Tension-type headache in childhood and adolescence

Tension-Type Headache in Children and Adolescents

In pediatric neurology, tension-type headache (TTH) represents a very common type of primary headache during the pediatric age. Despite the high prevalence of TTH, this diagnosis is often underestimated in childhood, with relevant difficulties in the differential diagnosis of TTH from secondary and primary headache manifestations. Even among primary headaches, a clinical overlap is not so infrequent in children: migraine attacks could present tension headache-like features while tension-type headaches may display migraine-like symptoms as well. Several variables play a role in the complex trajectory of headache evolution, such as hormonal changes during adolescence, triggers and genetic and epigenetic factors. The trajectories and outcomes of juvenile migraine and TTH, as well as the transition of one form to the other, have been investigated in several long-term prospective studies. Thus, the aim of this paper is to review the current literature on the differential diagnosis workout of TTH in pediatrics, the possible outcomes during the developmental age and the appropriate therapeutic strategies. Indeed, TTH represents a challenging diagnostic entity in pediatrics, both from a clinical and a therapeutic point of view, in which early diagnosis and appropriate treatment are recommended.

Primary headache disorders in adolescents in North- and South-Tyrol: Findings of the EVA-Tyrol-Study

OBJECTIVE

Assessment of the prevalence of primary headache disorders, associated risk factors and use of acute/preventive medication in a representative large sample of adolescents.

METHODS

Within the EVA-Tyrol project, a community-based non-randomized controlled cross-sectional study, data was collected from adolescents aged 14-19 years from 45 sites across North-, East- and South Tyrol. Headaches were classified according to the latest ICHD-3 and assessed by headache specialists in face-to-face interviews.

FINDINGS

Of 1923 participants 930 (48.4%) reported having headaches. Female to male ratio was 2:1. Migraine, tension-type headache and other headache were diagnosed in 10%, 30.2% and 8.2% respectively. Medication overuse was diagnosed in 3.4%, increasing up to 21.7% in participants with chronic headache. The use of preventative medication was not reported by any adolescent. Sleep disturbances (p < 0.05), alcohol consumption (p < 0.05), low physical activity (p < 0.01) and high screen time exposure (p < 0.01) were associated with an increased risk of headaches.

CONCLUSION

We report high prevalence of primary headache disorders and medication overuse in a large community-based sample of teenagers. Acute and preventive non-drug and pharmacological treatments are not established due to lack of paediatric headache outpatient clinics. Promoting health education in teenagers and encouraging public awareness, including that of health care providers is pivotal.Trial registration: EVA-Tyrol has been retrospectively registered at clinicaltrials.gov under https://clinicaltrials.gov/ct2/show/NCT03929692 since April 29, 2019.

A bibliometric analysis and visualization of tension-type headache

Background

Tension-type headache (TTH) is the most prevalent headache in the clinical practice, leading to impaired social activities, work-related disability, and heavy financial burdens. Previous studies have described possible inducement, potential pathophysiology, and clinical management of TTH; however, due to the lack of attention, literature involving bibliometric analysis is sporadic. Therefore, this study aimed to explore the current hotspots and future directions of the TTH field by bibliometric analysis.

Methods

By using CiteSpace and VOSviewer, literature regarding TTH between 2002 and 2021 from the Web of Science database was summarized and extracted. Annual publication trend, the most productive countries/regions and institutions, distribution of categories, co-citation of journals and references, and co-occurrence of keywords were analyzed.

Results

A total of 3,379 publications were included in the final visualization, indicating a stable trend in current research and a lack of breakthroughs over the past decades. These studies were mainly conducted in 120 countries/regions led by the United States and more than 600 institutions. Four eternal core themes were identified in TTH, including neurosciences, nursing, developmental psychology, and general/internal medicine. Cephalalgia ranked first, with the highest number of literature, and is the most influential journal in this area. Keyword analysis demonstrated that the similarities and differences between migraine and TTH, epidemiological studies, clinical double-blind trials, and potential populations have become key issues in the TTH field.

Conclusion

TTH has received less attention and breakthroughs in the past 20 years. To promote coordinated development between regions to fight headaches, cooperation and exchanges between countries and institutions are essential in the future. Relevant studies about headaches in children and adolescents, inducing factors such as emotional triggers and sleep disorders, concomitant diseases, possible pathogenesis, and headache treatments, are in the spotlight in recent years. This study offers a powerful roadmap for further research in this field.

Headache in Children and Adolescents: The Association between Screen Time and Headache within a Clinical Headache Population

BACKGROUND

More than half of children and adolescents have experienced headache within the last 3 months. Several risk factors for headache have been identified, including obesity and lack of sleep. The association between screen time and headache in children and adolescents is sparsely investigated. The aim of this study was to assess this association and evaluate if it varied according to headache diagnosis.

METHOD

This cross-sectional study was performed at the tertiary pediatric outpatient clinic for headache at Herlev University Hospital. A total of 139 participants who answered a questionnaire on lifestyle factors and their daily living were included. Diagnoses of migraine and tension-type headache (TTH) were made according to the International Classification of Headache Disorders-3. Children with both migraine and TTH were allocated to a mixed headache group. We differentiated between total, leisure, and school-related screen time.

RESULTS

The mean age was 13.20 ± 3.38 years and 53.2% were girls. Note that 25.2% were diagnosed with migraine without aura, 23.0% migraine with aura, 28.1% TTH, 15.8% mixed headache, and 7.9% had an unclassified headache diagnosis at the time of inclusion. There was no statistically significant difference in screen time across the five headache groups. An association between screen time and headache frequency was found in children with migraine with aura.

CONCLUSION

In this study, we investigated the association between screen time and headache in children and adolescents. More screen time was associated with more frequent headaches in children with migraine with aura. Future prospective studies are needed to determine the causality of this association.

Headache and distress during pregnancy

OBJECTIVE

To determine the prevalence of headache, review variables believed to be associated, and assess distress levels in pregnant women.

