Headaches in children are common. The International Classification of Headache Disorders, third edition (ICHD-3 beta version) lists over 200 headache disorders which may affect adults or children. In practice, the majority of headaches in children who seek evaluation will be migraine-related. Not infrequently these headache disorders will present first with non-headache symptoms, such as vomiting,abdominal pain, or vertigo. These “childhood periodic syndromes” are often misdiagnosed, ineffectively treated, and lead to frequent and expensive doctor visits and testing.
In the adult population, approximately 18% of women and 6% of men experience migraine. The pediatric population has quite different numbers which vary related to the age of the child, gender, and whether puberty has occurred. Headache prevalence is 3-8% in 3-year old children, rising to 57-82% in 8- to 15-year old children (Gelfand 2015). The prevalence of migraine is higher in boys versus girls prior to puberty, but after puberty more girls than boys will have migraine (Bigal 2009; Singhi 2014). It is also observed that subtypes of migraine, such as migraine headache with aura, are different in boys versus girls depending upon their ages (i.e. higher rates of migraine with aura occur in younger boys and older girls), which may be related to hormonal or other sex-mediated physiological factors.
Cyclic vomiting syndrome (CVS) is characterized by episodes of recurrent nausea and vomiting, occurring in a stereotypical manner and repeating predictably for an individual. According to ICHD-3 beta the nausea and vomiting should occur at least four times per hour, lasting from one hour to 10 days in duration. The cycles should occur at least five separate times with at least a one-week symptom-free interval between cycles. Individuals are otherwise completely well between attacks. As these symptoms are usually quite severe, most individuals will appropriately obtain a thorough evaluation for infectious, metabolic, or gastrointestinal diseases. The average age of onset for CVS is 5.2 years old, although it occurs in adults as well (Lee 2012).
Abdominal migraine is a well-recognized disorder. This condition is characterized by moderate to severe abdominal or midline pain, which is often accompanied by nausea, vomiting, impaired appetite, and pallor. Although this description may have features similar to cyclic vomiting syndrome (CVS), abdominal migraine is primarily a pain disorder, rather than a vomiting disorder. The abdominal symptoms may last from 2-72 hours in duration. As in CVS, the individual is entirely normal between attacks. Abdominal migraine is most often seen in individuals between the ages of 5-15 years old with a mean age of 7 years old (Gelfand 2015).
Benign paroxysmal vertigo (BPV) is another condition that is likely migraine-related. Age of onset is between 2-5 years old. While some children may grow out of the disorder, it is not uncommon for symptoms to recur throughout childhood and young adulthood (Krams 2011). BPV is characterized by brief and severe episodes of vertigo lasting minutes to hours. The events occur spontaneously and may be associated with vomiting, difficulty walking or unsteadiness, and abnormal movements of the eyes (nystagmus). It is not uncommon for a child to experience fear during the attacks. A typical evaluation will include audiometric and vestibular testing, and should be normal to meet the diagnosis of BPV.
Other rare episodic conditions that may be associated with migraine include infantile colic, benign paroxysmal torticollis, and alternating hemiplegia of childhood. Infantile colic is described as excessive and frequent crying in a baby who appears to be otherwise healthy and well-fed. Infants with colic have a greater likelihood of developing migraine later in life (ICHD-3 beta, Romanello 2013). Benign paroxysmal torticollis is characterized by recurrent episodes of head tilting. Alternating hemiplegia of childhood is a poorly understood condition characterized by recurrent attacks of left- or right-sided paralysis seen before the age of 1.5 years.
Correct diagnosis of childhood headache disorders often requires specialty evaluation. It is important to exclude other conditions which may mimic these symptoms. It is helpful to identify headache triggers when possible. Many children experience headaches related to stress, poor nutrition, and disorganized sleep. A headache diary is a critical tool that will allow both the patient and doctor to obtain baseline headache days and follow changes in headache frequency with treatment. Identifying disorders related to migraine in children may be helpful in treatment. It is not uncommon for children with headache to have undiagnosed depression, anxiety disorder, or other psychiatric conditions. What is the level of disability? Is the child missing school? Is the child missing family and social activities?
Treatment for children with headache can be complex and usually requires careful monitoring andsupervision. Certain medications may be used in order to treat the individual headaches and to reduce the frequency of the headaches. Unfortunately we do not have many well-designed studies regarding treatments for children, therefore the experience of the provider becomes important. A focus on structured lifestyle is imperative. Children who don’t regulate their sleep patterns and continue to frequently eat and drink processed foods and beverages typically continue with frequent and disabling headaches. Parents must also be committed to these changes for their children and actively participate in the treatment process.
Marshall C. Freeman, MD, FAHS is Director of Headache Wellness Center (HWC) in Greensboro, NC. He is a board-certified neurologist in Adult Neurology, Neuromuscular Medicine, and Electrodiagnostic Medicine. He holds specialty certification in Headache Medicine by the United Council of Neurological Subspecialties. HWC is the oldest and longest continuously operating headache specialty practice in North Carolina, serving the headache population since 1990.