Physio 101: Headaches in Children

I am by no means a headache expert, and have complete respect for my colleagues that successfully manage clients with chronic head and neck pain day in and out. Working in a paediatric tertiary hospital in oncology and neuro-rehabilitation, I have spent time managing the children who “fall through the cracks”, be it with intracranial pathology, chronic pain or misdiagnosis. This article is for my physio colleagues who may stumble upon a child or teenager in their practice seeking treatment for headaches, and recognise that kids are a little different and often need a different approach.

Case Study 1

Jude is a ten year old boy with a history of daily headaches that started about a month ago. They are worst in the morning but tend to linger all day. Jude feels that they are getting worse over time. His Mum thinks he is being bullied at school – she wonders if he is using his headaches to avoid school, and he is reporting nausea and vomiting in the mornings. He is a sensitive child, and his mother worries that this is related to school anxiety. His Mum has also noticed he is holding his neck quite stiffly when doing his homework, and hunching over the page. Mum has a history of headaches that have responded well to physiotherapy and is sick of nagging Jude to improve his posture and thinks he would benefit from some treatment

Case Study 2

Sarah is 5 years old and recently started Prep. She is complaining of headaches for a couple of hours every morning. These don’t prevent her from participating at school, but her teacher has reported she complains of pain most mornings. She tends to come home from school tired and have a nap on the couch when she gets home, which allows her to power on until sometimes 9 or 10pm at night. Her Mum jokes that she is a teenager already – up late and needs to be dragged out of bed in the morning.

If you are a generalist physiotherapist working in the community, a large chunk of your client base will be adults presenting with chronic headaches and neck pain. Cervicogenic dysfunction is a common underlying cause of headaches, and secondary changes to posture, muscle length, strength, and joint movement can also occur as a result of other chronic headache types like migraines. Life in this technology driven world is quite hard on the neck, and so it makes sense that dysfunction has the potential to emerge with time and age.

With physiotherapy becoming a more mainstream treatment for headaches, more parents are seeking treatment for their children. Headaches are common in children, but the underlying causes and treatment are somewhat different. If you have a short attention span and don’t want to read any further, the take home message is

Most headaches are benign but around 5% will be related to a more significant pathology and as first contact practitioners these can’t be missed!
The majority of headaches are related to non-musculoskeletal causes, and therefore physiotherapy intervention is not the most appropriate treatment choice.
Older children and teenagers are presenting with tension headaches related to poor posture, stress and anxiety. These children need a holistic approach to management and respond best to a combination of lifestyle and behavioural modifications, as well as hands off education and treatment.

Red Flags

Any of these signs warrant review by a medical professional before going any further. It’s amazing how often these symptoms aren’t mentioned unless you specifically ask about them!

Sudden onset of very severe headache
Headache is constant/frequent and steadily worsening over time
Any focal neurological symptoms or abnormal neurological exam
Headache/Vomiting on waking
Associated with Fever or Neck Stiffness
Hemiparesis or ataxia
Has a V-P shunt
Has Neurofibromatosis or Tuberous Sclerosis

Headaches and their Management

Acute Headaches

Single episode
Most causes are benign but not musculoskeletal. These include upper respiratory tract infections, sinusitis, ear infections, dehydration, minor head bumps and fatigue. These conditions respond well to simple analgesia, rest, hydration and hot/cold packs
These can also be caused by meningitis/encephalitis, VP shunt malfunctions, significant trauma, tumours and intracranial pathology. These conditions will nearly always present with changes on a neurological assessment such as abnormal eye movements, altered behaviour/level of consciousness, ataxia, weakness, visual changes or marked neck stiffness. These patients need to see a medical professional ASAP.

