Effectiveness of nasal sumatriptan in 5- to 12-year-old children

OBJECTIVE: To assess the tolerability and effectiveness of nasal sumatriptan in the treatment of migraine in 5- to 12-year-old children. BACKGROUND: Although headaches are a common disorder and occur in up to 10.6% of children, many of the new migraine abortive agents have not been well evaluated in this population. It has recently been reported that nasal sumatriptan is effective in the treatment of migraine in adolescents. In younger children, it is yet to be characterized. In addition, many children have significant amounts of vomiting with their migraines, limiting their use of oral medications. DESIGN AND METHODS: Children with headache were evaluated by a child neurologist, child psychologist, and pediatric nurse practitioner. Clinical and International Headache Society diagnoses were established for each child. Patients with headaches that were either unresponsive to oral medications or had significant vomiting were treated with nasal sumatriptan. Initial administration and tolerability were performed in the Headache Center at Cincinnati's Children's Hospital Medical Center. Patients or their parents were contacted to assess the overall effectiveness of nasal sumatriptan after home administration. RESULTS: Ten patients aged between 5 and 12 years (mean, 9.9 years) received either a 5-mg (n = 2) or 20-mg (n = 8) dose of sumatriptan. All 10 patients had a clinical diagnosis of migraine; 7 met the International Headache Society criteria for migraine. The mean age of headache onset was 6.6 years. A total of 57 headaches were treated; 47 (82.5%) responded to sumatriptan. Of the patients who treated headaches, the mean number of headaches treated was 5.2, while the mean number of responsive headaches was 4.3. One patient had no response, 2 patients had a 50% response, and 6 patients had 100% response to the nasal sumatriptan. Three patients reported persistent "bad taste." CONCLUSIONS: This report demonstrates that nasal sumatriptan may be effective in aborting migraine in young children (aged 5 to 12 years). It also suggests that there may be subgroups for which it works well. This information suggests that double-blind, placebo-controlled studies are necessary to determine the overall effectiveness of nasal sumatriptan in this age group.     

Clinical and Demographic Characteristics of Migraine in Urban Children

Objective.-To establish the frequency, symptoms, duration, and treatment methods of childhood migraine in an urban area.
Design.-Self-administered questionnaire survey. The questionnaire was designed according to criteria suggested by the International Headache Society (IHS).
Participants.-In 1994, with the help of school officials in 41 elementary and middle schools in the Greater Cleveland Area, 18000 questionnaires were distributed to the parents of schoolchildren who ranged in age from 5 to 13 years.
Results.-Of the total 2572 respondents, 222 children (8.6%) met the IHS criteria for migraine. Male to female ratio was 1:1.2 (99:120), 65.8% had a positive family history of migraine, 30.6% had onset of migraine at 4 to 5 years of age, and 54.1% reported having an aura (71% of these were visual aura). The headaches were mostly pulsating, poorly localized, lasted about 2 to 12 hours, and were aggravated by motion, noise, and bright light. The associated symptoms were nausea, vomiting, photophobia, and phonophobia. During the attack, 43% of the migraineurs had to stay in bed, and 27% were unable to attend school. Only 19.8% of the migraineurs were diagnosed to have migraine by their physicians, and most of these had not received treatment.
Conclusion.-This study in an urban area indicates that childhood migraine is a common, often underdiagnosed disorder that causes significant suffering for children and their families.     

Osmophobia in primary headaches

This study evaluates osmophobia (defined as an unpleasant perception, during a headache attack, of odours that are non–aversive or even pleasurable outside the attacks) in connection with the diagnosis of primary headaches. We recruited 775 patients from our Headache Centre (566 females, 209 males; age 38±12 years), of whom 477 were migraineurs without aura (MO), 92 with aura (MA), 135 had episodic tension–type headache (ETTH), 44 episodic cluster headache (ECH), 2 chronic paroxysmal hemicrania (CPH) and 25 other primary headaches (OPHs: 12 primary stabbing headaches, 2 primary cough headaches, 3 primary exertional headaches, 2 primary headaches associated with sexual activity, 3 hypnic headaches, 2 primary thunderclap headaches and 1 hemicrania continua). Among them, 43% with MO (205/477), 39% with MA (36/92), and 7% with CH (3/44) reported osmophobia during the attacks; none of the 135 ETTH and 25 OPH patients suffered this symptom. We conclude that osmophobia is a very specific marker to discriminate adequately between migraine (MO and MA) and ETTH; moreover, from this limited series it seems to be a good discriminant also for OPHs, and for CH patients not sharing neurovegetative symptoms with migraine. Therefore, osmophobia should be considered a good candidate as a new criterion for the diagnosis of migraine.     

