Pediatric Primary Headache Research Articles

Special Issue: “A Wider Look at Pediatric Primary Headaches”

Headaches represent a common and debilitating neurological disorder among the pediatric population [...]

Sex and age-related patterns in pediatric primary headaches: observations from an outpatient headache clinic.

Age reportedly affects headache prevalence differently in boys and girls. However, little empirical data exists regarding pediatric headache prevalence and headache-related burden in children and adolescents according to age and sex. In the present study, we considered age and sex while evaluating the distribution, characteristics, and impairment of primary headache disorders at a pediatric headache center in Germany. Medical records of children and adolescents attending the headache clinic of the Interdisciplinary Pain Center of the Carl Gustav Carus University Hospital in Dresden during the period 2015-2022 were retrospectively grouped and analyzed depending on age (< or ≥14 years) and sex. The study population consisted of 652 children and adolescents, aged between 3 and 18 years. Almost two-thirds of the patients (≈60%) were females, and almost two-thirds of these females (58%) were ≥14 years of age. Generally, the most prevalent headache diagnoses as defined by the International Classification of Headache Disorders 3rd edition were episodic migraine without aura and the combination of tension-type headache and episodic migraine with or without aura i.e., mixed-type headache (each ≈27%). In the younger group (<14 years), the mixed-type headache was the most prevalent in girls (28.6%), whereas, for boys, episodic migraine without aura was the most prevalent headache diagnosis (47.4%). In the older group (≥14 years), the mixed-type headache continued to be the most prevalent for girls (30%), and it became the most prevalent for boys (26.3%). Before the age of 14, about 16% of children were severely affected by their headaches. After the age of 14, this proportion increased to roughly one-third (33%) of adolescents, driven mainly by teenage girls (26%) who were severely affected by their headaches. Furthermore, the prevalence of comorbidities was significantly higher among girls (67%), particularly in the adolescent group (74%). Our data shows that headache disorders in a specialized pediatric clinic impose a significant burden, especially among teenage girls indicating high therapy needs. Enhancing awareness of early diagnosis and preventive care is crucial to mitigate the development of chronic headaches, and mitigate their adverse effects on life quality and educational capability.

P.044 Ambient air pollution and emergency department presentations for pediatric primary headache and seizure disorders in Calgary, Canada

Background: Climate change, and fossil fuel combustion threaten the health of children globally through direct and indirect mechanisms,1 such as the exacerbation of ambient air pollution.1,2 Increased ambient air pollutant concentrations are associated with emergency department (ED) visits for episodic and paroxysmal neurologic conditions in adults in the Toronto region of Canada.4,5 We hypothesize that, in Calgary, Alberta, increased ambient air pollutants will be positively associated with the daily burden of pediatric ED presentations for migraine and seizures, and that a greater effect size may be present due to increased regional variability in ambient PM2.5 concentrations.3,4 Methods: Emergency records from the National Ambulatory Care Reporting System, comprising 17552 primary seizure and headache cases between 0-18 years of age and presenting to Calgary-region emergency departments between January 2012-December 2021, will be included. Quasi-Poisson regression modeling incorporating ambient air pollutants, seasonality and meteorological covariates will estimate relative risk and 95% confidence intervals of ED visit counts relative to increases in air pollutants. Results: Results currently pending and will be available for presentation. Conclusions: Significant results may inform further inquiry into the impact of air pollutants on children with neurological conditions and identify potential contributions of air quality to healthcare service demand in the Calgary region.

Dedicated neuroimaging analysis in children with primary headaches: prevalence of lesions and a comparison between patients with and without migraines

BackgroundThis study evaluated the prevalence and types of intracranial lesions through dedicated imaging analysis of primary headaches in children and compared them between patients with and without migraine.MethodsThis study included 190 children diagnosed with primary headache who underwent neuroimaging, including brain computed tomography (CT), CT angiography (CTA), and brain magnetic resonance imaging (MRI). All patients with primary headaches was divided into two groups, namely, the migraine and non-migraine groups, on the basis of data from electronic medical records. Clinical characteristics and imaging findings were evaluated and compared between the two groups.ResultsPatients with migraine were old and had a longer period from symptom onset to diagnosis. CT was normal in 71 of 95 patients, whereas 7 of 29 patients who underwent CTA had vascular lesions; the migraine group (n = 6/20, [30%]) had higher incidence of vascular lesions than the non-migraine group (n = 1/9, [11.1%]); however, there was no statistically significant difference (p = 0.382). Furthermore, 57.5% (61/106) of children showed normal brain MRI. The most common brain MRI finding was dilated perivascular space (n = 18, [16.8%]). Most perivascular spaces were located in the basal ganglia (n = 72, [75.8%]) and were in linear patterns (n = 58, [63.0%]). There was no statistically significant difference between the two groups.ConclusionA low prevalence of significant abnormalities was found in children with primary headaches. Dilated perivascular space was the most common finding in both groups on MRI. CTA showed more vascular lesions in the migraine group than in the non-migraine group. Therefore, further evaluations are needed to reveal the relationship between vascular lesions or dilated perivascular space and pediatric primary headaches.

