Headaches are common in children, with the average age of onset at 7 for boys and 11 for girls. The frequency of migraine increases through adolescence. An estimated 8% to 23% of children aged 11 to 15 experience headaches. Headaches can be divided into two categories, primary or secondary. Primary refers to headaches that occur on their own and not as the result of some other health problem. Primary headaches (Figure 6-1) include migraine, migraine with aura, tension-type headache, and cluster headache.

Secondary refers to headaches that result from some cause or condition, such as a head injury or concussion, blood vessel problems, medication side effects, infections in the head or elsewhere in the body, sinus disease, or tumors (Figure 6-2). Signs and symptoms of the underlying cause need to be searched for. Headaches associated with infection may represent a systemic reaction to the infection and do not necessarily signify severe disease. For example, strep throat is frequently associated with headaches. There are many different causes for secondary headaches, ranging from rare, serious diseases to easily treated conditions. Sometimes headaches occur almost every day and are called chronic daily headaches.

Migraine is a headache condition that comes back again and again. Ten percent of children get migraines, and an even higher percentage of teenagers have them. These headaches are very painful and throbbing, and children who have them often look ill and pale. Relief is usually linked with sleep. One should focus on ruling out other serious diseases or conditions when first examining migraineurs.

Migraineurs have various signs and symptoms. Typically, a child migraineur has a severe headache located around the eyes, in the front of the head, or in the temples. Some children experience vision changes (“auras”) during a headache. A sick feeling in the stomach or vomiting is common. Many children avoid bright lights, loud noises, or strong odors, as these seem to make the headache worse. The severe head pain is often completely relieved by deep sleep. Recurring spells of dizziness may represent another form of migraine in children. An inherited tendency is believed to make some people more likely to have a migraine after some minor trigger (Table 6-1), although no single theory explains how the human body produces all the symptoms of a typical migraine headache. The key to recognizing migraines is identification of a pattern of short but very painful headache episodes that are relieved by sleep and separated by symptom-free intervals.

Although migraine headaches have long been considered a benign (relatively harmless) condition, they can cause a lot of damage to a person’s quality of life and ability to take part in normal life activities. The pain is so intense that migraineurs often cannot think or function very well during or right after episodes.

About 65% to 80% of children with migraines interrupt their normal activities because of the symptoms. In one study of 970,000 self-reported migraineurs aged 6 to 18 years, 329,000 school days were lost per month. The burden of migraines may cause emotional changes like anxiety or sadness. Appropriate diagnosis and treatment of migraines can greatly improve quality of life.

Studies suggest that migraine headaches occur in 5% to 10% of school-aged children in the United States, a percentage that constantly increases through adolescence and peaks at about age 44 years. Many people experience spontaneous remission, meaning that the headaches go away on their own for no clear reason.

Migraine headaches begin earlier in boys than in girls. From infancy to 7 years, boys are affected equally or slightly more than girls. The prevalence of migraines increases during the adolescent and young adult years, during which 20% to 30% of young women and 10% to 20% of young men experience migraines. After menarche (the time when the first menstrual period occurs), a female predominance occurs. This continues to increase until middle age. The frequency of migraines declines in both sexes by age 50 years.

Most migraineurs begin to experience attacks before turning 20 years old. Approximately 20% have their first attack before their 5th birthday. Preschool children experiencing a migraine attack usually look ill and have abdominal pain, vomiting, and a strong need to sleep. They may show pain by irritability, crying, rocking, or seeking a dark room in which to sleep.

Migraineurs aged 5 to 10 years experience headache, nausea, abdominal cramping, vomiting, photophobia (sensitivity to light), phonophobia (sensitivity to sound), osmophobia (sensitivity to smells), and a need to sleep. They usually fall asleep within an hour of the time the attack starts. The most common accompanying symptoms include paleness with dark circles under the eyes, tearing, swollen nasal passages, thirst, swelling, excessive sweating, increased urination, and diarrhea. Older children tend to present with headache on one side. Many sinus headaches are really of migrainous origin. The headache location and intensity often changes within or between attacks.

As children grow older, headache intensity and duration increases, and migraines start to happen at more regular intervals. Older children also describe a pulsating or throbbing character to their headaches. Headaches often shift to the one-sided temple location that most adult migraineurs report. Childhood migraines often stop for a few years after puberty.

To young children, non-headache symptoms may be more troubling than the headache. Younger children may experience photophobia and phonophobia without accompanying stomachache or headache. Some children have repeated bouts of stomach pain without accompanying headache.

Migraine headaches are recurrent headaches that occur at intervals of days, weeks or months.1 There may or may not be a pattern to the attacks—for example, teenage girls may tend to have attacks at a particular point in their monthly menstrual cycle. Migraines generally have some of the following symptoms and characteristics:

• Untreated, they can last from 2 to 48 hours in children. Sleep or medical treatment can reduce this time period.
  
• Headache starts on one side of the head. This may vary from headache to headache and in children, they may start in the front or in both temples.
  
• Throbbing or pounding pain occurs during the headache.
  
• Pain is rated as moderate to severe.
  
• Pain gets worse with exertion. The pain may be so severe that it is difficult or almost impossible to continue with normal daily activities.
  
• Nausea, vomiting, and/or stomach pain commonly occur with the attacks.
  
• Light and/or sound sensitivity is also common.
  
• Pain may be relieved with rest or sleep.
  
• Other members of the family have had migraines or “sick headaches.”
  
• Warnings called auras may start before the headache. These auras can include blurry vision, flashing lights, colored spots, strange tastes, or weird sensations, and usually precede the headache by 5 to 60 minutes.

Migraine Without Aura

• Much more common than classic migraine.
  
• 85% of children with migraine have common migraine.
  
• There is no aura.
  
• The headache is usually slower in onset then classic migraine, building over several minutes to hours. However, the time from onset to peak intensity may be as short as 15 to 30 minutes.
  
• These headaches are frequently bifrontal (forehead) in location but may be one sided.
  
• Many children will vomit within 30 minutes to 1 hour following onset of their headache.
  
• These headaches may be aggravated by exercise or movement.
  
• Child may have trouble concentrating when they have a headache.
  
• Other prominent symptoms may include
  
  
  
  • Nausea.
    
  • Vomiting.
    
  • Light sensitivity (photophobia).
    
  • Sensitivity to sound (phonophobia).
    
  • Sensitivity to strong odors (osmophobia).
  
  
• Children may seek a dark quiet room and attempt to sleep.
  
• Dizziness (an automatic feature) is seen, particularly in young females.
  
• Headaches last anywhere from 1 hour to 48 hours—sometimes longer.
  
• The child is normal between attacks.
  
• The children will frequently grab onto a nearby person or object.
  
• Episodes usually last less than 1 minute.
  
• Following the event, the child returns to normal.
  
• Though frightening to both child and parent, these are benign.
  
• If frequent, the attacks can be treated; however, treatment is usually not necessary.
  
• Typically this disorder resolves before age 5.
  
• A family history of migraine can usually be obtained.