Pediatric Annals

CME Article 

‘Other’ Headache Syndromes in Children

Ann Pakalnis, MD; Marcy Yonker, MD, FAHS

Abstract

Headaches are common in children and adolescents. Much current research on primary headache disorders has focused on migraine headaches. Because this disabling condition occurs frequently in the adult population, it is the most commonly studied type of headache, and there are many medications that have been shown to be safe and effective for adults. This has been beneficial to children with migraine, in whom many of these preparations are used, despite the lack of similar studies in this population.

Abstract

Headaches are common in children and adolescents. Much current research on primary headache disorders has focused on migraine headaches. Because this disabling condition occurs frequently in the adult population, it is the most commonly studied type of headache, and there are many medications that have been shown to be safe and effective for adults. This has been beneficial to children with migraine, in whom many of these preparations are used, despite the lack of similar studies in this population.

Ann Pakalnis, MD, is with Division of Pediatric Neurology, Ohio State University. Marcy Yonker, MD, FAHS, is with Pediatric Neurology, Phoenix Children’s Hospital.

Dr. Pakalnis has disclosed no relevant financial relationships. Dr. Yonker has disclosed the following relevant financial relationships: Allergan: Consultant.

Address correspondence to: Marcy Yonker, MD, FAHS: myonker@phoenix-childrens.com.

Headaches are common in children and adolescents. Much current research on primary headache disorders has focused on migraine headaches. Because this disabling condition occurs frequently in the adult population, it is the most commonly studied type of headache, and there are many medications that have been shown to be safe and effective for adults. This has been beneficial to children with migraine, in whom many of these preparations are used, despite the lack of similar studies in this population.

Tension-type headaches are probably the most common primary headache disorder in adults and children.1

Some of the other primary headache syndromes, such as cluster headache, paroxysmal hemicrania, primary stabbing headache, and new daily persistent headache occur much less commonly in children than migraine, so the likelihood of study is much less. Additionally, the trickle down of information regarding some of these conditions and their treatment in children seems less common, probably because of the rarity of their occurrence. Appropriately diagnosing these other primary headache syndromes is paramount, so appropriate therapies may be initiated to minimize disability related to headache attacks and the disruption of family dynamics that frequent headaches may cause.

Tension-Type Headache

Tension-type headaches may be episodic or chronic, according to ICHD-II criteria.2 Episodic headaches occur less than 15 days/month, and chronic headaches occur more than 15 days/month. Tension headaches differ from migraine in many respects. (see Sidebar 1, page 442). The duration is more variable (30 minutes to 7 days); the pain is mild to moderate (not severe), and there is generally no exacerbation with physical activity. Episodic tension-type headaches may be frequent (more often than once a month) or infrequent (less than once per month). The quality of the pain in tension-type headaches varies from migraine, is generally described as pressing or tightening, and may occur in a “hat band” distribution. Associated factors, such as nausea, visual disturbance, or abdominal pain, are uncommon.

Sidebar 1.

Frequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There is no nausea, but photophobia or phonophobia may be present.

Diagnostic Criteria

  1. At least 10 episodes occurring on ≥1 but <15 days per month for at least 3 months (≥12 and <180 days per year) and fulfilling criteria B-D

  2. Headache lasting from 30 minutes to 7 days

  3. Headache has at least two of the following characteristics:

    1. bilateral location

    2. pressing/tightening (non-pulsating) quality

    3. mild or moderate intensity

    4. not aggravated by routine physical activity such as walking or climbing stairs

  4. Both of the following:

    1. no nausea or vomiting (anorexia may occur)

    2. no more than one of photophobia or phonophobia

  5. Not attributed to another disorder

Tension-type headaches probably occur with about 10% to 25% prevalence in childhood and adolescence, making these types of headaches much more common than migraine. The prevalence of episodic tension-type headache in a recent Swedish population-based study using a questionnaire was 12%, and many children with migraine headache also experience tension-type headaches. In some studies, boys and girls tend to suffer from tension-type headache equally until about the age of 11 to 12 years, but after that, female preponderance usually occurs.3

Therapies of Tension-Type Headache

In contrast to migraine, many fewer studies in the neurologic literature are available regarding tension-type headache therapy. Simple, over-the-counter analgesics, such as ibuprofen (10 mg/kg/dose) or acetaminophen (15 mg/kg/dose), are safe, convenient to use, and readily available. If usage becomes frequent (more than three times per week for at least a 3-month period) and headaches increase to 15 or more days per month, satisfying criteria for chronic daily headache, then medication overuse probably exists. Therapy with withdrawal of analgesics and more aggressive management are then indicated.