METHODS

This is a cross-sectional study conducted on pregnant women who presented to a Training and Research Hospital in Sakarya, Turkey from June 1, 2020 to December 1, 2020. The study group consisted of 600 pregnant women who agreed to take part in the study. Chi-squared test and logistic regression analysis were used to analyze the data. Statistical significance level was accepted as P value of 0.05 or less.

RESULTS

The ages of pregnant women ranged from 19 to 44 years with a mean age of 29.01 ± 5.27 years. Prevalence of headache during pregnancy was found to be 55.7% (n = 334). The number of pregnant women at of distress was found to be 144 (24.0%). There was no difference between women with and without headache and between severity of headache and prevalence of distress (P > 0.05 for each).

CONCLUSION

Headache is an important health issue in pregnant women. There was no relationship between the presence and severity of headache and distress level.

Prevalence and Burden of Primary Headache Disorders in Kuwaiti Children and Adolescents: A Community Based Study

Background/Objective: Primary headaches are common in the pediatric and adolescent population and can be disabling for them and their families. We aimed to assess the prevalence and burden of primary headache disorders among children and adolescents in Kuwait.

Methods: A cross-sectional community-based study included Kuwaiti population aged 6–17 years. They were randomly recruited from all six governorates of Kuwait using stratified multistage cluster sampling. The Headache-Attributed Restriction, Disability, and Social Handicap and Impaired Participation (HARDSHIP) questionnaire for children and adolescents was used to collect the data.

Results: Data were collected from 3,423 subjects; 664 subjects were diagnosed as having primary headache disorders. The mean age was 12.61 ± 2.51 years and 64.2% were females. One year prevalence of headache was 19.4%. It was significantly prevalent in females compared to males (25.2% vs. 13.8%; P < 0.001). Primary headache disorder significantly increased in age group 12–17 when compared to age group 6–11 years (25.8% vs. 10.4 %; p < 0.001). One year primary headache prevalence showed non-significant differences in both males and females in age group 6–11 years (10.1% in males vs. 10.6% in females; P < 0.79), while it was significantly higher in female vs. males (38.1% vs. 15.8%; P < 0.001) in age group 12–17 years. Migraine prevalence was 10.9% followed by tension type headache (TTH) 6.2% and chronic headache 0.9%. Medical care utilization was reported in 67% of our cohort. The majority (95%) of the patients received symptomatic drugs for headache attacks and only 7.5% used preventive medication. The students with headache lost a mean of 1.29 ± 1.23 days of school, reported mean of 1.16 ± 1.50 days they could not do activities they had wanted to. Their parents lost a mean of 1.01 ± 1.02 days of work because of headaches of their children during the preceding 4 weeks of the study.

Conclusions: The estimated 1 year prevalence of headache was 19.4% overall. Primary headache prevalence increased with age and it was more prevalent in female adolescents compared to males of the same age. Headache disorders in children/adolescents affect school and social activities as well as their parents work. The awareness for early diagnosis and preventive medications for headache in this age group may reduce the headache burden.

The Nord-Trøndelag Health Study shows increased prevalence of primary recurrent headaches among adolescents over a four-year period

Objective Earlier epidemiological studies have shown that headaches are frequent among adolescents, especially girls. In particular, recurrent primary headache disorders such as migraine and tension-type headaches are common complaints in this age group. Headaches are increasingly being recognized as a significant health problem in adolescents and can lead to significant disabilities by affecting their lives, their school performance and their social lives. The aim of this study was to compare the prevalence of primary headaches among adolescents aged 16-20 years in Norway in two periods. Very few replicate studies have re-evaluated the prevalence of primary headaches in this age range and it is uncertain whether the prevalence is increasing. Methods Two cross-sectional, population-based studies were conducted in Norway from 1995 to 1997 (Young-HUNT 1) and from 1999 to 2001 (Young-HUNT 2). In Young-HUNT 1, 2594 adolescents in 2nd and 3rd grade in upper secondary school (aged 16-20 years) completed a comprehensive questionnaire including one question regarding headache during the last 12 months. In addition, 1730 of the students were interviewed about their headache complaints. In Young-HUNT 2, 2373 adolescents aged 16-20 years completed the same questionnaire and 1655 were interviewed in the same way as the earlier survey. The interviews were performed by trained nurses, and respondents were asked if they had experienced recurrent headache during the last year. If so, the headache was classified as migraine (MI), tensiontype headache (TTH) or non-classifiable headache (NCH). Headache frequency during the past year was recorded according to the following categories: Less than 1 day per month (less than monthly), 1-3 days per month (monthly), 1-5 days per week (weekly), or more than 5 days per week (daily). Results The participation rate was 88% in Young-HUNT 1 and 81% in Young-HUNT 2. The overall prevalence of having had headaches during the last 12 months did not change significantly (79.4% versus 77.5%; OR: 0.89, 95%CI: 0.79-1.02, p = 0.09), whereas the prevalence of recurrent headaches increased from 30.3% in Young-HUNT 1 to 35.4% in Young-HUNT 2 (OR: 1.26, 95%CI: 1.09-1.46, p = 0.002). The prevalence of tension-type headache changed significantly from 19.0% to 21.9% (OR: 1.20, 95%CI: 1.02-1.42, p = 0.03). Also the prevalence of migraine tended to increase (7.5% versus 8.7%, OR: 1.18, 95%CI: 0.92-1.52, p = 0.18). The overall frequency of recurrent headache changed towards more monthly and less weekly headache. Conclusions This is the first large-scale population-based study among adolescents in Norway assessing changes in the prevalence of primary headaches over a four-year period of time. The overall prevalence of recurrent headaches increased significantly from Young-HUNT 1 to Young-HUNT 2. An increase was seen in all types of recurrent headaches and was significant for tension-type headache. Implications Earlier follow-up studies have examined changes in prevalence of recurrent headaches in young age, but the results are diverging. Our findings support the impression that the prevalence of recurrent headache among adolescents is increasing, and underlines the need for prospective designed studies with emphasis on prognosis and etiological factors.

