Headaches in children

This article discusses headaches in children, which is becoming more prevalent as the school year begins.

As the school year approaches and begins, many parents may start to hear their children complain about headaches.

According to Nick DeBlasio, MD, a pediatrician in Cincinnati Children's Hospital Medical Center's Pediatric Primary Care Clinic, about 10% of school-aged children and 15-27% of teens experience them from time to time.

Headaches can be triggered by a number of different things. Here are the most common causes of occasional headaches in children:

Inadequate hydration. Not drinking enough fluids is one of the biggest causes of headaches. This is especially true when the weather gets warmer and kids become more active outside and lose fluid through sweating. If this is the case, the cure might be as simple as having your child drink more water.

Diet. Does your child eat regular meals? Skipping one meal, like breakfast, can trigger a headache. It's also important to make sure that your child is eating a well-balanced diet with lots of fruits and vegetables. Too much caffeine and certain foods can cause a headache as well.

Sleep. Kids in middle and high school typically need at least 10-12 hours of sleep a night. Not sleeping enough at night can cause a headache. And getting less than 10 hours isn't enough to feel well-rested.

Stress. We all experience stress from time to time, and children and teens are no exception. If your child is under a lot of pressure from school, or experiencing big changes at home like a divorce or a big move, a headache can result.

Vision problems. If your child is unable to see what's happening at the front of the classroom, he might be straining his eyes to see far away, which can result in a headache. A vision test can give you a better understanding of whether or not your child's headaches are being caused by vision problems.

Family history. Your child is more likely to have headaches if a parent gets them as well.

If your child has a headache, try giving her water and over-the-counter ibuprofen. Follow the instructions on the package for the appropriate dosage and do not give it to your child more than three times in a week. If it persists for a few days or worsens, call your child's pediatrician.

Fortunately the majority of headaches in children are not a cause for alarm. However, there are a few instances which require a little more investigation. If your child's headaches have become more frequent or severe, if he wakes up in the morning of the middle of the night from it, or if the headache causes vomiting, it's best to have your child evaluated by your pediatrician.

He or she will perform a physical exam and decide if any tests need to be done. Brain MRIs and CT scans are rarely needed. If your pediatrician suspects a migraine, she might refer your child to a neurologist who is familiar with medications to help prevent and treat them.

And if your child or teen is suffering from chronic headaches and migraines, recent research by Cincinnati Children's found that adding cognitive behavioral therapy to treatment of pediatric migraines improves relief.

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How to spot migraine headaches

This article discusses how to spot a migraine headache from other types of headaches.

Migraines are severe headaches that are extremely tough to deal with, but how would you know if you  are suffering from a migraine or just a normal headache? Well, here are the symptoms of a migraine that can help you tell it apart from just another headache.

The symptoms vary

It is important to realize that the symptoms of migraines are extremely subjective – they differ from person to person. Moreover, there are actually three phases to a migraine – before the onset of the condition called prodrome, during the episode and after the episode (postdrome). Here is what you might experience in all three states.

Before a migraine starts

Some people report experiencing depression, irritability, excessive hunger, thirst, feeling of euphoria (in some cases), and restlessness and nervousness.

Another phenomenon of a migraine is that some people notice an aura. People notice this about thirty minutes before a migraine strikes and it usually appears as wavy lines, or a bright flashes of light. Some of them also experience a ‘pins-and-needles’ sensation down one’s hands, arms and face.

During the migraine:

This is usually the most painful and debilitating part of the condition. A person suffering from it will notice the following symptoms:

• Throbbing pain on one or both side of one’s head
• Pain behind the ears
• A headache that is extremely severe and inhibits normal activity
• Pain that gets worse with normal, everyday activity
• Nausea and vomiting
• Pain that gets worse when there is light, too much sound, and sensitivity to some smells.

While these are the most common symptoms, there are other uncommon symptoms like tingling around the face, arms and shoulders, inability to speak and experiencing temporary weakness on one side of the body.

After the migraine:

After the migraine has passed patients usually feel tired, fatigued and in some cases dizzy. There are rare cases where some people feel euphoric after an episode of migraine.

But, not all headaches are migraines:

While these are the most common symptoms of a migraine, a severe headache can also be a sign of other more serious conditions. If you experience sudden ‘thunderclap’ (extremely painful) headaches, a headache with fever, confusion and disorientation or those kinds of headaches that get worse on coughing or exertion etc, visit your doctor  immediately. They could be a sign of something far more serious.

