Headache

Definition

A headache involves pain in the head that can arise from many disorders or may be a disorder in and of itself.

Description

Headaches can be categorized as primary or secondary. Primary headaches occur independently and are not the result of another medical problem. Secondary headaches are caused by illness, infection, or injury and account for less than 10 percent of all headaches.

There are many classifications of headaches, including more than 150 diagnostic headache categories identified by the International Headache Society. In general, there are three types of primary headaches, including:

Tension headaches—muscular contraction headaches that occur periodically or daily (chronic daily headache). The typical tension-type headache is described as a tightening around the head and neck, and an accompanying dull ache. The headache may last from 30 minutes to several days. Tension headaches usually are not associated with symptoms of nausea or vomiting .
Migraine—moderate to severe throbbing pain occurring on one or both sides of the head. Migraines are often accompanied by other symptoms such as nausea, vomiting, blurred vision, and sensitivity to light, sound, strong odors, and movement. A migraine with aura has accompanying "warning signs" that indicate a pending attack. A hemiplegic migraine is associated with weakness on one side of the face, arm, or leg. A migraine may last from two to 48 hours and usually occurs two to four times per month.
Cluster headaches—severe headaches characterized by pain centering around one eye, and eye tearing and nasal congestion occurring on the same side. The headache lasts from 15 minutes to four hours and may recur several times in a day. Cluster headaches have a characteristic grouping of attacks, which may last from two weeks to three months.

Some chronic tension headaches may start as migraines but become daily headaches. These are called transformed migraines. Drug rebound headaches are those that occur from over-using medications for headache pain; they result from exceeding labeling instructions or a physician's directions.

Headaches that occur along with other neurological symptoms, such as balance problems and vision changes, may be a sign of a disease process in the brain. These organic causes of headache may include hydrocephalus (abnormal build-up of fluid in the brain), infection of the brain, tumor, or other conditions.

Demographics

Headaches are very common in children and adolescents. One study reported that 56 percent of boys and 74 percent of girls between ages 12 and 17 have at least one headache within a 30-day period. Tension headaches are the most common type of headache, affecting 15–20 percent of adolescents. The American Council for Headache Education (ACHE) estimates 4–10 percent of children have migraine headaches. Many adults with headaches report that they first began in childhood, and 20 percent report headache onset before age 10. Before puberty , migraines occur equally in girls and boys. After puberty, girls are three times more likely to have migraines than boys because of associated hormonal changes and menstruation . Headaches are a major cause of missed school days.

Causes and symptoms

Causes

Most headaches in children and adolescents are benign and not the result of an underlying disease or disorder. Rather, most headaches in children are the result of stress and muscle tension, lack of sleep , orthe common cold , flu, or sinus or ear infection.

Traditional theories about headaches link tension-type headaches to muscle contraction, and migraine and cluster headaches to blood vessel dilation (swelling). Pain-sensitive structures in the head include blood vessel walls, membranous coverings of the brain, and scalp and neck muscles. Brain tissue itself has no sensitivity to pain. Therefore, headaches may result from contraction of the muscles of the scalp, face or neck; dilation of the blood vessels in the head; or brain swelling that stretches the brain's coverings. Involvement of specific nerves of the face and head may also cause characteristic headaches. Sinus inflammation is a common cause of headache.

Tension-type headaches are often brought on by emotional or mental stress, overexertion, poor posture, loud noise, and other external factors.

In post-puberty girls, a hormonal connection is likely, since headaches occur at specific points in the menstrual cycle.

Secondary headaches are caused by a wide range of conditions, including some rare diseases and other more treatable conditions. Secondary headaches may be the result of infection, meningitis , tumors, or localized head injury .

Some headaches have a genetic link; sensitivities to certain environmental triggers and migraines also have been identified in one or both parents.

HEADACHE TRIGGERS Migraines are often triggered by food and environmental factors. Known food triggers include chocolate; aged cheeses; pizza; monosodium glutamate (MSG); bananas; nuts; peanut butter; ice cream; yogurt; fatty or fried foods; processed meats containing nitrates, such as hot dogs and pepperoni; certain food dyes; artificial sweeteners such as aspartame; and caffeine . Environmental triggers include weather changes; smoking ; strong odors; and bright lights. Other triggers include sudden changes in sleep patterns and changes in hormone levels. By keeping a headache diary, the child and parents can identify and then avoid the specific substances that seem to cause headache symptoms.

