Recurrent primary headache is the most frequent manifestation of pain in childhood (Eggers, 1984) and is present in up to 8% of 6-year-old children (Haffner et al., 1998; Sillanp and Anttila, 1996). After the first year of school, headache prevalence doubles; therefore, school is an important influencing factor. Prevalence of recurrent primary headache during childhood has increased over the last few decades to 10.6% (Abu-Arafeh and Russell, 1994). Childhood headache has a high risk of chronification and persists into adulthood at about a 60% rate of recurrence (Bille, 1981). And in adults, chronic headache, especially migraine, causes high socioeconomic health care costs, mainly due to high indirect costs (e.g., absenteeism, reduced work efficiency) (Fishman and Black, 1999).
Characteristics of headache in children are less typical and more variable than in adults, and small children have more difficulties perceiving and describing headache characteristics in detail. Abdominal symptoms, such as cyclical vomiting or abdominal "migraine," are common precursors to migraines and occur especially in preschool children.
Most often, primary headache can be classified as migraine or tension-type headache. Diagnosis is made according to the (recently modified) criteria of the International Headache Society (IHS) (2004) and includes duration, quality and intensity of the headache, and vegetative or neurological symptoms (Table). Parents often underestimate intensity and frequency of their child's headaches; therefore, diagnosis should be based on four to eight weeks of prospective monitoring using a headache diary, to record headache characteristics, drug intake, probable trigger factors and impact on daily life in a standardized way. Self-monitoring and documentation of symptoms may even lead to a reduction of pain.
A thorough history, as well as a physical and neurological examination, is essential for ruling out underlying diseases or situations that can cause secondary headaches, such as head trauma, infection, organic lesion or sinus disorders (IHS, 2004). Psychotropic drugs can be another source of headaches. Laboratory tests, including electroencephalogram and imaging studies, should not be undertaken routinely, but they should be performed when warranted by any specific clinical evidence. Headache in children younger than 3 and occipital headache in children always call for diagnostic caution.
Migraines manifest in attacks lasting four to 72 hours in adults and one to 72 hours in children (IHS, 2004). Typical characteristics are unilateral location (in young children commonly bilateral), pulsating quality, moderate or severe intensity, aggravation by physical activity, and association with nausea and/or photo- and phonophobia (which may be inferred from particular behaviors in young children). Migraine episodes are frequently triggered by several factors such as emotional stress (school pressure, excitement), lack of or excess sleep, sensorial stimulation (loud noise, bright light), or sympathetic stimulation (physical activity). Up to 30% of patients with migraines occasionally experience auras--reversible focal neurological symptoms--(typically visual and/or sensory and/or speech symptoms--that develop gradually over minutes and last for less than one hour. Frequency of migraine aura seems to be nearly as high in children as in adults, but the less typical symptoms are usually only reported on request rather than spontaneously.
Tension-type headaches manifest in episodes lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality, and of mild or moderate intensity. Vegetative symptoms are negligible, and the headache does not worsen with routine physical activity. Chronic (>180 days/year) childhood headache (tension-type or migraine) is nearly always associated with psychiatric comorbidity (Guidetti et al., 1998) and may represent a correlate of a psychiatric problem.
There are only a few investigations of long-term outcomes of headache in children. Chronification rates of 60% for migraine and 45% for tension-type headache have been reported (Guidetti and Galli, 1998). Before puberty, the gender ratio is balanced, but young boys experience a two- to threefold greater rate of spontaneous remission of headaches. Chronification risk of childhood headaches increases enormously when psychiatric comorbidity is present. A follow-up study by Guidetti et al. (1998) reported headache in 85% of children with psychiatric comorbidity, but only in 60% of patients without psychopathology. None of the children in the study who experienced spontaneous remission of headache had clinically relevant psychiatric problems. On the other hand, children with frequent headache recurrence had an increased risk of multiple physical symptoms and psychiatric disorders in adulthood.
