|Ahead of print
Pediatric Headache: A basket of maladies
Divyani Garg1, Suvasini Sharma2
1 Department of Neurology, Lady Hardinge Medical College, New Delhi, India
2 Department of Pediatrics (Neurology Division), Lady Hardinge Medical College, New Delhi, India
|Date of Submission||15-Dec-2020|
|Date of Acceptance||11-Apr-2021|
|Date of Web Publication||11-Oct-2021|
Department of Pediatrics (Neurology Division), Lady Hardinge Medical College, New Delhi.
Source of Support: None, Conflict of Interest: None
Headache is the most frequent neurological disorder in the general population including children. It is among the most common reasons for outpatient and emergency visits. Headaches in children raise parental concerns, as the underlying cause of headache may range from entirely benign to life-threatening. The overall mean prevalence of headache in the pediatric population is 50% as per population-based studies. By the age of 3 years, nearly 3–8% children have already reported a headache, and by the age of 18 years, up to 82% of teenagers may experience a headache. Headaches among children have significant impact on quality of life.
There are several hospital-based studies on pediatric headache from India. In a study of 100 children from 3 to 14 years of age, children with primary headache were enrolled and those with secondary headaches were excluded. The most common primary headache in this study was migraine (46%) and tension type headache (31%). Other causes of primary headache included mixed (7%), psychogenic (8%), and non-specific headaches (8%). Migraine dominated among female adolescent children. In another tertiary center-based cross-sectional study in Delhi among 43 children between the ages of 3 to 18 years, 60.5% had migraine, 25.6% had tension type headache, and 9.3% had non-specific headache. Interestingly, none of the children in this study had headache secondary to an ophthalmological problem. In a cross-sectional study among school going children in Indore, 500 children between the age of 7 and 14 years were enrolled. The prevalence of recurring headache in this study was 25.5%. Of the children enrolled, 15.5% had migraine, 5% had tension type headache, and 5% had mixed symptoms of both migraine and tension type headache. Aggravating risk factors included increasing age, presence of family history of headaches, female sex, and “sensitive” personality traits. Days when headache was likely to occur concurred with science and mathematics test dates and days following the weekend.
Secondary headaches among children have also been reported to varying extents. In the present study from Himachal Pradesh, a secondary cause was identified in 25% children, most commonly due to refractive error, sinusitis, otitis media, and dental caries. Of children with secondary headache, 40% presented within 1 month of onset, unlike primary headaches which has a longer onset-to-presentation time. Certain clinical features have been described as red flags towards consideration of a secondary cause of headache: headache of less than 1-month duration, presence of seizures, absence of family history of migraine, thunderclap/ worst headache, occipital location, headache leading to awakening from sleep etc. Headache of less than 1-month duration had a higher likelihood of being associated with a surgical lesion in a retrospective series of 28 cases. However, more data are certainly necessary on strength of association of this clinical feature as a pointer towards secondary headaches. In terms of family history, only 15% of children in the current study harbored the same. Traditionally considered as a red flag for headache, the absence of family history should not be used to automatically commit the patient to neuroimaging. Family history may not be obtained due to lack of appropriate recognition or diagnosis among the parents, adoption, or the loss of a parent.
In the present study, 65% of patients with migraine reported exertional activity as a trigger. Triggers for pediatric migraine have also been variously identified. Among children with tension type headache, 65% reported lack of sleep as well as anxiety as a trigger. In a study from Delhi, stress was found to be a migraine trigger in a majority of the children, along with environmental noise and lack of sleep. In another study of retrospective nature from Eastern India among 200 children, triggers identified included environmental triggers such as sun exposure, humidity, smoke, noise as well as stress related to school.
Despite a number of studies emerging from India, certainly, further prospective and population-based studies on pediatric migraine related to clinical aspects are warranted. Such studies must necessarily include long-term outcomes and adverse impacts on quality-of-life parameters among Indian children, arising consequent to this common yet multidimensional malady.
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Conflicts of interest
There are no conflicts of interest.
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