Acute-Recurrent

Episodic headaches with symptom free periods in between. This type of presentation is most likely to present to a Physiotherapist as a first contact practitioner.
Most common cause in the literature is paediatric migraine (incidence 2.5% before school age, 7% in primary school age and 15% in teens). Symptoms last 1-48 hrs, are moderate to severe, aggravated by activity, and associated with nausea/vomiting and/or photo/phonophobia. Most will have a family history of migraines.
Treatment of migraines is symptom management not cure, so they should be sent to their GP for a management plan. This includes analgesics and anti-emetics, prophylactic medication, identification and removal of environmental and lifestyle triggers.
Multidisciplinary involvement – may involve a dietician if there is thought to be a dietary trigger or obesity is involved, or a psychologist if anxiety/psychosocial stress is a component. There is a rare variety called Benign Paroxysmal Torticollis, which is episodic wry neck in an infant associated with migraine symptoms, that may benefit from physiotherapy positioning and handling strategies if the torticollis persists longer than a few days.
Other causes can include tension headaches, and rarer presentations such as TMJ dysfunction and occipital neuralgia. These conditions can respond to physiotherapy treatment and be related to musculoskeletal dysfunction, though tension headaches in particular are often related to other lifestyle factors such as lack of sleep, eye strain, stress, etc. Tension headaches are thought to be common but are poorly researched in children, most likely because they usually resolve without medical intervention and are multi-factorial in nature. Postural education and strengthening may be beneficial if the tension headaches are thought to be related to excessive postural load, a problem that is more likely to occur in teens than younger children.

Chronic-Progressive

These headaches gradually increase in frequency and severity over time. This type of headache is associated with more sinister pathology, and should be referred for medical review.

Chronic Non-Progressive

This type of headache is frequent/constant, but not worsening over time, and occurs in <1% of children. Headaches need to last for 4 or more hours at least 15 times a month, for a period of 3 months. These headaches can be difficult to treat, and require a holistic approach. These patients may self refer or be referred to physiotherapy after a prolonged period of pain and frustration, and be associated witha number of unhelpful chronic pain behaviours. Physiotherapy can play a role in management of these patients, but the best approach is generally “hands off”. Management includes

Non-pharmacological pain management strategies as rebound headaches from analgesia withdrawal can be problematic
Psychological support to work on relaxation techniques and identification of triggers for headaches, and approaches to improve function and participation.
Lifestyle changes to diet, sleep, exercise and posture and school attendance

When a child presents with a headache, make sure you

Ask the right questions
Do a thorough neurological exam
Do not assume an underlying musculoskeletal pathology, seek evidence – more often than not, particularly in a younger child, the cause is benign but not cervicogenic.
Treatment should be holistic and focus on appropriate lifestyle changes and independent management

Case Study 1: Jude

Red Flags for Jude – Head aches daily and progressively worsening over time. Headache and vomiting occurs in the morning, which can be a sign of hydrocephalus. Mum also highlights potential global neck stiffness.

On questioning, Jude states he likes school, has a best friend and likes his teacher this year. His morning vomiting also occurs sometimes on the weekends, inconsistent with school anxiety. Jude identifies that the reason he is hunching over his page is that he is finding the writing a little difficult to read at times. On assessment, he has multiple beats of nystagmus when crossing the midline, and mild double vision. He has difficulty heel-toe walking and is mildly ataxic. He is globally tender in his shoulders and cervical spine, and palpation doesn’t significant change his symptoms. He has generalised decreased range of motion.

RESULT: Jude proceeded to have imaging based on his red flags, and was diagnosed with a brain stem tumour and began treatment.

Casey Study 2: Sarah

With further questioning, it seems Sarah’s headaches occur in the first couple of hours after she gets to school, and resolve by lunchtime. They are mild and don’t get worse with activity, but they do feel a little better if she has a rest. Sarah’s late afternoon naps are resulting in significantly less night time sleep and difficulty waking up. Because she is tired and grumpy in the mornings, she is refusing to eat breakfast. Her neurological exam was normal.

RESULT: Sarah was experiencing acute-recurrent headaches as a result of over-tiredness and hypoglycaemia. Her GP recommended improving her routine to ensure a consistent early bedtime, afternoon exercise and a healthy breakfast, and her headaches resolved.

References

American Family Physician: Headaches in Children and Adolescents

Royal Children's Hospital Melbourne: Clinical Practice Guidelines

RACGP: Managing childhood migraines