Experts' opinion about the primary headache diagnostic criteria of the ICHD-3rd edition beta in children and adolescents

BACKGROUND

The 2013 International Classification of Headache Disorders-3 (ICHD-3) was published in a beta version to allow the clinicians to confirm the validity of the criteria or to suggest improvements based on field studies. The aim of this work was to review the Primary Headache Disorders Section of ICHD-3 beta data on children and adolescents (age 0-18 years), and to suggest changes, additions, and amendments.

METHODS

Several experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the literature available on pediatric headache, they made observations and proposed suggestions for the primary headache disorders section of ICHD-3 beta data on children and adolescents.

RESULTS

Some headache disorders in children have specific features which are different from those seen in adults and which should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psycho-social basis in children and adolescents making primary headache disorders in children distinct from those in adults.

CONCLUSIONS

Several recommendations are presented in order to make ICHD-3 more appropriate for use with children.

Primary Headache Disorders- Part 2: Tension-type headache and medication overuse headache

In Part 2 of Primary Headache disorders, we discuss the fourth Primary Headache Disorder, Tension-Type Headache (TTHA). We are again using the ICHD-III (Beta) definitions of such headaches, taking into consideration episodic and chronic TTHA, as well as the presence or absence of pericranial muscle tenderness. We discuss the pathophysiology and pharmacotherapeutic treatment of TTHA, and the aspects of the Myofascial Pain Syndrome that enhance and help the development of TTHA. We then discuss Medication Overuse Headache (MOH), itself a Secondary headache disorder, but one that is extremely important as it assists with the chronification of both migraine and TTHA. Finally we discuss how to manage and treat those patients with MOH. Chronic migraine, which is TTHA, Migraine as well as, in many patients, MOH, is discussed along with the treatment of this multifaceted disorder.

A Possible Pathogenic Linkage Among Headache, Migraine, and Nocturnal Enuresis in Children

Purpose

This study aims to evaluate the prevalence of headaches and migraine in children with nocturnal enuresis (NE) and to improve knowledge on these conditions. In particular, for this purpose, a possible pathogenic relationship linking both conditions and the impact of headaches and migraine on NE persistence was evaluated.

Methods

Researchers enrolled 123 children with NE, aged between 5 and 15 years, referred to the Service of Pediatrics, Campus Bio-Medico University Hospital of Rome between January 2014 and January 2015. Parents of all children enrolled in the study were invited to complete a self-reported questionnaire. The study protocol was approved by the Human Research Ethics Committee of Campus-Bio-Medico University. The NE group data was compared with the data of a control group (107 children).

Results

Of the eligible patients, 7.8% suffer from headaches/migraine (mean age, 9.63 years; interquartile range [IQR], 3.5 years) and 47.1% have a family history of headaches (mean age, 8.46 years; IQR, 3.75 years). Of the 8 patients with headaches, all are male, 3 have tension-type headaches (2 of them have maternal family history) and 5 have migraine (3 of them have maternal family history). Of the 35.3% with a migraine family history (mean age, 8.36 years; IQR, 3.5 years), 22 are male, and 14 are female. Three of these patients have migraine. A total of 92.2% suffer from NE but not from headaches (mean age, 8.43 years; IQR, 3 years). Of these patients, 33 are female (35.1%), and 61 are male (64.9%). In the control group, 4.7% (5 out of 107) of the children suffer from headaches, and of these, 4 are affected by nonmigraine headaches and 1 by migraine.

Conclusions

In conclusion, according to the hypothesis, NE and headaches/migraine could be linked by several similarities.

Association between functional gastrointestinal disorders and migraine in children and adolescents: a case-control study

BACKGROUND

Functional gastrointestinal disorders and migraine are both common causes of medical attention. We have previously shown an association between migraine and infant colic. In this case-control study, we aimed to establish whether there is an association between migraine and other functional gastrointestinal disorders in children and adolescents.

METHODS

We included children and adolescents aged 6-17 years presenting to the emergency department of four tertiary hospitals in France and Italy. Patients diagnosed with either migraine or tension-type headache by the hospital's paediatric neurologist were enrolled as cases. Patients presenting to the emergency department with minor trauma and no history of recurrent headache were enrolled as controls. Investigators masked to a patient's group allocation diagnosed functional gastrointestinal disorders using the Rome III diagnostic criteria. Univariable and multivariable analyses were done to identify specific disorders and baseline factors associated with migraines and tension-type headache.

FINDINGS

Between Nov 1, 2014, and Jan 31, 2015, we enrolled 648 controls and 424 cases (257 patients with migraine and 167 with tension-type headache). 83 (32%) children and adolescents in the migraine group were diagnosed with functional gastrointestinal disorders compared with 118 (18%) in the control group (p<0·0001). Multivariable logistic regression showed a significant association between migraine and three gastrointestinal disorders: functional dyspepsia (odds ratio 10·76, 95% CI 3·52-32·85; p<0·0001), irritable bowel syndrome (3·47, 1·81-6·62; p=0·0002), and abdominal migraine (5·87, 1·95-17·69; p=0·002). By contrast, there was an inverse association between migraine and functional constipation (0·34, 0·14-0·84, p=0·02). 41 (25%) participants with tension-type headache had functional gastrointestinal disorders, which did not significantly differ from the prevalence of these disorders in the control group (p=0·07); no significant association was noted between any functional gastrointestinal disease and tension-type headaches.

INTERPRETATION

Three abdominal-pain-related functional gastrointestinal disorders were associated with migraine in children and adolescents. These findings are of value to the diagnosis and management of these common diseases. Future studies should investigate whether antimigraine drugs are of benefit in functional gastrointestinal disorders.

FUNDING

None.

Part II--Management of pediatric post-traumatic headaches

BACKGROUND

Post-traumatic headache is one of the most common symptoms occurring after mild traumatic brain injury in children.

