Unilateral Chronic Daily Headache in Children

Unilateral chronic daily headache occurs in approximately 2% of adult patients, and often represents a trigeminal autonomic cephalalgia. We now describe the characteristics of 23 children who presented with a persistently unilateral chronic daily headache. The clinical features of our patients' headaches were primarily migrainous; however, the diagnosis of a trigeminal autonomic cephalalgia or a secondary headache disorder was frequently made.     

Chronic Daily Headache in Children and Adolescents:Current Status and Recommendations for the Future

The Pediatric Committee of the American Association for the Study of Headache was created in 1994 to develop a plan for comprehensively addressing global issues of headache in childhood. It was the impression of clinicians and researchers with an interest in childhood headaches that a clearer focus was needed to facilitate progress in the study and management of pediatric headache. It was further felt that approaches to treatment and outcomes, as well as assessment and classification schema for pediatric patients needed to be examined separately. The goal of the committee is to integrate anecdotal, clinical, and research expertise into a plan for addressing headaches in the pediatric population in the future. During the last 5 years, substantial attention has been devoted to chronic daily headache, primarily in adult populations. It is the purpose of this paper to review the literature of chronic daily headache in children, and propose areas for further exploration, given the recent emergence of interest in this diagnostic entity.     

Paroxetine in the Treatment of Chronic Daily Headache

SYNOPSIS
Forty-eight patients with chronic daily headache, unresponsive to several combinations of pharmacological treatments, were selected for an open-label study using paroxetine. Patients were given 10 mg to 50 mg of paroxetine for a period of 3 to 9 months. Ninety-two percent of the patients improved significantly, based on the patients' percent of the reduction in number of headache days per month. The common side effects were fatigue, insomnia, and urogenital disturbances. The possible mechanism of action of paroxetine in the treatment of chronic daily headache is discussed. Paroxetine appears to be effective in the treatment of chronic daily headache; however, double blind studies are needed to confirm these preliminary findings.     

Chronic Daily Headache in Children and Adolescents: A 2-Year Prospective Study

Chronic daily headache in children and adolescents has not been well described. We analyzed data for 37 children and adolescents who presented with chronic daily headache to our Pediatric Headache Clinic over a 2-year period. These youngsters had five distinct headache patterns; 40% of them had the "comorbid" pattern, 35% were classified with new daily persistent headache, 15% with transformed migraine, 5% with chronic tension-type headache, and 5% could not be classified.
There were no significant differences by diagnosis in externalizing and internalizing behaviors, type A behaviors, disability, pain severity, days missed from school, and number of coping skills employed.
Children and adolescents with chronic daily headache have distinct clinical patterns, but for the most part, have similar disability. Differences between adult and childhood chronic daily headache are emphasized.     

Effectiveness of amitriptyline in the prophylactic management of childhood headaches

OBJECTIVE: To study the effectiveness of a standardized dose of amitriptyline, 1 mg/kg, for childhood headaches. BACKGROUND: Amitriptyline has been shown to be effective for the prophylaxis of migraine in adults. Studies in children, however, have been quite limited. In adults, the suggested effective dose range is 10 to 150 mg. In children, a standardized dosage is often not used, resulting in a dosage range in clinical practice that often varies from a very low dose to a dose equivalent to that used in adults. METHODS: Children with more than three headaches per month were treated with amitriptyline, slowly increasing the dose to 1 mg/kg per day. The frequency, severity, and duration of their headaches were initially evaluated and subsequently measured at each follow-up evaluation. Two hundred seventy-nine children had headaches occurring frequently enough to indicate prophylactic treatment. Of these children, 192 (68.8%) were treated with amitriptyline. The average age at presentation was 12.0 (+/- 3.0) years. The ratio of boys to girls was 1:1.74. The average frequency of headaches was 17.1 (+/- 10.1) days per month. The average severity was 6.84 (+/- 1.67) on a 10-point pain scale. The average duration was 11.5 (+/- 15.0) hours. The most frequent diagnoses using International Headache Society criteria were migraine (60.6%), migraine with aura (7.9%), and tension-type headache (10.4%). Of these children, 146 have been seen for at least one follow-up examination, occurring on average 67.3 (+/- 32.3) days after beginning prophylactic treatment. RESULTS: A total of 84.2% of the children reported an overall perception of being better, while 11.6% reported being the same. The frequency of headaches improved to 9.2 (+/- 10.0) days per month. The average severity was reduced to 5.1 (+/- 2.1), and the average duration was reduced to 6.3 (+/- 11.1) hours. If daily or continuous headaches were excluded, the improvements were more marked. Minimal side effects were reported from these children and their families. Long-term evaluation (156 to 415 days) showed continued sustained improvement. CONCLUSIONS: Amitriptyline is an effective prophylactic medication for children with frequent headaches. A standardized dosing regimen results in a significant number of children responding with minimal side effects. The children are able to tolerate this dosing scheme and demonstrate good adherence to a dosing schedule of once a day.     

