Headache associated with pituitary adenomas

The objectives of this study were to analyze the characteristics of headache in patients with pituitary adenoma and to investigate the mechanisms involved. Fifty-one patients (27 females and 24 males) with pituitary adenoma were examined. Nineteen (37.3%) of these patients (13 females and 6 males) had headache preoperatively. Most commonly, the headache was generalized (42.1%); overall headache was more frequent in the anterior half of the head (84.2%). Seventeen (89.5%) patients had bilateral headache. Headache was usually described as head heaviness (57.9%) and continuous (57.9%). Pulsating headache and dull pain were only reported by the female patients and were mostly intermittent. The mean age of patients with headache was younger than that of those without headache. Headache was more prevalent in patients with a prolactin-secreting adenoma (57.1%). There were no correlations between visual disturbances, hypopituitarism, tumor size, or cavernous sinus invasion and headache. Hemorrhagic pituitary adenoma in 4 (57.1%) of 7 patients did not always contribute to headache. The headache was improved after surgery in 14 (73.6%) of the 19 patients. In the male patients who survived postoperatively (5 of 6), headache was improved.     

Headaches associated with Rathke's cleft cyst

OBJECTIVE: Headaches are common presentations in patients with Rathke's cleft cyst (RCC). This study was conducted to elucidate the characteristics and underlying mechanisms of the headache. METHODS: We retrospectively studied 46 patients with RCC, 33 of whom underwent surgical intervention. RESULTS: Headache, particularly frontal headache, was the most common symptom, occurring in 27 patients (58.7%). Eleven patients with sudden episodic headache mimicking that of pituitary apoplexy. Although the presence of headache did not correlate with cyst size, it was significantly more common in RCCs with: high- and iso intensity content on T1-weighted MR image (P= .0363), mucous content within the cyst (P= .0023), and intense chronic inflammation at the cyst wall (P= .0276). Among 6 patients with histologically recognized intense inflammation, every patient had frontal headache (P= .0407), 5 patients had episodic headache (P= .0002), and 4 patients had associated hypopituitarism (P= .0073), none of which improved after surgical intervention. Headaches improved after surgery in 17 of 21 patients (81.0%). CONCLUSIONS: Headache, particularly frontal episodic headache, is a common and characteristic manifestation in patients with RCC and may indicate intermittent inflammatory reactions caused by mucous content. Patients with episodic headache should undergo surgical treatment to prevent exacerbation of the inflammation that can result in irreversible endocrine dysfunction.     

Transsphenoidal microsurgical treatment of prolactin-producing pituitary adenomas. Results in 100 patients

One hundred patients, 84 females and 16 males, with presumed prolactin-producing pituitary adenomas were treated with transsphenoidal microsurgery. Criteria for success of the operation were return of serum prolactin values to normal and reversal of the endocrine effects of hyperprolactinemia, eradication of the adenoma, and preservation of anterior pituitary function. Of the 84 females, 54 had a microadenoma (a noninvasive adenoma 10 mm or less in diameter), and of the 32 with preoperative values of serum prolactin of less than 100 ng/ml, 28 (88%) had a successful operative result, whereas 11 of 22 (50%) with preoperative values of 100 ng/ml or more had a successful result. Five of 10 patients (50%) with a diffuse adenoma (a noninvasive adenoma more than 10 mm in diameter) and 5 of 20 (25%) with an invasive adenoma had a successful result. Of the 16 males, 3 of 7 (43%) with diffuse adenoma and 3 of 16 (19%) with invasive adenoma had a successful result. There were no males with microadenoma. The largest success rate (88%) was among female patients with microadenoma and preoperative serum prolactin values of less than 100 ng/ml.     