METHODS

This is an expert opinion-based two-part review on pediatric post-traumatic headaches. In part II, we focus on the medical management of post-traumatic headaches. There are no randomized controlled trials evaluating the efficacy of therapies specifically for pediatric post-traumatic headaches. Thus, the algorithm we propose has been extrapolated from the primary headache literature and small noncontrolled trials of post-traumatic headache.

RESULTS

Most post-traumatic headaches are migraine or tension type, and standard medications for these headache types are used. A multifaceted approach is needed to address all the possible causes of headache and any comorbid conditions that may delay recovery or alter treatment choices. For acute treatment, nonsteroidal anti-inflammatories can be used. If the headaches have migrainous features and nonsteroidal anti-inflammatories are not effective, triptans may be beneficial. Opioids are not indicated. Medication overuse should be avoided. For preventive treatments, some reports indicate that amitriptyline, gabapentin, or topiramate may be beneficial. Amitriptyline is a good choice because it can be used to treat both migraine and tension-type headaches. Nerve blocks, nutraceuticals (e.g. melatonin), and behavioral therapies may also be useful, and lifestyle factors, especially adequate sleep hygiene and strategies to cope with anxiety, should be emphasized.

CONCLUSIONS

Improved treatment of acute post-traumatic headache may reduce the likelihood of developing chronic headaches, which can be especially problematic to effectively manage and can be functionally debilitating.

Psychiatric comorbidity in childhood and adolescence headache

Primary headaches among children and adolescents have a substantial impact on quality of life, daily activities, social interaction, and school performance in combination with psychopathological symptoms. The main purpose of the present paper is to summarize clinical and epidemiological evidence for psychiatric comorbidity among children and adolescents with headaches, to describe how evidence in headache research suggest different pathways involved in the development and maintenance of these comorbid conditions, and finally suggest some elements professionals may find helpful to assess the scope of complaints, related functional impairment, and potential precipitating factors in planning of more targeted treatments.

Multimodal compared to pharmacologic treatments for chronic tension-type headache in adolescents

Chronic tension-type headache (CTTH) in children and adolescents is a serious medical condition, with considerable morbidity and few effective, evidence-based treatments. We performed a chart review of 83 adolescents (age range = 13-18 years; 67 girls and 16 boys) diagnosed with CTTH. Two treatment protocols were compared: multimodal (osteopathic manipulative treatments, mindfulness, and qi gong) and pharmacologic (amitriptyline or gabapentin). Four outcomes (headache frequency, pain intensity, general health, and health interference) were assessed at three time points (baseline, 3 months, and 6 months). A fifth outcome, number of bilateral tender points, was recorded at baseline and 6 months. All five were evaluated statistically with a linear mixed model. Although both multimodal and pharmacologic treatments were effective for CTTH (time effects for all measures were significant at p < .001), results from each analysis favored multimodal treatment (the five group by time interaction effects were significant at or below the p < .001 level). Headache frequency in the pharmacologic group, for example, reduced from a monthly average (95% Confidence Interval shown in parentheses) of 23.9 (21.8, 26.0) to 16.4 (14.3, 18.6) and in the multimodal group from 22.3 (20.1, 24.5) to 4.9 (2.6, 7.2) (a substantial group difference). Pain intensity (worst in the last 24 hours, 0-10 scale) was reduced in the pharmacologic group from 6.2 (5.6, 6.9) to 3.4 (2.7, 4.1) and from 6.1 (5.4, 6.8) to 2.0 (1.2, 2.7) in the multimodal group (a less substantial difference). Across the other three assessments, group differences were larger for general health and number of tender points and less so for pain restriction. Multimodal treatment for adolescent CTTH appears to be effective. Randomized controlled trials are needed to confirm these promising results.

Tension-Type Headache in Children: The Cinderella of Headache Disorders!

Tension-type headache (TTH) may be as common a headache disorder as migraine in children and adolescents. TTH has a neurobiological basis with genetic and environmental factors making variable contributions to the different sub-types. The diagnostic criteria for TTH in the second edition of the “International Classification of Headache Disorders” appear to be applicable to children. Anxiety and mood disorders may be co-morbid with frequent episodic and chronic TTH. Psychosocial stressors play an important role in precipitating and maintaining TTH. Hence, a biopsychosocial approach should be adopted for care. Standardized histories and examinations together with prospective headache diaries are the foundations for good management; attention to ‘red flags’ will help identify secondary causes that present with headache similar to TT. There are no randomized controlled drug trials for the treatment of TTH. Relaxation and cognitive behavioral therapies are effective. TTH in children and adolescents warrants greater recognition from the clinician and scientist. Studies focusing on TTH are overdue.

Headache prevalence and characteristics among adolescents in the general population: a comparison between retrospect questionnaire and prospective paper diary data

Background

In the present school-based study, a convenience sample of 237 adolescents in grade 6-9 and second year in high school (age 12-18 years) was recruited from a city and a smaller town. The aim of the study was to compare information on the prevalence and various characteristics of headaches not related to disease in a retrospect questionnaire and prospective daily recordings of headaches in a standard paper diary during a 3-week period.

Methods

Besides headache severity, number of headache days, intensity levels and duration of headache episodes were estimated with both assessment methods. Most of the school children suffered from tension-type headaches and a smaller portion of migraine attacks.

Results

The overall results showed that school children significantly (p < 0.001) overestimated headache intensity in questionnaires as compared to diary recordings, whereas they underestimated frequency (p < 0.001) and duration (p < 0.001) of headaches. While the correlations on headache severity, frequency and duration between retrospect information in questionnaires and prospective diary recordings were low, the agreement varied with levels of headache characteristics.

Conclusions

Our findings concur well with results from a few similar community studies on headache complaints in school-aged children. We recommend that prospective recordings in diaries should be systematically used in clinical practice but also in epidemiological surveys to increase the validity and reliability in estimates of point prevalence of headache complaints in children and adolescents.

Headache types, related morbidity, and quality of life in survivors of childhood acute lymphoblastic leukemia: a prospective cross sectional study

BACKGROUND

Increased headache prevalence was recently reported in survivors of childhood ALL. Headache sub types, related morbidity, and effect on quality of life has not been reported thus far.

