P O S T G R A D U AT E C L I N I C
A Clinical Approach to Headache in Children
K. K. Sinha*
Headache is an important neurologic problem in
children and adolescents and has been the topic of a
number of articles in the literature and symposia in
recent times. The subject has been in the limelight
since 1873 when a British paediatrician, William
Henry Day wrote a chapter in his treatise “Essays on
Disease of Children” and concluded that headache
in children is caused by bad arrangements in their
lives and the same can be said even today for many
adults and many children1.
A very valuable epidemiological study on headache
was done in Upsala in Sweden2. Nine thousand
children between the ages of 7 and 15 were studied
by questionnaires. The study showed that there was
a stepwise increase in migraine; so that by age 15,
five per cent of all children had migraine and 15 per
cent had frequent headaches of other kinds such as
muscle contraction headache. When several hundred
of these children were studied by neurologists, several
good pieces of information began to surface and one
of them was that in children below the age of 10,
migraine is commoner in boys whereas after the age
of 10 it becomes commoner in girls.
If one takes a look at the profile of headaches of all
kinds whether in children, adolescents or adults, one
can identify a group of headaches of vascular type,
another of muscle contraction type and a more serious
group made of organic diseases of the brain and
head3. The largest subgroup in the vascular variety is
migraine of all kinds such as the common migraine
(now called migraine without aura), classic migraine
(now called migraine with aura) and complicated
migraine. For all practical purposes cluster headache
does not occur in children. It begins to appear in
young adults. Paroxysmal hemicranias are common
in female adolescents.
The second most common type is muscle contraction
headache, a term which is now considered erroneous,
because its definition is largely based on EMG finding
of increased activity in muscles of the scalp and neck.
However, a large segment of those who qualify for
* Neurologist
“Mansarovar”, Booty Road, Bariatu,
Ranchi-834 009, Bihar, India.
the clinical label of muscle contraction headache, do
not have an EMG activity in the scalp and neck
muscles at all. This group may be synonymous with
either “chronic tension headache” or “psychogenic
headache” of adults. The third group is the headache
occurring with organic diseases of the brain and head.
The usual causes are inflammatory disease of the
head and brain structures where there is a rise in
intracranial pressure or some traction and
displacement of structures of some other organic
aetiology.
Once delineated into these three categories, the
physician needs some guidelines that can help him
recognise and manage different types of headache
in children. One can begin by placing a particular
child with headache into one of following four clinical
headache syndrome patterns4. Nearly all patients with
headache whether children, adolescents or adults,
more or less follow these patterns.
Pattern I
Here the child comes with first attack of a bad
headache and this is typically represented by a child
who has no previous history of headache except the
current one that appeared abruptly and made his
parents go to see their physician. This variety of
headache poses the greatest diagnostic dilemma. It
could be the first attack of migraine, but it could be
any thing else as well. This is a situation which has
not been studied thoroughly and about which least is
known to physicians.
Pattern II
This is represented by a child who gives a history of
attacks of terrible headaches. He already has a
chronic intermittent or relapsing pattern of headache.
In 9 out of 10 cases, there is nausea or vomiting.
Some day the child is real bad but next day he may
be perfectly fine and participates in all activities.
Attacks of headaches are repeated weeks to months
later and in between the attacks he is headache free.
This is therefore a syndrome of recurrent acute
headaches with accompanying nausea or vomiting
and the diagnosis here is usually migraine. If one
sees the child after the first attack, one may not be so
sure of the diagnosis, but when he happens to see
him during subsequent attacks, one can easily identify
the disorder.
Pattern III
The next group of headaches is the one associated
with organic diseases of the brain and head. The thing
that brings the child to the doctor is the fear of the
brain tumour or an aneurysm or meningitis/some such
serious illness. This is the group that the physicians
need to be cautious and alert about. The physician’s
job here is first to convince himself and then convince
the parents and the child that there is no major organic
disease. One may strongly suspect it on clinical
grounds and then either confirm or reject it with
laboratory studies. Any headache in a child that gets
worse over a period of time should however alert the
physician. Here, definition of “worsening” includes
two features: a) headaches become more frequent
than ever and b) they become more severe than ever.
Such headache attacks might occur first thing in the
morning. After the onset they may plateau for a while
and then they may become worse again. They might
last all day with increasing or variable severity. They
might even disappear for a couple of days or even a
week and return with greater severity and can follow
a pseudointermittent pattern. On successive
examinations within a period of next two months or
so, abnormalities on neurologic examination appear.
