Special Patient Considerations

Headaches in Children

Headache is a common complaint of children and adolescents. Pediatric headaches may occur due to a variety of causes, including migraine and tension-type headaches (TTH), as well as secondary origins. As with adults, the physician must evaluate the physical and emotional factors that may have an impact on the headaches. The treating physician must also be aware of the various issues that influence therapy selection. In managing children with headache, the physician must be concerned with reassuring the parents about diagnosis and treatment.

The frequency of headaches in children has been astonishing to patients and physicians alike. In Bille’s classic epidemiologic study of children in a Swedish community, 15.5% of the subjects had experienced a migraine attack before age 15. Another 15% of the children had experienced daily or almost daily TTH before age 15. Bille conducted a 40-year follow-up study and found a gradual increase in migraine headache in girls from the age of 11 years. Migraine was experienced by a subgroup of 73 individuals from the original group. At age 25 years, 23% were migraine-free, the remission more significant among the males. The study by Linet’s group in Washington County, Maryland, revealed that 56% of boys and 74% of girls between ages 12 and 17 had experienced a headache within the month prior to the telephone interview. In a 2023 meta-analysis of epidemiological studies in children and adolescents, the pooled prevalence of migraine was 11% (8% for migraine without aura and 3% for migraine with aura) while that of TTH was 17%.

Classification of headache in children is the same as in adults. Headache history is the primary tool in determining the child’s diagnosis. In taking the history, the interviewer should address questions about:

• The mother’s pregnancy and labor and the delivery of the child
• The child’s growth and development
• Episodes of serious infection (meningitis, encephalitis) and trauma.

A computed tomography (CT) scan or magnetic resonance imaging (MRI) should be considered in patients with recent-onset headaches and in patients who have noted a recent change in headache pattern (see Table 2-2 for the American College of Radiology Appropriateness Criteria for Headache imaging). Electroencephalograms (EEGs) have long been considered essential in the workup of children with headache problems. However, EEGs will usually not provide any significant data. Many children with systemic illness will present with a generalized headache. Obtaining vital signs is important in the initial evaluation to rule out febrile headache. Sinusitis may occur in conjunction with allergies or upper respiratory infections. Headache associated with acute sinusitis is characterized by:

• Fever
• Focal tenderness over the affected sinus
• Elevated white blood cell count
• Elevated sedimentation rate.

Subacute or chronic sinusitis may or may not be associated with respiratory symptoms, and the patient may be afebrile. Sinus X-rays may be necessary to confirm the diagnosis. Complications associated with sinusitis are:

• Brain abscess
• Orbital cellulitis
• Meningitis.

Treatment measures include:

• Antibiotics
• Decongestants
• Surgical drainage, if required.

Encephalitis and meningitis should be ruled out in the patient with:

• Recent-onset headache
• Fever
• Lethargy
• Nuchal rigidity
• Other central nervous system (CNS) symptoms.

Appropriate laboratory testing should be undertaken immediately. Urgent, aggressive antibiotic therapy is required in these patients.

Some children may experience headaches due to ophthalmic causes, including:

• Astigmatism
• Refractive errors
• Eye strain
• Squint.

Eye strain should be considered if the headache is:

• Localized to the frontal area
• Triggered by screen time, reading, or doing schoolwork
• Relieved by stopping a given activity.

These patients should undergo an ophthalmologic examination.

Exertional headache in children may be related to a specific athletic activity, such as weight-lifting or running. This headache may occur once or may be recurrent. The headache is described as:

• Generalized
• Severe
• Throbbing
• Lasting from a few minutes to hours.

The neurologic examination is usually negative. However, if abnormalities are observed, further studies (CT scan, MRI) may be indicated. Indomethacin may be prescribed if the headaches are frequent and severe.

Trauma can be a frequent cause of headache in children. Similar to adults, the degree of pain may not be indicative of the degree of injury. During the initial evaluation, skull fracture or significant brain injury should be ruled out. Neuroimaging is an essential element in the workup. In the presence of subdural hematoma, if the history provided by the patient and/or parents is negative for trauma, the physician may be confronting a child-abuse case. Headache due to subdural hematoma is often accompanied by seizures and other focal neurologic deficits. The treatment of these brain lesions is discussed in Secondary Headaches Due to Organic Causes.