The prevalence and characteristics of different types of headache in patients with Behçet's disease, a case-control study

Background.— Headache is one of the most common neurologic symptoms of Behçet's disease (BD) that may be due to migraine, tension‐type headache, uveitis, or direct consequence of neuro‐Behçet's disease (NBD) or other causes. Objective.— To study the prevalence and characteristics of different types of headache in patients with BD. Method.— Subjects were recruited as consecutive patients who referred to Behçet's Clinic at the Nemazee Hospital, Shiraz, Southern Iran, from March 2004 to March 2006. All patients fulfilled the International Study Group criteria for BD. Each patient was interviewed for history of BD and headache. Neurological examinations and, if necessary, ancillary investigations were performed for each patient. Control group was an age‐ and sex‐matched population. Headache entities fulfilled the International Headache Society criteria. Results.— In total, 35% (63/180) of patients had no headache. Migraine with and without aura was the cause of headache in 1.7% (3/180) and 25.6% (46/180) of patients, respectively. Tension‐type headache was found in 23.9% (43/180) of patients. In 8.3% (15/180) of patients, headache could be justified by NBD. Headache due to uveitis was observed in 3.3% (6/180) of patients and 4 patients (2.2%) had other causes of headache. Migraine was significantly more common in patients than the control group (OR: 2.9, P < .0001). Considering the effect of gender, migraine was also significantly more frequent in patients than in the control group both in females (OR: 3.1, P < .0001) and males (OR: 3.2, P = .006). Conclusion.— Migraine and tension‐type headaches are the most prevalent types of headaches in Behçet's patients. NBD must be meticulously investigated in patients with BD who presented with headache.     

Chronic Migraine Prevalence,Disability, and Sociodemographic Factors: Results From the American Migraine Prevalence and Prevention Study

Objectives.— To estimate the prevalence and distribution of chronic migraine (CM) in the US population and compare the age‐ and sex‐specific profiles of headache‐related disability in persons with CM and episodic migraine. Background.— Global estimates of CM prevalence using various definitions typically range from 1.4% to 2.2%, but the influence of sociodemographic factors has not been completely characterized. Methods.— The American Migraine Prevalence and Prevention Study mailed surveys to a sample of 120,000 US households selected to represent the US population. Data on headache frequency, symptoms, sociodemographics, and headache‐related disability (using the Migraine Disability Assessment Scale) were obtained. Modified Silberstein–Lipton criteria were used to classify CM (meeting International Classification of Headache Disorders, second edition, criteria for migraine with a headache frequency of ≥15 days over the preceding 3 months). Results.— Surveys were returned by 162,756 individuals aged ≥12 years; 19,189 individuals (11.79%) met International Classification of Headache Disorders, second edition, criteria for migraine (17.27% of females; 5.72% of males), and 0.91% met criteria for CM (1.29% of females; 0.48% of males). Relative to 12 to 17 year olds, the age‐ and sex‐specific prevalence for CM peaked in the 40s at 1.89% (prevalence ratio 4.57; 95% confidence interval 3.13‐6.67) for females and 0.79% (prevalence ratio 3.35; 95% confidence interval 1.99‐5.63) for males. In univariate and adjusted models, CM prevalence was inversely related to annual household income. Lower income groups had higher rates of CM. Individuals with CM had greater headache‐related disability than those with episodic migraine and were more likely to be in the highest Migraine Disability Assessment Scale grade (37.96% vs 9.50%, respectively). Headache‐related disability was highest among females with CM compared with males. CM represented 7.68% of migraine cases overall, and the proportion generally increased with age. Conclusions.— In the US population, the prevalence of CM was nearly 1%. In adjusted models, CM prevalence was highest among females, in mid‐life, and in households with the lowest annual income. Severe headache‐related disability was more common among persons with CM and most common among females with CM.     

Improvement in Headaches With Continuous Positive Airway Pressure for Obstructive Sleep Apnea: A Retrospective Analysis

Objective.— We aimed to identify clinical features in patients with severe headaches that predicted obstructive sleep apnea (OSA) and determine clinical and sleep study characteristics that predicted headache improvement with continuous positive airway pressure (CPAP). Background.— Many patients with headaches complain of sleep symptoms and have OSA. There is often improvement of headaches with CPAP treatment. Methods.— We conducted a retrospective chart review of all patients referred to adult neurology clinic for headaches and sent for polysomnography between January 2008 and December 2009. Follow‐up ranged from 18 to 42 months. Results.— Eighty‐two headache patients (70 females, 12 males) were studied. Mean age was 45 ± 13 years (females 45 ± 13, males 43 ± 11) and mean body mass index was 32 ± 9. Headache types included 17% chronic migraine without aura, 22% episodic migraine without aura, 32% migraine with aura, 21% tension‐type headache, 6% chronic post‐traumatic headache, 11% medication overuse headache, and 7% other types. All patients were receiving standard treatment for their headaches by their neurologist. Fifty‐two patients (63%) had OSA. Increasing age, female gender, and chronic migraine without aura were predictive of OSA. Of the patients with OSA, 33 (63%) used CPAP and 27 (82%) were adherent to CPAP. Headache improvement was reported by 40 patients (49%) due to either standard medical therapy or CPAP. Patients with OSA who were CPAP adherent (21/27) were more likely to have improvement in headaches than patients intolerant of CPAP (2/6), those that did not try CPAP (8/19), and those who did not have OSA (16/30) (P = .045). Of the 33 patients who used CPAP, 13 reported improvement in headaches specifically due to CPAP therapy and 10 additional patients noted benefit in sleep symptoms. The presence of witnessed apneas (P = .045) and male gender (P = .021) predicted improvement in headaches due to CPAP. Conclusions.— Headache patients should be evaluated for the presence of OSA. Treating OSA improves headaches in some patients.     