OBJECTIVE

To study headache prevalence and type, related disability, and quality of life in a cohort of childhood acute lymphoblastic leukemia (ALL) survivors.

METHODS

Childhood ALL survivors in at least 1-year of remission and 5 years from diagnosis completed questionnaires and were evaluated by a neurologist. Disability was evaluated with Pediatric Migraine Disability Assessment scale and the Short Form-36 Health Survey assessed quality of life.

RESULTS

Thirty nine of 72 (54%) females and 37 of 90 (41%) males reported headaches. Median time from ALL diagnosis to first headache was 5.2 years and median age at headache onset was 10.1 years in 76 participants with headache. Migraine headaches were diagnosed in 51 (31%) and episodic tension-type headaches in 49 (30%); migraine and tension-type headaches co-existed in 24 (15%) and 18 (11%) participants had chronic daily headaches. Fatigue was associated with migraine headache while hypertension and female gender associated with tension type headache. Headache-related disability was mild in 22 (29%), moderate in 7 (9%), and severe in 5 (7%) survivors, and was absent in the remaining 42 (55%) survivors with headache. Both migraine and tension type headaches associated with reduced mental component scores, while headache related disability associated with a reduced physical component scores.

CONCLUSIONS

Headaches are common in ALL survivors but only a minority has significant disability or impairment of quality of life.

Risk factors for migraine and tension-type headache in 11 year old children

BACKGROUND

Though migraine and tension type headache are both commonly diagnosed in childhood, little is known about their determinants when diagnosed prior to puberty onset. Our aim was to determine psychosocial- and health-related risk factors of migraine and tension-type headache in 11 year old children.

METHODS

871 New Zealand European children were enrolled in a longitudinal study at birth and data were collected at birth, 1, 3.5, 7, and 11 years of age. Primary headache was determined at age 11 years based on the International Headache Society. Perinatal factors assessed were small for gestational age status, sex, maternal smoking during pregnancy, maternal perceived stress, and maternal school leaving age. Childhood factors assessed were sleep duration, percent body fat, television watching, parent and self-reported total problem behaviour, being bullied, and depression.

RESULTS

Prevalence of migraine and tension-type headache was 10.5% and 18.6%, respectively. Both migraine and TTH were significantly associated with self-reported problem behaviour in univariable logistic regression analyses. Additionally, migraine was associated with reduced sleep duration, and both sleep and behaviour problems remained significant after multivariable analyses. TTH was also significantly associated with antenatal maternal smoking, higher body fat, and being bullied. For TTH, problem behaviour measured at ages 3.5 and 11 years both remained significant after multivariable analysis. Being born small for gestational age was not associated with either headache group.

CONCLUSIONS

Although they share some commonality, migraine and tension-type headache are separate entities in childhood with different developmental characteristics. The association between primary headache and problem behaviour requires further investigation.

Relationship of childhood headaches with preferences in leisure time activities, depression, anxiety and eating habits: A population-based, cross-sectional study

OBJECTIVES

The objective of this article is to determine the relationship between headache frequency and socio-demographic data, personal characteristics, habits, daily activities, daily loss of ability, depression and anxiety in the headache subtypes in the pediatric population.

PATIENTS AND METHODS

Our sample group was composed of approximately 5355 children aged between 9 and 18 years. An eight-stage questionnaire was administered to the children. In the second stage of the study, headache subtypes were created according to the ICHD-II criteria. The resulting data were compared according to the results of the headache subtypes.

RESULTS

In school-age children, the prevalence of recurrent headaches was 39.4%, and the prevalence of migraine was 10.3%. The subjects with migraine mostly preferred sedentary activities in their leisure time, and preferred less exercise than the subjects with the other headache types. The PedMIDAS score of the children who preferred to play sports was significantly lower than those who did not prefer to play sports. In the group that preferred reading books, an opposite relationship was found. In overweight and obese migraine sufferers, other types of headache were found to be significantly higher.

CONCLUSIONS

In the management of treating childhood headaches, the association of psychiatric comorbidities should be considered. To minimize disability, children should be directed to more useful physical activities.

Neurologic morbidity and quality of life in survivors of childhood acute lymphoblastic leukemia: a prospective cross-sectional study

PURPOSE

Childhood acute lymphoblastic leukemia (ALL) is treated with potentially neurotoxic drugs and neurologic complications in long-term survivors are inadequately studied. This study investigated neurologic morbidity and its effect on quality of life in long-term survivors of childhood ALL.

METHODS

Prospective, single institution, cross-sectional, institutional review board-approved study of long-term ALL survivors. Participants were recruited from institutional clinics. Participants answered an investigator-administered questionnaire followed by evaluation by a neurologist. Quality of life (QOL) was also assessed.

RESULTS

Of the 162 participants recruited over a 3-year period, 83.3% reported at least one neurologic symptom of interest, 16.7% had single symptom, 11.1% had two symptoms, and 55.6% had three or more symptoms. Symptoms were mild and disability was low in the majority of participants with neurologic symptoms. Median age at ALL diagnosis was 3.9 years (0.4-18.6), median age at study enrollment was 15.7 years (6.9-28.9), and median time from completion of ALL therapy was 7.4 years (1.9-20.3). On multivariable analyses, female sex correlated with presence of dizziness, urinary incontinence, constipation, and neuropathy; use of ≥10 doses of triple intrathecal chemotherapy correlated with urinary incontinence, back pain, and neuropathy; cranial radiation with ataxia; history of ALL relapse with fatigue; and CNS leukemia at diagnosis with seizures. Decline in mental QOL was associated with migraine and tension type headaches, while physical QOL was impaired by presence of dizziness and falls. Overall, good QOL and physical function was maintained by a majority of participants.

CONCLUSIONS

Neurologic symptoms were present in 83% long-term ALL survivors. Symptoms related morbidity and QOL impairment is low in majority of survivors. Female sex, ≥10 doses of intrathecal chemotherapy, and history of ALL relapse predispose to impaired QOL.

