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Secondary Headaches in Children and Adolescents Nicholas S Secondary Headaches in Children and Adolescents Nicholas S. Abend, MD,* Donald Younkin, MD,* and Donald W. Lewis, MD† A majority of the children presented for evaluation of headache complaints, will have one of the primary headache disorder such as tension-type or migraine. During the course of the evaluation, consideration must be given to the diverse collection of other medical and systemic disorders which may also cause headache in children and adolescents. The purpose of this article is to review the spectrum of secondary headaches. In majority of the instances, a thorough medical and headache history coupled with physical and neurologic examination will uncover clues to the presence of these other disorders. This will also guide clinical decision making regarding the need for further diagnostic testing, including neu- roimaging, electrophysiological testing, or specific laboratory testing. Semin Pediatr Neurol 17:123-133 © 2010 Elsevier Inc. All rights reserved. he International Headache Society classifies headaches spine x-rays is (are) warranted. If focal neurologic symptoms Tinto the 3 broad categories, including primary headaches or signs are present, then evaluation for vascular injury (ie, (eg, tension type and migraines), cranial neuralgias (eg, tri- carotid dissection) may be indicated and detection may re- geminal neuralgias), and secondary headaches (eg, neo- quire specific magnetic resonance imaging (MRI) sequences plasms and idiopathic intracranial hypertension [IIH]).1 (magnetic resonance angiography or T1 fat-saturated images The focus of this article will be secondary headaches in or the neck). children and adolescents; other sections of this monograph Posttraumatic headache is defined as a headache that be- will cover primary headaches. We review the diverse collec- gins within 2 weeks of closed head injury. Posttraumatic tion of medical and systemic causes of headache in children headache is furthermore divided into acute posttraumatic according to the International Classification of Headache Dis- headache if the symptoms have been present Ͻ3 months and orders (ICHD-II). In the majority of instances, a thorough chronic if symptoms present Ͼ3 months. The precipitating medical and headache history coupled with a physical and head injury is considered “mild” if the loss of consciousness is neurologic examination will guide clinical decision making Ͻ30 minutes and “moderate or severe” if loss of conscious- as to the need for ancillary diagnostic testing, including neu- ness is Ͼ30 minute, the Glasgow Coma Scale is Ͻ13, and/or roimaging, electrophysiological testing, or specific laboratory the accompanying amnesia last Ͼ48 hours. Chronic post- testing. traumatic headache can be associated with dysequilibrium, irritability, depression, sleep disorder, and poor concentra- Headache Attributed to tion. The prognosis for posttraumatic headaches in children Head and/or Neck Trauma and adolescents is good with most patients recovering within 3 to 6 months. Any headache emerging within close proximity to head or A trauma-triggered migraine can be initiated by mild head neck trauma requires careful consideration for intracranial injury, and the key features are aura (eg, visual, cognitive, processes, such as subarachnoid hemorrhage, subdural he- motor or sensory), with a duration of 1 to 72 hours, frontal or matoma or epidural hematoma, and vigilant evaluation for unilateral location, moderate to severe pain, aggravation by craniocervical injury. If suspected, an emergent noncontrast routine activities, nausea and/or vomiting, and photophobia computed tomography (CT) scan of the head and cervical and phonophobia. A particular subset of posttraumatic mi- graine is termed “confusional” or “footballer’s migraine” From the *Division of Neurology, the Children’s Hospital of Philadelphia wherein mild head injury triggers an acute confusional state, University, Philadelphia, PA. often with agitation, accompanied by a headache with mi- †Department of Pediatrics, Children’s Hospital of The King’s Daughters, graine features. Eastern Virginia Medical School, Norfolk, VA. A recent prospective study of 117 children (81 males, 36 Address reprint requests to Donald W. Lewis, MD, Children’s Hospital of The King’s Daughters, Division of Pediatric Neurology, 850 Southamp- females; range, 3-15 years [mean age, 8.5 years]) admitted ton Avenue, Norfolk, VA 23510. E-mail: [email protected] with a closed head injury (minor 79%, major 21%) found 1071-9091/10/$-see front matter © 2010 Elsevier Inc. All rights reserved. 