Once the physician happens to see this pattern of
worsening headache, which is now more frequent
and more severe and perhaps also associated with
symptoms and signs such as papilloedema that might
suggest increased intracranial pressure or a
progressive neurologic disorder, one must now ask
for a reliable method of imaging such as a CT scan
or a MRI. Fortunately, this is the least common of all
headache syndromes, but requires the physician to
be alert.
Pattern IV
This group is made of the child with everyday
headache which occurs more frequently in a female
child and often first thing in the morning. It is present
nearly all day and for several days in a week and is
aggravated by exercise and is relieved only partly by
rest. The only other accompaniment is some dizziness.
These patients do not have signs of raised intracranial
Journal of Indian Academy of Clinical Medicine
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pressure and the neurological examination is perfectly
normal. This is probably a stress related syndrome.
However, one must remember that some children may
have a mixed pattern which is a blend of more than
one variety and which can confuse the issue.
At the end of the history taking and physical
examination, the standard practice with the physicians
should be to explain to the parents that these are the
usual headache types that they come across in
children and should label them as headache type I,
II, III and IV. The physician should then ask the parents,
what headache type does that particular child’s illness
fit in best. It makes things easy for the parents and
they most often than not pick up one of the patterns
that their child has, unless the child has a mixed type
of headache. This category of mixed headaches is
not very common but it needs some elaboration. By
mixed headache type, one means that there are at
least two different types of headache the child has; a
headache that occurs every day, which is often mild
and lasts about an hour and does not seem to have
any other symptom. Then there are episodes of bad
headaches with acute discomfort, nausea, vomiting
and photophobia in the background of that mild
every-day headache.
In order to arrive at a reasonably correct clinical
diagnosis, there are some critical questions that the
physicians need to ask the parents or the child5.
a) Was there a history of mild head trauma ?
b) How long has the headache been present ? - The
longer the headache has been present and more
detailed history one gets, easier is the diagnosis
and perhaps more benign is the condition. If the
symptoms get progressively worse, one needs to
watch out for an organic neurologic disease.
c) Another diagnostic clue is to ask how often does it
occur and how long does it last. Neuralgias and
some rare vascular headaches occur several times
in a day and last a few seconds; cluster headaches
once or twice in a day, for one to two hours almost
every day for a few weeks or months, and migraine
several times in a week to once or twice in a year
and usually over three hours in duration. So one
can tell from the intervals between headaches and
their duration, what kind of headache one is
dealing with.
d) The next important diagnostic question is; does it
occur at any special time or under special

No. 1 69
 circumstances ? One may come across a child who
has headaches from Monday morning through
Saturday morning, but not on Sunday, or school
holidays or during vacation. It is usually the school
related stressful problems that cause this kind of
headache.
e) Are there any warning symptoms of an impending
attack ? Ask the child to describe in his own
language and terminology, if he gets a warning
or if anything happens to him before he gets the
headache. Talking to small children is an art that
one needs to develop and it is best done in their
language.
f) As one proceeds in interrogative history one should
ask, where in their head does it hurt most. If they
can localise the pain at a specific region of their
head, one needs to watch out, because frequently
such a localised headache in a child is a marker
for the organic origin of pain.
g) Next, you may enquire of the child about the
character of the pain. Is it “pounding” like a drum
beat, “sharp” like a pin, or “squeezing”?
h) Does anything else happen to them when they have
headache ? Do they feel tired, weak or dizzy ? Do
they have nausea or vomiting ?
i) Next, one may ask what do they do when they get
headache ? Do they continue to play or watch TV?
If the answer is “yes”, it is perhaps a stress related
problem. If the answer is “no” and if they tell that
they go to their bed, shut out the light, close the
window and draw the curtains and lie quietly, the
diagnosis is usually migraine. Most children with
migraine do not want to be disturbed, they want
to go to their room and be left alone.
j) The physician may then ask whether anything
makes the headache worse or relieves it? Physical
activity of any kind will make any headache worse,
including migraine and tension headache. Rest,
on the other hand, is a partial non-specific reliever
of almost all kinds of non-organic headaches.
There is often a list of analgesic medications that
parents give as main relievers of headache, but
these don’t often help in the diagnosis.
k) The next question one may ask; does any other
member of the family have headache? If they have,
ask if they are blood or other relatives. Next, the
physician may try to find out what kind of headache
relatives have. It is important to know whether the
70
parents, particularly the mother has headaches or
not or the siblings have headache. Family history
of headache often points to migraine.
The physician should then ask a number of other
questions.
l) What kind of grade does he get in the school ?