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Headaches in children

This article gives a lot of information on headaches in children.

Why do children get headaches?

Headaches in children are common and usually not serious.  Causes include migraines, stress and tension headaches, trauma, sinus disease and eye problems.  Certain foods with nitrate preservatives and MSG (monosodium glutamate) can trigger headaches.  Brain tumors in children as a cause for headaches are extremely rare, and are usually associated with additional neurologic symptoms such as dizziness and lack of coordination.

How are children with headaches evaluated?

Children should have a thorough physical examination with a pediatrician.  He/she may order additional tests or refer to a neurologist.  It is helpful to keep a headache diary so that possible triggers (certain foods or activities) can be discovered.

If no obvious medical cause for the headaches is found by the pediatrician, a referral to an ophthalmologist is required to perform a complete eye exam.  The entire visual system should be examined.  This includes refractive error (the need for glasses), eye alignment, and binocularity (the ability to use both eyes together).  During this examination the pupils should be dilated.

 How do eye problems cause headaches in children?

Hyperopia (farsightedness) requires extra effort to focus clearly while reading.  This can sometimes lead to fatigue and headache.  Glasses can reduce the effort required to see clearly at near and improve the headache.

The decreased ability to pull the eyes toward each other when viewing near objects (convergence), particularly while reading, may cause headaches.  This is called convergence insufficiency, and symptoms include the doubling of images or words, blurred vision, fatigue, and headaches which worsen with prolonged reading.  Glasses are sometimes prescribed.  At home eye exercises, sometimes with the help of computer software, can help treat convergence insufficiency.  Expensive in office eye exercises are rarely indicated.

 Acute infections and inflammatory diseases of the eyes can cause headaches.  These problems are often accompanied by redness of the eye and/or eyelid and light sensitivity (photophobia).  Acute glaucoma can cause headaches, but rarely affects children.  A complete exam by an ophthalmologist can rule out these conditions.

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Fibromyalgia may be a sleep disorder

A neurologist can detect alpha intrusion on a sleep study. JR

A study claims that fibromyalgia syndrome may be a sleep disorder, or at least linked to one.

Nobody says, "I don't believe hypertension exists," or "I don't believe 'stroke' is a real thing." People with fibromyalgia syndrome (FMS) suffer not only from constant widespread pain, but they also sometimes face judgment and distrust from medical professionals who doubt if their condition is real. They are labeled as annoying and needy. In the literal sense, insult is added to injury.

The root cause of FMS is poorly understood, which may explain why its legitimacy is questioned by some healthcare professionals. FMS is characterized by chronic widespread musculoskeletal pain, stiffness, and tenderness at multiple points. The prevalence of FMS ranges from 2 percent to 3 percent of the general population, with women affected six to nine times more frequently than men.

In addition to pain symptoms from head to toe, people with FMS also complain of poor sleep, chronic fatigue, depressed mood, headaches, and many other symptoms. However, complaints of poor sleep and chronic fatigue may be more significant to individuals with FMS than pain symptoms. Analysis of slow-wave sleep in individuals with FMS often demonstrates characteristic alpha-wave intrusions in slow wave sleep, which are thought to contribute to poor sleep in this population. Furthermore, a trial using sodium oxybate, a medication known to increase slow-wave sleep, demonstrated improvement in fibromyalgia symptoms.

As the association between FMS and sleep has been further studied, more evidence has mounted that FMS in many cases is a byproduct of a sleep disorder. A 2006 study demonstrated a more than ten-fold increase in FMS in subjects with sleep-disordered breathing (SDB) compared to the normal population.

Research suggests that FMS is a disorder of hypersensitivity of the central nervous system (CNS). The peripheral nervous system (PNS) is constantly sending signals from various areas of the body to the CNS. The CNS then filters these signals, ignoring the insignificant while responding to the more pressing. Due to the hypersensitivity of the CNS in FMS, those lesser signals are not filtered, leading to widespread pain.

Poor sleep quality has a similar effect on CNS signal filtration. Many with chronic pain syndromes (e.g., arthritis) describe improvement in pain with a good night's sleep and vice versa. It is a well-known phenomenon in the neurology community that sleep deprivation is a powerful trigger for seizures. Seizures are caused by inappropriate hyperexcitation of certain neurons leading to a cascade of electrical discharges in the cerebral cortex that overcome (or "seize") the function of that region of the brain.