IMPLICATIONS FOR CANCER SURVIVORS

This study will educate survivors and their care providers regarding cancer or treatment-related neurologic symptoms and morbidity. This study will help them understand factors contributing to impaired QOL when present.

Pediatric headache: where have we been and where do we need to be

In this article, we hope to summarize current understanding of pediatric headache. We discuss epidemiology, genetics, classification, diagnosis, outpatient, emergency and inpatient treatment options, prevention strategies, and behavioral approaches. For each section, we end with a series of questions for future research and consideration.

Complementary and conventional medicine use among youth with recurrent headaches

OBJECTIVE

To identify prevalence and patterns of complementary and alternative medicine (CAM) use among youth with recurrent headaches (HA) and evaluate associations with co-occurring health problems and limitations as well as with the use and expenditures for conventional medical care.

METHODS

Variables were constructed for youth aged 10 to 17 by using linked data from the 2007 National Health Interview Survey and the 2008 Medical Expenditures Panel Survey. Bivariate, logistic, and 2-part regression analyses were used.

RESULTS

Of the 10.6% of youth experiencing HA, 29.6% used CAM, rising to 41% for the many HA sufferers who also experienced difficulties with emotions, concentration, behavior, school attendance, or daily activities. Biologically based products (16.2%) and mind-body therapies (13.3%) were most commonly used, especially by the 86.4% of youth with HA experiencing at least 1 other chronic condition. Compared with non-CAM users, youth with HA who used CAM also had higher expenditures for and use of most types of conventional care.

CONCLUSIONS

CAM use is most common among youth with HA experiencing multiple chronic conditions and difficulties in daily functioning. Associations among CAM use, multiple chronic conditions, and higher use of conventional care highlight the need for medical providers to routinely ask about CAM use to meet the complex health needs of their patients and facilitate the optimal integration of care. Research is needed to identify models for coordinating complementary and conventional care within a medical home and to understand the health benefits or risks associated with CAM use in conjunction with conventional treatments for patients with HA.

Fifteen minute consultation: headache in children under 5 years of age

Headache occurring in children under the age of 5 years may cause a high level of anxiety in both parents and medical professionals. Crucial to a consultation about this problem will be to actively seek out clues to sinister pathologies, and investigate or reassure as appropriate. Making a positive diagnosis of a primary headache disorder where one exists is also important; however, in young children, headache does not always conform to well-established diagnostic criteria. This short guide provides a practical overview using the scenario of a new referral to the outpatient clinic.

A preliminary study on the relationship between central auditory processing and childhood primary headaches in the intercritical phase

BACKGROUND

Recently, an increasing number of articles have appeared on central auditory processing disorders, but in the literature there is only one study that evaluated the possible correlation between migraine in the critical phase and central auditory processing. The aim of our study was to assess the correlation between auditory processing information and childhood primary headaches in the intercritical phase.

METHODS

This is an observational study. We enrolled 54 patients, 30 with primary headache (migraine and tension headache) and 24 normal controls, matched for sex and age. The mean age at first observation was 9 years 10 months; the duration of observational follow-up was 2 years. Both groups had normal audiological and neurological profiles, normal peripheral hearing acuity and normal cognitive and behavioral skills. We excluded patients who had undergone pharmacological prophylactic treatment for headaches in the 6 months preceding the study and subjects with a frequency of headache lower than one every two months. After enrolment, both groups were analyzed with a computerized test battery for Speech Perception Tests in silence and in noise background to assess speech perception disabilities. In addition, with a test battery of Speech Perception Tests, we compared patients with migraines and tension-type headaches. The non-parametric χ2 test, the Mann-Whitney U-test and the Wilcoxon signed ranks test were used for statistical analysis. P-values <0.05 were considered significant and STATA 10 software was used for statistical analyses.

RESULTS

Our results showed that patients with primary headache (migraine and tension-type headache), had a deficit of auditory processing in noisy background compared to control cases, but we found no significant differences when we compared patients with migraine and tension-type headache.

CONCLUSIONS

This is a work in progress and further studies are needed to assess the relationship between the impairment of auditory processing and primary headache, not only to improve the diagnostic approach to primary headache, but also to improve therapeutic intervention.

Pain sensitivity and pericranial tenderness in children with tension-type headache: a controlled study

Purpose

To compare tenderness and pain sensitivity in children (aged 7–17 years) with tension-type headache (TTH) and healthy controls using total tenderness score (TTS), pressure pain threshold (PPT), and pain perceived at suprapressure pain threshold (supraPPT).

Patients and methods

Twenty-three children with frequent episodic TTH, 36 with chronic TTH, and 57 healthy controls were included. TTS was measured bilaterally at seven pericranial myofascial structures. PPT and supraPPT were assessed in the finger, m. temporalis, and m. trapezius by a Somedic® algometer. SupraPPT was defined as the pain perceived at a stimulus calculated as the individual site-specific PPT + 50%.

Statistics

The effect of group, sex, age, headache frequency, intensity, and years on TTS, PPT, and supraPPT was analyzed by general linear models. Confirmatory factor analysis was analyzed for mutual relations between measurements.

Results and conclusion

Tenderness increased uniformly in both frequent episodic TTH (median 14; interquartile range [IQR] 10–18; P < 0.001) and chronic TTH (median 13; IQR 9–20; P < 0.001) compared to controls (median 5, IQR 3–11). However, the children with frequent episodic TTH and chronic TTH did not show significantly increased sensitivity when measured by PPT or supraPPT. Factor analysis confirmed that the site-specific measurements depended on general latent variables. Consequently, the PPT and supraPPT tests can be assumed to measure central pain-processing levels.

Menstrual suppression in the adolescent

Menstrual suppression, the use of contraceptive methods to eliminate or decrease the frequency of menses, is often prescribed for adolescents to treat menstrual disorders or to accommodate patient preference. For young women using hormonal contraceptives, there is no medical indication for menstruation to occur monthly, and various hormonal contraceptives can be used to decrease the frequency of menstruation with different side effect profiles and rates of amenorrhea. This article reviews the different modalities for menstrual suppression, common conditions in adolescents which may improve with menstrual suppression, and strategies for managing common side effects.