Treatment of Frequent or Chronic Primary Headaches in Children and Adolescents: Focus on Acupuncture.

Acupuncture is a spreading and promising intervention, which has proven to be very useful in the treatment and prevention of chronic pain, in particular chronic headaches, in adults; the literature about the treatment of pediatric chronic headaches is scarce. In addition, few guidelines advise its use in children. The aim of this review is to collect all relevant studies with available data about the use, effect, and tolerability of acupuncture as a treatment for pediatric primary headaches. This is a narrative review based on eight studies selected from 135 papers including pediatric cases treated with acupuncture for headache. Despite the differences in tools, procedures, and application sites, acupuncture demonstrated a positive effect on both the frequency and intensity of headaches and was well tolerated. There are no studies considering the long-term efficacy of acupuncture. Further additional studies are needed on acupuncture in children and adolescents, with larger series and standardized procedures, in order to better assess efficacy, tolerability, and long-term prognosis and to define guidelines for the use of this promising and safe treatment. It is particularly relevant to identify safe and well-tolerated treatment options in pediatric patients affected by recurrent and debilitating headaches.

Interictal Cognitive Performance in Children and Adolescents With Primary Headache: A Narrative Review.

Primary headache is a very common and disabling disease. The burden of pain and recurrent attacks may lead to a poor quality of life, anxiety and depression. An increased risk of low functioning and curricular performances in young patients with primary headache has been described. The mechanisms underlying the relationship between migraine and poor school achievement may be various and could be a reflection of weak cognitive skills. Data concerning the cognitive functioning in the free pain interval in pediatric age are under-investigated and results are far from conclusive. The present review article suggests that, though considered a benign disease, pediatric migraine may be associated to altered neuropsychological functioning in the interictal phase. Although children and adolescents with migraine generally have a normal intelligence, they may show a not homogeneous cognitive profile, characterized by possible difficulties in verbal skills, in particular comprehension abilities. Pediatric primary headache may present altered neuropsychological functioning involving attentional resources, processing speed and memory, particularly verbal memory. Given the impact that this disease can have on school performance and the tendency to persist from childhood to adulthood, a cognitive screening in young patients affected by primary headache is pivotal. Additional neuropsychological research using more homogenous methods is needed.

Improving Acute Treatment of Pediatric Primary Headache Disorders With a Novel Headache Treatment Center: Retrospective Review of Preliminary Outcomes.

To determine preliminary outcomes of targeted headache treatments provided at a novel outpatient acute care pediatric headache treatment center. Limitations exist in acute management of pediatric headaches, including inadequate access to specialty headache therapies and headache specialists in acute settings, variable success of emergency room treatments, and omission of comfort measures. An outpatient acute headache care clinic (the "Headache Treatment Center") was strategically initiated at a Midwestern pediatric academic hospital to provide acute and targeted headache therapies for children with active headaches. We conducted a retrospective chart review of 154 visits from September through November 2018 of patients ages 7-18 years visiting the Headache Treatment Center. On average, headache intensity (measured on an 11-point pain numeric rating scale) decreased after interventions used in the Headache Treatment Center (mean change = 2.85 ± 2.81, P < .05, Cohen d = 1.01). Large effect sizes for reducing headache intensity were observed for pericranial, occipital/auriculotemporal, and occipital nerve blocks, Cohen d = 1.56, 1.64 and 1.02, respectively. Large effect sizes for reducing headache intensity also were observed for a transcutaneous supraorbital nerve stimulator device (Cefaly) (Cohen d = 1.02), acupuncture (Cohen d = 1.09), and intravenous migraine cocktails (Cohen d = 0.91-1.34). Targeted headache therapies to abort pediatric primary headaches as part of a novel headache clinic model may be beneficial for short-term management.

