Chronic daily headaches in children and adolescents: a study of clinical characteristics

The clinical characteristics of chronic daily headache were studied in 40 children and adolescents, as well as the associated factors responsible for maintenance of the continuous headache pattern. The study of the clinical headache characteristics, showed a female preponderance (75%), mean age of 11 years old at the first consultation, and onset of headache symptomatology at a mean age of 8.5 years old. The average time interval for the evolution of sporadic headache into chronic daily headache was 1.4 years, and psychosocial stressors were present, acutely or chronically, during the period of headache-frequency increase in 47% of the children. Headaches were classified as transformed migraine (65%), mixed pattern (17.5%) and chronic tension-type headache (17.5%). Sixty per cent of patients had mothers with migraine. Data regarding common analgesic use showed an average intake of 11.2 days/month.     

Chronic daily headaches: clinical profile in Indian patients

Chronic daily headache (CDH) remains a relatively unexplored entity in India. Misconceptions are common, unnecessary investigations often done and inappropriate therapy prescribed. Analgesic overuse is seldom recognized. The present report appears to be the first of its kind from India. CDH has been defined as headaches occurring more than 15 days per month for more than 3 months (secondary causes excluded). Over 2 years (1998-1999) 849 cases (49.6% of all primary headaches) were seen. More than 1 year's follow-up data were available in 205 subjects (M 34; F 171). The distribution of these was as follows: (i), chronic tension-type headache (CTH), 33 (16.1%); (ii), chronic/transformed migraine (TM), 169 (82.4%); (iii), new persistent CDH, 3 (1.5%). There were 169 cases of TM (M : F 1 : 4.7; age 26-58 years). History of past episodic migraine was present in all. Transformation had been gradual (89.4%) or acute (10.6%). Possible factors in transformation included psychological stress (44.4%), analgesic overuse (28.4%), ergot overuse (4.1%). HRT seemed to be implicated in three female subjects. Analgesic overuse was limited between intake of 600 and 2400 mg of aspirin equivalent per day (mean 735 mg). Ergot overuse varied between 1 and 3 mg/day of ergotamine for > or = 3 days/week. With medical therapy approximately 70% TM and 40% CTH patients noted significant improvement. About 80% of these relapsed on therapy withdrawal. CDH in India is not uncommon. Analgesic/ergot overuse needs to be recognized early. The average dose of analgesic implicated in CDH seems much less compared with that reported in the West.     

Chronic daily headache in children and adolescents

OBJECTIVE: To describe the clinical features of children with chronic daily headache (CDH) and examine the usefulness of the International Classification of Headache Disorders-II. BACKGROUND: Few data are available on chronic daily headache and analgesic overuse in children and adolescents and there are no specific criteria for headache in children. METHODS: We retrospectively reviewed all charts of 79 children and adolescents (<16 years) with headache on > or =15 days/month presenting to the outpatient clinic of the Department of Neurology of the Leiden University Medical Center between 1994 and 2001. We classified their headaches according to the International Classification of Headache Disorders-II. RESULTS: Fifty-seven (72%) children had chronic daily headache for more than 6 months, with a duration of more than 4 hours a day in 60% of them. Quality, severity, and location of pain varied. Sixty patients (76%) used analgesics, 10 patients more than one type. Thirteen patients (16%) used analgesics daily. In one-third of patients, headache led to frequent school absenteeism and sleeping problems. Twenty-eight (35%) patients could be classified, 17 patients (22%) as chronic tension-type headache, 5 patients (6%) as chronic migraine, and 6 patients (8%) as probable medication overuse headache. Fifteen patients (19%) did not fit into any category and 36 (46%) could not be classified due to insufficient data. CONCLUSIONS: Chronic daily headache in children is a serious disorder. A relatively large number of patients overuse medication and it leads to frequent school absenteeism and sleeping problems. It remains difficult to classify their headaches with the new criteria for headache disorders.     

Chronic daily headache in children and adolescents

Chronic daily headache (CDH), an almost continual headache in the absence of organic pathology, is an exceptionally challenging type of headache to treat in children and adolescents. CDH has different expressions in children and adults; the different expressions may reflect several different etiologies or a developmental continuum. Although a positive family history predisposes children to develop headache, many environmental, biological, and psychological processes may share a role in the etiology. To date, no studies have examined the pathophysiology of CDH in children so that our understanding is presumed, rather than documented, and based primarily on extrapolation from adult studies. For some cases with migraine features, presumed mechanisms include a neurogenic inflammatory cascade, vascular reactivity, and serotonin, whereas for other cases, mechanisms may include pericranial muscle tenderness or musculoskeletal abnormalities, as noted recently for adults. A skilled and careful history is the first step to ensuring an accurate diagnosis for children with CDH. Pain assessment is an integral component of diagnosis and treatment. We need an objective measure of headache activity and an understanding of the factors that cause or exacerbate headaches for an individual child. Although many drug and nondrug therapies are available for treating children’s headache, we lack data about which therapies are best for children with CDH or its subtypes. The current principles guiding our management of CDH in children and adolescents are extrapolated from the existing literature on childhood headache, CDH in adults, and our clinical experience. A child-centered focus is particularly important in the treatment of CDH because it is not caused by an underlying disease or disorder.     