Other considerations, such as examination of lifestyle issues and stressors, are an integral component of headache therapy. Ensuring adequate hydration, regular meals, exercise, and good sleep hygiene, including minimizing caffeine, is a discussion to be undertaken early in the course of therapy with patients and parents. If school or extracurricular activities leave little relaxation time, then a reassessment of overscheduled time commitment should be suggested to the child/adolescent and parent/guardian. The importance of keeping a headache diary should never be minimized.

Other nonpharmacologic therapies that may provide benefit with further exploration include physiotherapy in children/adolescents with myofascial trigger points. Stülpnagel et al studied nine girls with TTH (mean age 13.1 years) with an average of 6.5 therapy sessions with trigger point-specific physiotherapy. Headache frequency was reduced significantly by 67.7%. A myofascial trigger point was defined in their study by the presence of a hyperirritable, palpable nodule within a taut band of muscle fibers associated with local tenderness, local twitch response, and referred pain. Although this was a small patient cohort, further studies are warranted utilizing this physical therapy treatment modality.4

Biobehavioral therapy, such as cognitive behavioral therapy, biofeedback, and relaxation therapy have long been employed in adult TTH with some studies in the pediatric population suggesting reasonable efficacy. These treatments are a consideration to offer patients and families, especially those children with concurrent behavioral or psychologic disorders, which are common in children with TTH. Often these same children have concurrent increased stressors compared with those children without headaches. Examination for these comorbidities in children with more refractory headaches also should be entertained.5–7

Few pharmacologic studies are available regarding prophylaxis of TTH. In some patients, prevention of the headaches might be necessary with significant headache frequency disability and to avoid medication overuse. Two naturalistic therapies have been evaluated in small prospective open-label studies. Grazzi et al used magnesium pidolate at a dosage of 2.25 g, twice per day, for 3 months.8 Forty-five pediatric patients were studied with a mean age of 13.1 years and with mean headache days per month of 9.2. At follow-up, headache frequency was significantly reduced. This therapy was well tolerated, with the only notable complaint being an unpleasant taste of the compound. Another recent study utilized the naturalistic therapy melatonin in TTH prophylaxis in children. Miano et al studied 22 children with mixed frequency headaches, including migraine and tension-type, prospectively with 3 mg melatonin daily. The mean age of this patient cohort was 12.2 years. Fourteen of the 21 patients completed the study, with one child dropping from the study due to excessive daytime sleepiness.9 Headache frequency was significantly diminished, with four of the 21 patients becoming headache-free. Melatonin may act by correcting circadian dysfunction or possibly altering the serotonin system in modulating headache. Regarding pharmacologic therapies, amitriptyline in low doses is usually first choice of therapy. Doses of approximately 1 mg/kg/day can be used. Andrasik et al studied amitriptyline versus relaxation therapy prospectively in pediatric patients with TTH.10 The amitriptyline dose was 10 mg/day. Positive clinical outcome was significant for both groups; however, relaxation therapy was, in general, thought to be better accepted by families than medication therapy, regarding overall safety in the pediatric group compared with a pharmacologic intervention.

Trigeminal Autonomic Cephalgia (TAC) in Children

The trigeminal autonomic cephalgias are a group of severe headache disorders associated with headache and cranial sympathetic dysfunction that includes cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) that are differentiated clinically primarily by duration and frequency of attacks. They are rare in childhood but are reported and worth review, because successful treatment of these disorders relies on differentiating among these syndromes clinically. Secondary trigeminal autonomic cephalgias have been described. These rare disorders should be considered diagnoses of exclusion in this age range and require neuroimaging, preferably magnetic resonance imaging (MRI) with and without contrast to rule out a secondary headache syndrome.

