This issue of Pediatric Annals is guest edited by Donald W. Lewis, MD, Chair of Pediatrics at Eastern Virginia Medical School and pediatric neurologist at the Children’s Hospital of the King’s Daughters in Norfolk, VA. He has organized comprehensive articles focused on the common pediatric problem of headaches, with considerable emphasis on migraines and their treatment options. Dr. Lewis emphasizes the importance of accurate diagnosis and aggressive therapy of migraines during childhood and adolescence by equating the impact of this intervention upon the patient’s well being to that of immunizations and weight control. Although I’m not totally convinced on that point, he might be correct in that particular population. By the way, “migraineur” (one who has migraines) is a new word to me but is apparently commonly used in the field.
Because migraine is common and, when severe, can be disabling, a variety of therapies for prophylaxis and/or treatment are available, including many for which scientific support of efficacy is lacking. The excellent article by Hershey and colleagues (see page 416) on treatment of pediatric and adolescent migraine includes brief mention of “nutriceuticals,” such as coenzyme Q10, butterbur (from the daisy family), riboflavin, and magnesium. None of these interventions appears to have been studied for efficacy in well-designed controlled trials, and superiority to placebo has not been proven.
The history of headache has ancient origins, with evidence of trepanation of skulls dating to about 7000 BC in Alsace, France (this cranial drilling procedure, if not curing headaches, certainly caused them), and a head wrapping method of treatment described in the Ebers papyrus from ancient Egypt around 1200 BC.
The great Hippocrates (460-377 BC), shown on the brown stamp from Hungary (see page 386), is credited with describing the visual symptoms often associated with migraine, as well as migraine’s association with exercise. Galen (129–199? AD), shown on the green 1996 stamp from Greece (see page 386), attributed headache to the presence of yellow bile (one of his four postulated humors) in the stomach and described relief in some patients after vomiting. Galen’s theories dominated medicine for about 1,300 years. In 1660, William Harvey (1578–1657), the discoverer of the circulation of blood, shown on the brown 1957 stamp from Russia (CCCP) (see page 386), recommended trepanation for a patient with intractable migraine. In 1672, Thomas Willis (1621–1675), who is considered the father of neuroscience, presented a fairly modern classification system for headache in his book, De Cephalalgia, and introduced the vascular theory of headache. He attributed migraine to vasodilatation and wrote about the relation of migraine to heredity, seasonal and atmospheric events, and diet. Around 1801, Erasmus Darwin (1731–1802), grandfather of Charles Darwin (shown on the 2009 souvenir sheet from The Gambia, see page 386) proposed treating migraine by centrifuging the patients to move blood from the head to the feet! Although Darwin never actually constructed such equipment, a similar device was used by Cox to treat mentally ill patients for several decades in the 19th century.
Classic pediatric textbooks gave little attention to the child or adolescent with headache. Holt’s first edition text of 1897, The Diseases of Infancy and Childhood, devotes only one page of its more than 1,100 pages to this topic. Holt provided a classification system for headaches in children: 1) toxic headaches (due to uremia, carbonic acid in poorly ventilated rooms, malaria, and absorption of toxins from the gut); 2) headaches from anemia and malnutrition (mostly in 10- to 14-year-old girls); 3) headaches of nervous origin (in those neurotic, epileptic, hysteric, or related to organic brain disease such as tumors, tuberculous, or syphilitic meningitis); 4) headaches related to disorders of organs of special sense (eyes, ears, nose); 5) headaches due to gout or rheumatism; and 6) headaches related to genital tract disturbances, especially in girls around puberty with menstrual problems.
By the 10th edition of Holt’s text in 1936, there was still only one page of information on headache, with a slightly different classification scheme: 1) toxic headaches, 2) headaches of functional nervous origin (neuroses, 10- to 14-year-old girls); 3) organic nervous disease (tumors, other organic diseases of brain); 4) migraine, which was thought to be rare in children; 5) disease of organs of special sense (eyes, ears, nose), and 6) genital tract disturbances. Diagnosis and therapy are limited to only seven lines of print.
The reviews in this month’s issue of Pediatric Annals are comprehensive, practical, and well worth reading.