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.     

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.     

Divalproex in the long-term treatment of chronic daily headache

OBJECTIVE: The purpose of this study was to assess the safety and efficacy of divalproex sodium in the long-term treatment of chronic daily headache. Correlations between treatment variables were assessed. BACKGROUND: Controlled and open-label trials of divalproex sodium have previously demonstrated its efficacy and safety in the treatment of migraine and chronic daily headaches. These data were primarily short-term and did not examine interaction between treatment variables. METHODS: Retrospective chart review with data extraction was conducted from headache diaries of 642 current patients under treatment with divalproex sodium for chronic daily headaches. One hundred thirty-eight of the patients were treated with only divalproex sodium. Demographic variables including age, sex, initial and final body weights, adverse events, dose of divalproex sodium, duration of treatment, and the ability to differentiate their chronic daily headache into its migraine and tension-type headache components were analyzed. Baseline and end of study headache frequency indices were obtained. RESULTS: The mean improvement was 47%, with an improvement in migraine of about 65%. At least a 50% reduction in headache frequency was reported by 93 of the 138 patients receiving treatment with only divalproex sodium. No correlation between response and age, sex, duration of treatment, and the prescribed dose of divalproex sodium was demonstrated. Adverse events occurred in approximately 35% of the patients. None were severe. Women were more likely to experience adverse effects than men. Weight gain, however, occurred less commonly in women (mean, 1.9 lbs) than in men (mean, 7 lbs). Initial body weight and age did not correlate with the weight change. CONCLUSIONS: Divalproex sodium can be used for a prolonged period as a sole agent for the successful treatment of chronic daily headache. Nearly 75% of the patients had at least a 50% reduction in headache frequency, and adverse effects occurred in approximately one third. Weight gain was negligible and hepatotoxicity did not occur during treatment periods of up to 6 years.     

Valproate in the Treatment of Persistent Chronic Daily Headache. An Open Label Study

Thirty patients with persistent chronic daily headache, unresponsive to various combinations of pharmacological and nonpharmacological treatment were selected for an open label study using divalproex sodium. All patients had normal liver function tests. After a baseline observation period of 1 month, patients were given divalproex sodium 1000 to 2000 mg per day, for a period of 3 months. Blood valproic acid levels were kept between 75 and 100 mcg/ml. Liver function studies and blood ammonia levels were obtained periodically. Based on weekly headache index, headache-free days, dysfunctional days and patients' general well-being rating and physicians' global assessment, two thirds of the patients improved significantly. The common side effects included weight gain, tremor, hair loss and nausea. Liver functions were unaffected by treatment. The possible mechanism of action of valproate in headache is discussed. Valproate appears to be a worthwhile addition to the prophylactic treatment of chronic recurrent headache.     

Recurrent Headaches in Children: An Epidemiological Survey of Two Middle Schools in Inner City Chicago

Objectives: The aim of this study was to longitudinally evaluate the epidemiological characteristics of headaches in a school‐based, community setting and to determine the impact of headache symptoms on the health of children. Methods: After institutional review board approval, a prospective cohort study was conducted at two Chicago public schools for a period of 6 months. Members of the research team surveyed both schools weekly for headache and other pain symptoms. The students rated each pain symptom on a 5‐point scale from 0 (“not at all”) to 4 (“a whole lot”). Demographic information was collected at the time of enrollment, and all participants were asked to complete age‐appropriate and validated pediatric surveys to assess the severity of concurrent somatic complaints, anxiety symptoms, functional limitations, and quality of life issues. Results: Of the participating children, 89.5% reported at least one headache during the study period. Females experienced more frequent headaches compared with males (P < 0.05). Children reporting headaches had a significantly increased risk of experiencing other troubling somatic symptoms (P < 0.05). Headache severity showed a moderate correlation with increased feelings of anxiety, functional disability, and a diminished quality of life (P < 0.05). Conclusions: School‐aged children commonly experience headaches. Children experiencing headaches are more likely to report other somatic symptoms, feelings of anxiety, functional limitations, and quality of life impairments.     