Cluster Headache

Cluster headache is primarily a disorder of adult boys, with a prevalence of approximately 0.4% in that population.11 The International Headache Society defines a cluster headache as consisting of severe, unilateral pain in the orbital, supraorbital and/or temporal regions unilaterally lasting 15 to 180 minutes (see Sidebar 2, page 442). They must be associated with at least one autonomic symptoms, such as ipsilateral eye redness, tearing, nasal congestion, rhinorrhea, eyelid swelling, forehead or facial sweating, miosis, ptosis or a sense of restlessness or agitation. These episodes occur with a frequency of every other day to eight per day. Episodic cluster consists of attacks of these headaches lasting 7 days to 1 year, with at least 1 month long remission. Chronic cluster is defined as episodes with remissions less than 1 month.11

Sidebar 2.

Attacks of severe, strictly unilateral pain that is orbital, supraorbital, temporal, or in any combination of these sites, lasting 15 to 180 minutes and occurring from once every other day to eight times a day. The attacks are associated with one or more of the following, all of which are ipsilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, eyelid edema. Most patients are restless or agitated during an attack.

Diagnostic Criteria

  1. At least five attacks fulfilling criteria B-D

  2. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes if untreated.

  3. Headache is accompanied by at least one of the following:

    1. Ipisilateral conjunctival injection and/or lacrimation

    2. Ipsilateral nasal congestion and/or rhinorrhea

    3. Ipsilateral eyelid edema

    4. Ipsilateral forehead and facial sweating

    5. Ipsilateral miosis and/or ptosis

    6. Sense of restlessness or agitation

  4. Attacks have a frequency from 1 every other day to eight per day

  5. Not attributed to another disorder

In children, occurrence of cluster is much rarer. A Swedish study of military recruits found a prevalence of 0.1% in 18-year-olds, and in the same study, 6% of patients with cluster reported their first symptoms between ages 10 and 15.12 In a population-based study of an ethnically homogeneous county in Minnesota, only two patients 15 to 19 years (both boys) were found to have cluster out of 6,400 patient records screened.13 A retrospective study from a specialty headache clinic identified 35 patients with cluster onset at 18 years of age or younger. Two-hundred-five of these patients had the onset of cluster at or before 10 years, with increasing incidence steadily until 18 years. Fourteen percent of patients had chronic cluster.14 A more recent retrospective specialty clinic identified 11 children younger than 16 years, with cluster seen over a 5-year period. Twenty-seven percent had chronic cluster. Age of onset ranged from 2 to 14 years. One of the patients had neither agitation nor autonomic symptoms and was indomethacin sensitive, as was another patient, so that the diagnosis in these particular patients in this series is in question. Medications that were successful in this series included inhaled 100% oxygen, methysergide, verapamil, zolmitriptan and dihydroergotamine. Nonsteroidal anti-inflammatory drugs (NSAIDs) and codeine were not found to be helpful.15

Although rarer than migraine, cluster headache is a severe headache syndrome that is reported in the pediatric age range. Although there is no evidence for the use of any specific medication for the treatment of this disorder, many of the agents used for prophylaxis and acute treatment in adults have been used to treat cluster in children. Prophylactic agents, such as topiramate and verapamil, could be considered in a child or adolescent with cluster. Inhaled 100% oxygen, subcutaneous sumatriptan, nasal zolmitriptan, or dihydroergotamine administered subcutaneously or intravenously could be used to relieve the severe pain of these attacks.

SUNCT

SUNCT is a rare disorder first described in adults in 1978.16 There is a paucity of information on the demographic characteristics and natural history in the adult population, although it seems to be seen most commonly in men older than 50 years (see Sidebar 3, page 443). The attacks in this disorder are stabbing pain of shorter duration and higher frequency than cluster. Pain is typically located in the orbital, supraorbital, or temporal regions associated with redness and tearing of the ipsilateral eye. Attacks last 5 to 240 seconds and can occur three to 200 times per day. In adults, symptomatic cases have been described with posterior fossa and pituitary lesions.2 Five cases of SUNCT have been reported in the pediatric literature, ranging in age from 5 to 14 years.17–21 Two cases were symptomatic (one with optic nerve hypoplasia and with pituitary dysfunction18 and the other with a pilocytic astrocytoma of the cerebellum with involvement of the trigeminal nerve root).21 Successful treatment in one idiopathic case was reported with lamotrigine.17 Several others had spontaneous remission. Although the disorder was initially thought to be refractory to treatment in adults, case reports exist of successful treatment with lamotrigine and gabapentin.