In children, as in adults, headache due to brain tumor may be nonspecific in location. Exertion and positional changes may increase the severity of the headache. Tumors due to intracranial lesions are also discussed in Secondary Headaches Due to Organic Causes.

Some headaches associated with hydrocephalus may not manifest until adolescence. For example, congenital abnormalities such as compensated aqueductal stenosis may not cause any symptoms until the patient has reached adolescence. Physical examination usually demonstrates:

• Macrocephaly
• Papilledema
• Sixth-nerve palsy.

Neuroimaging will confirm the diagnosis. As noted in Diagnosis, shunting is usually necessary.

Pseudotumor cerebri is a disorder caused by increased intracranial pressure without any evidence of obstruction to the cerebrospinal fluid (CSF); it is typically common in young female patients with obesity. The usual causes of the disorder are:

• Menstrual irregularity
• Obesity
• Chronic otitis
• Medications, such as steroids.

As discussed in Diagnosis the most evident signs are:

• Headache
• Papilledema
• Sixth-nerve palsy.

Visual field testing may reveal an enlarged blind spot. Neuroimaging is usually negative and lumbar puncture will disclose increased pressure with normal CSF elements. Treatment consists of removing adequate amounts of CSF to normalize the pressure. Diuretics may also be used.

The onset of migraine often occurs in childhood. However, it may not initially manifest as a headache. Migraine has higher predominance in females (3:1). Prior to puberty, migraine is more prevalent in males. The clinical features of migraine in children are:

• Paroxysmal headaches
• Relief after sleep
• Nausea, vomiting and abdominal pain
• Throbbing, pounding quality
• Unilateral headache.

A positive family history is reported by 69% of children with migraine. Migraine without aura is more common in children (~8%) than migraine with aura (~3%). Several triggers have been identified in children with migraine:

• Anxiety
• Minor head trauma
• Exercise
• Menses
• Travel
• Diet (chocolate, pizza, cola beverages).

In children with migraine, the premonitory symptoms are similar to those of adult patients with migraine, and include:

• Pallor
• Malaise
• Fatigue
• Irritability.

These symptoms are usually followed by frontal headache, nausea and vomiting. During an acute migraine attack, pediatric patients will often go to their room complaining of photophobia and phonophobia. They express a need to sleep, and the attack usually resolves in 2 to 6 hours. In children with migraine with aura, the prodromal symptoms are similar to those in adults with this disorder.

In treating children with migraine, certain factors will impact on the selection of agents in both the abortive and prophylactic therapies:

• Age of the patient
• Size of the patient
• Frequency of the attacks
• Severity of the attacks.

In children under age 14 with infrequent attacks, pain-relieving measures should be employed, including:

• Nonhabituating analgesics
• Triptans
• Antiemetics (as needed)
• Sedatives.

The use of subcutaneous (SC) sumatriptan has been evaluated in a study involving 50 children, age 6 to 18 years, who experienced severe migraine. The children were treated with SC sumatriptan 0.06 mg/kg. Eighty-four percent reported a global rating of good-to-excellent response. The recurrence rate was only 6%. Side effects in this population were mild and transient, and the author concluded that sumatriptan was effective and safe in childhood migraine. Studies in pediatric patients have led to the approval of rizatriptan (approved for patients 6 years of age and older) as well as almotriptan, sumatriptan/naproxen and zolmitriptan (all approved for patients 12 years of age and older).

For those patients experiencing more frequent attacks, prophylactic therapy may be indicated. The only pharmacologic agent currently Food and Drug Administration (FDA)-approved for the prophylactic treatment of children is topiramate (approved for patients 12-17 years of age). The recommended dose of topiramate for preventive treatment of migraine in adolescents is the same as that for adults – 100 mg per day (50 mg in the morning and 50 mg in the evening); this dose is reached by gradual up-titration over 4 weeks: 25 mg at week 1, 50 mg at week 2, 75 mg at week 3 and 100 mg at week 4. Other agents used in adult migraine prophylaxis – including divalproex, onabotulinumtoxinA, amitriptyline, nimodipine and flunarizine – have not demonstrated efficacy in children; CGRP-directed antibodies have also not been tested in pediatric patients.