Prevalence and Clinical Features of Chronic Daily Headache in a Headache Clinic

Although chronic daily headache is regarded as a syndrome encountered in headache clinics, clinical characteristics have only rarely been studied and the condition has not been documented in Thailand. To investigate the prevalence as well as clinical features of chronic daily headache in Thai patients, 220 patients visiting Chulalongkorn Headache Clinic were examined. Sixty cases (27.3%) were diagnosed as suffering from chronic daily headache (male to female ratio, 1:5.7).
The average age of these patients was 32.7 ± 9.6 years. Based on the International Headache Society (IHS) criteria, 30% of patients with chronic daily headache could be diagnosed as suffering from migraine end 36.7% from chronic tension-type headache, whereas the remainder had combined features of both headache types and were not classifiable. Diffuse steady pain was the most common headache type reported (65%), however, associated features characteristic of migraine were often noted. These included photophobia (70%), phonophobia (56.7%) and nausea (43%). Thirty-four cases (56.7%) reported that their headache could be aggravated by stress. Daily use of analgesics was reported in 58.3% of cases. We concluded that chronic daily headache is a common problem. Although the mechanism has not been fully clarified, the prevalence of associated psychological factors and analgesic overuse imply their involvement in the pathogenesis of this condition. The criteria of the IHS are not entirely suitable for diagnosis and classification of this disorder, and modification of this classification system is needed.     

The Role of Family Structure, Functioning, and Pain Modeling in Headache

In an initial attempt to examine relationships between family functioning and chronic headache disorders, the present study examined: a) family structure characteristics, b) family functioning, and c) family pain modeling. Subjects completed an assessment battery consisting of several measures of family functioning. Analyses showed that migraine sufferers (N = 42) as compared to headache-free controls (N = 59) were more likely to describe their families as emphasizing clear organization, structure, rules, and overall control, but less likely to encourage emotional expression. No differences were found between tension headache subjects (N = 43) and headache-free controls. While only an initial exploration of the importance of family characteristics in chronic headache, these results suggest that there are important differences in headache subjects' (particularly migraine) reports of family environment and functioning.     

Chronic Daily Headache in the Posttrauma Syndrome: Relation to Extent of Head Injury

OBJECTIVE: To evaluate the occurrence of continued intermittent headache and chronic daily headache in patients with head injury and the relationship between severity of the headache problem and intensity of the head injury. BACKGROUND: In the majority of patients with posttraumatic headache, the condition is self-limited, but a minority of patients may develop persistent headaches. The features of posttraumatic headache may vary, but the most distressing type is the chronic daily headache. This study evaluates occurrence of chronic daily headache in relation to the intensity of head injury. METHODS: All patients with head injury who were seen by the senior author (J.R.C.) in the Southern Illinois University Medical School (SIUMS) Neurology Clinic between 1980 and 1991 were identified from the SIUMS headache registry. Data on headache status before and after head injury was obtained, and patients with more than one headache per week before head injury were excluded. Each patient's headache status at the time of the clinic visit was classified as chronic daily headache (headache occurring at least 5 of 7 days for 6 months), intermittent migraine, or no headache. Head injury severity was graded by duration of loss of consciousness or amnesia as minimal (less than 5 minutes), mild (5 to 60 minutes), moderate (1 to 24 hours), or severe (more than 24 hours). RESULTS: There was an inverse relation between extent of head injury and occurrence of chronic daily headache. For minimal head injury (n = 54), 80% had chronic daily headache, and 11% had no headache, while for moderate/severe head injury (n = 23), only 27% had chronic daily headache, and 68% had no headache (P<.001, chi2). CONCLUSION: This study suggests that the risk of developing posttraumatic chronic daily headache is greater for less severe head injury compared with moderate/severe head injury. The reason for this relation is unclear.     

Classification of Daily and Near-Daily Headaches: Proposed Revisions to the IHS Criteria

SYNOPSIS
The International Headache Society (IHS) headache classification, while a major advance, does not adequately classify the daily and near-daily headache disorders known as chronic daily headache (CDH). We believe that chronic daily headache is a group of disorders which includes chronic tension-type headache (CTTH), transformed migraine (TM), new daily persistent headache (NDPH), and hemicrania continua (HC). We propose specific criteria for transformed migraine, new daily persistent headache, and hemicrania continua, and have modified the criteria for chronic tension-type headache.     

Relative Contributions of Life Events Versus Daily Hassles to the Frequency and Intensity of Headaches

This study investigated headache parameters (frequency and intensity) in relation to (the number and severity of) two types of psychosocial stress: major life events (as assessed by a revised Social Readjustment Rating Scale) and minor daily hassles (as assessed by a revised Hassles Scale). Subjects were 261 volunteers reporting headache. Results revealed that both headache frequency and intensity were significantly predicted by daily hassles, in particular, the average severity of these hassles, but there was a negligible relationship between headache parameters and any of the life event measures. Furthermore, a significant relationship emerged between life events and daily hassles themselves. This fits with recent findings that life events (while exerting little direct effect on headache) may trigger a succession of hassles which culminate in headaches. Also, it is not the number of hassles, but the perceived severity of these hassles that best predicts headache frequency and intensity. Finally, though significant as predictors, daily hassles explained a small portion of the variance in headache, thus pointing to the host of other possible biological and psychosocial contributions to headache.