Headaches are an important complaint in children. While the majority have rather simple causative factors, some may indicate more troublesome underlying diseases. Careful evaluation is mandatory in those cases where the headaches are either persistent or associated with other accompanying features.

The complaint of headache is a reasonably common one among children. Parents tend to worry about things such as brain tumours when a child complains of a headache. While the majority of basic causes for this complaint may be quite trivial, there may be some more serious underlying causes in a small proportion of cases. The complaint itself may be an isolated symptom or may be associated with other features. Several factors and other ancillary associations need to be taken into account when a complaint of headache needs to be evaluated in children. Many adults with persistent headaches had started having them as children. In fact, 20 per cent of adult headache sufferers say their headaches started before age 10 and 50 per cent report that their headaches started before age 20.

Children get headaches for many of the same reasons that adults get headaches. But, most headaches in children are usually due to an acute illness, infection, cold or fever. Some of the other conditions that can cause headaches include sinusitis (inflammation of the sinuses), pharyngitis (inflammation or infection of the throat), meningitis (inflammation of the coverings of the brain) or otitis (ear infection).

The real problem with headaches affecting children arises either when the headaches are persistent or when intermittent, they are so frequent or severe enough to affect normal life. Many children complain of occasional headaches which occur from time to time but they are usually inconsequential. Some children may also use them as attention seeking devices but such instances are rare and the complaint does not seem to bother them all that much. However, certain features should alert parents or guardians that the complaint should be taken seriously and medical help sought. Some of these features are :-

* Headaches that occur regularly at periodic intervals or quite frequently.

* Those that interfere with normal activities and play

* Those that follow an injury such as a blow to the head or a fall resulting in a head injury

* Early morning headaches, especially if combined with vomiting.

* Headaches that interfere with sleep.

* Any headaches that are accompanied by persistent vomiting or visual changes.

* Those that are accompanied by behavioural changes and deteriorating school performances or studies.

One type of headache that really bothers children is migraine. Migraine is a recurrent headache that occurs with or without warning (known as an aura). These headaches may last in children from 30 minutes to 48 hours. It is the most common cause of primary headache in children and is an important cause of disability and a significant cause of school absence in m. These often incapacitating experiences are noteworthy for their sudden onset and accompanying symptoms of nausea, abdominal pain, vomiting and relief by sleep.

Migraine may present with an array of various signs and symptoms. During a migraine episode, patients often endure the sudden onset of a severe headache located around the eyes, in the forehead region, or in the temples. Some children experience vision changes ("auras") just prior to the onset or during the headache. A sick feeling in the stomach or vomiting is common. Many children avoid bright lights, loud noises or strong odours since these may amplify the pain of their headache. While various medications may be employed to treat a migraine headache the severe head pain is often completely relieved by deep sleep.

The exact causes of migraine are unknown although they are related to changes in the brain as well as to genetic causes. For many years, scientists believed that migraines were linked to the expansion (dilation) and constriction (narrowing) of blood vessels on the brain surface. However, it is now believed that migraines are caused by inherited abnormalities in certain areas of the brain. An inherited tendency is believed to make some people more likely to have a migraine after some minor trigger although no single theory explains how the human body produces all the symptoms of a typical migraine headache. Emotional or physical stress, the onset of an illness, and / or certain foods or liquids may trigger a migraine headache. One rare migraine presentation at least has been shown to have specific gene mutations that predispose to the patient's symptoms. Most children and adolescents, over about 80 per cent, who have migraines have other family members with migraine. When both parents have a history of migraines, there is a 70 per cent chance that the child will also develop migraines. If only one parent has a history of migraine the risk is around 25 to 50 per cent. Children and adolescents with migraines may also inherit the tendency to be affected by certain migraine triggers such as fatigue, bright lights and changes in weather.

Although migraine headaches have long been considered a benign or relatively harmless condition, their symptoms may wreak havoc on a child’s quality of life and ability to take part in normal life activities. Migraine pain is so intense that sufferers often cannot think or function very well during or immediately following the episodes. The sense of vulnerability of the sudden and unanticipated onset of migraine symptoms may cause emotional changes such as anxiety or sadness. Appropriate diagnosis and treatment of migraine can greatly improve quality of life for a person who suffers from migraine headaches.