A woman with daily headaches

Headache, and migraine in particular, is the main neurological reason for consultation. We present the case of a 48–year–old woman who experienced a transformation of her episodic migraine attacks into daily headache episodes due to the ingestion of biscuits containing wheat as their main ingredient. This experience emphasises that a good clinical interview remains the most important point in the diagnosis and management of headache.     

The patient with daily headaches

The term "chronic daily headache" (CDH) describes a variety of headache types, of which chronic migraine is the most common. Daily headaches often are disabling and may be challenging to diagnose and treat. Medication overuse, or drug rebound headache, is the most treatable cause of refractory daily headache. A pathologic underlying cause should be considered in patients with recent-onset daily headache, a change from a previous headache pattern, or associated neurologic or systemic symptoms. Treatment of CDH focuses on reduction of headache triggers and use of preventive medication, most commonly anti-depressants, antiepileptic drugs, and beta blockers. Medication overuse must be treated with discontinuation of symptomatic medicines, a transitional therapy, and long-term prophylaxis. Anxiety and depression are common in patients with CDH and should be identified and treated. Although the condition is challenging, appropriate treatment of patients with CDH can bring about significant improvement in the patient's quality-of-life.     

Short-lasting headaches in children

Short-lasting headaches have been studied infrequently in children and it is not known if the main categories of primary headaches of this type in adults are applicable to children. We report our experience with a group of 20 children with a brief headache. Two patients had a secondary headache. One patient had a headache with some clinical characteristics of paroxysmal hemicrania. The remaining 17 had a very brief headache. They were in many aspects comparable to others from previous studies on idiopathic stabbing headache in children: no associated symptoms, no other associated headache, frequent family history of migraine. They differed, however, in the younger age of the patients and the more frequent extratrigeminal location of the pain. Extratrigeminal ice-pick pain may be a variant of idiopathic stabbing headache, more prevalent in young children.     

Chronic post-traumatic headaches classified and compared with natural headaches

This study sought to determine whether chronic post-traumatic headaches are different from or identical to the naturally occurring headaches. The chronic post-traumatic headaches of 48 patients were classified, as if they were natural headaches, by the diagnostic criteria of the International Headache Society. Thirty-six patients' headaches (75%) were chronic tension-type headache, 10 (21%) were migraine without aura , and 2 (4%) were unclassifiable. The characteristics and accompaniments of the headaches within each diagnostic group were then compared to those in a control group with natural headaches of the same type. No notable differences between the post-traumatic and control groups were found. Hence, chronic post-traumatic headaches have no special features, but are symptomatically identical to either chronic tension-type headache or migraine without aura (in this series of patients). This identity suggests that post-traumatic headaches are generated by the same processes causing the natural headaches, not by intracranial derangement from head blows or jolts.     

Management of headaches in children

Headaches are a common cause of disability in childhood. Although the symptom of headache raises concerns about serious neurologic disease, the cause is most commonly vascular or due to muscle contraction. The differentiation between muscle-contraction and vascular headaches is clinical, and laboratory studies rarely are required. Treatment of muscle-contraction headaches is symptomatic. Migraine headaches sometimes require periods of prophylactic therapy. The chronic nature of headaches mandates a comprehensive approach to management of the child and family. This approach is best carried out in the primary care setting.     

Clinical and descriptive analysis of chronic daily headaches

With an ad hoc, previously validated clinical record, we analysed the headache characteristics in 245 patients (F, 78.4%, M, 21,6%; mean age, 43.1±12.9 years) affected by chronic daily headache (CDH) attending 9 Italian headache centers. Migraine without aura was the episodic headache preceding CDH in 72.3% of the cases. We divided CDH into 3 categories: chronic tension-type headache (CTTH), chronic coexisting migraine and tension-type headache (CCMTTH), and chronic migraine (CM). CCMTTH accounted for 46.5% of the cases, followed by CM (30.2%) and CTTH (23.3%). Female prevalence was more marked in CCMTTH and CM groups, in which episodic headache started earlier. Migraine without aura was the episodic headache preceding CDH not only in most cases of CCMTTH (83.0%) and CM (91.9%), but also in 25% of CTTH patients.Analgesics misuse (abuse of weak analgesics and/or combination drugs in almost all the cases) prevailed among CCMTTH (61%) and CM (89%) patients with respect to CTTH patients (37%).     