Cyproheptadine (Periactin) or propranolol (Inderal) represent additional options for preventive therapy in pediatric patients. Children have demonstrated excellent responses to cyproheptadine in doses of 4 mg to 8 mg at bedtime. The major side effects of this drug are sedation and increased appetite. Propranolol has also been used successfully in children and adolescents with migraine. The side effect profile appears to be milder in younger patients. Propranolol is contraindicated in patients with asthma. Depending on the size of the patient, the usual dose is 80 mg to 160 mg daily. Attempts are made after 6 months to gradually taper and then discontinue the drug.

Some children will present with migraine associated with neurologic manifestations. These patients should be evaluated for possible arteriovenous malformations (AVMs), tumor, or aneurysm. Neuroimaging is essential in these patients. To establish the diagnosis, the physician should determine whether there is a family history of similar headaches. Subtypes of migraine which may occur in children include:

• Hemiplegic
• Ophthalmoplegic
• Brainstem aura migraine.

Adolescents experiencing an acute attack of migraine with brainstem aura may be suspected of using street drugs. These patients may present with a variety of symptoms that may be alarming to the treating physician:

• Episodes of altered consciousness
• Agitation
• Receptive or expressive aphasia
• Occipital headache
• Nausea and vomiting
• Vertigo
• Tinnitus
• Facial weakness.

The diagnosis can be established by determining whether there is a previous history of migraine or a family history of similar attacks. Neurologic symptoms usually disappear within 6 hours. Prophylactic agents used with other forms of migraine are indicated in these patients.

As stated previously, migraine in children may not manifest as headaches but rather as acephalic variants. In young children between the ages of 2 and 6 years, episodes of paroxysmal vertigo may occur. These episodes are brief and sudden, and the child may not able to maintain posture due to the vertigo. Due to the sudden onset and difficulty in walking, the child and the parents are typically alarmed. These attacks abate within a few minutes but are recurrent. Secondary causes should be ruled out and the parents reassured about these symptoms. Cyproheptadine may be used successfully in these patients.

At a later age, patients with migraine may recall a history of cyclic vomiting during childhood. These episodes of cyclic vomiting are associated with abdominal pain and are paroxysmal, similar to migraine attacks. The physician should rule out structural gastrointestinal (GI) etiologies and determine if there is a family history of migraine. Prophylactic agents used in migraine may be beneficial in these cases, including in the absence of headache attacks.

Cluster headaches rarely occur in children, although patients may present with them as early as age 8. In adolescents, the initial onset of cluster headaches may occur. Male predominance is evident in cluster headaches. Treatment would be similar to that in adult cluster patients.

Tension-type headaches do occur regularly in children. These headaches may be described as:

• Diffuse pain
• Bandlike sensation (occasionally)
• Not usually associated with nausea and vomiting
• May be associated with muscle spasm and tenderness at the neck.

These headaches are not always related to stressful situations. It is essential that a careful inventory of the patient’s family, social and school relationships be included in the initial history.

Chronic TTH may present in adolescents, but rarely occur in children under age 10. The frequency of these headaches varies from a daily pattern to several times per week or several brief headaches in a day. As with adults, the location and character of the headaches vary. Nausea and vomiting may be associated with these headaches. The headaches are usually related to some type of emotional problem. Frequent school absences are typical, and certain questions should be addressed during the initial interview:

• Family history of similar headaches
• Parental absence from home (separation, divorce)
• Substance abuse by family members
• Over- or underachievement
• Significant school problems
• Previous emotional problems.

As part of the workup, psychological testing, such as the Minnesota Multiphasic Personality Inventory (MMPI) is indicated. Intelligence and achievement tests may also be indicated in children presenting with school difficulties. Adolescents with chronic TTH requires a multifaceted treatment approach with medical, psychological and pharmacologic modalities. Treatment modalities include:

• Family counseling
• Individual counseling
• Antidepressants
• Biofeedback.