Evolution of migraine after a 10-year follow-up

OBJECTIVE: To assess the evolution of headaches in a workplace cohort over a 10-year period. BACKGROUND: Migraine headaches are associated with significant handicap in everyday activities and poor quality of life. The prevalence of migraine shows a bell-shaped age distribution with a peak during the third and fourth decades. However, there is little longitudinal data available on the natural history of this condition. A prospective health survey undertaken in a large workplace cohort since 1989 provides an opportunity to assess the evolution of migraine and other headache syndromes over a 10-year period. METHODS: A sample of 2500 subjects who reported regular headaches was chosen at random from those with headache identified in a cohort of 46,244 employees of the French national power company aged between 35 and 50 years in 1989 participating in a yearly health survey. In 1993, all subjects were sent a headache questionnaire to complete and return. In 2003, an identical questionnaire was sent to all subjects who had returned exploitable data in 1993. Headache diagnosis was assigned retrospectively using the International Headache Society (IHS) criteria to migraine (IHS categories 1.1 and 1.2), migrainous disorder (IHS category 1.7), or other episodic headaches. RESULTS: Of 2500 subjects sampled, 2051 (82%) returned exploitable data for the first questionnaire in 1993. In 2003, 1250 (61%) of these provided a second data set. In 1993, 623 (30.4%) of subjects fulfilled diagnostic criteria for migraine. However, only 37% of these retained the diagnosis 10 years later. In contrast, the proportion of subjects with other forms of episodic headache rose from 23.7% to 31.6%. In 2003, 9.5% of the sample were headache-free. Retention or acquisition of a diagnosis of migraine was more common in women than in men, and age was associated with evolution to a less severe headache syndrome. In those subjects who continued to have headaches, frequency and severity were lower at the second assessment. CONCLUSIONS: Only a minority of subjects diagnosed with migraine or migrainous disorder retain the diagnosis 10 years later, with most subjects evolving to a less disabling headache type.     

Chronic daily headache in children and adolescents: a clinic based study from India

Chronic Daily Headache (CDH) is uncommon in Indian children compared to their adult counterpart. This is a retrospective study looking at the headache phenomenology of CDH in Indian children and adolescents. The validity of the case definitions of subtypes of chronic primary headaches mentioned in the IHS 2004 classification have been evaluated. 22 children (age range 8-15 years; M : F-16 : 6) diagnosed as having primary CDH using a modified definition seen between 2002 and 2003 have been studied. CDH has been defined as daily or near daily headaches > 15d/month for > 6 weeks. The rationale for this modified definition has been discussed. Majority of children (15/22) had a more or loss specified time of onset of regular headache spells resembling New Daily Persistent Headache (NDPH) but did not fulfil totally the diagnostic criteria of NDPH as laid down by IHS 2004. In all cases headache phenomenology included a significant vascular component. Headache phenomenology closely resembled Chronic Tension Type Headache (CTTH) in 4 patients and Chronic Migraine in 3 patients. However, in no patient in these groups, a history of evolution from the episodic forms of the diseases could be elicited. Heightened level of anxiety mostly related to academic stress and achievement was noted in the majority (19/22). Only a minority of patients (3/22) had anxiety and depression related to interpersonal relationships in the family. Medication overuse was not implicated in any patient. CDH in children in India is very much different from CDH in adults with the vast majority of patients exhibiting overlapping features of migraine and tension-type headache. There is need for a modified diagnostic criteria and terminology for chronic primary headaches in children.     

Migraine in children – an evaluation of the IHS criteria

The purpose of the present study was to compare the new criteria by the International Headache Society (IHS) with criteria for the definition of childhood migraine previously used. In particular, we considered the problem of the minimally acceptable headache duration in children. In a postal questionnaire, 36.5% of 3580 children 8–9 years old reported headache attacks. Ninety-five children (2.7%) fulfilled the IHS criteria. Three percent fulfilled the previously used migraine definition of Vahlquist. Some of the children in the latter group had considerably shorter headache attacks than those of the IHS patients, but otherwise their symptoms were very similar. When the IHS criterion of headache attack duration was lowered from a minimum of 2 h to 1 h, or omitted, the number of migraine patients increased from 95 to 114 and 127, respectively.     

