Pain and disability in migraine or other recurrent headaches as reported by children

To evaluate the pain intensity and physical disability during migraine attacks, 340 children suffering from headache were studied in an outpatient setting. A validated self-reporting five-faces scale was used. Intensity of headache was more severe and attacks longer but less frequent in 253 children with migraine than in 87 children with other types of headache. On a pain scale, 69% of the children with migraine expressed maximal pain vs 32% of those with other types of headache. Bed rest for migraine attacks was required by 96% of the children. Severe migraine was at least as common in prepubertal as in pubertal children. The severity of the pain and disability related to migraine attacks should be evaluated carefully and treated appropriately.     

Polysomnographic findings in children with headaches

Although previous studies suggested a relationship between headache and sleep disturbances, polysomnographic findings in children with headache are rarely described. We investigated polysomnographic findings in children with headaches, and correlated them with headache type and severity, body mass index, and medical treatment. Analysis of polysomnographic findings of 90 children with migraine (60), chronic migraine (11), tension headache (6), and nonspecific headache (13) indicated that sleep-disordered breathing was more frequent among children with migraine (56.6%) and nonspecific headache (54%) vs chronic migraine (27%). Tension headache was not associated with sleep-disordered breathing. In the nonspecific headache group, children with sleep-disordered breathing had higher body mass indexes (P = 0.008). Severe migraine and chronic migraine were associated with shorter sleep time, longer sleep latency, and shorter rapid eye movement and slow-wave sleep. Fifty percent of children with tension headache manifested bruxism vs 2.4% of children with nontension headache (odds ratio, 1.95; 95% confidence interval, 1.2-4.34). Our results support an association between migraine and sleep-disordered breathing, and between tension headache and bruxism, in children. Moreover, disrupted sleep architecture with reduced rapid eye movement and slow-wave sleep in severe and chronic migraine headaches may support an intrinsic relationship between sleep and headache disorders.     

Tension-type headache in childhood and adolescence

The prevalence of non-migrainous headache is 10-25% in childhood and adolescence. Although tension-type headache and migraine are the two most common types of headache in children and adolescents, most articles address migraine headache. The distinction of tension-type headache from migraine can be difficult; use of The International Classification of Headache Disorders criteria helps. However, these criteria might be too restrictive to differentiate tension-type headache from migraine without aura in children. The pathophysiology of tension-type headache is largely unknown. The smaller genetic effect on tension-type headache than on migraine suggests that the two disorders are distinct. However, many believe that tension-type headache and migraine represent the same pathophysiological spectrum. Some indications of effective treatment exist. For children with frequent headache, the antidepressant amitriptyline might be beneficial for prophylaxis, although no placebo-controlled studies have been done. Restricted studies have suggested the efficacy of psychological and cognitive behavioural approaches in the treatment of childhood tension-type headache.     

Epidemiology, characteristics and distinctiveness of headaches in children from Vojvodina, Serbia

From 1988 to 2004, an investigation was carried out on a population of 30,636 children (50.38% boys and 49.62% girls) in 9 towns of Vojvodina, province in northern Serbia. Idiopathic recurrent headache was found in 27.46% of children aged 3-17 years (26.8% of males and 28.4% of females). Migraine headache was found in 8.63% of children aged 3-17 years (8.0% of males and 9.6% of females). Recurrent headaches showed an occurrence that increased with age in the observed group, from 16.65 to 32.87% in boys and from 14.23 to 40.50% in girls (ages 3-5 and >12 years, respectively). Of the children with migraine, 25.55% had migraine with aura, 67.21% had migraine without aura and 7.23% had other migraine types. Idiopathic recurrent headache was found in children at a mean age of 9 years and 2.5 months (range 3-17 years). The presence of both recurrent and migraine headaches was found to be higher than previously described. In children, these headaches appear to be significantly associated with incomplete families, a poor economic situation and being the second-born child. Children with recurrent headache were diagnosed and followed by a general practitioner in 31.5% of cases, by a pediatrician in 21.6% and by a neurologist or neuropediatrician in the remaining 46.8%. Normal daily activity was compromised in children with recurrent headache for 3.91 days per year.     

Recurrent headache in chinese children: any agreement between clinician diagnosis and symptom-based diagnoses using the International Classification of Headache Disorders (Second Edition)?