When to call the doctor

The parent or caregiver should call the child's pediatrician or neurologist when the child has these symptoms or conditions:

headache pain that interrupts sleep
early morning vomiting without an upset stomach
worsening headache symptoms
headaches that prevent the child from participating in usual activities
frequent headaches, occurring three or more times per week
headache characteristics that are completely different or new
headache caused by strenuous activity, bending, coughing, or exertion
headaches that become more severe and/or frequent over time
family history of neurological disease
headache pain requiring a pain reliever daily or almost every day
headache pain requiring more than the recommended dose of over-the-counter pain relievers

The parent or caregiver should seek prompt medical attention when the child has these symptoms or conditions:

Headache is described as the "Worst headache of my life." This may indicate an aneurysm or other neurological emergency.
Headache accompanied by weakness, numbness , paralysis, visual loss, speech difficulty, loss of balance, falling, seizures, shortness of breath, mental confusion, or loss of consciousness. These symptoms could indicate a pending stroke .
Sudden onset of headache, especially if accompanied by a fever and stiff neck. These symptoms could indicate meningitis.
Visual changes, including blurry vision, "blind spots," or double vision.
Headaches that persist after a head injury or accident.
Personality changes or inappropriate or unusual behavior.
Headaches accompanied by severe nausea or vomiting.
A fever, rash, or stiff neck that occurs with a headache.

Diagnosis

All children who experience headaches on a relatively regular basis should be evaluated. Since headaches arise from many causes, a physical exam assesses general health and a neurological exam evaluates the possibility of neurological disease that is causing the headache. The doctor will look for signs of illness, including fever, high blood pressure, muscle weakness, difficulties with balance, or visual problems.

If the headache is the primary illness, the doctor elicits a thorough history of the headache to help classify the headache, including:

age of onset
duration and frequency
types of headaches experienced
when the headaches occur
pain intensity and location
accompanying symptoms or warning signs of headache onset
possible triggers or causes of the headaches
types of headache treatments used and their effectiveness
presence of any prior symptoms
impact on school and activities

The child's medical and family history help the physician determine if the child has any conditions or disorders that might contribute to or cause the headache. A family history of migraines or neurological disease might suggest a genetic predisposition to the condition.

The diagnostic evaluation for headache may include blood tests and urinalysis to rule out other medical conditions that may be causing the headaches. Neurological imaging tests such as computed tomography (CT) scan or magnetic resonance imaging (MRI) may be performed to rule out the presence of neurological diseases or disorders. Other tests may include a sinus x ray and ophthalmology examination. If a condition affecting the brain and spinal cord is suspected, a lumbar puncture or spinal tap may be performed.

A psychological assessment is not part of a routine headache evaluation but may be performed to identify stress triggers.

Treatment

The specific treatment prescribed will depend upon the type and frequency of the headache, its cause, and the child's age.

Headache diary

A headache diary can be used to record the characteristics of headaches, including possible triggers, such as foods, weather changes, odors, mood, stressful situations, emotions, or menstrual phases. It also can help the doctor identify the appropriate treatment.

Lifestyle changes

Making certain dietary and lifestyle changes can significantly improve the child's headache symptoms. Exercise is an important part of a healthy lifestyle. It aids in stress reduction and improves circulation, which may help reduce headache symptoms. Relaxation and stress management techniques may help the child cope with headache symptoms. Getting enough sleep is equally important; most children and adolescents need at least eight to 10 hours of sleep per night. Counseling can help the child identify stressful situations or events that cause the headaches. It also can teach the child various coping strategies.

Medications

Some children may find enough relief with over-the-counter pain relievers in the right dose. Other children need more aggressive treatment that includes preventive (prophylactic) medication.

Headache medications are classified as abortive, prophylactic, or symptom relief. Abortive medications treat a headache in progress, prophylactic medications prevent a headache, and symptom relief medications relieve associated headache symptoms.

Abortive medications are taken with the onset of the first sign of a migraine. Some prescribed abortive medications include the triptan drugs such as sumatriptan (Imitrex), zolmitriptan (Zomig), naratriptan (Amerge), and ergotamine tartrate and caffeine (Caffergot).

Prophylactic medications are prescribed to treat frequent tension headaches or migraines, or the combination of both headaches. These medications must be taken daily to reduce the frequency and severity of headaches, and they may take a few weeks to be fully effective. Some prophylactic treatments include antidepressants , antihistamines , nonsteroidal anti-inflammatories (NSAIDs), prednisone, beta-blockers, and calcium channel blockers.

Symptom relief medications are used to relieve symptoms associated with headaches, including headache pain or nausea. These drugs may include over-thecounter pain-relieving medications such as acetaminophen , ibuprofen, naproxen, or anti-nausea medications (called antiemitics). Prescribed symptom relief medications may include sedatives (to induce sleep) and muscle relaxants. If symptom relief medications are needed more than twice a week, the child should see his or her doctor, who can make adjustments to the treatment plan. When taken more than three times per week, symptom relief medications can actually cause a type of headache called a rebound headache. To treat rebound headaches, all pain-relieving medications are usually discontinued for a few weeks (as advised by the physician), then used no more than two to three times per week to relieve symptoms.