Assessment of International Headache Society diagnostic criteria: a reliability study

In 1988 the International Headache Society (IHS) introduced new diagnostic criteria for headaches and craniofacial pain. Since headaches can be diagnosed solely on the basis of information provided by the patient, it is essential that the criteria are reproducible and consistent. Two neurologists evaluated the clinical records of 100 consecutive outpatients and transferred the data on headache and associated phenomena to a form designed to reflect the IHS criteria. Interobserver concordance (kappa statistics) in the application of the diagnostic criteria of primary headaches was: (i) "perfect" to "substantial" for the first IHS digit, being kappa = 1.0 for cluster headache and paroxysmal hemicrania; kappa = 0.88 for migraine; kappa = 0.75 for tension-type headache; (ii) "almost perfect" to "substantial" for the second digit (kappa = 0.94 for cluster headache; kappa = 0.90 for migraine with aura; kappa = 0.81 for episodic tension-type headache; kappa = 0.78 for migraine without aura; kappa = 0.71 for chronic tension-type headache; kappa = 0.66 for cluster headache-like disorder not fulfilling the criteria; (iii) "moderate" for migrainous disorder (kappa = 0.48) and headache of the tension-type (kappa = 0.43) not fulfilling the criteria. These results show that the IHS diagnostic criteria are satisfactorily applicable to high quality medical records abstracted by experienced neurologists.     

Decreasing the minimal duration of the attack to 1 hour: is this sufficient to increase the sensitivity of the ICHD-II diagnostic criteria for migraine in childhood?

Abstract We applied the second edition of the International Classification of Headache Disorders (ICHD-II) in 417 children (age range, 2–12 years) with chronic headaches attending a pediatric headache clinic. The initial diagnosis was made according to the ICHD-II while the final diagnosis was, based on the longitudinal intuitive clinical diagnosis (LICD), deemed to be the gold standard. The diagnosis of migraine without aura had a sensitivity of 52%, a specificity of 100% and a positive predictive value of 100%; for the diagnosis of migraine (at the one-digit level) these values were 87%, 100% and 100%, respectively. The ICHD-II criteria for migraine without aura have high specificity but low sensitivity in childhood, even considering the minimal duration of the attacks to be 1 hour. Other factors, such as the existence of subgroup 2.4 (probable tension-type headache), are responsible for the low sensitivity of ICHD-II criteria for the diagnosis of migraine without aura in patients of this age group.     

Diagnosis of migraine in children attending a pediatric headache clinic

The International Headache Society (IHS) criteria for migraine are not sufficient to diagnose migraine in children. Specifically, the duration and localization of the headache are different in children and adults with migraine. This study compared the formal IHS criteria with pediatric-amended IHS criteria and IHS criteria with the duration factor removed in children younger than 18 years. In addition, the older criteria by Vahlquist and by Prensky and Sommer were also compared. Finally, clinical diagnosis of migraine was compared with IHS criteria with the duration factor removed. The study showed that many children with a shorter duration headache have migraine and also that a number of children with a very long duration of headaches still fit the diagnosis of migraine. Unilateral headache is quite uncommon. The majority of children with migraine complained of bilateral headaches. It is concluded that the IHS criteria for pediatric migraine should be revised. We suggest making the duration factor a minor criteria for migraine in children or to exclude headaches lasting longer than 72 hours only in children younger than 15 years.     

Chronic tension-type headache in children and adolescents

In this study, the causes, predisposing factors and clinical features of chronic daily headache in children and adolescents were studied within the population of patients attending a specialist headache. The International Headache Society's (IHS) criteria for the diagnosis of chronic tension type headache (CTTH) were assessed for their applicability in the paediatric age group. Over a period of three years, demographic and clinical data were collected prospectively on all children who attended the clinic and suffered from daily attacks of headache. One hundred and fifteen children and adolescents (32% of all clinic population) had chronic daily headache, of whom 93 patients (81%) fulfilled the IHS criteria for the diagnosis of CTTH. They were between 3-15 years of age (mean: 11.1, SD: 2.3) and their female to male ratio was 1.2 : 1. Around one third of the patients also suffered from migraine (mainly migraine without aura). The headache was described as mild in 60.9%, moderate 36.5% and severe 2.6%. Headache was located at the forehead in 53% or over the whole of the head in 29.6%. Pain was described as 'just sore' or dull by 73.9%. During attacks of headache, at least half the patients reported light intolerance, noise intolerance, anorexia or nausea. Thirty-two percent of patients had at least one underlying chronic disease that may have contributed to the pathogenesis of the CTTH. Eleven percent had serious stressful events related to family illnesses and in four patients headaches were triggered by family bereavement. Fourteen percent were investigated with neuroimaging and 22% were referred for clinical psychology assessment and management. In conclusion, CTTH is a common cause of headache in children attending a specialist headache clinic. The clinical features closely match those of adult population and the IHS criteria for the diagnosis of CTTH can be adapted for use in children. Predisposing stressful risk factors, physical or emotional, are present in a large proportion.     