123 doi:10.1016/j.spen.2010.04.001 124 N.S. Abend, D. Younkin, and D.W. Lewis that 8 (7%) children (5 males, 3 females; mean age, 10.5 graines with aura should be evaluated for PFO and whether years) reported chronic posttraumatic headaches. Five (4%) PFO closure would have any impact on migraine. children had episodic tension-type headache, and 3 (2.5%) had migraine with or without aura. Headache resolved over 3 Vascular Dissection 2 to 27 months in all patients. Neck pain and headaches are frequent symptoms in children with cervicocephalic vascular dissection, occurring in 68% with carotid artery dissection (47% as initial manifestation) Headache Attributed and 69% with vertebral artery dissection (33% as initial man- to Vascular Disorders ifestation) and may precede ischemic symptoms by hours or days (mean 4 days for carotid dissection and 14 hours for Hypertension vertebral dissection).5 The headache is often constant, non- It is unclear whether hypertension (HTN) alone causes head- throbbing, and unilateral (ipsilateral to the dissection), but ache in children. Furthermore, children with HTN often have throbbing, thunderclap, and gradually worsening headaches coexisting renal or endocrine disease (ie, chronic renal failure have been reported. Headaches generally last several days but and pheochromocytoma). Pheochromocytoma most com- may persist for months to years. Risk factors for arterial dis- monly presents with sudden-onset headache that is often section include genetic disorders resulting in abnormal vessel severe, frontal or occipital, and lasts less than 15 minutes to 1 walls (eg, Ehlers-Danlos syndrome, fibromuscular dysplasia, hour in most patients. Other common adrenergic symptoms alpha-1-antitrypsin deficiency, Marfan syndrome, and ho- are tachycardia, diaphoresis, tremor, and anxiety. HTN has mocystinemia), infection, coughing or vomiting, intraoral also been reported in association with cerebral autosomal trauma, chiropractic manipulation, sports injury, and trivial dominant arteriopathy with subcortical infarcts and leukoen- neck turns or injury. A recent review of a pediatric stroke cephalopathy (CADASIL), which can present with head- registry showed that head or neck trauma was present in aches. HTN is more frequent in adults with chronic migraine 50%, and 38% had warning symptoms including headaches than episodic migraine headache, but no such correlation has (44%), altered consciousness (25%), seizures (12.5%), and focal been identified in children. deficits (87.5%).6 Arterial dissection with focal neurologic symp- HTN has also been reported to cause headache in posterior toms must be differentiated from complicated migraines. Diagnosis reversible encephalopathy syndrome (PRES). PRES denotes a is generally made by MRI/magnetic resonance angiography and hypertensive encephalopathy manifest as imaging changes may require specific neck sequences (T1 fat-saturated images). that are most prominent in the posterior white matter but Treatment may involve emergent anticoagulation with heparin fol- that may extend to other areas and also include gray matter. lowed by several months of oral anticoagulation. The pathogenesis of PRES is thought to be related to vascular injury caused by a toxin or HTN resulting in altered cerebral autoregulation and the development of vasogenic edema. Headaches Attributed to The most frequent clinical manifestations in children are sei- Nonvascular Intracranial Disorders zures, visual disturbances, headache, or altered mental sta- tus, and most children manifest several of these signs. Treat- Idiopathic Intracranial ment is aimed at correcting the underlying condition or Hypertension (Pseudo-tumor Cerebri) stopping the offending medication (ie, cytotoxic or immuno- This subject is covered by Gladstein and Pakalnis elsewhere. suppressive medications) and reducing blood pressure, often using short-acting intravenous antihypertensive agents. It is Intracranial Hypotension important to consider that headaches may be part of the Low-pressure headaches may occur after lumbar puncture 3 prodrome of hypertensive encephalopathy. (LP) or other processes that cause a tear in the dura, including penetrating trauma or surgery. The cardinal clinical feature is Patent Foramen Ovale orthostatic headache; the appearance of a severe pounding, nauseating headache upon standing or sitting; and a resolu- Although there are no data on patent foramen ovale (PFO) tion of symptoms when the patient lies down. Specific diag- and migraines in children, studies in adults have suggested nostic criteria are available (Table 1). Although most post an association between PFO and migraines with aura. As spinal tap headaches resolve spontaneously, the persistence summarized recently, PFO is found in about 50% of adults of disabling symptoms may necessitate consideration of a with migraines with aura and in 20% of the general popula- “blood patch” or other technique to repair the source of the tion. Furthermore, PFO is thought
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