The clinical properties of a migrainous population in eastern Turkey-Erzurum

OBJECTIVES: The purpose of this study was to determine the clinical and demographic characteristics of patients with migraine headache, in the vicinity of Erzurum, Turkey. METHODS: A uniform questionnaire was given to 185 patients diagnosed as having migraine according to the International Headache Society diagnostic criteria between August 2001 and July 2002. One hundred forty five females (78.4%) and 40 males (21.6%) were included in the study. The male to female ratio was 1:3.2. The mean age of the cases was 32.4 +/- 10.2 years and the mean age of onset was 22.8 +/- 9.1 years. RESULTS: One hundred and thirty seven patients (74.6%) fulfilled the criteria for migraine without aura (MwA) whereas forty-eight patients (25.4%) fulfilled the criteria for migraine with aura (MA). The males had been suffering from migraine headaches for a mean of 8.3 +/- 6.3 years versus a mean of 9.3 +/- 7.6 years in females. More than half (61.4%) of the females were housewives, and 84.3% of the cases were living in urban areas. About half (48.7%) of them had at least 11 years of education, most (79.5%) reported low or medium income level. Also, 70.8% were married. There was a high rate of headache in family history (72.4%). A majority of patients (75.7%) complained of severe headaches. One fourth (24.9%) had more than three attacks per month. Headache was unilateral in 71.9% and was throbbing in 77.8%. In 117 patients (63.2%) the symptoms were aggravated by physical activity. Attacks were accompanied by nausea in 84.9%, vomiting in 50.3%, photophobia in 80.0%, and phonophobia in 78.4%. In 58% of the cases, the headache was severe enough to disturb daily activities. CONCLUSIONS: This study showed that migraine is more commonly seen in urban areas, in females, and is associated with high education plus low income, and is comprised of a wide complex of symptoms.     

The hypnic ("alarm clock") headache syndrome

Hypnic headache syndrome is a rare, sleep-related, benign headache disorder. We report 19 new eases (84% females) with follow-up data. The mean age at headache onset was 60.5 ± 9 years (range 40–73 years). Headache awakened the patients from the night's sleep at a consistent time, usually between 1.00 and 3.00 a.m. (63%); three patients (16%) reported that identical headaches could occur also during daytime naps. Headache frequency was high, occurring more than 4 nights/week in 68% of the patients. Headache resolution occurred within 2 h in 68% of patients. Neurologic examination, laboratory studies, and brain imaging were unrevealing at the time of diagnosis. Headache severity largely remains unchanged or attenuates over time, but frequency may vary in either direction. Only one patient had spontaneous relief from headache. Four patients (24%) achieved permanent suppression of headache with medication, and two were able to abort individual headache attacks. Caffeine in a tablet or beverage was helpful in four patients. Lithium carbonate therapy caused side effects requiring cessation of treatment in four patients.     