Responsiveness of non-IHS migraine and tension-type headache to sumatriptan

In a long-term efficacy and satiety study, 424 patients were treated with sumatriptan (6 mg sc) for 1,904 migraine attacks. The patients were diagnosed with migraine based on IHS criteria but individual migraine attacks treated in the study were physician diagnosed; not necessarily required to meet IHS criteria. A re-analysis of the treatment response to open label sumatriptan (6 mg sc) indicated that 43 patients had treated at least one migraine that fulfilled IHS criteria for tension-type headache. Analysis of this population revealed they treated 232 headaches. Of these headaches, 114 were classified per IHS criteria as migraine; 76 as tension-type; and 42 as. non-IHS migraine (not classifiable as IHS migraine or IHS tension-type headache). Of the 114 migraines a positive response to sumatriptan occurred in 109 (96%) cases; of the 76 tension-types, 73 responded to sumatriptan (97%); of the 42 non-IHS migraine, 40 (95%) responded to sumatriptan. An equivalent response to sumatriptan among three diagnostic groups of headache supports the concept of a common biologic mechanism involving 5HT₁ receptors that spans a range of clinical presentations.     

Migraine headaches in adolescents: a student population-based study in Monreale

We assessed the prevalence of migraine headaches in an epidemiological survey of an 11 to 14-year-old student population. Migraine headaches were classified on the basis of questionnaires and neurological examination using the operational diagnostic criteria of the International Headache Society. Prevalence of migraine without aura (IHS code 1.1) was 2.35%; that of migraine with aura (IHS code 1.2) was 0.62%. Migraine without aura was equally distributed among males and females, whereas migraine with aura was preponderant in the female cohort. The prevalence of migraine headaches in males was constant through the ages studied, whereas the prevalence of migraine headaches in females reached a peak at age 12 and plateaued over the following two years. Although the new IHS classification criteria of migraines are reliable and exhaustive, some subcriteria may not be valid in a juvenile population. For instance, the duration of the pain in young migraineurs is often briefer than in adults, and the intensity of pain was almost always described as moderate or severe. Therefore, in order to increase the reliability and comprehensiveness of the IHS classification, minor modifications should be made.     

Outcome of juvenile headache in outpatients attending 23 Italian headache clinics. Italian Collaborative Study Group on Juvenile Headache (Società Italiana Neuropsichiatria Infantile [SINPI])

A multicenter 3-year follow-up study was carried out on young patients with headache referred to tertiary headache centers or pediatric clinics. Three years after the first examination in 1993, 442 (of an original sample of 719) young outpatients with headache (226 females and 216 males) were re-examined. The diagnostic criteria of the International Headache Society (IHS) and those modified for migraine without aura by Winner et al were applied at both the baseline evaluation and the 3-year re-examination. At the follow-up, 290 children still had headache, 101 were in clinical remission, and 51 had dropped out. Using the current diagnostic criteria, only 46.2% of patients having migraine without aura, 50% of those having migraine with aura, and 35.3% of those suffering from migraine disorders which do not fulfill IHS criteria for migraine received the same diagnosis at the time of follow-up. The percentage of patients receiving a diagnosis of migraine without aura rose significantly when new modified criteria were used (60.5%), whereas a drop in the frequency of migraine disorders not fulfilling IHS criteria was observed at follow-up, both in patients with the diagnosis of migraine without aura at the first examination (4.6%) and in patients with migraine not always fulfilling IHS criteria at the first examination (6.2%). Among all patients who received this latter diagnosis at the first examination, it was possible to make a diagnosis of migraine with aura at the follow-up in 8.8% of cases and that of migraine without aura in 26.5%. No significant variations in the frequency of either episodic tension-type headache or chronic tension-type headache were found, with the exception of a slight decrease in the percentage of tension-type headache which did not fulfill IHS criteria, but the difference between the first examination and the follow-up values does not reach the level of statistical significance (5% versus 12%). As far as the evolution of migraine is concerned, 17.4% of patients with migraine were headache-free at the 3-year follow-up. In tension-type headache, the percentage of patients who were headache-free was particularly high in those with the episodic form (32.9%) and in those suffering from tension-type headache not fulfilling IHS criteria (29.1%). The majority of patients who had been diagnosed as having unclassifiable headache at the first examination received a correct diagnosis at the follow-up with the exception of one patient. As observed in adult patients, variations in the headache characteristics were also observed in children and adolescents (that is, migraine with aura can change to migraine without aura, or the latter can transform into episodic tension-type headache or chronic tension-type headache can change into the episodic form). This follow-up study was aimed at reaching a better understanding of headache disturbances in children and adolescents, examining, in particular, variations of headache with time in this stage of life.     