Sidebar 3.

This syndrome is characterized by short-lasting attacks of unilateral pain that are much briefer than those seen in any other TAC and very often accompanied by prominent lacrimation and redness of the ipsilateral eye.

Diagnostic Criteria

  1. At least 20 attacks fulfilling criteria B-D

  2. Attacks of unilateral orbital, supraorbital, or temporal stabbing or pulsating pain lasting 5 to 240 seconds.

  3. Pain is accompanied by ipsilateral conjunctival injection and lacrimation.

  4. Attacks occur with a frequency from three to 200 per day.

  5. Not attributed to another disorder

Paroxysmal Hemicrania

Unlike the other TACs, paroxysmal hemicrania is more frequently a disorder of women (see Sidebar 4, page 443).

Sidebar 4.

Attacks with similar characteristics of pain and associated symptoms and signs to those of cluster headache, but they are shorter-lasting, more frequent, occur more commonly in girls, and respond absolutely to indomethacin.

Diagnostic Criteria

  1. At least 20 attacks fulfilling criteria B-D

  2. Attacks of severe unilateral orbital, supraorbital or temporal pain lasting 2 to 30 minutes

  3. Headache is accompanied by at least one of the following:

    1. ipsilateral conjunctival injection and/or lacrimation

    2. Ipsilateral nasal congestion and/or rhinorrhea

    3. Ipsilateral eyelid edema

    4. Ipsilateral forehead and facial sweating

    5. Ipsilateral miosis and/or ptosis

    6. Attacks have a frequency above 5 per day for more than half the time, although periods with lower frequency may occur.

  4. Attacks are prevented completely by therapeutic doses of indomethacin

  5. Not attributed to another disorder

Attacks are similar in location to cluster but are of shorter duration (2 to 30 minutes compared with 15 to 180 minutes) and are more frequent (greater than five times a day compared with once every other day to eight per day). As in cluster, they must be associated with one or more autonomic symptoms, but unlike cluster, they are responsive to indomethacin. Chronic paroxysmal hemicrania is diagnosed when attacks occur with less than 1 month remission for more than 1 year.2

There are approximately 17 cases of paroxysmal hemicrania reported in the pediatric literature, both episodic and chronic, although some question of whether some of these cases represent cluster or PH remains.22–27 Nearly all children reported responded to indomethacin in doses ranging from 0.5 to 5 mg/kg/day, although aspirin and verapamil were also noted to have efficacy in a few cases. The youngest onset reported was 1 year of age.23 Among the cases reported, there was a female predominance.

New Daily Persistent Headache

According to the International Headache Society, NDPH is a headache lasting at least 3 months that becomes daily within 3 days of onset and is not caused by another disorder (see Sidebar 5, page 444). In its symptomatology, it most resembles a chronic tension type headache. The pain should be bilalteral, non-pulsating, of mild to moderate intensity, and not aggravated by routine physical activities. A patient may have light sensitivity, sound sensitivity, or mild nausea, but no more than one of these symptoms and should be accompanied by moderate to severe nausea or vomiting.2

Sidebar 5.

Headache that is daily and unremitting from very soon after onset (within 3 days at most). The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity. There may be photophobia, phonophobia or mild nausea.