Evolution of headache in childhood and adolescence: an 8-year follow-up

Objective . Headache is a notable problem in clinical practice and a frequent symptom in childhood and adolescence. The main aim of the present study is to analyze the evolution of migraine and tension headache (TH) using an 8-year follow-up. Method . 100 subjects (F60, M40; mean age 17.9; SD 2.6; range 12–26), randomly selected among all patients first seen in 1988 at the Headache Center, were directly contacted. We employed IHS criteria both in 1988 (the data were taken by the clinical charts) and 1996. We took into account changes in headache types and improvement, unchanging, worsening or remission of headache. This analysis was made with regard to gender differences and age at onset of headache, too. The chi-squared test is employed. Findings . High tendency to remit (34%) or improve (45%) was recorded. A worsening situation was seen in 6% and an unchanging situation in 15%. In 1988, we had 57% migraine without aura (MwoA), 7% migraine with aura, 28% episodic tension-type headache (ETTH), and 8% chronic TH (CTTH). In 1996, we saw 30% MwoA, 2% MwA, 31%, ETTH, and 3% CTH. Migraine shows a lower tendency to remit than TH (28.1% vs 44.4%) MwoA persists in the same form in 43.8% and becomes ETH in 26.3%. ETTH persists in the same form in 26.3% and changes in MwoA in 10.7%. Of headache-free subjects, we recorded a high tendency to remit (34%) and improve (95%); 13 were females (21.7%) and 21 were males (52.5%). The course of headache is not related to age at onset. Conclusion . Headache with juvenile onset changes its characteristics over time, with a high tendency to remit (mostly in males) or improve. The implications for pathophysiology and the role of hormonal factors are called into question.     

颈部压痛点处的手法治疗对紧张型头痛的效果观察

背景在颈部软组织压痛点和痛性结节处施用手法治疗可否改善紧张性头痛的症状及体征.目的观察颈部压痛点与紧张型头痛(tension-headche,TTH)之间的关系,探讨手法治疗的作用.设计以诊断为依据的病例对照研究.地点和对象TTH患者280例,男80例,女200例;诊断标准参照1988年国际头痛学会头痛分类标准.对照组150例,为无头痛症状的健康体检者,男50例,女100例.方法触诊枕外隆突下至颈棘突止中线及其旁开,记录每一压痛点、痛性结节总数及部位,实施揉拿、弹拨、点按使颈部压痛点及痛性结节的手法治疗.观察肌肉痉挛的缓解程度及局部血液循环的改善.主要观察指标TFH组和对照组压痛点、痛性结节阳性率,TFH患者压痛点和痛性结节在枕颈部分布情况,采用手法治疗后疗效评定结果.结果TTH组和对照组压痛点、痛性结节阳性率分别为(58.9%,28.6%和1.3%和0.6%)(x2=262.6,P＜0.005).主要分布在上颈段(C1～2,C2-3)棘中线和棘突旁.经1～6次治疗,痊愈183例(65.4%),显效58例(20.7%),好转27例(9.6%),无效2例(0.7%),总显效率86.1%.结论颈部肌肉障碍在TTH的发病机制中起重要作用,针对压痛点手法治疗,产生显著的疗效.     

Headache associated with acute ischemic stroke

Headache occurs frequently in acute ischemic stroke, but its frequency varies widely among different studies. We have prospectively studied headache features in patients with first-ever ischemic acute stroke and assessed the relationship between headache, stroke location, and etiology. The study included consecutive patients admitted to our Stroke Unit for a first-ever ischemic acute stroke. The study included 154 consecutive patients with ischemic stroke, and 54 of these (35.1%) had headache during stroke onset. Twelve patients (22.2%) with headache during stroke had history of headache; no patients without headache had history of headache. Headache was present in 25.8% (32/124) of the patients with anterior circulation stroke and in 73.3% (22/30) of the patients with posterior circulation stroke (p=0.001). Large artery disease was more frequent with than without headache (40.7% versus 14.0%, p=0.04). Headache was present in more than one-third of the patients with ischemic stroke. All patients with positive history for headache had headache during stroke onset. The cephalic pain was much more common among patients with infarcts in the posterior circulation than in patients in whom the anterior circulation was involved. Headache was more common when the cause of stroke was large artery disease. Received: 5 January 2001 / Accepted in revised form: 6 April 2001     

