Medical Comorbidities in Pediatric Headache.

Comorbid conditions frequently occur in pediatric headaches and may significantly affect their management. Comorbidities that have been associated with pediatric headaches include attention-deficit or hyperactivity disorder, autism, developmental disabilities, depression, anxiety, epilepsy, obesity, infantile colic, atopic disorders, inflammatory bowel disease, and irritable bowel syndrome. The goal of this article is to review these comorbidities associated with pediatric headache, thereby empowering child neurologists to identify common triggers and tailor management strategies that address headache and its comorbidities.

Pediatric headache: where have we been and where do we need to be.

In this article, we hope to summarize current understanding of pediatric headache. We discuss epidemiology, genetics, classification, diagnosis, outpatient, emergency and inpatient treatment options, prevention strategies, and behavioral approaches. For each section, we end with a series of questions for future research and consideration.

Pediatric headache: a clinical review.

In this review we describe the epidemiology, classification, and approach to the diagnosis and treatment of episodic and chronic migraine in children. We review both traditional and alternative medications, and offer a glimpse into the future of pediatric headache.

Chronic daily headache in children and adolescents.

Chronic daily headaches (CDH) in children and adolescents is reviewed. Three major forms of CDH exist: transformed migraine, chronic tension type headache, and new-onset daily persistent headache. Diagnostic criteria, epidemiology, pathophysiology, evaluation, differential diagnosis, and treatment options are discussed.

Headaches and hormones.

It is clear that hormones play an important role in modulating and exacerbating headaches. From an epidemiologic standpoint, we know that before puberty, incidence of new headache is similar for boys and girls. By age 18, however, most new cases of migraine occur in young women. The role of sex hormones in headache is described in the context of pubertal development. Obesity and Pseudotumor also impact headache through hormonal influences. Menstrual migraine will often present in the teenage years. Oral contraceptives may worsen or ameliorate headache. This article will introduce these concepts and help the reader become familiar with the role of hormones in headache.

Management of chronic daily headache in children and adolescents.

Chronic daily headache (CDH) occurs in 1-2% of children and adolescents. It can evolve from either episodic tension-type headache or episodic migraine, or can appear with no previous headache history. As with other primary headache disorders, treatment is based on the level of disability. There are children and adolescents who cope well, but there are others who are markedly disabled by their chronic headaches. As in adults, children and adolescents with CDH are at risk for medication overuse. CDH is a diagnosis of exclusion, based on a thorough history, normal physical examination, and negative neuroimaging findings. Along with the chronic headaches, children with this condition may have co-morbid sleep problems, autonomic dysfunction, anxiety, and/or depression. Principles of treatment include identifying migrainous components, stopping medication overuse, stressing normalcy, using rational pharmacotherapy, and addressing co-morbid conditions. Successful outcomes often involve identifying an appropriate headache preventative, reintegration into school, and family participation in resetting realistic expectations.

Chronic daily headache in the pediatric population.

Very limited long-term follow-up data exist for the population of children and adolescents with chronic daily headache (CDH). One abstracted report discusses short-term follow-up on 24 adolescents (peak age 13 years) with CDH; in a 6-month follow-up, more than 50% experienced a reduction of 75% or more in headache frequency, and one third showed an improvement of greater than 90% in headache frequency. A wide variety of preventive agents were used, but amitriptyline and topiramate provided the largest percentage of successful outcomes. With an improving classification scheme, we have the possibility of using multicenter studies to elucidate whether the clinical patterns seen by experienced observers translate into rational differentiation of treatment approaches. If the entities of CDH are, indeed, different, then therapeutic, prophylactic, and behavioral trials could guide us in offering a more evidence-based approach to the treatment of this fascinating, yet sometimes debilitating condition.

Pediatric headache.

Migraine is very treatable in children and adolescents. Principles of treatment include early intervention, elimination of triggers, involvement of parents and schools, and judicious use of medicines. Although there is no pediatric indication in the United States, triptans are safe and effective in this age group. Prophylactic drugs should be used when significant disability from migraine exists. Choice of drug is based upon comorbidity. Nonpharmacologic treatment has an important role.

Secondary headaches.

In this article, we develop an approach to the headache patient based upon pattern of headache. Headache can be acute recurrent, acute, chronic progressive, and chronic nonprogressive. Within each pattern we go through the differential diagnosis, with a focus on secondary causes of headache. Although most patients presenting with headache will end up having migraine, we must be able to recognize the other causes when they present.

Headache.

The patient who presents with headache can be diagnosed quickly and efficiently once the correct pattern has been identified. Most patients will have migraine, and treatment is based on the severity and disability. If the identified patient has significant disability, a medication that treats comorbidity should be prescribed. Patients who have a serious underlying disorder can be recognized by a thoughtful history and careful examination and can be worked up accordingly. Patients who have an acute new onset headache problem that requires immediate attention can be triaged and treated once their pattern and history are clear. Hopefully, increasing comfort levels with diagnosing headaches will allow the primary care practitioner to treat headache patients more effectively and efficiently.

Use of the ICHD-II criteria in the diagnosis of pediatric migraine.

