changes in behavior, changes in eating or drinking habits, unexplained falls, postural imbalance, weakness of the body or sensory changes, new onset strabismus in a child with headaches – all require medical evaluation.

Are there factors that worsen or relieve headaches?

Headaches that are worsened or relieved by certain activities such as coughing, physical activity, weight-lifting or worsen on laying down – must be evaluated by a medical professional.

Are there certain medical conditions or underlying illnesses that could cause headaches?

Children with any sort of immune suppression (whether primary or secondary to medications that suppress the immune system), children that are treated with daily medications, children with chronic illnesses that develop new onset headaches – all require medical assessment.

So, what can we do in practice when a child is experiencing a headache?

We start with a visit to the pediatrician, and this includes thorough history taking. In most cases we will be able to find out the cause of the headaches already at this stage, and most of the time the cause is benign, not dangerous, and does not require any more investigations.
A detailed physical examination by a pediatrician, including a thorough neurological assessment (including measuring the head circumference in a baby) and measuring the blood pressure.

When there is no clear reason for the headache and it cannot be explained by anything, and it the headache has odd characteristics, your pediatrician will refer your child to an eye test (fundus) and a neurological assessment by a pediatric neurologist.
In fact, your pediatrician will assess the urgency of the required investigations (whether an emergent assessment at the hospital is required versus a neurologist in the community) and will refer you to the right professional, as needed.
Following a diagnostic assessment and a physical and neurological examination, the pediatric neurologist will decide whether there is a medical cause for the headaches (such as a migraine) and if further investigations are required, they will refer you to the right tests (brain imaging, eye tests, certain blood tests, etc.)

What is an eye fundus examination?

The optic nerves, which start in the orbits of the eyes and enter the skull until they reach the brain, form a sort of “window” that allows us to receive some important information about different pathological processes that involve the brain.
For example, when there is increased pressure inside the brain for different reasons, there is a dysfunction of the optic nerves and a fundoscopic exam can give us important information about this condition and allow us to refer the patient to the right treatment promptly.

When it comes to brain imaging, are CTs or MRIs preferrable?

In most cases, the preferred imaging technique is an MRI for investigation of a headache. Usually, there is no place for CT tests except for cases that present with acute/recurrent headache with odd characteristics that requires an immediate diagnosis to rule out severe conditions that may warrant immediate management.

In summary, this is not an easy topic to write about. I hope that what you have read will provide you with the right tools to help you properly approach, together with your pediatrician, the headaches your child has been complaining about.

Good luck.