Acute pain may be relieved by simple analgesics, and habituating drugs should be avoided. Children with headaches have demonstrated excellent response to biofeedback training. These young patients are more open to learning new techniques, enjoy using the instrumentation, and have not yet adapted a chronic pain pattern into their daily lives.

If a migraine attack occurs while the child is at school, treating the headache presents a challenge. While many children and adolescents find benefit being in a dark, quiet place during an acute attack, this scenario is almost impossible in a school setting. The parents should discuss the child’s headaches with the school nurse and/or school administration. If the pupil finds relief from a medication, using the agent as early as possible in the headache is preferable, and the cooperation of the school authorities will be necessary to insure early intervention.

Informing and educating the school administration is essential to avoid the child being returned to class without receiving treatment because the headache has not reached its peak. Students with migraine needs to receive early intervention in the form of acute therapy with a medication, and should be allowed to rest. Also, the parents and teachers should work cooperatively if the child has experienced frequent absences due to headache. Lowering grades may be harmful to the child’s well-being and recovery. Finally, children with migraine should not be allowed to stop attending school due to headaches. After a long absence, it may be too stressful and challenging for the student to “catch-up” with the classwork.

Headaches in the Elderly

Headache is a frequent complaint of the elderly. Although many headaches start in the early adult years, the patient may continue to experience the attacks late in life. Other patients will note the onset of their headaches after age 50. In comparison to other complaints of the elderly, the frequency of headache does not seem to be a major problem. Actual incidence of headache in the elderly is inversely related to age. The onset of headache in the elderly may be a manifestation of a serious illness, such as:

• Stroke
• Temporal arteritis
• Glaucoma
• Subdural hematoma
• Brain tumor.

The need for a complete history, as well as a thorough physical and neurologic examination, is prominent. Patients may also experience headache onset or an exacerbation of symptoms due to medications used for medical illness, such as the vasodilators. Also, certain agents used for headache therapy may be contraindicated in concomitant medical disorders. Treating headache in the elderly requires comprehensive evaluation and careful consideration of therapeutic options.

The initial onset of migraine rarely occurs after age 50. Patients typically report a gradual decrease in the frequency and severity of migraine attacks as they age. Women with migraine will often report a dramatic decrease in their migraine attacks after menopause.

Patients with migraine with aura may note the disappearance of the headaches but they will continue to experience the prodromes in the absence of headache. These migraine equivalents or “migraine without headache” consist of episodes of transient neurologic dysfunction or deficit. A previous history of migraine will establish the diagnosis. The symptoms include:

• Scintillating scotoma
• Vertigo
• Transient global amnesia
• Mood disorders
• Cardiac arrhythmias.

Secondary causes of these symptoms should be ruled out. Treatment measures are similar to standard therapies for migraine prophylaxis.

For those patients whose migraine attacks continue into their later years, the clinical presentation of acute headaches does not change. However, special consideration must be given to selecting agents for abortive and prophylactic therapy of migraine. Agents such as ergotamine or triptans that have peripheral vasoconstrictive properties are not well tolerated in the elderly, and are contraindicated in those with cardiovascular disease. Gepants – CGRP blockers – may be useful option for older patients with migraine. Isometheptene mucate is another option for abortive therapy in older patients with migraine, although it should be used with caution in patients with peripheral vascular or cardiovascular disease.

For pain relief, the physician should note that a delay in the absorption of medications during a migraine attack has been observed in the elderly. The addition of metoclopramide with an analgesic (aspirin, acetaminophen, or ibuprofen) may enhance the effects. However, metoclopramide has been associated with extrapyramidal symptoms and must be used judiciously in older patients, with the preferred dose being 10 mg at onset of the attack. The physician should also monitor the amount of analgesics used, asking a simple question, “How long does a bottle of 100 aspirin tablets last?” Because nonsteroidal anti-inflammatory drugs (NSAIDs) may mask a concurrent infection, the patient should be regularly monitored. Also, if the patient is using NSAIDs for migraine attacks as well as for symptoms of osteoarthritis, there is a tendency for GI complications, including ulcer. Routine complete blood counts should be considered to prevent serious complications of GI bleeding. Analgesic abuse may contribute to a rebound-headache pattern, particularly with those agents containing caffeine. Patients should be detoxified from the habituating analgesic, whether over-the-counter or prescribed, before prophylactic therapy is initiated.