Alternative treatment

Alternative headache treatments include:

relaxation techniques, such as meditation, deep breathing exercises, progressive muscle relaxation, guided imagery, and relaxation to music
yoga
acupuncture or acupressure
biofeedback
chiropractic
homeopathic remedies chosen specifically for the individual and his or her type of headache
hydrotherapy
massage to reduce stress and tension and relieve tight muscles in the neck and shoulders
essential oils such as lavender, ginger, peppermint, and wintergreen that can provide relief by simply smelling them or applying them to the temples or neck
regular physical exercise

Biofeedback, which teaches patients how to direct mental thoughts to influence physical functions, may be helpful for some patients. For example, patients can use certain relaxation techniques to help them learn how their personal response to muscle tension is related to their headache symptoms. By practicing biofeedback, a patient may be able to stop a migraine attack before it occurs or prevent headache symptoms from becoming worse.

Follow-up care

It is important for the child to keep a regular followup appointment schedule so the doctor can monitor the effects of treatment and make any necessary medication adjustments.

KEY TERMS

Abortive —Referring to treatment that relieves symptoms of a disorder. Abortive headache medications are used to stop the headache process and prevent symptoms of migraines, including pain, nausea, sound and light sensitivity, and other symptoms.

Acupuncture —Based on the same traditional Chinese medical foundation as acupressure, acupuncture uses sterile needles inserted at specific points to treat certain conditions or relieve pain.

Acute —Refers to a disease or symptom that has a sudden onset and lasts a relatively short period of time.

Analgesics —A class of pain-relieving medicines, including aspirin and Tylenol.

Aneurysm —A weakened area in the wall of a blood vessel which causes an outpouching or bulge. Aneurysms may be fatal if these weak areas burst, resulting in uncontrollable bleeding.

Anti-inflammatory —A class of drugs, including nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, used to relieve swelling, pain, and other symptoms of inflammation.

Antidepressant drug —A medication prescribed to relieve major depression. Classes of antidepressants include selective serotonin reuptake inhibitors (fluoxetine/Prozac, sertraline/Zoloft), tricyclics (amitriptyline/Elavil), MAOIs (phenelzine/Nardil), and heterocyclics (bupropion/Wellbutrin, trazodone/Desyrel).

Antiemetic drug —A medication that helps control nausea; also called an antinausea drug.

Antihistamine —A drug used to treat allergic conditions that blocks the effects of histamine, a substance in the body that causes itching, vascular changes, and mucus secretion when released by cells.

Aura —A subjective sensation or motor phenomenon that precedes and indicates the onset of a neurological episode, such as a migraine or an epileptic seizure. This term also is used to refer to the emanation of light from living things (plants and animals) that can be recorded by Kirlian photography.

Biofeedback —A training technique that enables an individual to gain some element of control over involuntary or automatic body functions.

Chiropractic —A method of treatment based on the interactions of the spine and the nervous system.

Chiropractors adjust or manipulate segments of the patient's spinal column in order to relieve pain.

Chronic —Refers to a disease or condition that progresses slowly but persists or recurs over time.

Cyclic vomiting —Uncontrolled vomiting that occurs repeatedly over a certain period of time.

Decongestants —A group of medications, such as pseudoephedrine, phenylephrine, and phenylpropanolamine, that shrink blood vessels and consequently mucus membranes.

Episodic —Occurring once in a while, without a regular pattern.

Homeopathy —A holistic system of treatment developed in the eighteenth century. It is based on the idea that substances that produce symptoms of sickness in healthy people will have a curative effect when given in very dilute quantities to sick people who exhibit those same symptoms. Homeopathic remedies are believed to stimulate the body's own healing processes.

Hydrotherapy —The use of water (hot, cold, steam, or ice) to relieve discomfort and promote physical well-being. Also called water therapy.

Inflammation —Pain, redness, swelling, and heat that develop in response to tissue irritation or injury. It usually is caused by the immune system's response to the body's contact with a foreign substance, such as an allergen or pathogen.

Lumbar puncture —A procedure in which the doctor inserts a small needle into the spinal cavity in the lower back to withdraw spinal fluid for testing. Also known as a spinal tap.

Magnetic resonance imaging (MRI) —An imaging technique that uses a large circular magnet and radio waves to generate signals from atoms in the body. These signals are used to construct detailed images of internal body structures and organs, including the brain.

