Introduction
Though often thought of in an adult context, headaches are a surprisingly common complaint in childhood, affecting approximately half of children by the age of 7, and three quarters of those aged 15.[1]
,[2]
Indeed, headache is the most common type of pain reported in children over the age of 7.[3]
Despite this prevalence, specific guidelines for the management of headache in children are lacking: the National Institute for Clinical Excellence guidelines only apply to individuals aged 12 or over,[4]
while the British Association for the Study of Headache (BASH) 2010 guidelines recommend treating children conservatively, but ultimately in the same way as adults, barring restrictions on medications or doses.[5]
The third edition of the International Classification of Headache Disorders gives more child-specific guidance on diagnosis, but little discussion on therapy.[6]
Despite their familiarity with adult headaches, the current situation, coupled with the comparatively greater speed of symptom change in children[7]
can leave pharmacists reluctant to advise parents of children with headache. Consequently they may often recommend the child see a GP for what is usually an easily managed and short-lived episode; and which may well pass before the child can be assessed. Guidelines that specifically focus on headache in children would be of clear benefit to pharmacists and primary care as a whole.
Following a recent meeting of experts (London, April 2016) who discussed the challenges around paediatric headache, this article aims to provide advice and guidance to pharmacists faced with the condition. It covers the information that is currently available, and highlights the points that would be useful if formal guidelines were to be developed to aid healthcare professionals in the management of headache in children.
Differentiation of headache subtypes
Like adult headaches, the vast majority of paediatric headaches are not indicative of any underlying problem;[8]
,[9]
rather they occur in individuals with a predisposition. They can also be triggered by environmental factors such as stress or dehydration. Paediatric primary headaches fall into the same four categories as adult headaches: tension-type headaches (TTH); migraine; cluster headache (CH), and medication-overuse headache (MOH).[5]
,[10]
,[11]
As with adults, TTH is the most common type of headache in children, followed by migraine, and both may be episodic or chronic.[12]
,[13]
CH is comparatively rare in children[5]
but is considered serious, and if suspected should always be referred to a GP. The data available on the prevalence of paediatric MOH is varied, but the condition may be responsible for a significant proportion of children with chronic headache.[14]
,[15]
While many symptoms are consistent between adult and paediatric patients with headaches, there are also important differences; of particular note is abdominal migraine, which may affect up to 4% of children.[16]
* The key similarities and differences between these headaches across adults and children are laid out in table 1.
Recognising red flags
Due to the lack of an obvious physical cause, headaches in children can cause parents great concern. It is important to reassure parents that the overwhelming majority of headaches are no cause for alarm and can be easily treated by the pharmacy. However pharmacists must be aware of the “red-flag” symptoms listed in table 2, which can indicate a more serious pathology such as concussion, meningitis or a possible tumour.[6]
,[17]
,[18]
A child exhibiting any of these symptoms should be referred to their GP or in more extreme cases, taken to their local A&E department.
Distinguishing TTH from migraine
Most headaches in children are either TTH or migraine – these are best managed through lifestyle changes to ameliorate symptoms and avoid triggers.[7]
TTH and migraine can also be treated with analgesics such as ibuprofen or paracetamol[2]
,[9]
,[19]
, however, if analgesics prove ineffective parents should always seek input from their GP or the NHS. Once the red flags for serious illness and injury, CH or MOH have been discounted, parents may gain further reassurance by categorisation of the headache into TTH or migraine. The questions laid out in figure 1 will aid differentiation between the two.
| Figure 1: Questions for differentiation of paediatric tension-type headache and migraine | |
| If the answer to any of these are “yes”, headache is probable migraine. If not, tension-type headache is more likely, especially if headache is not recurring. | |
| 1. Does the child experience any sensory symptoms prior to, or at the start of the headache?[1] ,[2] ,[12] e.g. changes to vision, a strange taste or smell, dizziness, or feeling physically weaker than usual | Y/N |
|---|---|
| 2. Is the headache very intense?[2] ,[5] i.e. the child cannot be distracted by games or television | Y/N |
| 3. Does the child experience any nausea or stomach problems along with their headache?[5] ,[12] | Y/N |
| 4. Does the child seem more sensitive to light or noise than usual?[2] ,[5] ,[12] | Y/N |
| Table 1: Features of major primary headaches and differences between adult and paediatric patients | |||
| Headache type | Similarities with adult patients | Differences in paediatric patients | Recommended approach unless flags are present |
| Tension-type headache |
| Treat in-pharmacy with analgesics and lifestyle advice. Advise parents to seek medical advice if the headache starts to recur more than once a week, becomes more severe, or if additional symptoms appear[20] ,[21] ,[22] | |
|---|---|---|---|
| Migraine | Treat in-pharmacy with analgesics and lifestyle advice. Advise parents to seek medical advice if the headache starts to recur more than once a week, becomes more severe, or if additional symptoms appear[20] ,[21] ,[22] | ||
| Cluster headache | If suspected, do not treat. Refer to GP | ||
| Medication overuse headache | If suspected, do not treat. Refer to GP and advise parent to withdraw analgesics immediately[4] | ||
Treatment of paediatric headache
Parents or carers should be advised of relief techniques and analgesic options, taking into account the child’s age, abilities and lifestyle. Intermittent oral analgesics such as ibuprofen or paracetamol are well tolerated in children, and a suitable first line treatment for both TTH and migraine;[4]
,[19]
,[28]
,[29]
however BASH recommends ibuprofen over paracetamol,[5]
and ibuprofen has demonstrated superior efficacy for treatment of childhood pain,[30]
paediatric migraine[31]
and adult TTH.[32]
Asthma is not a contraindication for use of ibuprofen, but the NHS recommends that individuals with asthma use it with caution.[33]
Aspirin is not recommended without prescription in children under 16 (due to risk of Reye’s Syndrome),[34]
and codeine is not recommended for children under the age of 12.[35]
In some cases where a child suffers migraine with nausea, a GP referral may be helpful to discuss the use of anti-emetics.[28]
Depending on the age of the child, their lifestyle and physical ability, parents may find different analgesic formulations optimal. For example, liquids are ideally suited for very young children, but can be awkward as children grow and spend more time away from the home. Chewable capsules are suitable for preadolescent children and do not require administration with food or water. As children move into adolescence, they may be happy to take tablets and capsules, which they will then be able to swallow whole.
