Classification and Approach to Headaches

I. Classification of Headache

Two main classification systems are used in pediatrics.

A. International Classification of Headache Disorders (ICHD-3)

1. Primary Headaches: No underlying structural or metabolic cause.
   • Migraine (with or without aura).
   • Tension-Type Headache (TTH).
   • Trigeminal Autonomic Cephalalgias (e.g., Cluster headache - rare in children).
2. Secondary Headaches: Symptom of underlying pathology.
   • Attributed to infection (meningitis, sinusitis).
   • Attributed to head/neck trauma.
   • Attributed to vascular disorder (AVM, bleed).
   • Attributed to non-vascular intracranial disorder (tumor, IIH).
3. Painful Cranial Neuropathies: e.g., Occipital neuralgia.

B. Temporal Classification (Rothner’s Classification)

Clinically most useful for establishing differential diagnosis.

1. Acute: Single, sudden onset event.
2. Acute Recurrent: Distinct episodes separated by symptom-free intervals.
3. Chronic Progressive: Gradual increase in frequency and severity over time.
4. Chronic Non-Progressive (Chronic Daily): Frequent/daily headache without worsening severity.
5. Mixed: Chronic headache with superimposed acute exacerbations.

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II. Causes of Headache in Children (Based on Temporal Pattern)

Pattern	Common Causes	Less Common / Serious Causes
Acute	Systemic Infection: Viral fever, Influenza. CNS Infection: Meningitis, Encephalitis. Sinusitis: Acute bacterial. Dental: Abscess.	Hemorrhage: SAH, Intracranial bleed. Trauma: Concussion. First presentation of Migraine.
Acute Recurrent	Migraine: (Most common cause). Tension-Type Headache (Episodic).	Epilepsy: Ictal headache. Paroxysmal Hypertension: Pheochromocytoma. Neuralgias.
Chronic Progressive (Red Flag Category)	Raised ICP: Brain Tumor (Posterior fossa), Hydrocephalus, Abscess. Pseudotumor Cerebri (Idiopathic Intracranial Hypertension).	Subdural Hematoma (Chronic). Chiari Malformation. Lead Poisoning.
Chronic Non-Progressive	Chronic Tension-Type Headache. Psychogenic: Conversion, Somatization. Analgesic Overuse Headache.	Refractive Errors. Post-concussion syndrome.

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III. Approach to a 10-Year-Old Child with Headache

Step 1: Detailed History (The “OLDCARTS” Mnemonic)

• Onset: Sudden (SAH) vs. Gradual (Tumor).
• Location: Unilateral (Migraine) vs. Band-like (Tension) vs. Occipital (Posterior fossa tumor/Chiari).
• Duration: Hours (Migraine) vs. Continuous (IIH).
• Character: Throbbing (Migraine) vs. Squeezing (Tension) vs. Worst headache of life (Hemorrhage).
• Aggravating factors: Coughing/Straining (Raised ICP), School stress (Tension), Light/Sound (Migraine).
• Relieving factors: Sleep (Migraine), Vomiting (Raised ICP - transient relief).
• Timing: Early morning worsening (Raised ICP).
• Severity: Interference with play/school.

Screen for “Red Flags” (SNOOP 4):

• Systemic symptoms (Fever, Weight loss).
• Neurologic signs (Squint, ataxia, focal deficit).
• Onset sudden (Thunderclap).
• Occipital location (pathologic until proven otherwise in kids).
• Pattern change (New or progressive).
• Precipitated by Valsalva (coughing/sneezing).
• Parental concern (Family history of aneurysm/tumor).
• Papilledema.

Step 2: Physical Examination

• Vitals: Blood pressure (Hypertensive encephalopathy), Temperature.
• Anthropometry: Head circumference (unlikely to change at 10y, but check for macrocephaly history).
• General: Skin (Neurofibromas, Café-au-lait spots), Sinus tenderness.
• Ophthalmology (Mandatory):
  • Visual Acuity: Refractive errors.
  • Fundoscopy: Papilledema (Raised ICP).
• Neurology:
  • Gait/Coordination (Cerebellar signs).
  • Cranial Nerves (Diplopia/Squint - CN VI palsy).
  • Motor/Reflexes (Asymmetry).

Step 3: Diagnostic Investigations

• Neuroimaging (MRI Brain preferred over CT):
  • Indications: Abnormal neurologic exam, Papilledema, Chronic progressive pattern, Headache waking child from sleep, Persistent vomiting, Occipital headache.
  • Note: Routine imaging is NOT indicated for classic Migraine or Tension headache with normal exam.
• Lumbar Puncture: Indicated if meningitis suspected or to measure opening pressure (Pseudotumor cerebri) after ruling out mass effect.
• EEG: Only if history suggests seizure equivalents (otherwise low yield).
• Sinus X-ray/CT: If chronic sinusitis suspected.

Step 4: Management Algorithm

1. Acute Management:
   • Migraine: NSAIDs (Ibuprofen > Paracetamol), Triptans (Sumatriptan/Rizatriptan approved for >6y/12y), Antiemetics.
   • TTH: Relaxation, Hydration, NSAIDs.
2. Preventive Therapy: Indicated if headache frequency >3-4/month or severe disability.
   • Migraine: Flunarizine, Propranolol, Topiramate, Amitriptyline.
   • TTH: Amitriptyline, CBT.
3. Lifestyle Modification (Bio-behavioral):
   • Sleep hygiene (regular schedule).
   • Hydration.
   • Stress management (school issues).
   • Dietary trigger avoidance (caffeine, chocolate, cheese - if identified).