What Are the Different Types of Headaches?
In the pediatric age group, “headaches” is a relatively common complaint and most of the headaches will not require any neurological consultation. In the very young, one must distinguish true headaches from an incorrectly used “headache” term. Some children may use the word headaches to express toothache, fatigue, or dizziness. When evaluating headaches, one must take into consideration the duration of the complaint (when did it first start), the severity, and the specific features of the complaint. One must distinguish painful headaches from harmful headaches. In the U.S., 10% of children under 15 years of age have migraine headaches and about 1% have chronic tension headaches.
The different types of headaches include the following:
Migraine headaches occur in about 10% of children and exhibit specific features (see migraine section). These features sometimes overlap with tension headaches, presenting as “mixed type headaches,” mostly with migrainous characteristics.
Chronic tension headaches
These headaches are mostly bilateral (both sides) and diffuse. The pain is dull and fluctuating, usually not worsened by physical activity (unlike migraines). This headache may occur on a daily basis with relatively short intervals of being headache free. These children may be using a large quantity of painkillers. This causes them to have withdrawal headaches as the medicine comes out of their system and the pain then rebounds.
The treatment of these headaches is difficult and requires the discontinuation of frequent use of over-the-counter medications. Preventative (prophylactic) treatment may include Pamelor (nortriptyline) or Elavil (amitryptylin), which are tricyclic antidepressants with an excellent pain control quality. Another advantage of these medications is that they may improve sleep and control the depressed mood sometimes associated with chronic headaches.
These include caffeine withdrawal or medication withdrawal (mostly Tylenol, Motrim, or other pain killers containing caffeine, such as Excedrin). These headaches are cyclical and respond promptly to caffeine medications but reappear a few hours later when the substance is out of the system.
Treatment of these headaches may be complicated, since the body is “addicted” to a substance and may require hospitalization.
One may develop headaches from exposure to any substance such as fumes or different smells of food. Some foods may cause headaches but may also trigger true migraines. The medical literature reports that about 17% of children have some relation between food and their headaches. My personal experience is that this number should be higher (about 30%). Foods known to trigger headaches or migraines include: nitrates (hot dogs, bologna, bacon, salami); chocolate; monosodium glutamate (MSG) such as in Chinese food; nuts and peanuts; some fruits such as strawberries, bananas, and orange juice (including other citrus); and caffeine. Also, any kind of prescription or nonprescription medication may cause headaches.
Episodic tension headaches
These are very common headaches in all age groups and are associated with the stresses of life. Fatigue, stress, oversleep, or exertion may trigger these headaches. These headaches will not have migrainous characteristics (nausea, vomiting, fatigue, sensitivity to light). The treatment is with over-the-counter analgesics and removal of the stress.
Exertion (exercised induced) headaches
These are very characteristic headaches. They start fast and strongly (like a thunderclap) and resolve rapidly. They are always related to an acute, rapid, strong exertion such as starting to exercise. These headaches respond readily to treatment with Indocin ( a strong anti-inflammatory medication that penetrates into the brain when given before the exertion). My experience, however, is that many children with this type of headache respond to milder anti-inflammatory medications such as ibuprofen when given one hour before exertion.
These are severe acute headaches that are extremely rare in children and occur mostly in men who smoke. The cluster usually consists of daily headaches for one to two months, most often in the spring and fall. The pain may last one hour behind one eye and is excruciating. This may repeat two to six times per day and the patients can’t sit still. This pain may respond to oxygen, given by mask, or to Imitrex. Prevention with prednisone, lithium, calcium channel blockers, or methysergide may be helpful.
Eyestrain is commonly blamed for causing headaches but is rarely a true cause. If eyestrain is the cause, resting the eyes should resolve the headaches. It is related to ocular near fixation rather than refractive errors.
Headaches Caused by Other Medical Conditions
A brain tumor is a major concern that brings children to the neurologist for an evaluation. Brain tumors are a very rare cause for headaches and many brain tumors do not present with headaches. Headaches related to a brain tumor will be caused by increased intracranial pressure and will present with certain characteristics. These include a gradual worsening over the course of time and pain mostly in the morning hours that may be associated with nausea or vomiting and may resolve towards the afternoon hours. One must remember, however, that different presentations may be possible. As a rule, by the time the vast majority of tumors will cause a headache, there are going to be some abnormalities on physical examination.
This is a “scary” condition in the pediatric age group. If caused by bacteria, it must be promptly diagnosed and treated. Fortunately, there are clear clinical signs that help us identify it (fever, stiff neck, lethargy, vomiting) but early on these may be missed.
Encephalitis, viral meningitis, or any other bacterial or nonbacterial infections that cause fever, even when not involving the central nervous system, may cause headaches (e.g. bad cold). The specific source of infection must be identified and treated.
Sinusitis (like eye strain) is very commonly implicated in causing headaches even when this is not the case. Many children with migraines or tension type headaches end up on one or more courses of antibiotics before arriving for a headache consultation. Sinusitis obviously should not be missed but it must be appropriately evaluated. Sinusitis headaches are worst when bending down and are associated with pain or pressure over the sinuses. They may be diagnosed with a sinus film or cat scan. Frequently, there will be a greenish nasal discharge with sinusitis.
Following a severe head trauma with a concussion, an individual may develop chronic headaches that resolve gradually, but on some occasions they will persist. Other symptoms of a “post concussion syndrome” will include sleeping difficulties, learning problems, short attention span, irritability, and personality changes.
Temporomandibular joint syndrome (TMJ)
TMJ is more common in adolescents and it is caused by impairment inflammation of the joint that connects the jaw to the skull. Chewing induces the pain which may then radiate to the ear and upwards. The pain may be severe at times and radiate to the rest of the skull or the same side. Treatment is provided by a night stabilizer of the joint (teeth brace) and by oral surgery. Anti-inflammatories may be helpful. The most accurate diagnosis of this condition is clinical and by an MRI of the temporomandibular joint.
Whiplash and other neck injuries
Whiplash and other neck injuries may cause a chronic occipital headache.
Children with seizures may have headaches following a seizure attack. On rare occasions, the seizures are unidentified and the presentation is with headaches alone.