How Children and Parents Evaluate the Headache Centre's Intervention

Background.— While adult headache patients' satisfaction with treatments has been widely investigated, less attention has been paid to children and adolescent headache patients' opinions and their parents' views. Objective.— The aim of our follow‐up survey was to analyze the outcomes of the Headache Centre's intervention and the evolution of headache according to patients until the age of 16 and their parents. Methods.— We studied all outpatients suffering from episodic primary headache according to International Classification of Headache Disorders 2nd edition criteria, seen for the first time in 2005‐2006 at the Headache Centre of the University Hospital of Modena (Italy), and at least one of their parents. The duration of the follow‐up ranged from 1 to 3 years. For the purpose of the study, a specific questionnaire was created and administered by a telephone interview. Results.— We enrolled 84 patients (38 females, 45%; 46 males, 55%; mean age ± SD: 12.9 ± 2.9 years) with primary headache: migraine without aura 66%, episodic tension‐type headache 23%, migraine with aura 11%. At the follow‐up, 70% of the patients reported that headache had improved; frequency had decreased significantly more than severity (P = .000, Fisher's exact test), both in those who had followed a prophylactic treatment and in those who had not. A high percentage of the children and parents could precisely indicate trigger factors for headache: especially excessive worrying and studying. The patients reporting an improvement attributed it to pharmacological prophylactic treatment, but also to other factors: first of all, better school results and more happiness than before. Seventy‐seven percent of the parents thought that the Headache Centre's intervention had helped them to better understand and manage their children's headache. Conclusions.— Children's and adolescents' headache has in most cases a favorable prognosis; the Headache Centre's intervention is considered effective by most parents. We must increase and focus therapeutic efforts addressed to the few patients with worsening headaches in spite of treatment, since these children's/adolescents' headache also is at risk to progress in the adult age.     

Quality of life in young Italian patients with primary headache

OBJECTIVE: To compare the quality of life of young Italian patients with headache with that of the juvenile Italian population free of chronic disease. METHODS: The Quality of Life Headache in Youth (QLH-Y) Questionnaire developed by Dutch investigators was translated into Italian and validated in a young Italian population. The forward/backward translation and, for psychometric testing, the factor analysis and Cronbach coefficient alpha were used. A new instrument (Questionnaire for Young Subjects Affected by Primary Headache) was developed to assess psychological, physical, and social functioning and functional status and was used to compare the quality of life of the patients with headache with that of headache-free controls. For psychometric testing (via the questionnaire), we selected a sample of 394 subjects (178 males and 216 females, aged 10 to 18 years): 320 subjects from three schools of North Italy and 74 patients with headache from the Paediatric Headache Center of Padua. In the latter group, 48 patients had tension-type headache and 26 had migraine without aura, according to the International Headache Society diagnostic criteria. RESULTS: The data derived from the comparison of 84 headache-free subjects (control group) and the 74 young patients with headache confirmed that primary headache negatively influenced the latter's quality of life: patients scored significantly (P<.05) lower on psychological, physical, and social functioning than the headache-free controls. CONCLUSIONS: Quality of life is compromised significantly in young patients with primary headache disorders. The questionnaire used in this study is a valid and reliable self-administered instrument that may facilitate clinical research in headache.     

The Role of Computed Tomography in the Diagnostic Work‐Up of Headache Patients in Nigeria

Objective.— To determine the yield of computed tomography (CT) scan of the brain in the evaluation of patients presenting with headache at the University of Port Harcourt Teaching Hospital (UPTH). Background.— Headache is a pain in the head or upper neck. It is one of the most common locations of pain in the body that leads patients to see a physician. CT scan is invaluable as an imaging tool in assessment of intracranial lesions that may present with headache. Methods.— The records of all the patients referred from a variety of inpatient and outpatient settings to the radiology department of UPTH with the main complaint of headache for brain (CT) scan were identified. Data extracted include referral source, indication for CT, age, sex, presenting complaint, duration of headache, and CT findings. The data were analyzed using SPSS 14.0 statistical package. Results.— A total of 80 patients with chronic or recurrent headache met the selection criteria. The age range was 16 to 85 years with a mean of 39.8 ± 14.62 years. There were 36 males and 44 females with male to female ratio of 1 : 1.2. About half of the patients were ≤45 years. Of the total number, 72 (90%) patients had normal CT findings, 2 (2.5%) had cerebral atrophy, 2 (2.5%) had cerebral edema, 2 (2.5%) had intracerebral hematoma while 1 (1.25%) patient each had cerebral infarction and subdural hematoma, respectively. There was no case of brain tumor. Conclusions.— The yield of correctable abnormalities from routine CT scan of the brain in headache patients with normal neurologic findings is low and does not justify its use in a resource poor country. (Headache 2010;50:1346‐1352)     