There has been a lack of published data on the pattern of recurrent headache in Chinese children. The validity of the International Classification of Headache Disorders criteria has not been evaluated in Chinese children. We performed a retrospective medical record review of 124 children aged <18 years with an International Classification of Diseases coding of headache followed up in a general outpatient clinic in a university-based hospital over a 3-year period (2000-2002). The aims of our study were to (1) study the pattern of recurrent headache in Chinese children and (2) study any agreement between clinical diagnoses made by our board-certified pediatricians and symptom-based diagnoses using the second edition of the International Classification of Headache Disorders (International Classification of Headache Disorders-II). The most common type was unclassified headache (70.2%), followed by infrequent episodic tension-type headache (24.2%) and migraine without aura (5.6%). A family history of headache or migraine was more commonly found in children with infrequent episodic tension-type headache or migraine without aura (P = .0109). The co-occurrence of abdominal pain with infrequent episodic tension-type headache was 30%; for unclassified headache, it was 19.5%. Dysmenorrhea occurred in 7.1% of girls with infrequent episodic tension-type headache and 8.6% of girls with unclassified headache. However, migraine without aura was not associated with abdominal pain or dysmenorrhea. Children with migraine without aura were more frequently referred to child neurologists (P = .0207) and admitted (P = .0000). Neurologic investigations, including electroencephalography, computed tomography, or magnetic resonance imaging of the brain, were performed in less than 30% of cases. Abnormal results were found in only seven cases; with two referred to a neurosurgeon and none requiring surgical intervention. Thus, by using the clinical diagnosis of our board-certified pediatricians as the standard, the sensitivity and specificity of International Classification of Headache Disorders-II-based definition of migraine without aura was 23.1% and 93.4%, respectively, and for infrequent episodic tension-type headache, it was 37.5% and 76%, respectively. The typical characteristics of migraine tend to emerge later and might have led to underdiagnosis of the younger age group, with a higher rate of referral and inpatient management. The new edition of the International Classification of Headache Disorders criteria is still restrictive in clinical practice and might not be able to reflect current pediatric practice. Further studies with a defined study period or recurrent headache might be more useful in analyzing the use of these new International Classification of Headache Disorders criteria in the diagnosis of recurrent headache in children.     

Prevalence of headache and migraine in children and adolescents: a systematic review of population‐based studies

Aim The aim of this study was to review systematically the prevalence of headache and migraine in children and adolescents and to study the influence of sex, age, and region of residence on the epidemiology. Method We systematically searched the literature in electronic databases to cover the period between 1 January 1990 and 31 December 2007. We assessed and included population‐based studies on epidemiology of headache and migraine in children and adolescents if they fulfilled the following criteria: (1) reporting on unselected childhood population; (2) reliable methods of data collection using a questionnaire or face‐to‐face interviews; (3) using the International Headache Society’s (IHS) criteria (1988 or 2004) for the diagnosis of migraine; and (4) provision of sufficient and explicit data for analysis. We used Excel, Stata, and Confidence Interval Analysis software. Results We identified and analysed 50 population‐based studies reporting the prevalence of headache and/or migraine in children and adolescents (<20y). The estimated prevalence of headache over periods between 1 month and lifetime in children and adolescents is 58.4% (95% confidence interval [CI] 58.1–58.8). Females are more likely to have headache than males (odds ratio [OR] 1.53, 95% CI 1.48–1.6). The prevalence of migraine over periods between 6 months and lifetime is 7.7% (95% CI 7.6–7.8). Females are more likely than males to have migraine (OR 1.67, 95% CI 1.60–1.75). Regional differences in prevalence of migraine, though statistically significant, may not be of clinical significance. The change in the IHS’s criteria for the diagnosis of migraine was not associated with any significant change in the prevalence of migraine. Interpretation This study confirms the global high prevalence of headache and migraine in children and adolescents. Sex, age, and regional differences are evident.     

Childhood periodic syndromes: a population-based study

The objective of the present study was to estimate the prevalence and relative risk of symptoms suggestive of childhood periodic syndrome in migraine, migraine subtypes, and tension-type headache, relative to control subjects. The target population was all children (age 5-12 years) enrolled in public elementary schools in one Brazilian city (n = 2173). Consent was obtained for 1994 children; analyzable data were available for 1906 children, for a final sample of 1113 children with migraine, tension-type headache, or no headache. Parents were interviewed using validated questionnaires. Headache diagnosis was assigned according to the International Classification of Headache Disorders, 2nd edition. Relative risk of symptoms was drawn by headache categories relative to controls. For episodic migraine, the relative risk of all symptoms except nocturnal enuresis was significantly increased: motion sickness, recurrent limb pain, recurrent abdominal pain, and parasomnias, such as sleep talking, somnambulism, and bruxism. For tension-type headache, only nocturnal enuresis and motion sickness were not more common than in controls. In multivariate analyses, any interictal symptom was independently associated with any headache (P < 0.001), migraine headaches (P < 0.001), and tension-type headaches (P < 0.01). These findings indicate that interictal symptoms suggestive of childhood periodic syndromes are common in the population, and are associated with migraine and specific migraine subtypes, but also with tension-type headache.     

