Classification and Approach to Headaches
I. Classification of Headache
Two main classification systems are used in pediatrics.
A. International Classification of Headache Disorders (ICHD-3)
- Primary Headaches: No underlying structural or metabolic cause.
- Migraine (with or without aura).
- Tension-Type Headache (TTH).
- Trigeminal Autonomic Cephalalgias (e.g., Cluster headache - rare in children).
- Secondary Headaches: Symptom of underlying pathology.
- Attributed to infection (meningitis, sinusitis).
- Attributed to head/neck trauma.
- Attributed to vascular disorder (AVM, bleed).
- Attributed to non-vascular intracranial disorder (tumor, IIH).
- Painful Cranial Neuropathies: e.g., Occipital neuralgia.
B. Temporal Classification (Rothner’s Classification)
Clinically most useful for establishing differential diagnosis.
- Acute: Single, sudden onset event.
- Acute Recurrent: Distinct episodes separated by symptom-free intervals.
- Chronic Progressive: Gradual increase in frequency and severity over time.
- Chronic Non-Progressive (Chronic Daily): Frequent/daily headache without worsening severity.
- Mixed: Chronic headache with superimposed acute exacerbations.
II. Causes of Headache in Children (Based on Temporal Pattern)
| Pattern | Common Causes | Less Common / Serious Causes |
|---|---|---|
| Acute | Systemic Infection: Viral fever, Influenza. CNS Infection: Meningitis, Encephalitis. Sinusitis: Acute bacterial. Dental: Abscess. |
Hemorrhage: SAH, Intracranial bleed. Trauma: Concussion. First presentation of Migraine. |
| Acute Recurrent | Migraine: (Most common cause). Tension-Type Headache (Episodic). |
Epilepsy: Ictal headache. Paroxysmal Hypertension: Pheochromocytoma. Neuralgias. |
| Chronic Progressive (Red Flag Category) | Raised ICP: Brain Tumor (Posterior fossa), Hydrocephalus, Abscess. Pseudotumor Cerebri (Idiopathic Intracranial Hypertension). |
Subdural Hematoma (Chronic). Chiari Malformation. Lead Poisoning. |
| Chronic Non-Progressive | Chronic Tension-Type Headache. Psychogenic: Conversion, Somatization. Analgesic Overuse Headache. |
Refractive Errors. Post-concussion syndrome. |
III. Approach to a 10-Year-Old Child with Headache
Step 1: Detailed History (The "OLDCARTS" Mnemonic)
- Onset: Sudden (SAH) vs. Gradual (Tumor).
- Location: Unilateral (Migraine) vs. Band-like (Tension) vs. Occipital (Posterior fossa tumor/Chiari).
- Duration: Hours (Migraine) vs. Continuous (IIH).
- Character: Throbbing (Migraine) vs. Squeezing (Tension) vs. Worst headache of life (Hemorrhage).
- Aggravating factors: Coughing/Straining (Raised ICP), School stress (Tension), Light/Sound (Migraine).
- Relieving factors: Sleep (Migraine), Vomiting (Raised ICP - transient relief).
- Timing: Early morning worsening (Raised ICP).
- Severity: Interference with play/school.
Screen for "Red Flags" (SNOOP 4):
- Systemic symptoms (Fever, Weight loss).
- Neurologic signs (Squint, ataxia, focal deficit).
- Onset sudden (Thunderclap).
- Occipital location (pathologic until proven otherwise in kids).
- Pattern change (New or progressive).
- Precipitated by Valsalva (coughing/sneezing).
- Parental concern (Family history of aneurysm/tumor).
- Papilledema.
Step 2: Physical Examination
- Vitals: Blood pressure (Hypertensive encephalopathy), Temperature.
- Anthropometry: Head circumference (unlikely to change at 10y, but check for macrocephaly history).
- General: Skin (Neurofibromas, Café-au-lait spots), Sinus tenderness.
- Ophthalmology (Mandatory):
- Visual Acuity: Refractive errors.
- Fundoscopy: Papilledema (Raised ICP).
- Neurology:
- Gait/Coordination (Cerebellar signs).
- Cranial Nerves (Diplopia/Squint - CN VI palsy).
- Motor/Reflexes (Asymmetry).
Step 3: Diagnostic Investigations
- Neuroimaging (MRI Brain preferred over CT):
- Indications: Abnormal neurologic exam, Papilledema, Chronic progressive pattern, Headache waking child from sleep, Persistent vomiting, Occipital headache.
- Note: Routine imaging is NOT indicated for classic Migraine or Tension headache with normal exam.
- Lumbar Puncture: Indicated if meningitis suspected or to measure opening pressure (Pseudotumor cerebri) after ruling out mass effect.
- EEG: Only if history suggests seizure equivalents (otherwise low yield).
- Sinus X-ray/CT: If chronic sinusitis suspected.
Step 4: Management Algorithm
- Acute Management:
- Migraine: NSAIDs (Ibuprofen > Paracetamol), Triptans (Sumatriptan/Rizatriptan approved for >6y/12y), Antiemetics.
- TTH: Relaxation, Hydration, NSAIDs.
- Preventive Therapy: Indicated if headache frequency >3-4/month or severe disability.
- Migraine: Flunarizine, Propranolol, Topiramate, Amitriptyline.
- TTH: Amitriptyline, CBT.
- Lifestyle Modification (Bio-behavioral):
- Sleep hygiene (regular schedule).
- Hydration.
- Stress management (school issues).
- Dietary trigger avoidance (caffeine, chocolate, cheese - if identified).