Does he get “A” grade, or is an ordinary student
or a “flunk”? Vast majority of children who have
stress related problems are often “A” grade
students.
m) One should try to find out if there have been family
disasters such as the death of a loved one, or
separation or tense relationship between parents,
and, between parents and other members of the
family. Such events may be a precipitating factor.
n) It is also now important to find out if the child or
adolescent has had trouble with drugs. Parents
often do not bring out these behavioural problems
in children or adolescents voluntarily. Here one
has to ask questions.
Do all children with headaches need
special investigations such as X-rays, CT
Scan and MRI ?
If 5 to 6% of all children of both genders will have
migraine at some time or the other, one would not
like to do these special tests on all of them. So the
physicians have to select their patients to see who
needs these tests and who does not. There is very
little use for plain x-rays of skull now, even for sinus
related problems. One can order for a few sections
of the CT scan of the head, if the facilities are
available, including some sections of sinuses which
give infinitely much better answers.
What is the value of EEG in the diagnosis
of headache ?
The EEG is a widely overrated test which has no value
in the diagnosis of simple headaches6. Even when
done properly it brings more confusion to the issue
than it clarifies. Benign focal epileptiform discharges
in migrainous children are a glaring example. There
has been a lot of debate about the borderland
between migraine and epilepsy and the relation of
one with the other. A lot of this confusion has been
brought about by the EEG. The patient who is often a
child has a history of headaches and he is subjected
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No. 1
to an EEG test which definitely and unequivocally
demonstrates epileptiform spikes or sharp wave
discharges. So a number of physicians begin treating
these migraine patients with anticonvulsants. This
strategy might work occasionally, but not always and
the reason is, that about 1.9 per cent of normal
children without headache, may show frank epilepsy
later on. In addition, 10 per cent of those who have
migraine may have spikes in their EEG without any
appearance of clinical seizures. These children have
been followed up for several years without
anticonvulsants and they have rarely developed
epilepsy. All of them seem to improve with
antimigraine treatment. However, one must realise
that migraine and epilepsy can co-exist in the same
patient and their relationship has not been clarified
yet and if they occur together, they must be treated
independently.
What disorders need to be differentiated
from childhood migraine ?
There are some disorders of episodic, recurrent nature
that might come close to the differential diagnosis of
recurrent headaches. Some of the disorders can occur
as a co-morbid condition in migraine patients. One
is benign paroxysmal vertigo, where patients have
episodic paroxysmal vertigo without any disorder of
consciousness7. It lasts about a minute or so and is
common in children between the ages of 2 and 7.
This is not an epileptic disorder and the EEG is normal.
It can however coexist with migraine; and migraine
has been known as one of the important
accompaniments of episodic vertigo even in adults.
By some, it is considered a migraine variant without
any solid argument to support this view except that
treatment for migraine helps some of these patients.
The big issue at this stage is to find out whether these
children have something major in the posterior fossa.
So although CT or MRI may not be necessary in the
initial workup, parents are often advised to watch the
child and bring him to the physician for revaluation,
in case there is something suspicious or something
new develops. At the slightest suspicion of a possible
posterior fossa lesion the CT scan is strongly indicated.
How does one treat such children with
paroxysmal vertigo ?
In the majority of cases, nothing except reassurance
is required, however some patients might need
Journal of Indian Academy of Clinical Medicine
Vol. 5
benadryl or cyproheptadine. Although majority of
patients will remain as paroxysmal vertigo, which
disappears over time, some might develop
migrainous headaches later on in life, when they
become adults and may have attacks of episodic
vertigo and episodic headaches, or both.
Another disorder which is episodic in nature and can
cause problems in differentiation, is the condition
called “cyclic” or “periodic vomiting” in children8. Here
the child has recurrent bouts of abrupt onset
unexplained nausea and vomiting every so often. He
can keep nothing down and may get dehydrated and
often needs i.v. fluids. Headache is not an
accompaniment but abdominal pain sometimes is. It
is considered by many as a “migraine variant”, but
one should rule out intermittent intestinal volvulus.
Cyclic vomiting is a potentially serious illness on
account of acute and life threatening dehydration that
it might produce. The immediate treatment is
metoclopromide injection and i.v. fluids, but the
attacks can be prevented by the continuous
prophylactic use of cyproheptadine for several
months.
Migraine in children may follow different patterns.
Some children have one kind of pattern, others may
have another kind or a mixed pattern9. In the latter,
there are some headaches that occur every two to
four weeks, and they last 4 hours but there are others
which occur once or twice a week and last only half
an hour. Headaches are mostly bifrontal, occur in
the afternoon when the child comes from the school.
During the attack these children look quiet; they are
photophobic and they would like to remain in bed,
undisturbed. When they wake up next morning they
are free from headache.