Abu-Arafeh I, Russell G (1994), Prevalence of headache and migraine in schoolchildren. BMJ 309(6957):765-769.
Apley J (1975), The Child with Abdominal Pains, 2nd ed. Oxford, U.K.: Blackwell Scientific Publications.
Bille B (1981), Migraine in childhood and its prognosis. Cephalalgia 1(2):71-75.
Campo JV, Fritsch SL (1994), Somatization in children and adolescents. J Am Acad Child Adolesc Psychiatry 33(9):1223-1235.
Egger HL, Costello EJ, Erkanli A, Angold A (1999), Somatic complaints and psychopathology in children and adolescents: stomach aches, musculoskeletal pains, and headaches. J Am Acad Child Adolesc Psychiatry 38(7):852-860.
Eggers C (1984), Der Kopfschmerz im Kindesalter. [Headache in children.] Dtsch Med Wochenschr 109(50):1930-1935.
Fishman P, Black L (1999), Indirect costs of migraine in a managed care population. Cephalalgia 19(1):50-57 [see discussion].
Glover V, Jarman J, Sandler M (1993), Migraine and depression: biological aspects. J Psychiatr Res 27(2):223-231.
Guidetti V, Galli F (1998), Evolution of headache in childhood and adolescence: an 8-yearfollow-up. Cephalalgia 18(7):449-454 [see comments].
Guidetti V, Galli F, Fabrizi P et al. (1998), Headache and psychiatric comorbidity: clinical aspects and outcome in an 8-year follow-up study. Cephalalgia 18(7):455-462.
Haffner J, Esther C, Münch H et al. (1998), Veränderte Kindheit-Neue Wirklichkeiten. Verhaltensauffälligkeiten im Einschulungsalter. Ergebnisse einer epidemiologischen Studie. Heidelberg, Germany: Praxisbüro Gesunde Schule/Rhein-Neckar-Kreis i. Sv.
Hermann C, Kim M, Blanchard EB (1995), Behavioral and prophylactic pharmacological intervention studies of pediatric migraine: an exploratory meta-analysis. Pain 60(3):239-255.
Hockaday JM, ed. (1988), Migraine in Childhood and Other Non-Epileptic Paroxysmal Disorders. London: Butterworths.
IHS (2004), The International Classification of Headache Disorders, 2nd Edition. Cephalalgia 24(suppl 1):9-160. Available at: 126.96.36.199/ihscommon/guidelines/pdfs/
ihc_II_main_no_print.pdf [PDF]. Accessed March 22.
Just U, Oelkers R, Bender S et al. (2003), Emotional and behavioural problems in children and adolescents with primary headache. Cephalalgia 23(3):206-213.
Lehmkuhl G, Blanz B, Lehmkuhl U, Braun-Scharm H (1989), Conversion disorder (DSM-III 300.11): symptomatology and course in childhood and adolescence. Eur Arch Psychiatry Neurol Sci 238(3):155-160.
Lewis DW, Scott D, Rendin V (2002), Treatment of paediatric headache. Expert Opin Pharmacother 3(10):1433-1442.
Liakopoulou-Kairis M, Alifieraki T, Protagora D et al. (2002), Recurrent abdominal pain and headache-psychopathology, life events and family functioning. Eur Child Adolesc Psychiatry 11(3):115-122.
Livingston R, Taylor JL, Crawford SL (1988), A study of somatic complaints and psychiatric diagnosis in children. J Am Acad Child Adolesc Psychiatry 27(2):185-187.
Mullins LA, Olson RA (1990), Familial factors in the etiology, maintenance, and treatment of somatoform disorders in children. Family Systems Medicine 8:159-175.
Sillanp M, Anttila P (1996), Increasing prevalence of headache in 7-year-old schoolchildren. Headache 36(8):466-470.
Torgersen S (1986), Genetics of somatoform disorders. Arch Gen Psychiatry 43(5):502-505.