Pharmacologic treatment of pediatric headaches: a meta-analysis

OBJECTIVE To assess the effectiveness of prophylactic headache treatment in children and adolescents. DATA SOURCES PubMed, EMBASE, Cochrane Database of Clinical Trials, and bibliography of retrieved articles through August 11, 2012. STUDY SELECTION Randomized trials of headache treatment among children and adolescents (&lt;18 years old). INTERVENTION Any placebo-controlled trial or comparisons between 2 or more active medications. MAIN OUTCOME MEASURE Number of headaches per month. RESULTS Among 21 included trials, there were 13 placebo-controlled and 10 active comparator trials (2 also included placebo). Twenty trials focused on episodic migraines and 1 on chronic daily headaches. Drugs more effective than placebo for episodic migraines (&lt;15 headaches per month) included topiramate (difference in headaches per month, -0.71; 95% CI, -1.19 to -0.24) and trazodone (-0.60; 95% CI, -1.09 to -0.11). Ineffective drugs included clonidine, flunarizine, pizotifen, propranolol, and valproate. A single trial of fluoxetine for chronic daily headaches found it ineffective. Patients given placebo experienced a significant (P = .03) decline in headaches, from 5.6 (95% CI, 4.52-6.77; Q = 8.14 [Cochran Q is a measure of the heterogeneity of the included studies]) to 2.9 headaches per month (95% CI, 1.66-4.08; Q = 4.72). Among the 10 active comparator trials, flunarizine was more effective than piracetam (difference in headaches per month, -2.20; 95% CI, -3.93 to -0.47) but no better than aspirin, dihydroergotamine, or propranolol. Propranolol was compared with valproate as well as behavioral treatment, and 2 studies compared different doses of topiramate; none of these trials showed significant differences. CONCLUSIONS Topiramate and trazodone have limited evidence supporting efficacy for episodic migraines. Placebo was effective in reducing headaches. Other commonly used drugs have no evidence supporting their use in children and adolescents. More research is needed.

Altered pain perception in children with chronic tension-type headache: is this a sign of central sensitisation?

AIM

The aim of this article is to investigate if children (7-17 years) with frequent episodic tension-type headache (FETTH) or chronic TTH (CTTH) have an altered pain perception compared to healthy controls.

METHODS

We applied a pressure of five increasing intensities to m. trapezius and m. temporalis with a Somedic Algometer II. Visual analogue scale-score was rated and area under the curve (AUC) calculated. An average AUC in each person was used as an outcome variable in further univariate multiple linear regression analysis because factor analysis showed that AUC represents only one dimension underlying both muscles.

RESULTS

Participants included 22 children with FETTH, 36 children with CTTH and 57 controls. The CTTH group had a significantly higher AUC compared to the control group ( P < 0.001). The FETTH group represented an intermediate state. AUC did not change with increasing age, headache years, headache intensity, headache frequency or sex.

CONCLUSION

Children with CTTH show significantly increased pain sensitivity in a range of pressures compared to the FETTH group and the controls. Since AUC in m. trapezius and m. temporalis represents only one general latent tenderness, it might indicate that the altered pain perception is mainly due to central sensitisation.

Reliability of four experimental mechanical pain tests in children

Purpose

In order to study pain in children, it is necessary to determine whether pain measurement tools used in adults are reliable measurements in children. The aim of this study was to explore the intrasession reliability of pressure pain thresholds (PPT) in healthy children. Furthermore, the aim was also to study the intersession reliability of the following four tests: (1) Total Tenderness Score; (2) PPT; (3) Visual Analog Scale score at suprapressure pain threshold; and (4) area under the curve (stimulus–response functions for pressure versus pain).

Participants and methods

Twenty-five healthy school children, 8–14 years of age, participated. Test 2, PPT, was repeated three times at 2 minute intervals on the same day to estimate PPT intrasession reliability using Cronbach’s alpha. Tests 1–4 were repeated after median 21 (interquartile range 10.5–22) days, and Pearson’s correlation coefficient was used to describe the intersession reliability.

Results

The PPT test was precise and reliable (Cronbach’s alpha ≥ 0.92). All tests showed a good to excellent correlation between days (intersessions r = 0.66–0.81). There were no indications of significant systematic differences found in any of the four tests between days.

Conclusion

All tests seemed to be reliable measurements in pain evaluation in healthy children aged 8–14 years. Given the small sample size, this conclusion needs to be confirmed in future studies.

Validation of a migraine interview for children and adolescents

OBJECTIVE

To date there are no structured interviews to ascertain the diagnostic criteria for headache in children. The objective of this study was to assess the validity of the Diagnostic Interview of Headache Syndromes-Child Version (DIHS-C), which was developed at the National Institute of Mental Health for a community-based family study of headache syndromes and comorbid disorders.

METHODS

The DIHS-C is a fully structured diagnostic interview composed of an open-ended clinical history, modules with key symptoms for each of the major headache subtypes, and associated impairment, duration, frequency, course, and treatment. This article presents the validation of the interview in a sample of 104 children evaluated as part of a community-based family study of migraine.

RESULTS

The sensitivity of interview diagnosis compared with an expert neurologist's diagnosis of migraine was 98%, and the specificity was 61%. Similar levels of sensitivity and specificity were found by gender and age of the children.

CONCLUSIONS

The DIHS-C provides a new tool that can enhance the reliability of pediatric diagnoses in both clinical and community settings.

Tension-type headache

PURPOSE OF REVIEW

This article provides an update on the appropriate diagnosis and evaluation of patients with tension-type headache, with reviews of the latest concepts regarding pathogenesis and the evidence-based recommendations for management of this disorder.

