Introduction

Headaches are common with 30% – 50% of children in middle childhood and 50 – 60% of adolescents under 15 years of age experiencing headaches. 10% of them experience headaches that are severe enough to interfere with daily activity.

Headaches can be single or recurrent in nature, and localized to one or more areas of the head and face. Many children may feel pain that is throbbing in nature, but pain can also be sharp, constricting and often not easy to describe properly.

Younger children have difficulty expressing their symptoms, so it may be more helpful to observe their behaviour when the headaches occur.

Causes of headache in children

Headache per se is not a disease. The pain itself is not coming directly from the brain but rather from the structures around the head such as blood vessels, sinuses, muscles and meninges.Therefore, headaches are merely the symptoms of some underlying diseases or conditions.

There are many causes of headaches. Some are common and often not dangerous. There are only very few sinister causes of headache in children that need urgent evaluation and treatment.

The common causes of headaches include:

• Illness and infections
  • Headaches may actually accompany many minor childhood illnesses and fever such as flu, pharyngitis and particularly sinusitis. Headache may also feature prominently in more serious infections such as dengue, typhoid and malaria.
  • These headaches usually occur acutely and do not recur.
• Migraine
  • Migraine headaches are fairly common in children. It can occur in children as young as 5 years old.
  • It may or may not be accompanied by abnormal vision or sensation (aura).
  • Migraine may be inherited, so there may be other affected members in the family.
• Tension headache
  • This occurs more commonly in older children and adolescence and usually run a chronic and recurring course.
• Eye strain
  • This is not as common, but children with headache need to have their eyes and vision checked.
  • Headache due to eye strain are felt as dull aching pain behind the eyes.
  • This results from prolonged near fixation in children with latent convergence disturbance.
  • Refractive error per se does not cause eye strain in children.

Less common causes of headache:

• Brain infections such as meningitis and encephalitis.
• Increased pressure within the head (intracranial). This could be due to the presence of:
  • Brain tumour
  • Pus accumulation (abscess)
  • Excessive fluid in the brain (hydrocephalus)
  • Unexplained conditions such as idiopathic intracranial hypertension
• Abnormal blood vessels in the brain
• Intracranial bleeding
• Recent or previous injury that resulted in head concussion

In most of those rare but serious conditions, headache is usually not the only symptom. It is usually accompanied by other problems such as high grade fever and neck stiffness (meningitis), unsteadiness or vision problems (brain tumour), or reduced consciousness (bleeding).

When to seek help from a doctor?

Most headaches are benign, but you should seek help from a doctor if the headaches are severe and frequent enough to disrupt your child’s daily activity and schooling.

There are also other important symptoms and conditions to look for. These may indicate underlying serious conditions that need urgent medical intention:

• Headaches that are constant or getting progressively more severe over time.
• Sudden and very severe, intense headache that your child had not experienced before.
• Reduced consciousness.
• Change in behavior.
• Headaches that accompany fever and made worse by bright light or stiffness of the neck.
• Headache that awaken the child in the middle of the night.
• Headaches that start very early in the morning.
• Vomiting without nausea.
• Weakness of the arms or the legs.
• Seizures.
• Unsteadiness.
• Visual disturbance such as seeing double.
• Headache that are made worse by bending or coughs and sneezes.

Tension headaches in children

Features of tension headache are:

• Usually occur in older children or adolescence.
• It may occur chronically (more than 15 days per month) or periodically.
• Pain may be described as dull ache over the forehead, temple or back of head and neck, resembling a ‘band’ of pain around the scalp. However a clear description may be difficult.
• Typically occur during mid-day or towards the end of the day and last for hours.
• The pain normally eases away after a period of rest or sleep.
• Usually there is no specific precipitating factors.
• No aura or associated symptoms. There should not be associated unsteadiness, weakness or any neurological damage.

The headaches are thought to be associated with muscle tightening. This could be due to:

• Inadequate rest
• Poor posture
• Emotional or mental stress, including depression

This stress may be known (overt) or unknown (covert) to the patient and his or her parents. The most common sources of stress in children and adolescents include school, family, and friends or peers.

Treatment for Tension Headache

• Stress management. Recognizing and treating the underlying stress and tension are proven to be effective.
• Ensure adequate sleep. There are many measures that can be done to achieve better and more restful sleep. (seen section on sleep problems).
• Relaxation technique. This includes breathing exercise, progressive muscle relaxation, mental imagery relaxation and various other techniques. Discuss with your doctors.
• Medication. The usual medications such as paracetamol and ibuprofen are helpful to relieve the pain. However if your child needs to take these medications for more than 2 days in a week, he or she should be referred to a doctor or paediatrician.