The classification of chronic daily headache in French children and adolescents: a comparison between the second edition of the International Classification of Headache Disorders and Silberstein-Lipton criteria

Few data are available on the applicability of both the criteria proposed by Silberstein and Lipton (S-L) and the International Classification of Headache Disorders-II (ICHD-II) in the classification of children and adolescents with chronic daily headache (CDH). The International Headache Society recently added revised criteria (ICHD-IIR) for chronic migraine to its Appendix. We retrospectively reviewed all charts of 34 children and adolescents (<17 years) with primary CDH presenting to the outpatient clinic of the Universitary Department of Neuropediatrics of Lille between February 2004 and February 2006 and tried to classify their CDH according to both S-L criteria and the recently published ICHD-IIR. Thirty-two children (94%) and 33 children (97%) could respectively be successfully classified into one subtype of CDH according to the S-L classification and the ICHD-IIR. Transformed migraine was the most common diagnosis (61.8%), followed by new daily-persistent headache (20.6%) when the S-L criteria were used. Twenty-three children and adolescents (67.6%) could be classified under one of the migraine categories according to the ICHD-IIR classification. We think that both S-L and ICHD-II classifications, when used with detailed headache histories and diaries, are adequate to classify chronic daily headache in children and adolescents.     

Validity of graphic headache diary for children having primary headaches

We investigated whether the graphic headache diary is useful for diagnosing headache types in children, especially suffering from chronic daily headaches. Our study involved 109 children who completed the diaries for more than 3 weeks. The headache diary was a modified version of that used in the study by Sakai et al. Of 109, 84 had migraine, 15 had tension-type headache and 10 had both tension-type headache and migraine from the questionnaire and the first interview. The diary disclosed that 20 children, initially diagnosed as having migraine, had co-existing chronic tension-type headache with a variety of psychosocial problems. The graphic headache diary seems to be helpful for headache diagnosis and awareness of stress in children who suffered from strong and persistent headaches. Our study suggested that the graphic headache diary is useful not only for diagnosing headache types in children but also for finding out problems in school and/or family.     

Prevalence of headache and its association with sleep disorders in children

An association between headache and sleep disturbances has been reported in previous studies, but there is a lack of research examining this relationship in a community sample of children in order to reveal the magnitude of the problem. Among 32 District Educational Directorates in Istanbul, nine school districts and within each district eight schools were randomly selected. A questionnaire consisting of sociodemographic variables and evaluating headache and sleep disturbances was sent to students' homes to be completed by their parents. The prevalence of headache was 31.4% (95% confidence interval: 29.5-33.4%). Migraine prevalence was 3.3%, whereas nonmigraine headache prevalence was 28.1%. The prevalence of headache was similar between males and females (29.6% vs 33.3%, P > 0.05). The frequency of headache increased with age for both sexes. Snoring, parasomnias, sweating during sleep, and daytime sleepiness were more common among children with migraine compared with nonmigraine and no headache groups. Headaches are common among schoolchildren. Because children with migraine headaches have a high prevalence of sleep disturbances, they should always be evaluated for the presence of sleep problems.     

Chronic daily headache, medication overuse, and obesity in children and adolescents

Obesity and headaches are common in children and adults. Adult studies suggest obesity is a risk factor for chronic daily headache and increased migraine frequency and severity. Pediatric studies have suggested a relationship between obesity, increasing headache frequency, and disability. The authors retrospectively evaluated 925 children from their Pediatric Headache Clinic between July 2004 and July 2008, assessing headache frequency, medication overuse, and body mass index compared to population-based norms. The pediatric headache group as a whole had a greater percentage of overweight than the general population. This was also true with the subgroup of patients with chronic tension-type headache, although the numbers were small. Data did not show increased incidence of overweight in children with medication overuse or chronic migraine. This contrasts with adult data, which have suggested a closer link between chronic migraine and obesity and have not supported a link with chronic tension-type headache.     