Elderly patients may be more susceptible to serious cardiovascular effects from agents used in migraine prophylaxis, such as the β-blockers or calcium channel blockers. There is also a greater potential for drug interactions in this group of patients, and the physician should use lower doses and titrate increases or decreases gradually. The tricyclic antidepressants have been used successfully in migraine prophylaxis (Migraine Headaches).

Some elderly patients may present with a previous history of migraine in which the headaches gradually diminished, but then recently started to recur. The physician should inventory the medications used for concomitant illness, such as cardiac problems or hypertension. Agents such as nitroglycerin or hydralazine are recognized as migraine triggers. Indomethacin, an NSAID often used for osteoarthritis, is also known to precipitate severe headaches.

Cluster headaches in the elderly follow the same pattern as those in younger patients. There is a female predominance in patients experiencing initial onset of cluster headache after age 60. Chronic cluster headache is noted for the older age at onset. Again, treatment options are highly impacted by the patient’s age. Because of the vasoconstrictive properties of the ergot preparations and triptans, oxygen inhalation is the treatment of choice for acute therapy. This procedure is presented in Trigeminal Autonomic Cephalalgias. Prophylactic agents that may be well suited for older patients include gabapentin and galcanezumab, although direct data is lacking. Vigilance must be adopted with the use of lithium in the treatment of chronic cluster headaches in the elderly. Serum lithium level tests must be performed at regular intervals to prevent toxicity. Drug interactions are also a problem with cluster prophylaxis.

Psychological aspects of chronic TTH render it a common complaint in the elderly. The 1-year prevalence of TTH among the elderly population has been estimated at 25-35%. The most common cause of chronic TTH in elderly patients is an underlying depression. The daily headache pattern is similar to that of younger patients with headache. Frequently, the patient will note a diurnal variation to the headaches, with the pain worse in the morning and evening. Sleep disturbance (in the form of early or frequent awakening) is a common complaint of these patients. They will also present with a multitude of somatic, emotional and psychic complaints (Table 7-1, Table 7-2 and Table 7-3). Elderly patients with chronic TTH may present with memory and cognitive difficulties, and some patients may be misdiagnosed with senile dementia or Alzheimer’s disease.

The treatment of choice is antidepressant therapy. Selection of antidepressant is based on the presence of sleep disturbance. Amitriptyline and doxepin have sedative effects, whereas protriptyline is indicated in those patients without sleep disturbance. Two antidepressants, fluoxetine and bupropion, have been effective in older patients with chronic TTH without sleep disturbance who are refractory to other agents. Trazodone is also effective in elderly patients with depression. The treatment of chronic TTH is discussed in more detail in Tension-Type Headaches/Coexisting Migraine and Tension-Type Headaches.

Headaches due to organic causes, such as temporal arteritis, trigeminal neuralgia and postherpetic neuralgia, have been discussed previously in Secondary Headache Due to Organic Causes. Any patient presenting with initial onset of headache after age 50 should be evaluated to rule out a secondary cause. For example, all patients over age 50 should undergo a sedimentation rate by the Westergren method to rule out temporal arteritis.

Treatment of trigeminal neuralgia in the elderly presents a complicated therapeutic scenario. The potential for toxicity associated with anticonvulsant therapy is higher in older patients. Also, elderly patients are more likely to be refractory to conventional forms of therapy. Depression and drug habituation are common problems faced in elderly patients with these chronic disorders.

The physician treating the elderly patient with headaches has a dual role—treating the headache problem and managing the physical effects of therapy. An elderly patient experiencing side effects of therapy may:

• Easily become fatigued
• Exhibit altered sensations
• Complain of soft tissue pain.

Patient compliance may be difficult in elderly patients, particularly in patients with depression, disturbed cognition or memory, or altered senses. These patients especially need and deserve a continuity of care.