Meningitis —An infection or inflammation of the membranes that cover the brain and spinal cord. It is usually caused by bacteria or a virus.

Nervous system —The system that transmits information, in the form of electrochemical impulses, throughout the body for the purpose of activation, coordination, and control of bodily functions. It is comprised of the brain, spinal cord, and nerves.

Neurologist —A doctor who specializes in disorders of the nervous system, including the brain, spinal cord, and nerves.

Neurology —The study of nerves.

Nitrate —A food additive, commonly found in processed meats, that may be a headache trigger for some people.

Prophylactic —Preventing the spread or occurrence of disease or infection.

Stroke —Interruption of blood flow to a part of the brain with consequent brain damage. A stroke may be caused by a blood clot or by hemorrhage due to a burst blood vessel. Also known as a cerebrovascular accident.

Trigger —Any situation (people, places, times, events, etc.) that causes one to experience a negative emotional reaction, which is often accompanied by a display of symptoms or problematic behavior.

Prognosis

Most headaches are benign (not the result of a severe disease). Headaches are typically resolved through the use of analgesics and other treatments. As a child grows, the headaches may disappear.

Prevention

Some headaches may be prevented if the child avoids triggering substances and situations, or practices alternative therapies, such as yoga or biofeedback. Regular exercise and good sleep habits also can help prevent headaches.

Nutritional concerns

Since food allergies are often linked with headaches, especially cluster headaches and migraines, identifying and eliminating the allergy-causing food(s) from the diet can be an important preventive measure. To help control migraines, the child should eat three balanced meals at regular intervals, take a multi-vitamin supplement to maintain adequate nutrient needs, and drink four to eight glasses of non-caffeinated fluids per day. Sports drinks during exercise and during a headache can help balance sugar and sodium levels. To prevent headache symptoms associated with certain foods, parents should work with a registered dietitian to facilitate specific dietary changes. They also should carefully read food labels to identify and avoid dietary triggers.

Parental concerns

It is important for parents to reassure their child that most headaches are not caused by a serious illness. Parents can help their child create and maintain a headache diary to record headache symptoms, triggers, as well as the duration and frequency of the headaches. Parents should make sure their child drinks enough fluids, eats three well-balanced meals each day, gets plenty of sleep, and balances activities to avoid an over-crowded schedule that may cause stress and lead to a headache. When headaches occur, parents should allow the child to take a nap; a dark, quiet room is usually preferred by the child. In addition, parents can help the child learn relaxation techniques to help relieve or prevent headache symptoms. If the headaches are linked to anxiety or depression, the parents should ask the child's doctor for a referral to a counselor who can provide additional assistance.

Resources

BOOKS

Diamond, Seymour, M.D. Headache and Your Child: The Complete Guide to Understanding and Treating Migraine and Other Headaches in Children and Adolescents. New York: Fireside, 2001.

Silberstein, Stephen D., M.D., FACP, et al. Headache in Clinical Practice. 2nd ed. London, England: Martin Dunitz, Ltd., 2002.

Wolff, Harold G., et al. Wolff's Headache and Other Head Pain. New York: Oxford University Press, Inc., 2001.

ORGANIZATIONS

American Council for Headache Education (ACHE). 19 Mantua Road, Mt. Royal, NJ 08061. (856) 423-0258. Web site: http://www.achenet.org.

American Headache Society. 19 Mantua Rd., Mt Royal, NJ 08061.(856) 423-0043. Web site: http://www.ahsnet.org.

MAGNUM (Migraine Awareness Group: A National Understanding for Migraineurs). 113 South St. Asaph St., Suite 300, Alexandria, VA 22314. (703) 739-9384. Web site: http://www.migraines.org.

National Headache Foundation. 820 N. Orleans, Suite 217, Chicago, IL 60610. (888) NHF-5552. Web site: http://www.headaches.org.

National Institutes of Health (NIH). National Institute of Neurological Disorders and Stroke. NIH Neurological Institute. P.O. Box 5801, Bethesda, MD 20824. (800) 352-9424. Web site: http://www.ninds.nih.gov.

WEB SITES

Excedrin Headache Resource Center. Sponsored by Bristol-Myers Squibb Company. Available online at: http://www.Excedrin.com.

Headache Impact Test. A tool to measure the impact headaches are having on patients' lives, to track headaches over time, and to share this information with the physician. Available online at: http://www.headachetest.com.

Migraine Information Center. Sponsored by GlaxoSmithKline. Available online at: http://www.migrainehelp.com.

"When Kids Get Headaches." The Nemours Foundation . [cited October 12, 2004]. Available online at: http://www.kidshealth.org/parent/general/aches/headache.html.

Julia Barrett Angela M. Costello