Integrative Management of Pediatric Primary Headaches

Pediatric primary headache disorders are best treated using a comprehensive and integrative approach, due to the complex interactions between psychosocial and biological processes. Although more quality research is needed for treatment approaches to pediatric headaches, current practice management includes both pharmaceutical and nonpharmaceutical management. This article describes the integrative treatments used in a large regional pediatric headache program. Lifestyle approaches, nutraceuticals and dietary supplements, acupuncture, transcutaneous neurostimulation, relaxation, clinical hypnosis, biofeedback, and psychological services are discussed in detail for clinicians who may consider applying to their practice. [Pediatr Ann. 2019;48(6):e231-e235.].

Uncommon Pediatric Primary Headache Disorders.

Migraine and tension-type headaches are common primary headache disorders encountered among children and adolescents presenting to a pediatric clinic. At times, children present with a headache with unusual or peculiar features that can be alarming and perplexing. These can be in the form of a brief stabbing headache with lacrimation in one eye or a continuous headache locked to one side of the head or face. These headache syndromes tend to be more common among adults but, on occasion, are known to occur or have their onset during childhood. This review outlines some of the uncommon primary headache disorders in children and adolescents that may be encountered in a pediatric clinic. Knowledge of these interesting conditions may avert the need for immediate neurological consultation and prevent delays in initiating specific therapy. [Pediatr Ann. 2018;47(2):e69-e73.].

Management of Pediatric Migraine Headache in the Emergency Room and Infusion Center.

Migraine is a common disorder that starts at an early age and takes a variable pattern from intermittent to chronic headache with several exacerbations throughout a lifetime. Children and adolescents are significantly affected. If an acute headache is not aborted by outpatient migraine therapy, it often causes severe disability, preventing the child from attending school and social events. Treating the acute severe headache aggressively helps prevent prolonged disability as well as possible chronification. Multiple medications are available, mostly for the outpatient management of an attack and include the use of over-the-counter anti-inflammatory medications as well as prescribed medications in the triptan group. These therapies do sometime fail and the exacerbation can last from days to weeks. If the headache lasts 72 hours or longer it will fall in the category of status migrainosus. Status migrainosus is described as a severe disabling headache lasting 72 hours or more by the ICHD3 criteria. Disability is a major issue in children and adolescents and aggressive acute measures are to be taken to control it as soon as possible. Early aggressive intravenous therapy can be very effective in breaking the attack and allowing the child to be quickly back to normal functioning. This article reviews what is available for the treatment of pediatric primary headaches in the emergency room.

Neurophysiologic peculiarities of pediatric primary headaches

In spite of the high prevalence of primary headaches in pediatric age, most neurophysiologic studies in these diseases have concerned only adulthood. The neurophysiologic investigation of the pathophysiological mechanisms subtending migraine and tension-type headache in children and adolescents could be particularly interesting, since during the developmental age the migrainous phenotype is scarcely influenced by many environmental factors that can typically act on adult headache patients. Reduced habituation of evoked potential amplitude, that represents the neurophysiologic abnormality most frequently found in adult migraineurs, was confirmed also in migraine children, although it was shown to involve also children with tension-type headache. Some studies have shown abnormalities in the maturation of brain functions in migraine children and adolescents. While the visual system maturation is slowed in young migraineurs, the psychophysiological mechanisms subtending somatosensory spatial attention in migraine children are more similar to those of healthy adults than to those of age-matched controls. There are still some unexplored fields that will have to be subjects of future studies. In particular, the technique of transcranial magnetic stimulation, which has given an important contribution to our knowledge of primary headache pathophysiology in adults, has not yet been used in young migraineurs. It will possibly provide further elements about brain excitability in migraine children.

Effects of Gender, Age, Family History and Shoulder Pain on Pediatric Primary Headache

Effects of Gender, Age, Family History and Shoulder Pain on Pediatric Primary Headache