Diagnostic Criteria

  1. Headache for >3 months fulfilling criteria B-D

  2. Headache is daily and unremitting from onset or from < 3 days from onset

  3. At least two of the following pain characteristics:

    1. bilateral location

    2. pressing/tightening (non-pulsating) quality

    3. mild or moderate intensity

    4. not aggravated by routine physical activity such as walking or climbing stairs

  4. Both of the following:

    1. no more than one of photophobia or phonophobia or mild nausea

    2. neither moderate nor severe nausea nor vomiting

  5. Not attributed to another disorder

Unfortunately, both the adult and pediatric literature includes patients with episodes of headache consistent with migraine, so it is difficult to draw conclusions regarding diagnosis and treatment based on the literature.28,29 In the most extensive study of this disorder in children to date, approximately 30% of patients with chronic headache that were daily at onset, nearly 30% had the sudden onset of daily migraine. The most common triggers for the afore-mentioned symptoms were febrile illness, minor head trauma, or extracranial surgery.29 In our experience, pediatric patients without full-blown migraine symptoms most often have the onset of the headache of NDPH during an illness. The symptoms of the acute illness fade, and they are left with headache. Discontinuation of NSAIDs does not affect the headache pattern. These patients are typically able to continue activities but experience some dysfunction because of daily pain.

The differential diagnosis of these symptoms can include medication overuse, headache, aseptic meningitis, pseudotumor without papilledema, sinus thrombosis, postural tachycardia syndrome (POTS), and autoimmune disease, in addition to migraine. In the authors’ opinion, although imaging, blood work, and lumbar puncture are frequently undertaken, in those with normal physical and neurologic examinations, an etiology is rarely found.

Treatment strategies include treatment with topiramate or tricyclic antidepressants and adjunctive psychotherapy, if no underlying cause is found. For patients more refractory or disabled, inpatient therapy with IV dihydroergotamine and/or IV steroids (after infectious etiology is ruled out) is sometimes successful. In an adult series, elevations of TNF-alpha in the CSF of patients were reported, so minocycline has been suggested, although chronic minocycline induced autoimmunity has been reported in children, so extreme caution should be undertaken when considering this treatment.30,31 Successful treatment of NDPH with botulinum toxin A has been reported in the literature; however, the patient’s symptoms were occipital in location and described as sharp at times, so clear differentiation from occipital neuralgia cannot be made on the basis of this case report.32

Primary Stabbing Headache

“Ice pick” headache, now referred to as primary stabbing headache, was first reported in adults in 1980.33 This syndrome consists of brief stabs in the distribution of the first division of the trigeminal nerve (see Sidebar 6, page 445). There is an absence of autonomic features, which distinguishes it from TACs. However, it is also an indomethacin-responsive syndrome, so is sometimes discussed with these disorders. Patients report single or repetitive jabs of intense but brief pain in orbit, temple, or parietal area. Attacks may occur multiple times a day to occasionally.

Sidebar 6.

Transient and localized stabs of pain in the head that occur spontaneously in the absence of organic disease of the underlying structures or of the cranial nerves.

Diagnostic Criteria

  1. Head pain occurring as a single stab or series of stabs and fulfilling criteria B-D

  2. Exclusively or predominantly felt in the distribution of the first division of the trigeminal nerve (orbit, temple, and parietal area)

  3. Stabs last for up to a few seconds and recur with irregular frequency, ranging from one to many per day

  4. No accompanying symptoms

  5. Not attributed to another disorder

In a series of 83 pediatric patients in Italy, ranging in age from 2.5 years to 18 years, there was an essentially equal number of boys and girls identified. Attacks lasted from seconds to minutes and occurred no more than once a week. Intensity was severe in 30% of patients. Location was most frequently anterior (69%), although vertex and occipital pain was also reported. Curiously, almost 50% of patients reported other symptoms, such as photo/phonophobia, nausea, and vertigo. No cause was found in any patient who underwent a variety of diagnostic evaluations. Seventy percent of patients were symptom-free 1 to 5 years after initial evaluation.34

In the authors’ experience, this syndrome can occur comorbidly with migraine and independently. Patients seeking medical attention for this typically have nearly daily attacks that are intense enough to stop activities briefly. These attacks are easily abolished with indomethacin treatment, although the gastrointestinal side effects sometimes limit its use. Neuroimaging, although frequently performed, is typically unrevealing in those with normal exams.

