Headaches

Dear Lisa,

My 3 year old son has been suffering from head pain and visual disturbance for about the past 2 months. These "episodes" happen every day up to 6 times a day and last about 5 minutes or so. He complains that his head hurts and that he is "blind". He asks for a washcloth to rub his eyes while he is experiencing the pain. He rubs his forehead, however, favors the right side (temple) and eye. He has had a CAT scan and EEG and an MRI. The CAT scan & EEG appeared normal. The MRI showed increased white matter on the right side of the brain, but I was told that this would not be the cause of his head pain and vision disturbances.

I have now been instructed to have him seen by a psychologist to find out what "stresses" could be causing his symptoms. I'm not sure if I should get a second opinion from a pediatric headache doctor or a more thorough eye exam? I just know my son is not an attention seeker and I firmly believe he is truly having head pain and vision problems. He will rub his head and eyes several times a day everyday, even when he doesn't know I am even looking. I have been reading a little bit on cluster headaches, and thought it might be possible he is having these. What would you suggest I do to look into this further? I am worried every day.

Dear “Worried Mom”,

Your son has had a quite extensive evaluation for his headaches and visual disturbance. The good news is that his MRI and CT scan of the brain is normal which rules out a brain tumor or mass which is most parent’s greatest fear. You did not mention if he had an evaluation by your Primary Care Physician or screening blood work performed.

It would be important to see your son’s Pediatrician for his headaches if you haven’t done this yet. Sometimes headaches are caused by other health conditions outside of the neurologic system. For example cervical spine abnormalities, vascular malformations, medication side effects, dental abnormalities, sinusitis and tick born illnesses can all cause headaches. (1, 2) You did not mention any medication, over the counter products or herbal supplements that your child is taking. In some cases headaches in children can be due to a side effect of a medication or supplement.

A complete evaluation by your son’s Primary Care Physician can review these issues and rule out these conditions as possible causes of your son’s headaches. Assuming that the evaluation by your Pediatrician and blood work was normal, at this point it would be a good idea to see both a Pediatric Ophthalmologist and a Pediatric Neurologist who specializes in headaches.

A Pediatric Ophthalmologist can evaluate your son’s vision, and eye structures, including the retina. In some cases a Retina specialist or Neuroophthalmologist may also be consulted in order to get to the root of a child’s visual disturbance. A second opinion with a pediatric Neurologist who specializes in headaches will be able diagnose the type of headaches that your son has.

Before seeing a specialist it would be a good idea to record your son’s symptoms in a Headache Diary. The Headache Diary should include specific information about the headache such as; the time of day that the headache occurs, the part of the head that hurts, the duration of the pain, the intensity of the pain, a description of the pain (throbbing, sharp), diet, activity, factors that aggravate the headache, accompanying symptoms and location where headache occurred (i.e. sunny room). Knowing this information, your doctors will be able to pinpoint the type of headache that your child is having, determine its cause and subsequent course of treatment. (3,4)

In regards to your question about Cluster headaches, they tend to occur in the adult population. The average age of patients diagnosed with Cluster Headaches is 27 to 31 years old. (5) This type of headache is rarely seen in children less than 10 years old. (3)

Cluster headaches are headaches that occur once to several times per day over the period of several weeks to months. (3) There are headache free periods between the Cluster headaches. The pain is throbbing, severe and unilateral or occurring on one side. Cluster headaches are associated with nasal congestion, a red eye and tearing or the eye. (3). The pain typically lasts 30 minutes to an hour and can occur any time of day. The cause of cluster headaches is unknown, but can be precipitated by alcohol consumption, exercise, hot baths, elevated environmental temperature during an attack period.

The Diagnostic Criteria for Cluster headaches developed by the International Headache Society includes:

At least five headache attacks meeting two criteria:
1. Severe unilateral pain (pain on one side of the head) lasting 15 to 180 minutes
The presence one or more of the following:
a. restlessness
b. conjunctival injection (red eye), tearing, nasal congestion, runny nose, eyelid swelling, sweating, miosis (constriction of the pupils), ptosis (drooping of the upper eyelid).
2. Attack frequency ranges from one to eight headaches per day.
3. Other disorders ruled out. (5)

From your description it doesn’t seem that your son fits the criteria for Cluster headaches. Although, a full history and physical examination performed by a Headache Specialist would be the best person to rule this out and determine the cause of your son’s headaches.

Migraines headaches are the type of headaches that are more prevalent in the pediatric population. Headache specialists agree that the majority of the pediatric patients who seek consultation for recurring, disabling headaches have Migraines. (6) The average age of onset for Migraine headaches in boys is 7.2 years old and in girls is 10.9 years old. (7) Migraine Headaches are characterized by symptoms of intense, recurrent headaches separated by pain-free intervals. They are often associated with other complaints such as nausea or vomiting. Migraine Headaches tend to be exacerbated by exertion and often resolve after vomiting or with sleep. (8) Ninety percent of the pediatric patients diagnosed with migraine headaches have at least one primary relative who also has Migraines. (6)

The main difference between Migraine Headache in adult and in children is that children tend to have shorter episodes of pain. (8) The diagnostic criteria for Migraine headaches in the pediatric population according to the International Headache Society includes:

At list five attacks with the following criteria:
1. Headache lasting 1 to 72 hours
2. Headache has at least two of the following symptoms:
a. location in the frontal or temporal areas (not the back of the head)
b.pulsing quality
c. moderate or severe pain intensity
d. aggravation by or causing avoidance of routine physical activity
3. During the headache at least one of the following:
a. nausea/vomiting
b. photophobia or photophobia
4. The headache is not attributed to another disorder. (9)

You mentioned that your son will be seeing a Psychologist in order to address any “Stressors” in his life which may be causing his symptoms. When the results of the physical examination and test results are normal it is common for Doctors to consider a psychological cause. This reflects their effort to be thorough and investigate all possible avenues. It is common for children to develop somatic complaints such as stomachache or headaches when they are under stress. Therefore investigating this area is many times necessary. Having an evaluation by a Psychologist is a sometimes a necessary step so that a psychological cause can be ruled out and other areas can be considered.

Parents usually know their child best. Parents are the ones who spend the most time caring for their child and they are the ones who know their child’s personality the best. If you believe that your son is not using his headaches to get attention and is truly experiencing pain then other causes of headaches should be investigated.

Your son is very lucky to have a mom who is so concerned about him. I hope you find the answers to all of your questions and your son is pain free soon. Keep up the good work!


References:
(1)Linder S. Understanding the Comprehensive Pediatric Headache Examination. Pediatric Annals. 2005. 34(6):442-446.
(2)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:480-481.
(3)Rubin D, Suecoff S, Knupp K. Headaches in Children. Pediatric Annals. 2006. 35(5):345-353.
(4)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:918-919.
(5) Alper B, Passarelli C. Cluster Headaches. The Clinical Advisor. 2006. Aug:85-86.
(6) Perlman EM. Managing migraine in children and adolescents. Prim Care. 2004;31:407-415.
(7) Lewis D, Ashwal S, Hershey A. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology. 2004;63(12):2215-2224.
(8)Unger J. Pediatric Migraine: Clinical Pearls in Diagnosis and Therapy. Consultant for Pediatricians. 2006. Sept:545-551.
(9)Olsen J. The international classification of headache disorders. Cephalagia 2004;24(Suppl 1):1-160.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Parents with Sick Children