New Daily Persistent Headache in Children

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Source: Strong E, Pierce EL, Langdon R, et al. New daily persistent headache in a pediatric population. J Child Neurol. 2021; 36(10):888–893; doi:10.1177/08830738211004514Investigators from Children’s National Hospital, Washington, DC, conducted a retrospective study to describe the characteristics of new daily persistent headache (NDPH) in pediatric patients. Study participants were patients seen at the Children’s National Hospital Headache Clinic between 2016 and 2018 who were included in a clinic patient registry and were identified as having NDPH using ICD-10 codes. All enrolled youths were evaluated by headache specialists; a standardized history intake form was used to record clinical characteristics. Data abstracted from the medical record of study participants included demographics, site of headache and quality of pain, presence of migrainous features (photophobia, phonophobia, reduced activity), medications and non-pharmacologic treatments, head imaging results, comorbidities, and family history of headaches. Patients additionally were diagnosed with medication overuse headaches based on International Classification of Headache Disorders, 3rd Edition criteria.Among a total of 3,620 visits to the headache clinic during the 2-year study period, 245 patients were diagnosed with NDPH. The average age of the NDPH patients was 14.7 years, with a range of 12.7 to 16.8 years. Among these youths with NDPH, 79% were female, and 73% were white. The most common site of headache was frontal in 66% of patients, followed by occipital (26%), and temporal (22%). The quality of the pain was described as pulsatile and throbbing in 38% of study participants, and the median pain level on the Wong-Baker FACES scale was 6 out of 10. Migrainous features were common, with 85% of patients reporting photophobia, 85% phonophobia, and 88% reduced activity level. Comorbidities in the NDPH patients included anxiety (reported in 19%) and depression (10%); there was a history of head trauma in 23%. Overall, 54% of participants had undergone neuroimaging, including MRI in 43% and CT in 11%. No findings to explain headaches were seen. There was a family history of headache in 70% of patients. Abortive medications had been tried in nearly 80% of study participants, with ibuprofen (51%) and acetaminophen (29%) most commonly used. A diagnosis of medication overuse headache was made in 36% of patients. Preventive medications were used by 35%. Non-pharmacologic treatment had been tried in 16%, including pain-focused cognitive behavioral therapy, acupuncture, and physical therapy desensitization.The authors conclude that NDPH is a common cause of chronic headache in pediatric patients.Dr Alissa has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Headache in children is a concerning complaint for both parents and physicians. Although generally benign, the fear of a tumor or a serious underlying condition is real.1 In 2019, the American Academy of Pediatrics’ Healthy Children publication released instructions to parents about when to call their pediatrician if their child suffers a headache. The instructions stated that although most headaches are harmless, recurrent headaches can cause school problems, behavioral problems, and/or depression.2 The same instructions warned parents to be careful using over-the-counter medication because more than 3 doses per week can cause medication overuse headache.2 In a recent study, Neiswand et al were not able to find any reliable effects of preventive medications to treat children with headache when compared to adults.3NDPH may have features of both migraine and tension-type headache. The same preventive medications indicated for chronic migraine or chronic tension-type headache, including tricyclic antidepressants amitriptyline and topiramate, commonly are used in NDPH despite the lack of standardized guidelines.4 Integrating conventional medicine with mind-body-spirit methods such as acupuncture, stimulation, and physical therapy has been useful in managing headache in adolescents.5The current investigators diagnosed 14% of their total headache population with NDPH. Migrainous features were noted in nearly 90% of their adolescent patients compared to 50% of adults,6 which suggests that pediatric NDPH is more likely to present with characteristics consistent with migraine than adults. Abortive medications had been used in 79% of participants, most commonly ibuprofen and acetaminophen, and more than half had failed at least 1 medication. On the other hand, 35% of participants were treated with preventive medication, most commonly amitriptyline and topiramate, with the same failure proportion.This study’s limitations included lack of reporting the morbidity of headaches, such as missing school for the patients and/or work for their parents. The authors failed to provide guidance regarding appropriate interventions or preventive measures to consider when facing patients with NDPH.NDPH is a relatively common diagnosis in children with chronic headache. It is debilitating and highly refractory to treatment.For the uninitiated, NDPH is a relatively newly described subtype of chronic headache.7 It is severe, unremitting, and persists for at least 3 months. Perhaps the authors failed to report effective preventive and abortive pharmacotherapies as they have yet to be identified.