Headache in Children
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Direct answer
Recurrent headache in a school-going child is migraine until the history proves otherwise, while the clinician's real job is to separate primary headache from the small minority caused by raised intracranial pressure. Paediatric migraine (at least five attacks lasting 2 to 72 hours) is characteristically bilateral in younger children, worsened by routine activity, and accompanied by nausea, vomiting, photophobia or phonophobia. Red flags demanding imaging include early-morning headache with vomiting, progressive frequency or severity, headache exacerbated by coughing or straining, any new neurological deficit, papilloedema, a change in personality or school performance, and headache in a child younger than three. Acute attacks respond to paracetamol 15 mg/kg or ibuprofen 10 mg/kg given early; propranolol, topiramate and flunarizine anchor prophylaxis.
What you must remember
- Migraine, paediatric style: at least five attacks of 2 to 72 hours, bilateral or holocranial more often than the adult hemicranial pattern, pulsating quality, aggravation by activity, nausea or vomiting plus photophobia and phonophobia; motion sickness and a family history are classic companions.
- Migraine equivalents: cyclic vomiting, abdominal migraine and benign paroxysmal vertigo of childhood are all part of the migraine spectrum and share the family history.
- Tension-type headache: band-like, bilateral, non-pulsating, no nausea, may occur daily around exam time — the commonest chronic headache in adolescents.
- Red flags (the SNOOP memory hook): systemic symptoms or fever with neck stiffness, neurological deficit, papilloedema, onset before age three, progressive pattern, thunderclap onset, morning headache with vomiting, or trigger by cough and valsalva — any one of these pushes imaging to the front of the queue.
- Acute therapy dosing: paracetamol 15 mg/kg per dose or ibuprofen 10 mg/kg per dose taken within the first hour; nasal sumatriptan is the best-studied triptan in children; avoid opioids and beware medication-overuse headache (simple analgesics on more than 10 to 15 days a month).
- Prophylaxis: propranolol, topiramate, cyproheptadine in younger children, and flunarizine — the last a distinctly popular choice in Indian prescription practice — started when headaches occur four or more times a month or disable schooling; regular sleep, meals and a headache diary are the non-drug pillars.
- Idiopathic intracranial hypertension: obese adolescent girl, daily headache, transient visual obscurations, pulsatile tinnitus, sixth nerve palsy, normal MRI, and CSF opening pressure above 25 cm of water on lumbar puncture; weight reduction and acetazolamide are the treatment core.
Reading the case from the history sheet
Two children, two pathways. The first is a 12-year-old with a year of unilateral throbbing headaches, one every fortnight, each lasting an afternoon, relieved by sleep in a dark room, with a mother who has "sinus headaches" that throb. Normal examination and fundus: migraine without aura, needing no imaging — early analgesia, a trigger diary, and prophylaxis only if schooling erodes.
The second is an eight-year-old with two months of headaches that have moved from weekly to daily, vomiting before breakfast, a stumble on the left foot, and a fundus showing blurred disc margins. This child gets an urgent MRI, not a prescription — the concern is a posterior fossa tumour, the commonest brain tumour location in children, where morning vomiting and ataxia outrank headache as early signs. Between these two sits the obese 14-year-old with daily retro-orbital pain, double vision on looking sideways and a normal MRI: the pathway ends in a lumbar puncture with manometry, and the diagnosis of idiopathic intracranial hypertension is confirmed by an elevated opening pressure. Each child needed a different next step, and the history alone chose it.
Where marks are lost
The classic error is ordering imaging for every headache child — imaging is driven by red flags and an abnormal neurological or fundoscopic examination, not by parental anxiety alone, and a vignette usually plants one deliberate red flag if imaging is the intended answer. The second error is missing medication-overuse headache in the adolescent taking combination analgesics daily; the treatment is withdrawal, not a stronger drug. The third is the fundus: any headache stem in an exam implicitly asks whether you looked for papilloedema before reaching for a triptan — quoting "fundoscopy in every child with headache" in a viva earns quiet approval. Finally, do not dismiss morning headache as "school refusal" when it comes with vomiting; posterior fossa tumours in children present precisely that way.
Frequently asked questions
Which features of headache in a child mandate neuroimaging?
Early-morning headache with vomiting, progressive course, thunderclap onset, cough- or strain-triggered pain, neurological deficits, papilloedema, age under three years, or personality and school-performance change.
How does paediatric migraine differ from adult migraine?
Attacks are shorter (2 to 72 hours), more often bilateral, abdominal symptoms and motion sickness are prominent, and sleep commonly terminates the attack.
What is the first-line acute drug treatment for migraine in children?
Paracetamol 15 mg/kg or ibuprofen 10 mg/kg taken early in the attack, with nasal sumatriptan reserved for adolescents with poor response.
When should migraine prophylaxis be started in a child?
When attacks occur four or more times per month, disrupt schooling, or fail to respond to abortive therapy — options include propranolol, topiramate and flunarizine.
How is idiopathic intracranial hypertension confirmed in an adolescent?
Normal MRI (or venogram excluding sinus thrombosis) followed by lumbar puncture showing an opening pressure above 25 cm of water with normal CSF composition.