Cluster Headache is an Inherited Disorder in Some Families

We investigated the familial occurrence of cluster headache in 370 probands with cluster headache, diagnosed according to the operational diagnostic criteria of the International Headache Society. Seven probands belonged to three families. A positive family history of cluster headache was found in 7% (25 of 366) of the families. Compared with the general population, the first- and second-degree relatives of the 370 probands with cluster headache had a 14- and 2-fold increased risk of having cluster headache, after standardization for sex and age. This increased familial risk strongly suggests that cluster headache has a genetic cause. The patterns of segregation were assessed by complex segregation analysis performed with the computer program, POINTER. The segregation analysis suggests that cluster headache has an autosomal dominant gene with a penetrance of 0.30 to 0.34 in males and 0.17 to 0.21 in females. The gene is present in 3% to 4% of males and 7% to 10% of females with cluster headache.     

Post-angiography headaches

Headache is a common symptom after cerebral angiography, although it has seldom been studied. We aimed to evaluate the frequency of headache at 24 h and 6 months after angiography and to describe its characteristics. We used a cross-sectional survey of consecutive patients submitted to angiography and determined headache presence and its characterization. Headache occurrence was analyzed against headache history, clinical data, technical and demographical variables. Of 107 procedures studied, 51.3% patients experienced headaches within 24 h. Patients more likely to experience headaches were females or had subarachnoid hemorrhage. Six months post-procedure 48.8% of patients had frequent headaches. These patients had a positive headache history before the procedure, migraine in particular. Half of patients undergoing routine angiography experience benign post-procedure headaches within 24 h (especially women), yet it does not seem to predispose to chronic long-term headaches.     

A prospective study of migraine with aura attacks in a headache clinic population

In order to investigate the prevalence of migraine with aura (MA) attacks according to the criteria set by the International Headache Society (IHS) for diagnosis down to the three-digit level of classification, and to determine the recurrence and possible variability of MA attacks over time, we conducted a 6-15-month-long prospective study on 64 MA patients (42 women and 22 men) consecutively referred for the first time to the University of Parma Headache Centre. At the end of the follow-up period, diagnosis was the same as at the first visit for 80.0% of patients, while it was changed for 20.0%. Throughout the duration of the study, the average number of attacks for each patient was 5.3 +/- 6.2 (range 0-30). Attacks of migraine with typical aura were the most frequent (69.1% of patients), but migraine aura without headache (29.1%) and migraine with prolonged aura (20.0%) were also common; by contrast, basilar migraine and migraine with acute onset aura were reported only by one patient in either case. Migraine aura without headache was statistically significantly more frequent in males than in females. Our study results suggest that in most cases the frequency of recurrent MA attacks is relatively low and provide interesting indications about the prevalence of the different MA subtypes listed in the IHS classification, albeit in a headache clinic population.     

Headache and coping in a female working population

Tension-type headache is a common disorder amongst working people and, because of its very high prevalence, represents one of the most costly ailments in modern society. To study the frequency of tension-type headache in a working female population and to investigate how females who have experienced tension-type headache cope with pain compared with the way healthy pain-free subjects cope with stress. A total of 400 females working at a university hospital in Sweden were asked about their experience of headache in the previous 3 months. Instruments used were a specific Headache Questionnaire, the Jalowiec Stress-coping Questionnaire and Coping Strategy Questionnaire. Before the study, approval from the board of directors and the employees' council was obtained. About 257 females (64.3%) answered the questionnaire and 78% of them (n = 199) reported that they had experienced headache in the previous 3 months. About 90% of the participants had never had an appointment with a doctor concerning headache and 57% reported a relationship between stress and headache. Regarding pain-coping strategy, increased pain behaviour was the most frequent strategy used. With regard to stress-coping style, a significant difference in the use of emotive style was found between females reporting headache and females not reporting headache. The results indicate that prevention programmes emphasizing stress management and coping may influence the experience of tension-type headache.     