For effective relief, headaches should be treated with the recommended, age-appropriate dose of analgesic as soon as symptoms appear,[5]
,[7]
,[19]
and subsequent doses taken on time when required. Parents should always check the dosing recommendations for the specific product being used, and they should be encouraged to communicate any changes in their child’s symptoms to their pharmacist.
Lifestyle advice for children with paediatric headache
Acute self-help techniques
When suffering from a headache, children may find relief using the same techniques adults find useful: ensuring that the child is adequately hydrated and not suffering from low blood sugar; helping them avoid noise and light by allowing them to rest in a cool darkened room; helping them relax, breathe deeply and when appropriate, engage in stress management techniques.[7]
Sleep often speeds up recovery and in some cases, children may benefit from placing a cool, moist cloth on their forehead.[7]
These techniques can all be applied on their own or in conjunction with medication.
Prophylactic lifestyle advice
In many cases children can find relief from recurring headaches through lifestyle changes. As well as dehydration and low blood sugar, poor sleep, and/or excessive caffeine exposure are frequently associated with headache.[7]
,[28]
,[36]
Parents should ensure their children are getting the recommended amounts of water, calories and sleep for their age brackets, and to steer them away from sources of caffeine such as coffee, tea, cola, energy drinks or chocolate.
Some children may have specific dietary triggers for their headaches; examples include dairy, nuts, pickles, processed foods and additives such as aspartame[37]
or monosodium glutamate (MSG).[28]
,[38]
MSG in particular is a common trigger for headaches, and is frequently found in processed, canned and fast foods, especially snacks, sauces, broths and dressings.[38]
,[39]
Stress and anxiety also have well-documented links with headaches in children and adolescents,[40]
and extensive use of digital displays has become a common trigger for childhood headache.[44]
Exercise can be an indirect trigger for headache (due to effects on blood pressure and dehydration)[7]
, but lack of appropriate exercise can also have a negative impact on mental health and sleep.[45]
Identifying triggers is often a challenging process and many children benefit from the use of a headache diary in which they can document the frequency, time of day and intensity of their headaches,[2]
,[4]
(e.g. from Migraine Action: http://www.migraine.org.uk) Where dietary triggers are being considered, coupling this with a food diary may be beneficial. Similarly a reflective journal may help children identify and better process emotional stress as a trigger for their headaches.
| Table 2: “Red flag” headache symptoms that may warn of a more serious underlying cause. If you identify a red flag symptom, advise the parent to make an immediate appointment with their GP or, in more extreme cases, to take the child immediately to the nearest A&E Department. | |
|---|---|
| Red flag symptoms | |
| Headache type |
|
| Headache with neurological or sensory symptoms |
|
| Headache with physical, immunological or gastric symptoms |
|
| Headache with medical history |
|
Role of pharmacy in the management of childhood headache
In most children headaches are short-lasting, unpredictable and not of any clinical concern.[8]
,[9]
Pharmacists are ideally placed as a point of first contact for minor childhood ailments such as headache; they are already providing valuable support for parents,[46]
and their expertise is recognised by patients and the NHS alike.[47]
As the role for pharmacists as a point of contact for primary care looks certain to expand in coming years,[48]
,[49]
they will be required to give greater guidance to parents and carers on common ailments which affect their children.
In order to achieve this shift, pharmacists, GPs and other healthcare professionals must work collaboratively. This can best be achieved through providing pharmacy with practical guidance on effectively recognising and managing headache in children, with direction on when to refer on to GPs and other healthcare professionals. Furthermore, as assessing headache in a child can be challenging, partly because of communication barriers, it would also be valuable to provide pharmacy with support on how to engage and have effective conversations with parents and paediatric patients.
Conclusions
Although there are no specific guidelines for pharmacists to follow when presented with a child suffering from headache, there is a wealth of consistent material available from a number of sources. This article seeks to collate them into a single document which pharmacists can use to support their practice, and to make decisions that better serve the needs of their patients.
Through improved knowledge, pharmacists will find it easier to ask the right questions about the child’s symptoms, educate and reassure parents and children about triggers and the proper use of headache diaries, and recommend treatment with age-appropriate formulations. It is hoped that this guidance will give pharmacists the confidence and tools to assess and better manage paediatric headache in their local community.
*Based on a study enrolling 159 children aged 5-15
Key points
- Headache is a poorly recognised condition in children under 12. Guidelines are lacking that support healthcare professionals to advise parents of children with headache
- Though often similar, headaches in children can feature symptoms less commonly seen in adults, and some types of adult headaches are less common in children
- As with adults, most childhood headaches do not indicate any serious underlying condition, and can be treated with rest, hydration and other physical management techniques, as well as ibuprofen or paracetamol
- Identifying and avoiding headache triggers can reduce the frequency of headaches
- Pharmacy has an important role to play in reducing the burden of childhood headache on the NHS
Christine Glover, BSc, FRPharmS, MIPharmM. Registered Pharmacist, Glover’s Integrated Heathcare, Yew Tree House, Church Lane, Amesbury, Wiltshire SP4 7HA. Tel: 01980 677301. Email: gloversihc@aol.com
Download the whitepaper here
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