Diagnosis and treatment of SDB and other chronic sleep conditions can lead to significant improvement in FMS independent of any other therapy. However, since the overwhelming majority of FMS sufferers are women, and many women with SDB have more subtle airflow disruptions than their male counterparts, it is essential that testing be sensitive enough to detect these less obvious changes. Those who have had a prior negative sleep study or who do not snore should seek a sleep center that focuses on diagnosing and treating subtle SDB, such as Upper Airway Resistance Syndrome. Esophageal manometry can be used to measure intrathoracic pressure during sleep. This metric can help detect increased respiratory effort and subtle changes in airflow during sleep that can cause sleep fragmentation and that otherwise would be missed.

FMS sufferers with poor sleep may experience frequent nighttime arousals, tossing and turning in bed, morning headaches, nasal congestion in the morning that was not present upon going to bed, dry mouth during the night, episodes of waking up with palpitations, teeth clenching or grinding at night, temperomandibular joint (TMJ) or jaw pain in the morning, and acid reflux during the night or in the morning. While these are not specific signs independently, they all are suggestive of irregular breathing during sleep.

So for the four to six million Americans suffering from FMS, perhaps it's time to see a sleep specialist. A proper night's sleep just might cure what ails you.

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Pediatric emergency department visits due to headaches depend on the month

A study that looked at monthly changes in emergency department visits for children caused by headaches shows that children are more likely to go to the emergency department after they return to school from winter or summer breaks. The authors believe this is due to a change in daily lifestyle.

The objective of this article is to determine the monthly variation of emergency department (ED) visits for pediatric headache. The authors hypothesized youth have increased headache–related ED visits in the months associated with school attendance. In adolescents they found higher ED utilization in January and September, the same months associated with school return from vacation for a majority of children nationally. No significant reduction in the summer suggests that school itself is not the issue, but rather changes in daily lifestyle and transitions.

Methods

• Using a United States representative sample of ED visits in the National Hospital Ambulatory Medical Care Survey from 1997 to 2009, the authors estimated number of visits associated with ICD-9 codes related to headache, migraine, status migrainosus, or tension-type headache in 5- to 18-year-olds.
• Age-stratified multivariate models are presented for month of visit (July as reference).

Results

• There was a national estimate of 250,000 ED visits annually related to headache (2.1% of total visits) in 5- to 18-year-olds.
• In 5- to 11-year-olds, the adjusted rate of headache-related visits was lower in April (OR 0.42, 95% CI 0.20, 0.88).
• In 12- to 18-year-olds, there were higher rates in January (OR 1.92, 95% CI 1.16, 3.14) and September (OR 1.64, 95% CI 1.06, 2.55).

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Headaches and migraines in teens can be caused by chewing gum

Headaches and migraines in teenagers could be caused by or worsened by frequently chewing gum due to the joint between the jaw and the skull.

Teenagers are notorious for chewing a lot of gum. The lip smacking, bubble popping, discarded gum stuck to the sole give teachers and parents a headache.

Now, Dr. Nathan Watemberg of Tel Aviv University-affiliated Meir Medical Center has found that gum-chewing teenagers, and younger children as well, are giving themselves headaches too. His findings, published in Pediatric Neurology, could help treat countless cases of migraine and tension headaches in adolescents without the need for additional testing or medication.

"Out of our 30 patients, 26 reported significant improvement, and 19 had complete headache resolution," said Dr. Watemberg. "Twenty of the improved patients later agreed to go back to chewing gum, and all of them reported an immediate relapse of symptoms."

Right under our noses

Headaches are common in childhood and become more common and frequent during adolescence, particularly among girls. Typical triggers are stress, tiredness, lack of sleep, heat, video games, noise, sunlight, smoking, missed meals, and menstruation. But until now there has been little medical research on the relationship between gum chewing and headaches.

At Meir Medical Center's Child Neurology Unit and Child Development Center and community clinics, Dr. Watemberg noticed that many patients who reported headaches were daily gum chewers. Teenage girl patients were particularly avid chewers -- a finding supported by previous dental studies. Dr. Watemberg found that in many cases, when patients stopped chewing gum at his suggestion, they got substantially better.

Taking a more statistical approach, Dr. Watemberg asked 30 patients between six and 19 years old who had chronic migraine or tension headaches and chewed gum daily to quit chewing gum for one month. They had chewed gum for at least an hour up to more than six hours per day. After a month without gum, 19 of the 30 patients reported that their headaches went away entirely and seven reported a decrease in the frequency and intensity of headaches. To test the results, 26 of them agreed to resume gum chewing for two weeks. All of them reported a return of their symptoms within days.