Effect of age on the fulfilment of the IHS criteria for migraine in children at a headache clinic

In a headache clinic, 247 children suffering from severe recurrent headaches were studied in relation to the IHS criteria for migraine. Of the 247, 163 had migrainous headache, with 110 (67.5%) of these having migraine in accordance with the IHS criteria. The remaining 53 (32.5%) had headache attacks fulfilling all but one of the IHS criteria. Coverage of the IHS criteria for migraine was 93%. Symptoms of unilateral headache, aggravation by physical activity, and nausea showed the greatest differences in frequency between those with migraine and those with probable migraine. All children with aura fulfilled criteria for migraine. Children with migraine with aura (11.8, 95% CI: 11.0–12.6 years) were older than those without aura (10.1, 9.4–10.8 years; p = 0.001). Children with pulsating headache were slightly older than children without pulsating headache. No differences in age were detected for the other IHS criteria.     

Comorbidity of headaches and depression in the elderly.

The comorbidity of headache and depression is rarely studied in the elderly. Confounders were seldom controlled in previous studies. From August 1993 to March 1994, we conducted a door-to-door survey to investigate the relationship of headache and depression in a Chinese elderly population (age > or = 65 years old) in two townships of Kinmen, Taiwan. A total of 1421 participants (71%) out of 2003 eligible citizens completed five measurements: a structured headache interview, Geriatric Depression Scale-short form (GDS-S), a survey of chronic medical illness. Cognitive Abilities Screening Instrument and an evaluation of activities of daily living. Headache diagnoses were made according to the criteria of the International Headache Society (IHS), 1988. Depression was defined as a GDS-S score > or = 8. After adjustment for confounding, subjects with more frequent headaches, more severe headaches, diagnoses of IHS migraine or chronic tension-type headaches in the past year, or a lifetime history of any headache including migraine were more likely to be depressed. In addition, the most relevant headache-related predictors of depression were the presence of any reported lifetime headache (odds ratio (OR) = 1.8, P < 0.01) and headache frequency > or = 7 days/month in the past year (OR = 2.0, P = 0.01). This study provided evidence that headache is independently associated with depression in the elderly. A high comorbidity of depression was found in the elderly with IHS migraine or chronic tension-type headaches. Not only the headache profile in the past year but also that in their lifetime was important in predicting current depression in the elderly. 1     

Application of ICHD 2nd edition criteria for primary headaches with the aid of a computerised, structured medical record for the specialist

We tested the computerised, structured medical record by entering and analysing the consecutive clinical sheets of primary headaches in the episodic forms (200) and chronic headache (200) and the corresponding output diagnoses of patients attending our Headache Centre. A diagnosis of one of the primary headache forms was obtained in 67.9% of cases. A certain diagnosis of primary headache plus that of a probable form was obtained in 24.4% of cases (12.7% represented by chronic migraine (CM) or chronic tension–type headache (CTTH)+probable medicationoveruse headache). Only probable forms were diagnosed in the remaining 7.3% (as single probable diagnosis in 5.8% of cases or multiple diagnoses of probable forms in the remaining ones). The percentage of certain diagnoses mainly in the chronic headache group (28.4%), and to a lesser extent tension–type headache (6.5%), were obtained in 34.9% of cases. A certain diagnosis of one chronic form plus that of a probable form was obtained in 50.8% of cases (26.9% represented by probable medication–overuse headache). Only probable forms were diagnosed in 13.46% (as single probable diagnosis in 8.73% of cases or multiple diagnoses of probable forms in the remaining ones). In the other cases, the ICHD–II classification does not allow the diagnoses of CM, CTTH or probable forms and medicationoveruse headache because the mandatory criteria for the diagnoses are too stringent and do not reflect modifications of the headache pattern in relation to its chronicity. These preliminary results underscore the usefulness of a computerised device based on the ICHD 2nd edition for diagnostic purposes in tertiary centres dedicated to headaches in clinical practice as well as its relevance for research. This computerised device may help to validate the new diagnostic criteria and to answer some emerging questions from the application of the new classification version, the relevance of which should be verified in clinical practice.     