OBJECTIVE: To evaluate the sensitivity of the new International Classification of Headache Disorders-2nd edition (ICHD-II) criteria in the diagnosis of childhood migraine and to propose specific criteria for the diagnosis of childhood migraine. BACKGROUND: In 2004, ICHD-II was adopted by the International Headache Society. The prior version had been criticized for its lack of sensitivity in diagnosing childhood headaches. ICHD-II is felt to be an improvement as it provides for some differences between pediatric and adult migraine diagnosis in its footnotes, however, has yet to be validated. Clinically, it is the impression of many pediatric headache specialists that children's migraines are of shorter duration, tend to be bilateral rather than unilateral, and that children more often report either photophobia or phonophobia, rather than both. METHODS: The characteristics of headache in 260 patients, ages 18 and under, clinically diagnosed with migraine at two large pediatric headache centers were compiled using standard intake questionnaires. Inter-rater reliability in clinical diagnosis was determined by consensus of the clinical diagnosis. These data were analyzed applying the International Classification of Headache Disorders-1st edition (ICHD-I) and ICHD-II criteria for migraine to determine sensitivity of migraine diagnosis in comparison with clinical impression. Each headache characteristic in ICHD-II was analyzed individually to determine its effect on sensitivity of diagnosis. RESULTS: 183/260 patients (70.4%) met ICHD-I criteria. 161/260 patients (61.9%) met the ICHD-II criteria with a 4- to 72-hour range. When the footnoted allowance of ICHD-II for short duration (2 hours) was utilized, 187/260 patients (71.9%) met criteria, while this improved to 192/260 patients (73.9%) with 1-hour duration. If duration was excluded, 210/260 patients (80.8%) met criteria. The most common reasons for patients not meeting the standard criteria were the requirement of unilateral location, headache duration and number of associated symptoms. Based on these observations, modified criteria were empirically derived and the sensitivity increased to 84.4%. Data were reanalyzed using the criteria of focal head pain, either bilateral or unilateral, shortened duration, and modified associated symptoms, which resulted in an improved sensitivity in migraine diagnosis of 84.4%. CONCLUSIONS: Modification of ICHD-II criteria to include bilateral headache, headache duration of 1 to 72 hours, and nausea and/or vomiting plus two of five other associated symptoms (photophobia, phonophobia, difficulty thinking, lightheadedness, or fatigue), in addition to the usual description of moderate to severe pain of a throbbing or pulsating nature worsening or limiting physical activity, improved sensitivity of migraine diagnosis to 84.4%.

Children and adolescents with chronic daily headache.

Chronic daily headache is a significant problem in children and adolescents. The goal of this review is to paint a picture of this malady. The epidemiology is unclear because definitions have not been uniform. Classification systems reflect what is known in adults. Because the disease duration and the transformation period are so different in children with this disorder, shoehorning children into adult criteria may be problematic. Nevertheless, this article presents an approach to diagnosis and treatment based on what is present in the literature, what has worked with adults, and the consensus among pediatric headache practitioners. Because there is little literature on this subject, the review ends with a series of questions for future study.

Chronic daily headache in children and adolescents presenting to tertiary headache clinics.

BACKGROUND: Adults with chronic daily headache often describe a transformation from episodic migraine and partial retention of migrainous features. Although chronic daily headache has not been investigated as carefully in the pediatric population, one study showed a predominance of coexisting daily headache and episodic migraine, without a clear history of transformation. OBJECTIVE: To identify the clinical features of chronic daily headache in children and adolescents, to evaluate the efficacy of current headache classification criteria, and to compare the features of coexistent daily and episodic headaches so as to determine whether they represent separate syndromes or different stages in the "transformation" process. DESIGN: We surveyed 189 consecutive patients, 18 years of age or younger, who presented for initial evaluation of daily or near daily headache at one of 9 tertiary headache clinics. Data were collected in semistructured interviews employing a standard questionnaire and analyzed using Statistical Analysis Systems and Stata statistical software computer programs. RESULTS: Of the patients enrolled, 70% were female and 87% were white. Mean age was 13.0 +/- 3.1 years. Male gender was associated with a higher degree of reported disability. A family history of headache (typically migraine) was described in 79%. Use of nonsteroidal anti-inflammatory drugs 5 days per week or more was reported by 44% of patients. The International Headache Society (IHS) criteria failed to classify 64% of patients and criteria proposed by Silberstein et al failed to classify 31% of patients. Participating physicians misclassified patients according to criteria of the IHS and Silberstein et al in one third of cases. Nearly one quarter of patients reported two separate headache types with distinguishing characteristics. "Baseline" headache was present 27.3 +/- 4.1 days per month with a mean pain intensity of 5.9 +/- 2.1 on a 10-point scale. Superimposed episodic headache occurred 4.7 +/- 3.8 days per month with a mean pain intensity of 8.4 +/- 1.4, and was more often accompanied by other migrainous symptoms. After logistic regression to control for pain intensity, the only statistically significant difference between the two headache types was a lower prevalence of tension-type head pain with the superimposed headache. CONCLUSIONS: Our data suggest that rather than having two coexistent headache types, children and adolescents with chronic daily headache have a single syndrome that, in many cases, will paroxysmally worsen and gather migrainous features.