References

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  3. Laurell K, Larsson B, Eeg-Olofsson O. Prevalence of headache in Swedish schoolchildren, with a focus on tension-type headache. Cephalalgia. 2004;24(5):380–388. doi:10.1111/j.1468-2982.2004.00681.x [CrossRef]
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  5. Holden EW, Deichmann MM, Levy JD. Empirically supported treatments in pediatric psychology: recurrent pediatric headache. J Pediatr Psychol. 1999;24(2):91–109. doi:10.1093/jpepsy/24.2.91 [CrossRef]
  6. Pilarska E, Olszewska A. Temperament traits of children with episodic tension-type headaches. Eur J Paediatr Neurol. 2009;13(4):327–331. Epub 2008 Aug 8. doi:10.1016/j.ejpn.2008.06.007 [CrossRef]
  7. Pakalnis A, Tischner J, Colvin A, et al. Emotional and behavioral disorders in pediatric episodic tension headaches. J Pediatr Neurol2008;6(2):109–113.
  8. Grazzi L, Andrasik F, Usai S, Bussone G. Magnesium as a preventive treatment for paediatric episodic tension-type headache: results at 1-year follow-up. Neurol Sci. 2007;28(3):148–150. doi:10.1007/s10072-007-0808-y [CrossRef]
  9. Miano S, Parisi P, Pelliccia A, Luchetti A, Paolino MC, Villa MP. Melatonin to prevent migraine or tension-type headache in children. Neurol Sci. 2008;29(4):285–287. doi:10.1007/s10072-008-0983-5 [CrossRef]
  10. Andrasik F, Grazzi L, Usai S, Bussone G. Pharmacological treatment compared to behavioural treatment for juvenile tension-type headache: results at two-year follow-up. Neurol Sci. 2007;28Suppl 2:S235–S238. doi:10.1007/s10072-007-0786-0 [CrossRef]
  11. Linet MS, Stewart WF. Migraine headache: epidemiologic perspectives. Epidemiol Rev. 1984;6:107–139.
  12. Ekbom K, Svensson DA, Pedersen NL, Waldenlind E. Lifetime prevalence and concordance risk of cluster headache in the Swedish twin population. Neurology. 2006;67(5):798–803. doi:10.1212/01.wnl.0000233786.72356.3e [CrossRef]
  13. Swanson JW, Yanagihara T, Stang PE, et al. Incidence of cluster headaches: a population-based study in Olmsted County, Minnesota. Neurology. 1994;44(3 Pt 1):433–437.
  14. Lampl C. Childhood-onset cluster headache. Pediatr Neurol. 2002;27(2):138–140. doi:10.1016/S0887-8994(02)00406-X [CrossRef]
  15. Majumdar A, Ahmed MA, Benton S. Cluster headache in children--experience from a specialist headache clinic. Eur J Paediatr Neurol. 2009;13(6):524–529. doi:10.1016/j.ejpn.2008.11.002 [CrossRef]
  16. Sjaastad O, Russell D, Horven I, Bunaes U. Multiple neuralgiform, unilateral headache attacks associated with conjunctival injection and tearing:a nosologic problem. Proceeding of the Scandinavian Migraine Society1978;31.
  17. Unalp A, Oztürk AA. SUNCT syndrome in a child: a rare cause of paroxysmal headache. Ann Saudi Med. 2008;28(5):386–387. doi:10.4103/0256-4947.51695 [CrossRef]
  18. Theeler BJ, Joseph KR. SUNCT and optic nerve hypoplasia. J Headache Pain. 2009;10(5):381–384. doi:10.1007/s10194-009-0135-1 [CrossRef]
