A 12-year-old boy comes to you complaining of recurrent headaches. He has had five episodes over the last 4 months. They started around the time he began high school, which coincided with his parents’ divorce. Each time they began with a throbbing pain that was usually focused on the right side of his head. On one occasion he vomited. On each occasion he came home from school, took some paracetamol and lay down. He is not happy at school and is finding it hard academically and socially.
You examine him carefully. His blood pressure is 110/67 and pulse is 64. He has no neurological signs.
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(a) What diagnoses do you consider?
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The most likely diagnoses are tension headaches or migraine. Tension headaches are more common than migraine, and it certainly sounds like this boy is stressed, having to contend with a new school and his parents’ divorce. However, the pain in tension headaches is classically ‘band-like’. Other causes of headache include raised intracranial pressure from any cause, dental caries, infections such as sinusitis and eye strain. If he had frequently used non-steroidal analgesics you might consider analgesic headaches.
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(b) What features make you consider that migraine is a probable diagnosis? What else would you look for in the history?
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Migraine is a possible diagnosis, particularly as the headaches are one-sided, and as he has vomited on at least one occasion. Features that would reinforce this diagnosis include a history of aura, nausea, a positive family history and a history of travel sickness.
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(c) What features in a history of headache would make you worry that he might have raised intracranial pressure?
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You would be concerned that he might have raised intracranial pressure if any of the following symptoms are present:
• pain is worse on lying down
• actual regression in his academic achievements
• hypertension
• papilloedema
• focal neurological signs
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(d) What treatment would you consider?
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The first-line treatment for his headaches is rest and simple analgesia. You should enquire sensitively into his family and social situation. You might suggest that he confides in someone—a mentor or teacher at school—or even refer him for counselling. As you consider migraine as a diagnosis, you could suggest that he avoids cheese, chocolate and nuts. If the attacks become more frequent or severe in the future, prophylaxis with beta-blockers or pizotifen is a possibility.
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(e) When would you consider requesting investigations?
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Imaging of the brain by CT scan or MRI is only indicated if there are signs of raised intracranial pressure or focal neurological signs, or if headaches persist and are not responsive to normal analgesia.