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

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

Chronic daily headache

Chronic daily headache (CDH) represents one of the most challenging medical conditions that a health care provider is called on to treat. This article outlines the scope of this misunderstood condition,updates the reader on the revised diagnostic criteria for chronic daily headache, and gives practical insight into diagnosis and treatment. Four specific subtypes of CDH are covered: chronic tension-type headache, chronic migraine, new daily persistent headache, and hemicrania continua. Through better recognition and treatment of this all too common condition, this segment of our population can be better helped to lead quality lives.     

Transformed migraine is a cause of chronic daily headaches

Chronic daily headaches (CDH) consist of episodes of head pain occurring daily; more than 15 days each month; often associated with a history of migraine, with or without aura; or with a history of tension-type headaches occurring alone or both occurring together. Chronic daily headaches are frequently associated with rebound headaches after ergotamine, barbiturate, caffeine, and analgesic abuse. We previously reported that migraineurs with typical intermittent headaches exhibited excessive cerebral cortical vasodilation after oral acetazolamide which usually precipitated and reproduced their typical headaches. In the present study, cerebral vasodilator responses were tested by measuring changes in local cerebral blood flow (ΔLCBF) utilizing xenon-contrasted CT scanning, before and after oral administration of 14.3 mg/kg of acetazolamide, in 11 patients with CDH. The results were compared with 12 age-matched typical migraineurs, with and without aura, who had a history of migraine attacks occurring at intervals of 1 month or longer. Global and subcortical gray and white matter ΔLCBFs were quantitated and compared between both groups. After acetazolamide, ΔLCBF increased in cortical gray matter by 11.8% among patients with CDH and by 16.7% among migraineurs, with no significant differences between groups. Typical migraine attacks were provoked by acetazolamide in 9 patients (82%) with CDH and in 11 (92%) migraineurs with intermittent headaches. These observations are taken as evidence that at least 82% of patients with CDH have transformed migraine as judged by the provocation by acetazolamide of typical migraine attacks associated with excessive ΔLCBF increases. Serotonin agonists should be considered in the treatment of CDH to avoid ergotamine, caffeine, barbiturate, and analgesic abuse.     

Chronic daily headache

Abstract Chronic daily headache relates to the daily or almost daily occurrence of headache in a nonparoxysmal pattern. In this review, I discuss the presentation, development, outcome, and treatment of chronic daily headache. In the context of the development of chronic daily headache, a headache continuum is presented along with its underlying pathophysiology. The treatment section covers rebound headache, analgesic and vasoconstrictor withdrawal, and the use of long-acting opioids in intractable patients. The review concludes with a discussion of hemicrania continua, an indomethacin-responsive headache syndrome.     

Intravenous treatment of chronic daily headaches in the outpatient headache clinic

The most likely future of aggressive headache treatment will reside in the sphere of the specialist’s clinic. This is a far more cost- and time-effective mode of treating intractable chronic daily headaches (CDH), including chronic migraines. We have used this technique successfully in our clinic for many years. Our experience with intravenous treatment of headaches and migraines was summarized recently and a 97.5% success rate for this type of treatment was found in the clinic. Compared with the treatments commonly available in the emergency department, the specialist’s clinic can offer more effective headache-altering definitive treatments. Patients can be offered a maximum degree of success for control of their intractable headaches. In this article, approaches to aggressive treatment of ongoing CDH using intravenous methods of therapy are discussed. All of these can be performed in the clinic setting, avoiding some of the costly aspects of treatment that are present in an emergency room setting.     

Migraine headaches and sleep disturbances in children

OBJECTIVE: The aim of the present study was to investigate the prevalence of sleep disturbances in children with migraine headaches and to describe individual differences in sleep behaviors based on headache features (eg, frequency, duration, intensity). BACKGROUND: A relationship between migraine headaches and sleep disturbances has been suggested in both children and adults, but there is a lack of research examining the relationship between specific headache features and the range of sleep behaviors in children. METHODS: One hundred eighteen children, aged 2 to 12 years (mean, 9.1; standard deviation, 2.3) were evaluated for headaches at two pediatric neurology departments. Parents completed the Children's Sleep Habits Questionnaire and a standardized questionnaire regarding headache characteristics. RESULTS: Parents reported a high rate of sleep disturbances in children, including sleeping too little (42%), bruxism (29%), child co-sleeping with parents (25%), and snoring (23%). Children with migraine headaches experienced more sleep disturbances compared to published healthy control norms. After controlling for child demographics, we found that the frequency and duration of migraine headaches predicted specific sleep disturbances, including sleep anxiety, parasomnias, and bedtime resistance. CONCLUSIONS: Children with migraine headaches have a high prevalence of sleep disturbances. The direction of the relationship between headaches and sleep is unknown. Regardless, interventions targeting sleep habits may improve headache symptoms, and effective treatment of headaches in children may positively impact sleep.