Introduction

In a busy pediatric clinic, an ophthalmologist rarely gets the chance to fully explore underlying causes for headaches in one visit, particularly if these are non-organic. Which symptoms should be taken seriously as belying significant pathology and which reflect less severe disease are important to recognize. A simple algorithm which helps make the decision whether to neuroimage is of significant benefit.

Childhood migraine is under-recognized as ophthalmologists tend to use their own diagnostic criteria for adult migraine. Understanding the differences in symptoms and treatment between the pediatric and adult form of migraine is essential.

Classification and etiology

Headaches in children can be classified as primary and secondary. The two most common types of primary headaches are migraine and chronic daily headaches (CDH). Other primary headaches are listed in Box 108.1.

The International Classification of Headache Disorders (ICHD-I) was created to improve the understanding of the range of conditions. It was criticized for a lack of specificity and sensitivity for children’s headaches, which prompted some amendments concerning childhood migraine being made in the second edition (ICHD-II).¹ Hershey has proposed further modifications to this classification to aid the diagnosis of pediatric migraine without aura (see below).²

Between a third and a half of children have a significant headache by the age of 7 years. Over three-quarters will have one by the age of 15.³ In a study of Turkish adolescents between 12 and 17, the prevalence of recurrent headaches increased from 42% at the younger end of the spectrum to 61% at the older end; 26% of children had tension headaches and 14.5% had migraine.⁴ Other studies have found the prevalence of migraines to be between 2.6% and 6.9% with 50% more girls than boys suffering from this condition.^5–8

When is a headache worrying?

Young children are poor historians. A new pain for a 4- or 5-year-old can be very difficult to describe. Parents may offer explanations for perceived discomfort, which their child then adopts. Any odd sensations that a child has never experienced before can “become” a “headache” or “pain.” A child may copy their parent who may be holding their head regularly out of worry rather than pain, which may then lead to an unsafe diagnosis of headache in a child.

Young children (2 to 4 years old) find describing pain difficult, but they are usually honest and do not suffer from “functional” headache (“medically unexplained symptoms”). A child in this age group who is holding their head in obvious discomfort must be taken seriously. For instance, monocytic acute myeloid leukemia can present with central nervous system disease, which can be associated with severe head pain.

Children under the age of 6 years usually require sedation or general anesthesia for MRI or CT scanning. This organizational hurdle unfortunately can dissuade a physician from neuroimaging even the worrying child. A Korean study looked at 1562 new patients presenting with recurrent headaches to nine pediatric neurology clinics in tertiary hospitals. Seventy-seven percent of these children had brain imaging, but only 9.3% had abnormal findings on the scans. If there were abnormal neurologic exam findings, 50% of the scans identified an organic condition.⁹ Lewis et al. developed a practice parameter for evaluating children and adolescents with recurrent headaches,³ which has been adapted and expanded in Box 108.2.

Chronic daily headaches

These children typically suffer continuous diurnal headaches for more than 15 days per month. This may well be on the migraine spectrum as children have often previously had episodic migraine headaches. CDH can develop from episodic tension-type headaches. There can be a precipitating illness or associated stress (changing schools, parental break-up, etc.). Idiopathic intracranial hypertension (IIH) can rarely present without papilledema and can present in a similar way to CDH.¹⁰ CDH appears to have migraine features although they do not reach the diagnostic criteria in ICHD-II.¹¹

The progression to daily headaches can be related to medication overuse or concurrent psychologic problems. Primary school children often have regular drinks provided during the day, whereas secondary school adolescents rarely drink sufficient water. Mild dehydration can exacerbate headaches.

Over time, the frequency of headaches improves resulting in a return to episodic migraines or tension-related headaches.¹² Treatment requires a multi-disciplinary approach involving careful use of medication (avoiding overuse) and preventative and bio-behavioral therapies.¹¹

Migraine

An adult with classic migraine has a visual aura followed by unilateral headache associated with often-severe systemic symptoms. Childhood migraine often presents differently. Headaches are usually bilateral although they may start unilaterally. In one study,¹⁴ 20% had a unilateral onset with 27% complaining of eye pain, 66% frontal pain, and 12% temporal pain. Younger children find the descriptors used in adult migraine (“pounding”, “pressing,” “vice-like”) difficult to relate to and will often agree with the questioner rather than understanding what is being asked. A surrogate marker of migraine severity is how much school is missed. It has been reported that 10% of children with migraines miss 1 day of school in every 2 week period with 1% missing four times that.¹⁴ Using the PEDs QL 4.0, a pediatric quality of life questionnaire, migraines had the same impact on quality of life (in terms of emotional and school development) as rheumatologic, oncologic, and cardiac diseases.¹⁵

For an adult headache to be classified as a migraine it should last more than 4 hours. Migraine headaches in children often last less than 4 hours, in some cases only 30 minutes. This is one of the principal reasons that there have been proposals made to alter the ICHD-II (see Box 108.3).

A predromal aura of a scintillating scotomata or other sensory or motor symptoms occurs in only a third of pediatric migraine sufferers.¹⁶

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