Chronic daily headache in French children and adolescents

To characterize the clinical profile, comorbidity and aggravating factors, and outcomes, a consecutive series of 34 French children and adolescents with chronic daily headache was studied. Of 206 referred over an inclusive interval of 2 years for the evaluation of headaches, 34 merited a diagnosis of chronic daily headache, which was defined as persistent or daily headaches of at least 3 months in duration. The overwhelming majority were female (61.8%), with a mean age at diagnosis of 10.5+/-3.1 years (range, 2.9-14.8 years). According to the Silberstein-Lipton criteria, transformed migraine was the etiology in 61.8%, whereas according to the second edition of the International Classification of Headache Disorders, chronic migraine accounted for 50% of cases. Stressors were recognized in 82%. Analgesic abuse was evident in 52.9%. Of the 29 for whom follow-up information was available, headaches resolved or greatly improved in 93.1%. Children and adolescents with chronic daily headache are thus a small subset of children with headache seen in general ambulatory practice. They tend to be girls in the midteen years experiencing a transformed migraine complicated by analgesic abuse, suggesting potential preventability. Simple measures, which can include reassurance and analgesia education, can be expected to result in improvement and eventual resolution of headache symptoms.     

Prevalence and features of migraine in Japanese junior high school students aged 12-15 yr

Migraine is the most common cause of recurrent headache among children and adolescents resulting in missing of school and disabling their daily life. The purpose of this study is to determine the prevalence and clinical features of headache in junior high school children in Japan. In December 2004, questionnaires were sent to 14 junior high schools. There were multiple-choice type questions on headache, mainly migraine. The questionnaires were given during school hours, and 6472 answers were obtained. One thousand four hundred seventy-eight (22.8%) students experienced severe headache and 476 (7.4%) had consulted physicians. Three hundred thirteen (4.8%) were identified as having migraine based on the ICHD-II criteria, consisting of 110/3346 boys (3.3%) and 203/3126 girls (6.5%): 91 (29.1%) with aura and 222 (70.9%) without aura. In about half of the children the migraine attacks were of short duration, ranging from 1 to 3 h. There were 36 boys (1.1%) and 45 girls (1.4%) who had shorter attacks of less than 1 h, whom we did not diagnose as having migraine according to the ICHD-II criteria. Although migraine is common among schoolchildren, it is often under- or miss-diagnosed since the clinical figure for childhood migraine differs from that for adults.     

Clinical categorization of 312 children with chronic headache

Three hundred and twelve children referred to an outpatient pediatric neurology clinic, with headache that lasted more than 3 months, were retrospectively reviewed. On average, the age of pain onset was 8.4 years. Migraine was diagnosed in 54% of these children and tension-type headache was found in 22% of those with chronic headache. Most children (85%) had common migraine, while classic and complicated migraine was found in only 8.8% and 5.3%, respectively. Brief headaches, lasting from seconds to a few minutes, were found in 5.1% of the children evaluated. In this subgroup, a high rate of epileptic EEG activity was found. Out of 110 children who had undergone computerized tomography, only one was pathological (posterior arachnoid cyst). Our results indicate that chronic and recurrent headache without accompanying neurological symptoms are usually benign and therefore in most cases neuroimaging is not indicated.     

Rare and atypical forms of migraine

There are three categories of rare forms of migraine headache. Atypical aura can raise difficult diagnostic questions due to their clinical expression (visual or sensorial illusions and hallucinations), their mode of onset (sudden aura, developing in less than 4 minute), their duration (prolonged aura lasting more than 60 minutes), and the lack of an accompanying headache. Differential diagnostics include partial epilepsy or AIT, requiring careful search for the underlying cause. Rare migraine syndromes are separate clinical entities, most of which are recognized by the International Headache Society (IHS). These syndromes include basilar migraine, familial hemiplegic migraine, ophthalmoplegic migraine and the exceptional retinal migraine. Confusional migraine, usually observed in children, is no individualized by the IHS but can be included here. For secondary migraines there is a triggering factor leading to migraine in patients with no history of migraine previously. These include post-traumatic migraine and cervical migraine as well as migraine occurring with epileptic seizures and rare symptomatic migraine headache disclosing a general disease or an intracranial neurological lesion.     