  19. D’Andrea G, Granella F. SUNCT syndrome: the first case in childhood. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. Cephalalgia. 2001;21(6):701–702.
  20. Sékhara T, Pelc K, Mewasingh LD, Boucquey D, Dan B. Pediatric SUNCT Syndrome. Pediatr Neurol. 2005;33(3):206–207. doi:10.1016/j.pediatrneurol.2005.03.017 [CrossRef]
  21. Blättler T, Capone Mori A, Boltshauser E, Bassetti C. Symptomatic SUNCT in an eleven-year-old girl. Neurology. 2003;60(12):2012–2013.
  22. Kudrow DB, Kudrow L. Successful aspirin prophylaxis in a child with chronic paroxysmal hemicrania. Headache. 1989;29(5):280–281. doi:10.1111/j.1526-4610.1989.hed2905280.x [CrossRef]
  23. Blankenburg M, Hechler T, Dubbel G, Wamsler C, Zernikow B. Paroxysmal hemicrania in children--symptoms, diagnostic criteria, therapy and outcome. Cephalalgia. 2009;29(8):873–882. doi:10.1111/j.1468-2982.2008.01813.x [CrossRef]
  24. Klassen BD, Dooley JM. Chronic paroxysmal hemicrania-like headaches in a child: response to a headache diary. Headache. 2000;40(10):853–855. doi:10.1046/j.1526-4610.2000.00155.x [CrossRef]
  25. Gladstein J, Holden EW, Peralta L. Chronic paroxysmal hemicrania in a child. Headache. 1994;34(9):519–520. doi:10.1111/j.1526-4610.1994.hed3409519.x [CrossRef]
  26. de Almeida DB, Cunali PA, Santos HL, Brioschi M, Prandini M. Chronic paroxysmal hemicrania in early childhood: case report. Cephalalgia. 2004;24(7):608–609. doi:10.1111/j.1468-2982.2004.00732.x [CrossRef]
  27. Shabbir N, McAbee G. Adolescent chronic paroxysmal hemicrania responsive to verapamil monotherapy. Headache. 1994;34(4):209–210. doi:10.1111/j.1526-4610.1994.hed3404209.x [CrossRef]
  28. Kung E, Tepper SJ, Rapoport AM, Sheftell FD, Bigal ME. New daily persistent headache in the pediatric population. Cephalalgia. 2008;29:17–22 doi:10.1111/j.1468-2982.2008.01647.x [CrossRef]
  29. Mack KJ. New daily persistent headache in children and adults. Curr Pain Headache Rep. 2009;13(1):47–51. doi:10.1007/s11916-009-0010-4 [CrossRef]
  30. Rozen T, Swidan SZ. Elevation of CSF tumor necrosis factor alpha levels in new daily persistent headache and treatment refractory chronic migraine. Headache. 2007;47(7):1050–1055. doi:10.1111/j.1526-4610.2006.00722.x [CrossRef]
  31. El-Hallak M, Giani T, Yeniay BS, Jacobs KE, Kim S, Sundel RP, Dedeoglu F. Chronic minocycline-induced autoimmunity in children. J Pediatr. 2008;153(3):314–319. doi:10.1016/j.jpeds.2008.03.013 [CrossRef]
  32. Spears RC. Efficacy of botulinum toxin type A in new daily persistent headache. J Headache Pain. 2008;9(6):405–406. doi:10.1007/s10194-008-0078-y [CrossRef]
  33. Raskin NH, Schwartz RK. Icepick-like pain. Neurology. 1980;30(2):203–205.
  34. Soriani S, Battistella PA, Arnaldi C, De Carlo L, Cernetti R, Corrà S, Tosato G. Juvenile idiopathic stabbing headache. Headache. 1996;36(9):565–567. doi:10.1046/j.1526-4610.1996.3609565.x [CrossRef]