Two previous studies linked gum chewing to headaches, but offered different explanations. One study suggested that gum chewing causes stress to the temporomandibular joint, or TMJ, the place where the jaw meets the skull. The other study blamed aspartame, the artificial sweetener used in most popular chewing gums. TMJ dysfunction has been shown to cause headaches, while the evidence is mixed on aspartame.

Gumming up the works

Dr. Watemberg favors the TMJ explanation. Gum is only flavorful for a short period of time, suggesting it does not contain much aspartame, he says. If aspartame caused headaches, he reasons, there would be a lot more headaches from diet drinks and artificially sweetened products. On the other hand, people chew gum well after the taste is gone, putting a significant burden on the TMJ, which is already the most used joint in the body, he says.

"Every doctor knows that overuse of the TMJ will cause headaches," said Dr. Watemberg. "I believe this is what's happening when children and teenagers chew gum excessively."

Dr. Watemberg says his findings can be put to use immediately. By advising teenagers with chronic headaches to simply stop chewing gum, doctors can provide many of them with quick and effective treatment, without the need for expensive diagnostic tests or medications.

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Is it migraine or occipital epilepsy? Panayiotopoulos syndrome (PS) can cause vomiting and headache!

What are the key differences between occipital seizures and migraine? 

Sometimes its hard to tell...JR 
Panayiotopoulos syndrome (PS) 

Benign childhood focal epilepsies: assessment of established and newly recognized syndromes

1. Chrysostomos P. Panayiotopoulos, 
2. Michael Michael, 
3. Sue Sanders, 
4. Thalia Valeta and
5. Michael Koutroumanidis

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1. Department of Clinical Neurophysiology and Epilepsies, St Thomas’ Hospital, Guy's and St Thomas NHS Foundation Trust, London, UK

1. Correspondence to: Michael Koutroumanidis, MD, Department of Clinical Neurophysiology and Epilepsies, St Thomas’ Hospital, London SE1 7EH, UK E-mail:michael.koutroumanidis@gstt.nhs.uk

• Received April 14, 2008.
• Revision received June 30, 2008.
• Accepted July 1, 2008.

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Summary

A big advance in epileptology has been the recognition of syndromes with distinct etiology, clinical and EEG features, treatment and prognosis. A prime and common example of this is Rolandic epilepsy that is well known by the general pediatricians for over 50 years, thus allowing a precise diagnosis that predicts an excellent prognosis.

However, rolandic is not the only benign childhood epileptic syndrome.

Converging evidence from multiple and independent clinical, EEG and magnetoencephalographic studies has documented Panayiotopoulos syndrome (PS) as a model of childhood autonomic epilepsy, which is also common and benign. Despite high prevalence, lengthy and dramatic features, PS as well as autonomic status epilepticus had eluded recognition because emetic and other ictal autonomic manifestations were dismissed as non-epileptic events of other diseases.

Furthermore, PS because of frequent EEG occipital spikes has been erroneously considered as occipital epilepsy and thus confused with the idiopathic childhood occipital epilepsy of Gastaut (ICOE-G), which is another age-related but rarer and of unpredictable prognosis syndrome. Encephalitis is a common misdiagnosis for PS and migraine with visual aura for ICOE-G. Pathophysiologically, the symptomatogenic zone appears to correspond to the epileptogenic zone in rolandic epilepsy (sensory-motor symptomatology of the rolandic cortex) and the ICOE-G (occipital lobe symptomatology), while the autonomic clinical manifestations of PS are likely to be generated by variable and widely spread epileptogenic foci acting upon a temporarily hyperexcitable central autonomic network.

Rolandic epilepsy, PS, ICOE-G and other possible clinical phenotypes of benign childhood focal seizures are likely to be linked together by a genetically determined, functional derangement of the systemic brain maturation that is age related (benign childhood seizure susceptibility syndrome). This is usually mild but exceptionally it may diverge to serious epileptic disorders such as epileptic encephalopathy with continuous spike and wave during sleep.

Links with other benign and age-related seizures in early life such as febrile seizures, benign focal neonatal and infantile seizures is possible. Overlap with idiopathic generalized epilepsies is limited and of uncertain genetic significance.

Taking all these into account, benign childhood focal seizures and related epileptic syndromes would need proper multi-disciplinary re-assessment in an evidence-based manner.


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