Headache in children's drawings

Headache is a common health problem in childhood. Children's drawings are helpful in the diagnosis of headache type. Children, especially younger ones, communicate better through pictures than verbally. The aim of the present study is to evaluate the usefulness of drawings of the child's headache in the diagnostic process carried out by a pediatrician and a pediatric neurologist. At the beginning of a visit in a neurological clinic, or on the first day of hospitalization, the child was asked, "Please draw your headache," or "How do you feel your headache?" without any additional explanations or suggestions. Clinical diagnosis of headache type was made on the basis of the standard diagnostic evaluation. For the purpose of this study, children's headaches were categorized as migraine, tension-type headache, or "the others." One hundred twenty-four drawings of children with headaches were analyzed by 8 pediatricians and 8 pediatric neurologists. The analysts were unaware of the clinical history, age, sex, and diagnosis of the patients. The clinical diagnosis was considered the "gold standard" to which the headache drawing diagnosis was compared. There were 68 girls 5-18 years of age and 56 boys 7-18 years of age. Of the 124 children, 40 were clinically diagnosed with migraine (32.2%), 47 with tension-type headache (37.9%), and 37 (29.8%) as the others. Children with migraine most frequently draw sharp elements. Children with tension-type headache mainly drew compression elements and pressing elements. In the group of "the other" headaches, 21 children were diagnosed with somatoform disorders. The most frequent element in this group's drawings was a whirl in the head. Colors used most frequently were black and red, which signify severe pain. There was no difference in sensitivity of diagnoses between neurologists and pediatricians. Because the evaluation of drawings by children with headaches done both by pediatricians and pediatric neurologists was correct for approximately half of the children, the authors decided to prepare a set of test pictures, including characteristic presentations of pain. Preparing a ready set of test drawings may facilitate differentiation for the inexperienced doctors and encourage those children who refuse to draw.     

Migraine in junior high-school students: A prospective 3-academic-year cohort study

Migraine is a common childhood illness with expected favorable outcome. A study of the long-term clinical course of childhood migraine will provide information of evolution of migraine. A cohort study for 3-academic-year was conducted in Thai junior high-school children from July 2005 to February 2008 to determine the clinical course of migraine. Two hundred and forty-eight students in four junior high schools diagnosed with migraine according to ICHD-II in July 2005 were recruited. Each student was serially evaluated twice yearly from 7th grade during each semester of the academic year until the second semester of 9th grade. Determination of the characteristics, severity, frequency, and treatment of headache were obtained by questionnaire and direct interview. At the final evaluation, clinical course of headache was categorized into seven patterns. Among enrolled students, 209 (84.3%) completed the study. Twenty-eight (13.5%) students had no recurrent headache while that of 153 (73.5%) improved. No improvement of migraine and worsened migraine were observed in four students (1.8%) and 24 students (11.2%), respectively. Spontaneous remission and avoidance of precipitating causes contributed to relief of migraine in the majority of the students. Stress-related daily school activities and inadequate rest were reported as common precipitating factors among students with non-improving or worsening outcome. Chronic daily headache and tension-type headache was observed in 6 and 30 students, respectively. This study confirms that clinical course of migraine in schoolchildren is benign. Frequency and intensity of headache can be reduced with reassurance and appropriate guidance. Early recognition and appropriate prevention of migraine attack will decrease the risk of chronic migraine and disease burden.     

Headache in childhood

Migraine in children is diagnosed in presence of paroxystic episodes of headache which recur with free intervals, provided intracranial diseases are excluded. Pathogenesis of this disorder is unclear; migraine with and migraine without aura may be different entities. Many factors can precipitate a migraine attack. In school age, psychologic stress is the commonest factor. Main characteristics of attacks in children are headache, which may be hemicranial; nausea and vomiting, abdominal pain, paraesthesiae. Scotomata are not very common in the pediatric age. In some cases, migraine attacks are complicated by sensory or motor symptoms (paraesthesiae, paresis), usually at one hemisoma. In the basilar artery migraine syndrome, features of brain-stem dysfunction predominate. In a few patients a migraine attack presents itself as an acute confusional state. In migraine, EEG abnormalities are frequent (predominance of diffuse or focal slowing). In some cases a CSF pleocytosis is found after an attack of complex migraine. Prognosis is good. Preventive treatment is necessary if the attacks are severe and if they cannot be relieved by rest or sleep. Symptomatic headaches may be produced by a variety of causes. Rarely, it is secondary to increased intracranial pressure. In the great majority of cases recurrent headache is due to migraine. Usually, clinical data are sufficient for diagnosis, though in some cases the diagnosis is difficult and it is necessary to perform laboratory examinations in order to exclude symptomatic headache.     

Headache in children with brain tumors

To study the criteria for early differential diagnosis between migraine and headache due to brain tumors, we analyzed the symptoms and signs of two groups of children. The first group consisted of 67 children in whom a brain tumor had been diagnosed. The second group was composed of 600 children who had been diagnosed as migraine cases. Among the features of headache that are considered to be alarming symptoms of a brain tumor, the following were found to indicate a brain tumor with the greatest sensitivity: nocturnal headache or headache present on arising, both associated with vomiting, and increased frequency of headache. Nocturnal headache or headache present on arising, associated with vomiting, and/or progressive neurological symptoms or signs occurred in 65 of 67 children with brain tumor within 2 months of the onset of their headaches and in all 67 within 6 months.