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Most children have complained of headaches at some point in their childhood, but not all cases warrant going to a paediatric neurologist. Up to 57–82 per cent of children by 15 years of age have complained of headache during their childhood. It is important to recognise and manage headaches early, as they may result in missed school days and extra-curricular activities, suboptimal participation in regular activities, and loss of productivity.

There are numerous causes of headaches in children, but here I will focus on the recurrent and long-term headaches that critically require input from a paediatric neurologist.

Migraines

Migraine headache is by far the common cause of recurrent headaches in children. It is defined as multiple attacks of intense unilateral (usually one sided, but can be both sides) headaches with a throbbing sensation and can be accompanied by nausea, vomiting, insensitivity to bright lights and sound lasting from few hours to a couple of days. Children may have associated “aura” e.g seeing zig-zag lines and patterns, rainbow colours, blurred vision, smell, or speech changes etc.

The doctor treating the case will put together a thorough history taking simple bedside tests before making a diagnosis of migraine. Neuroimaging, for example CT or MRI Brain is not needed once a convincing history and normal neurological examination is established.

Tension headaches

Tension headaches are usually less painful than migraines and have a “band-like” quality, are shorter in duration, bilateral, and usually in the temples. It may have a muscular component, especially in the neck and upper back.

The treatment of tension headaches is usually conservative, and aimed at decreasing the stress related event that gives rise to headaches. The author usually treats these with simple over-the-counter medications like paracetamol and Ibuprofen with an advice not to overuse these medications to avoid “medication overuse headaches”.

Chronic daily headaches

The term chronic daily headache does not define any particular type of headache, but children usually complain of “dull ache” to high intensity pain on a daily basis. The cause may include overuse of analgesic medication, depression, poorly treated migraines or tension headaches. More often than not, there are underlying psychological issues that may aggravate the headaches.

General management of headaches in children

The author recommends a two-pronged approach to manage headaches in childhood, which includes lifestyle modifications as well as medical management.

The recognition of certain trigger factors causing migraine and learning to avoid these triggers e.g caffeine containing food products is key. Apart from this, adequate hydration, a regular sleep schedule, stress management and regular exercise are helpful remedies. These lifestyle changes are under-rated but extremely effective and maybe enough to stop the attacks. A headache diary is recommended to establish the frequency and intensity of attacks before starting prophylactic medications.

Chronic headaches on the other hand are by far the most difficult group to manage; therefore, a multidisciplinary approach is necessary. It is important to discontinue overuse of analgesics and stick to various lifestyle modifications. The intervention of a child psychologist to unpick any underlying psychological factor that may aggravate headache is often useful.

In closing, headaches in children are under-diagnosed entities, which need careful monitoring and treatment to avoid long-term morbidity and improving the child’s psychosocial well being. A multidisciplinary approach including the services of a paediatric neurologist, paediatrician and child psychologist should be undertaken wherever possible.