Recurrent and chronic headaches in children below 6 years of age

The objective was to determine the frequency of headache subtypes, according to International Headache Society (IHS) criteria, in a population of children below 6 years visiting a Center for Diagnosis and Treatment of Headache in Youth. Medical records of the children below 6 years at their first visit, admitted for headache between 1997 and 2003, were studied. Headache was classified according to the IHS criteria 2004. Children with less than three headache attacks or less than 15 days of daily headache were excluded. We found 1598 medical records of children who visited our Headache Center in the study period. One hundred and five (6.5%) were children younger than 6 years. The mean age at the first medical control was 4.8±1.3 years (range 17–71 months). There were 59 males (56.1%) and 46 females (43.9%). The mean age at onset of headaches was 4.3 years (range 14–69 months). According to the IHS criteria we found 37 cases (35.2%) with migraine, 19 cases (18%) with episodic tension headache, 5 cases (4.8%) with chronic daily headache, 13 cases (12.4%) with primary stabbing headache, 18 cases (17.1%) with post–traumatic headache, 7 cases (6.6%) with other non–dangerous secondary headaches (otorhinolaryngological diseases, post–infectious headaches), 3 cases (2.85%) with dangerous headaches (Arnold–Chiari type 1 malformation, brain tumour) and 9 cases (8.6%) with unclassifiable headaches. Six children (5.7%) reported more than one headache subtype. The prevalence of dangerous headaches was higher than those in school age (χ²=4.70, p<0.05). Our study shows some differences in headaches in this population vs. school children. In fact at this age migraine is the most common headache, but we also found an increase of secondary causes among the chronic/recurrent and daily headaches, especially posttraumatic disorders and potentially dangerous headaches. Finally our study shows the highest prevalence of the idiopathic stabbing headache in pre–school children in comparison with other ages.     

Head pain referral during examination of the neck in migraine and tension-type headache

Objective.— To investigate if and to what extent typical head pain can be reproduced in tension‐type headache (TTH), migraine without aura sufferers, and controls when sustained pressure was applied to the lateral posterior arch of C1 and the articular pillar of C2, stressing the atlantooccipital and C2‐3 segments respectively. Background.— Occipital and neck symptoms often accompany primary headache, suggesting involvement of cervical afferents in central pain processing mechanisms in these disorders. Referral of head pain from upper cervical structures is made possible by convergence of cervical and trigeminal nociceptive afferent information in the trigemino‐cervical nucleus. Upper cervical segmental and C2‐3 zygapophysial joint dysfunction is recognized as a potential source of noxious afferent information and is present in primary headache sufferers. Furthermore, referral of head pain has been demonstrated from symptomatic upper cervical segments and the C2‐3 zygapophysial joints, suggesting that head pain referral may be a characteristic of cervical afferent involvement in headache. Methods.— Thirty‐four headache sufferers and 14 controls were examined interictally. Headache patients were diagnosed according the criteria of the International Headache Society and comprised 20 migraine without aura (females n = 18; males n = 2; average age 35.3 years) and 14 TTH sufferers (females n = 11; males n = 3; average age 30.7 years). Two techniques were used specifically to stress the atlantooccipital segments (Technique 1 – C1) and C2‐3 zygapophysial joints (Technique 2 – C2). Two techniques were also applied to the arm – the common extensor origin and the mid belly of the biceps brachii. Participants reported reproduction of head pain with “yes” or “no” and rated the intensity of head pain and local pressure of application on a scale of 0 ‐10, where 0 = no pain and 10 = intolerable pain. Results.— None of the subjects reported head pain during application of techniques on the arm. Head pain referral during the cervical examination was reported by 8 of 14 (57%) control participants, all TTH patients and all but 1 migraineur (P < .002). In each case, participants reported that the referred head pain was similar to the pain they usually experienced during TTH or migraine. The frequency of head pain referral was identical for Techniques 1 and 2. The intensity of referral did not differ between Technique 1 and Technique 2 or between groups. Tenderness ratings to thumb pressure were comparable between the Techniques 1 and 2 when pressure was applied to C1 and C2 respectively and across groups. Similarly, there were no significant differences for tenderness ratings to thumb pressure between Technique 1 and Technique 2 on the arm or between groups. While tenderness ratings to thumb pressure for Technique 2 were similar for both referral (n = 41) and non‐referral (n = 7) groups, tenderness ratings for Technique 1 in the referral group were significantly greater when compared with the non‐referral group (P = .01). Conclusions.— Our data support the continuum concept of headache, one in which noxious cervical afferent information may well be significantly underestimated. The high incidence of reproduction of headache supports the evaluation of musculoskeletal features in patients presenting with migrainous and TTH symptoms. This, in turn, may have important implications for understanding the pathophysiology of headache and developing alternative treatment options.