New daily persistent headache in the paediatric population

We conducted a clinic-based study focusing on the clinical features of new-onset chronic daily headaches (CDH) in children and adolescents. The clinical records and headache diaries of 306 children and adolescents were reviewed, to identify 187 with CDH. Relevant information was transferred to a standardized form that included operational criteria for the diagnoses of the headaches. Since we were interested in describing the clinical features of these headaches, we followed the criteria A and B of the 2nd edn of the International Classification of Headache Disorders (ICHD-2) and refer to them as new daily persistent headaches (NDPH) regardless of the presence of migraine features (therefore, this is a modified version of the ICHD-2 criteria). From the 56 adolescents with NDPH, most (91.8%) did not overuse medications. Nearly half (48.1%) reported they could recall the month when their headaches started. NDPH was more common than chronic tension-type headache in both adolescents overusing and not overusing medication. Individuals with NDPH had headaches fulfilling criteria for migraine on an average of 18.5 days per month. On most days, they had migraine-associated symptoms (one of nausea, photophobia or phonophobia)). NDPH is common in children and adolescents with CDH. Most subjects do not overuse medication. Migraine features are common.     

Epidemiology and symptomatology of migraine among school children: Denizli urban area in Turkey

OBJECTIVE: This study was aimed at finding the prevalence, associated factors, and symptomatology of migraine among 5 to 8 grades of secondary and 9 to 11 grades of high school children (age range between 11 and 18 years old) in the Denizli urban area in the western part of Turkey. BACKGROUND: Data from the developed countries indicate that migraine is the most common cause of recurrent headaches in children. Also, childhood migraine is sufficiently severe to prevent the half of the suffering children from carrying on their usual daily activities. METHODS: A cross-sectional school-based study was conducted between May 2000 and June 2000. There were 2,490 participants selected by a multistage stratified clustered sampling procedure. A validated self-administered questionnaire designed according to the International Headache Society criteria was given to the school children of age between 11 and 18 years. RESULTS: Overall migraine prevalence was 8.8%; it was 6.7% in boys and 11.0% in girls (OR: 1.7; 95% CI: 1.3 to 2.3). Among girls, the highest prevalence (17.7%) occurred at 15 years of age, but among boys, the highest prevalence (11.9%) occurred at 16 years of age. Of children with migraine, 56.5% had a positive family history, and only 29.1% visited a doctor for headache. CONCLUSION: Migraine is a common health problem among school children in Denizli urban area and it often goes underdiagnosed.     

Comorbidity of psychiatric and behavioral disorders in pediatric migraine

OBJECTIVE: To determine whether behavioral and psychiatric disorders occur more frequently in school-age children with migraine headache. To also elucidate treatment response related to comorbid psychiatric or behavioral diagnosis. BACKGROUND: Recurrent migraine headaches are common in school-age children. Concurrent behavioral or psychiatric diagnoses could significantly impact headache frequency, severity, and response to treatment. METHODS: Healthy children from 6 to 17 years of age presenting to our headache clinic with migraine headache according to International Headache Society (IHS) criteria were identified. Parents/guardians were asked to complete the Child Symptom Inventory, 4th edition (CSI-4) after written informed consent. Children with positive rating scales underwent psychological interviews for confirmatory diagnosis. Results were compared to controls. Headache patients were assigned our usual treatment paradigm. Response regarding headache frequency was assessed at 3 months. RESULTS: A total of 47 patients were diagnosed with migraine headaches. The mean age was 10.55 years. Thirty controls were identified. After completing the CSI-4 and confirmatory psychological interview, 14 of 47 headache patients fulfilled Diagnostic and Statistical Manual (DSM-4) criteria for a psychiatric or behavioral disorder. Oppositional defiant disorder (ODD) was significantly represented among children with migraine compared to the control group of children. Headache patients improved significantly post-treatment regarding their headache frequencies regardless of comorbid psychiatric or behavioral disorder. No significant differences were noted between boys and girls regarding diagnoses or treatment outcome. CONCLUSION: ODD was a significant comorbidity in our headache population. Although families complained of significant behavioral symptomatology in their children, most of these symptoms did not qualify their children for a psychiatric diagnosis and may be related to the stressors of headache on social/school disruption.