In other children, headache, nausea and vomiting
and photophobia lasts for two days or longer. The
common migraine is much more common in children
than the classic migraine. Most children with migraine
do not have visual auras.
How should one treat migraine in
children ?
Abortive treatment for acute headaches.
To suppress an attack one has to use a therapeutic
strategy depending upon how bad the attacks are . If
the attacks are mild or moderate, one would prefer
small doses of paracetamol or aspirin and some cold

No. 1 71
compression to the head. Now many milder acting
nonsteroidal anti-inflammatory drugs such as
naproxene and nimesulide are available. If attacks
are associated with nausea and vomiting, one would
advise administration of domperidon or
metoclopromide before giving paracetamol.
Sumatriptan which is a specific drug for migraine is
now available to abort or suppress the attacks and
can be used in children10. Sumatriptan is supposed
to be the most effective medication so far discovered
and relieves headaches in less than 30 minutes. It is
now available in our country in oral tablets and
subcutaneous injectable forms. The doses are
correspondingly smaller for children than in adults.
They are sold in 25 mg, 50 mg and 100 mg tablets.
Ampoules containing 6 mgm injectable sumatriptan
for subcutaneous injections are available. If everything
else fails, one may give the child ½ tablet or 1 tablet
of 25 mg, and failing that, 2 or 3 mg of sumatriptan
through subcutaneous route.
How does one prevent the attacks if they
are very frequent ?
If the child has frequent attacks, one has to use one
of the prophylacatic agents and the choice here often
is between cyproheptadine, and small doses of
propranolol. If the child is an older one, one may
also try low dose amitryptiline or flunarizine. If he or
she is a thin child with low weight, cyproheptadine is
the preferred drug, because it improves their appetite
and weight and parents are happy to see the
improvement in the general appearance of the child.
In obese children, one does not normally advise the
use of cyproheptadine, unless there are some other
reasons for using it such as when propranolol is
contraindicated. Another side effect of cyproheptadine
is its growth retarding property on prolonged use.
This is probably due to its opposing action on pituitary
growth hormone. So cyproheptadine should not be
used for indefinite period. The other drug one may
use for prevention is propranolol. When using
propranolol one is advised to start with 1 or 2 mg
per kg. of body weight per day.
How long should they be treated
prophylactically ?
In the first instance, it is advisable to treat them for six
months and then discontinue the drug and then watch
them, but a clear answer to this question is not
72
available yet and physicians are advised to judge each
patient independently before advising them on this
point. Often children do much better than adults do,
in prophylactic treatment. Majority of them respond
remarkably to cyproheptadine or to propranolol and
require about 6 to 9 months of treatment.
The family needs to be told that migraine is a life
long disorder and the child may need treatment
intermittently for indefinite period although the initial
response to preventive treatment is often very
impressive.
In western countries one important emerging
therapeutic mode is “biofeedback” treatment with the
help of a clinical psychologist. Although we are not
culturally primed to consult psychologists for such
disorders there is no reason why it should not be tried.
The general conclusion is that primary headaches in
paediatric population are relatively common and they
are a major cause for concern to physicians and
parents. But most such children have migraine and
the incidence of a serious underlying condition is low
and most children would improve with proper
medication.
References
1. Day WH. Essays on Diseases of children. J & A Churchil,
London,1873.
2. Bille BS. Migraine in school children. Act Paediatr Scand
1962; 51 (Suppl. 136): 1.
3. Rothner AD. The diagnosis and treatment of headache
syndrome in children. In Pediatrics Update. Elsevier
Biomedicals, New York, 1983: 55-77.
4. Rothner AD. Headache in children: a review. Headache
1978: 18 (3): 169.
5. Rothner AD. Diagnosis and management of headache in
children and adolescents. Neurol Clin 1983; 1: 511.
6. Kinast M, Leuders H, Rothner AD et al. Benign focal
epileptiform discharges in childhood migraine (BFEDC)
Neurology 1982; 32: 1309.
7. Fenichel, GM. Migraine as a cause of benign paroxysmal
vertigo of childhood. J Pediatr 1968; 71: 114-5.
8. Rabe EF. Recurrent paroxysmal nonepileptic disorders Curr.
Probl. Pediatr 1974; 4: 3-31.
9. Rothner AD. The migraine syndrome in children and
adolescents. Pediatr Neurol 1986; 2: 121.
10. Linder SL. Subcutaneous sumatriptan in the clinical setting.
The first 50 consecutive patients with acute migraine in
paediatric neurology office practice. Headache 1996; 36:
419-22.
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