Charles F. Barlow HEADACHES AND MIGRAINE IN CHILDHOOD Philadelphia: JB LJppincott Company, 1984, 288 pages, $34.95.
In terms of frustration for all concerned, headaches in childhood are like backaches in adults, except that the consequences of error in diagnosis are potentially much mote serious when the brain is the part involved. How far does the physician go with a work'up? When does he/she refer for a consultation? The twin-horned dilemma of cutting costs and avoiding potential legal problems because of "neglect" referred to so often as "defensive medicine," poses a difficult position for the conscientious practitioner - in addition to his/ her own personal dismay at "missing something."
Dr. Barlow gives an excellent overview of a particular complex; and is guilty of "laundry listing" only toward the end with symptomatic headache, here again perhaps "covering a waterfront" which is probably necessary at least to describe. Apart from the common headache of early fever and infection, most childhood headaches appear to be vascular and periodic (ie, migraine). The author discusses his observations from a personal series of 300 patients, and sprinkles the text with a fascinating group of over 50 case histories, which dramatically illustrate his themes regarding differential diagnosis between migraine and psychogenic and organic (structural intracranial disease) syndromes. Pediatricians do get nervous about these differentials, as we are aware. Little is known about the etiology of migraine beyond the very common familial diathesis (90%) and the "triggers" of which the parent and child are often quite knowledgeable. Of special interest is the documented incidence of motion sickness (55% vs. 32% in the controls) in migrainics.
What is in all this for the practicing pediatrician? I think the following specifics may be drawn from the text and I hope these pique the interest of pediatricians to spend some time with this very readable monograph.
1. There is a thorough exposition of what we know about the etiology of migraine (genetic, humoral, endogenous, exogenous, psychogenic factors).
2. There is a good discussion of psychogenic and organic diseases, including epilepsy, tumors, vascular conditions.
3. Migraine is considered as contributor, masquer, masquerader, and overlapper with other more serious conditions. Migraine in migrainics becomes a part qf the picture in the onset or concomitance of other intracranial disease.
4- There is an interesting discussion of other periodic syndromes as possibly being migraine in variation or disguise.
5. The threshold for headaches is lower in migrainics whatever the rest of the picture.
6. The EEG is not routinely employed or necessarily useful in children's migraine. It can be over-read.
7. CT scans are often valuable in detecting organic disease, probably more useful than x-rays. A small early lesion may not be demonstrated in the CT scan and a repeat study a little later will often reward the careful and perplexed diagnostician, whose indices of suspicion are high.
8. Beware of headaches in children under 5 years.
9. The differentia] between migraine and seizure syndromes is important because of differing commitments to medication.
10. Chapter 8 gives an excellent discourse on treatment.
There are numerous "pearls" in this definitive volume - such as "seizure followed by headache is common and likely to be benign (but) the reverse sequence carries a high risk of organic cerebral lesions of surgical significance." Little is mentioned of headache in differential diagnosis of the "surgical abdomen." There is one useful point, ie, migraine symptoms are apt to improve in a few hours, surgical conditions to worsen. This reviewer has long considered headache to be very infrequent in appendicitis, so it seems unfortunate to see case #14 involve an unusual pairing of the two conditions.
Whereas the dilemma posed in my first paragraph is not completely resolved (nor can it be except by the individual pediatrician with the individual child and even then not always), this admirable text born of painstaking investigation and backed by considerable experience goes a long way toward elucidation of complex and overlapping entities, and provides both knowledge and comfort to those laboring in the vineyard, with their own intuitions and insights.