There are other types of headaches such as tension headaches due to stresses of life, headaches due to psycho-somatic causes, headaches as a feature of malingering etc. These are, by and large, rather innocuous in the sense that there is no serious underlying brain disorder. Headaches may also be a feature of visual disturbances such as refractive errors of the eyes and very rarely, headaches may indicate elevated blood pressure.

A very important cause of headaches in children is a brain tumour. While some of the tumours may be benign, the majority are malignant. There are several features that point to the possibility of a brain tumour. Warning signs that a headache may be associated with a brain tumour include a worsening or increase in the number of headaches that a child is having, persistent vomiting, seizures or convulsions, having a headache first thing in the morning or one that wakes the child up from sleep, changes in a child's personality and behaviour, disturbance of memory and deterioration in school performance, a headache that is worse when lying down or when coughing or sneezing, double vision, or difficulty walking.

If a child develops persistent or worsening headaches, it is imperative that the child is seen by a qualified doctor. A detailed history of the problem and a comprehensive clinical examination is essential to sort out the problem. In some cases, further investigation may be necessary. These are required to arrive at a definitive diagnosis or to exclude more sinister causes for the headaches. These tests may include:

* Computerized tomography (CT Scan). This imaging procedure uses a series of computer-directed X-rays that provide a cross-sectional view of the brain. This helps doctors diagnose tumours and some other possible medical problems that may be causing headaches.

* Magnetic resonance imaging (MRI Scan). MRIs use radio waves and a powerful magnet to produce very detailed views of the brain. MRI scans help doctors diagnose tumours, strokes, blood vessel abnormalities, neurological diseases and other brain abnormalities. An MRI can also be used to examine the blood vessels that supply the brain.

* Spinal tap (lumbar puncture). If your doctor suspects that an underlying condition, such as bacterial or viral meningitis, is the cause of the child's headaches, he or she may recommend a spinal tap (lumbar puncture). In this procedure, a thin needle is inserted between two vertebrae in the lower back to extract a sample of cerebrospinal fluid (CSF) for laboratory analysis.

* Psychological evaluation. Busy schedules, anxiety and high expectations from parents and relatives are frequently associated with all types of childhood headaches. Some children benefit from working with a psychologist to learn biofeedback and relaxation therapy.

It is axiomatic in medicine that the root cause of any symptom needs to be addressed. The proper treatment will depend on several factors, including the type and frequency of the headache, its cause and the age of the child. Treatment may include education, stress management, biofeedback and medications. Some of the more sinister causes have their own standardised forms of treatment. However, other causes such as migraine and headaches due to psychological stresses of life need careful assessment and certain forms of appropriate management. Headache education of the parents and the child includes identifying and recording what triggers the child's headache such as lack of sleep, not eating at regular times, eating certain foods or additives, caffeine, environment or stress. Helping a child keep a headache diary can help a great deal. Avoiding headache triggers is an important step in successfully treating the headaches. To successfully treat tension headaches it is important for kids and their parents to identify what causes or triggers the headaches. Then they can learn ways to cope or remove the stressful activities or events. Inherent biofeedback equipment of the child includes natural sensors connected to the body to monitor the child's involuntary physical responses to headaches such as breathing, pulse, heart rate, temperature, muscle tension and brain activity. By learning to recognize these physical reactions and how the body responds in stressful situations, biofeedback can help a child to learn how to release and control tension that causes headaches.

There are some drugs that may be useful in treating or preventing the problem. There are three categories of headache medications for children, including those that provide symptomatic relief, drugs used to abort episodic headaches and preventive medications. Many of the medications used to treat adult headaches are also used in smaller doses to treat headaches in children and adolescents.

Non-specific headaches may improve as a child gets older. However, in some cases, the headaches may disappear only to return later on in life. By the stage of senior school many boys who have migraines outgrow them, but in girls, migraine frequency may increase because of hormonal changes. It is known that migraine is three times more likely to occur in adolescent girls than in boys. Headaches due to stress and other psycho-somatic causes resolve when the basic causative problem is either addressed or when there is a significant change in the real life situations.