CME Educational Objectives

  1. Determine the clinical features of tension-type headache in children.

  2. Define the features of the trigeminal autonomic cephalgias in children.

  3. Cite the clinical findings suggestive of paroxysmal hemicrania.

Sidebar 1.

Frequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There is no nausea, but photophobia or phonophobia may be present.

Diagnostic Criteria

  1. At least 10 episodes occurring on ≥1 but <15 days per month for at least 3 months (≥12 and <180 days per year) and fulfilling criteria B-D

  2. Headache lasting from 30 minutes to 7 days

  3. Headache has at least two of the following characteristics:

    1. bilateral location

    2. pressing/tightening (non-pulsating) quality

    3. mild or moderate intensity

    4. not aggravated by routine physical activity such as walking or climbing stairs

  4. Both of the following:

    1. no nausea or vomiting (anorexia may occur)

    2. no more than one of photophobia or phonophobia

  5. Not attributed to another disorder

Sidebar 2.

Attacks of severe, strictly unilateral pain that is orbital, supraorbital, temporal, or in any combination of these sites, lasting 15 to 180 minutes and occurring from once every other day to eight times a day. The attacks are associated with one or more of the following, all of which are ipsilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, eyelid edema. Most patients are restless or agitated during an attack.

Diagnostic Criteria

  1. At least five attacks fulfilling criteria B-D

  2. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes if untreated.

  3. Headache is accompanied by at least one of the following:

    1. Ipisilateral conjunctival injection and/or lacrimation

    2. Ipsilateral nasal congestion and/or rhinorrhea

    3. Ipsilateral eyelid edema

    4. Ipsilateral forehead and facial sweating

    5. Ipsilateral miosis and/or ptosis

    6. Sense of restlessness or agitation

  4. Attacks have a frequency from 1 every other day to eight per day

  5. Not attributed to another disorder

Sidebar 3.

This syndrome is characterized by short-lasting attacks of unilateral pain that are much briefer than those seen in any other TAC and very often accompanied by prominent lacrimation and redness of the ipsilateral eye.

Diagnostic Criteria

  1. At least 20 attacks fulfilling criteria B-D

  2. Attacks of unilateral orbital, supraorbital, or temporal stabbing or pulsating pain lasting 5 to 240 seconds.

  3. Pain is accompanied by ipsilateral conjunctival injection and lacrimation.

  4. Attacks occur with a frequency from three to 200 per day.

  5. Not attributed to another disorder

Sidebar 4.

Attacks with similar characteristics of pain and associated symptoms and signs to those of cluster headache, but they are shorter-lasting, more frequent, occur more commonly in girls, and respond absolutely to indomethacin.

Diagnostic Criteria

  1. At least 20 attacks fulfilling criteria B-D

  2. Attacks of severe unilateral orbital, supraorbital or temporal pain lasting 2 to 30 minutes

  3. Headache is accompanied by at least one of the following:

    1. ipsilateral conjunctival injection and/or lacrimation

    2. Ipsilateral nasal congestion and/or rhinorrhea

    3. Ipsilateral eyelid edema

    4. Ipsilateral forehead and facial sweating

    5. Ipsilateral miosis and/or ptosis

    6. Attacks have a frequency above 5 per day for more than half the time, although periods with lower frequency may occur.

  4. Attacks are prevented completely by therapeutic doses of indomethacin

  5. Not attributed to another disorder

Sidebar 5.

Headache that is daily and unremitting from very soon after onset (within 3 days at most). The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity. There may be photophobia, phonophobia or mild nausea.

Diagnostic Criteria

  1. Headache for >3 months fulfilling criteria B-D

  2. Headache is daily and unremitting from onset or from < 3 days from onset

  3. At least two of the following pain characteristics:

    1. bilateral location

    2. pressing/tightening (non-pulsating) quality

    3. mild or moderate intensity

    4. not aggravated by routine physical activity such as walking or climbing stairs

  4. Both of the following:

    1. no more than one of photophobia or phonophobia or mild nausea

    2. neither moderate nor severe nausea nor vomiting

  5. Not attributed to another disorder

Sidebar 6.

Transient and localized stabs of pain in the head that occur spontaneously in the absence of organic disease of the underlying structures or of the cranial nerves.

Diagnostic Criteria

  1. Head pain occurring as a single stab or series of stabs and fulfilling criteria B-D

  2. Exclusively or predominantly felt in the distribution of the first division of the trigeminal nerve (orbit, temple, and parietal area)

  3. Stabs last for up to a few seconds and recur with irregular frequency, ranging from one to many per day

  4. No accompanying symptoms

  5. Not attributed to another disorder

Authors

Ann Pakalnis, MD, is with Division of Pediatric Neurology, Ohio State University. Marcy Yonker, MD, FAHS, is with Pediatric Neurology, Phoenix Children’s Hospital.

Dr. Pakalnis has disclosed no relevant financial relationships. Dr. Yonker has disclosed the following relevant financial relationships: Allergan: Consultant.

Address correspondence to: Marcy Yonker, MD, FAHS: .myonker@phoenix-childrens.com

10.3928/00904481-20100623-08

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