Pharmacological and non-pharmacological treatment of pediatric primary headaches

Primary headaches represent highly prevalent diseases in childhood and adolescence. Unlike in adulthood, in children the most common primary headache is migraine, while tension-type headache (TTH) is less diffused, especially up to 10 years of age. Cluster headache is to be considered exceptional, showing a prevalence of 0.1%. While in TTH painful attacks are often of weak intensity and do not require particular treatment, migraine attacks often impair child’s quality of life and need to be interrupted. The first choice drug for the migrainous attack treatment should be ibuprofen. In case of failure, paracetamol and other NSAIDs should be considered. Triptans, which are the most effective drugs for the migraine attack treatment in adults, are not authorized in children, with the exclusion of sumatriptan 10 mg spray. Whether migraine attacks become too frequent or they do not respond to symptomatic treatment, a prophylactic therapy should be considered. Among drugs used for migraine prophylaxis, only flunarizine and topiramate have solid evidence of effectiveness, although there are also some data in favor of valproate and amitriptyline. It should be underlined that the practice to use minerals or herbs for migraine prophylaxis does not have any scientific support. Non-pharmacological treatments have also been proposed for pediatric migraine. Cognitive treatment, associated with amitriptyline, has proved useful in chronic migraine. In different painful syndrome, acupuncture was demonstrated to have an analgesic effect. Although a specific demonstration of acupuncture efficacy in pediatric migraine is lacking, this non-pharmacological intervention should be considered, especially in drug resistant cases.

Primary Headache in Children and Adolescents: Update on Pharmacotherapy of Migraine and Tension-Type Headache

Primary headache disorders are frequently encountered in the pediatric population. The therapeutic approach consists of a multimodal program, including lifestyle modification, psychotherapeutic intervention, pharmacotherapy, and complementary measures. This systematic review focuses on the pharmacotherapy of pediatric migraine and tension-type headache (TTH). In addition to the general treatment principles, the results of 33 clinical reports published on the topic since 2008 are outlined in detail. Furthermore, a tabular summary of previously investigated agents not studied since 2008 is given, as is an overview of promising pharmacologic approaches so far only evaluated in adults. A variety of pharmacologic options is available, but high-quality evidence is limited to single agents. At this time, approval is restricted to four triptans and flupirtine for the symptomatic treatment of pediatric acute migraine and TTH, respectively. No agent has been approved for the prevention of pediatric primary headaches. This review does not grade the drugs hierarchically because the complex profiles of many agents differ only slightly or even overlap. However, a detailed expert opinion is provided. On the basis of the outlined facts, the team of physician, patient, and parents has to decide on the most appropriate regimen for the individual situation in the sense of personalized medicine.

Zufriedenheit der Eltern mit einem psychosozialen Behandlungsprogramm für primäre Kopfschmerzen im Kindes- und Jugendalter

Patient satisfaction represents a significant outcome criterion in the context of systemic psychotherapeutic therapy research. This study investigated parent satisfaction with a psychosocial treatment program (comprising three components: child group therapy, parents' evenings, systemic family sessions) for pediatric primary headache (diagnosed according to IHS criteria). 10 weeks after the end of the treatment program, the parents were sent a questionnaire containing open questions and ten-point numerical rating scales. The sample comprised n=48 families. The return rate was 89%. The qualitative content analysis showed a hierarchical category system consisting of 3 major categories, 7 main groups and 69 sub-categories. The parents stated that they were satisfied with (1.) the effects of the treatment program, (2.) the specific treatment techniques and the medical and psychosocial headache-related information provided, and (3.) the therapeutic relationship. The mean satisfaction for all three therapy components on the ten-point numerical rating scale was 8.1 with a standard deviation of 2.0 (child headache group: 8.5; parents' evenings: 8.2; family sessions: 7.5). The results are discussed with reference to methodological aspects: avoidance of ceiling effects and social desirability in measuring customer satisfaction, order effects of items, weighting of the significance of satisfaction levels as an outcome criterion.

Diagnostic factors in pediatric primary headache

Primary headaches are frequent in children. They are difficult to diagnose because there is much disagreement about the interpretation of the historical data and the use of signs and/or symptoms in diagnosis. It would be useful, therefore, to standardize this procedure. We used linear discriminant analysis to determine a classification rule capable of diagnosing new cases of chronic and recurrent primary headache in children. We considered 23 symptoms in 118 patients. Through discriminant analysis we chose five variables: frequency of the attacks, type of pain, neurologic deficits, nausea, and vomiting. With this classification rule, we obtained a total correct classification of 84.7% for migraine, psychogenic headache, and non-defined headache in respect to the diagnoses formulated by a pediatrician and a child neuropsychiatrist after 3 months of follow-up. Our method for diagnosing migraine has a sensitivity of 95% and a specificity of 100%. The algorithm, validated on another 105 pediatric patients, produced a total correct result of 82.9%.