RECENT FINDINGS

Pericranial myofascial mechanisms are probably of importance in episodic tension-type headache, whereas sensitization of central nociceptive pathways and inadequate endogenous antinociceptive circuitry seem to be more relevant in chronic tension-type headache. While acute treatment with simple analgesics is generally helpful, recent data attempting to document the efficacy of preventive therapies are unconvincing.

SUMMARY

Tension-type headache is the most common form of headache in the general population. It is characterized by recurrent episodes of headache that are relatively featureless and mild to moderate in intensity. The diagnosis is based solely on the history and examination. Exclusion of secondary headaches or forms of migraine is important in the assessment process. Despite extensive investigation, the underlying pathophysiology remains a matter of speculation, with peripheral muscular and CNS components both likely involved. Acute management with simple analgesics, nonsteroidal anti-inflammatory drugs, and caffeine-containing compounds is typically effective. Preventive therapies include a number of nonpharmacologic recommendations as well as several antidepressant drugs. Prognosis is generally favorable.

Headache prevalence and characteristics among school children as assessed by prospective paper diary recordings

In the present school-based study, a convenience sample of 477 students in grades 6-9 and second year in high school from a city and a smaller town recorded daily occurrence and intensity of headaches in a standard paper diary during a 3-week period. Total headache activity (headache sum), number of headache days, intensity level and duration for weekly headaches were estimated. Approximately 85% of the adolescents had experienced headache of any intensity level during the 3-week recording period. On the average, they reported 2.5 headache days per week and a mean intensity level for headache episodes of 1.7. Our estimates for headache of any intensity level (1-5) occurring at least once a week was surprisingly high (73.8%). For the highest intensity level across the whole 3-week period, almost identical proportions of mild and moderate headaches were reported by students (22.3-22.5%), while about twice as many (40.7%) had experienced severe headaches. Girls consistently reported more headaches than boys, in particular of the moderate and severe intensity types. Students in the city also reported more frequent and intense headaches than those in the town. Peak headache activity was observed at noon and in the afternoon and in the days from the middle of the week until weekend. The use of prospective recordings in diaries will further advance our knowledge on the prevalence and characteristics of recurrent headaches among children and adolescents in community samples.

Perceived teacher unfairness and headache in adolescence: a cross-national comparison

OBJECTIVES: The present study examines the prevalence of headache in early adolescents in 21 European and North-American countries and the role of perceived teacher unfairness in predicting this health complaint across different countries. METHODS: Data were taken from the "Health Behaviour in School-aged Children" study (HBSC), a World Health Organization cross-national survey on health behaviors in 11-, 13- and 15-year-old students. Headache and perceived teacher unfairness were measured through a self-administered questionnaire filled out by 115,212 adolescents. RESULTS: The overall prevalence of frequent headaches (at least once a week) was 28.8%, ranging from 18.9% in Slovenia to 49.4% in Israel. After adjusting for gender, grade, family affluence, school achievement, being bullied and lifestyles (drinking, smoking, eating and physical activity), teacher unfairness showed a significant association with frequent headache in all but two countries (Ukraine and Luxembourg). CONCLUSIONS: Our results show that headache is a common health symptom in European and North-American countries, even though there are substantial differences in its prevalence across countries. The study indicates that perceived teacher unfairness can be a significant predictor of frequent headache during adolescence, and this association is consistent across countries.

Parent-child agreement in the reporting of headaches in a national sample of adolescents

The aim of this article is to assess the concordance between parent and adolescent headache ratings in a representative sample of 6483 US adolescents (aged 13-18 years). Headaches were assessed using modified criteria from the International Headache Society's International Classification of Headache Disorders, Second Edition. Caregiver report was based on a self-administered questionnaire. Overall concordance between caregivers and adolescents on the presence or absence of headaches was quite low (κ = 0.39). Female caregivers were twice as likely as male caregivers to report headaches in their offspring. Positive endorsement of headaches in offspring by caregivers was associated with adolescent-reported chronic headaches, longer headache duration, and photophobia or phonophobia. These findings suggest that relying solely on parent report may result in an underestimate of the true prevalence of headaches in the general population. In addition, collecting information from both parents and adolescents could be critical to effective treatment and prevention of the severe consequences of migraine.

Genetic contribution of catechol-O-methyltransferase polymorphism (Val158Met) in children with chronic tension-type headache

Our aim was to investigate the relationship between Val158Met polymorphisms, headache, and pressure hypersensitivity in children with chronic tension-type headache (CTTH). A case-control study with blinded assessor was conducted. Seventy children with CTTH associated with pericranial tenderness and 70 healthy children participated. After amplifying Val158Met polymorphism by polymerase chain reactions, we assessed genotype frequencies and allele distributions. We classified children according to their Val158Met polymorphism: Val/Val, Val/Met, Met/Met. Pressure pain thresholds (PPT) were bilaterally assessed over the temporalis, upper trapezius, second metacarpal, and tibialis anterior muscles. The distribution of Val158Met genotypes was not significantly different (p = 0.335), between children with CTTH and healthy children, and between boys and girls (p = 0.872). Children with CTTH with the Met/Met genotype showed a longer headache history compared with those with Met/Val (p = 0.001) or Val/Val (p = 0.002) genotype. Children with CTTH with Met/Met genotype showed lower PPT over upper trapezius and temporalis muscles than children with CTTH with Met/Val or Val/Val genotype (p < 0.01). The Val158Met catechol-O-methyltransferase (COMT) polymorphism does not appear to be involved in predisposition to suffer from CTTH in children; nevertheless, this genetic factor may be involved in the phenotypic expression, as pressure hypersensitivity was greater in those CTTH children with the Met/Met genotype.

Tension-type headache in paediatric age

The aim of this paper is to review the main topics about the management of paediatric tension-type headache. A Medline search was undertaken of all reports and reviews published between 1990 and 2010 using MeSH search terms 'tension-type headache (TTH), 'treatment' and 'children'. TTH is a very common disorder in childhood and adolescents. In many cases, the frequency and intensity of episodes may be likely to interfere with school and social activities. For this reason, a correct diagnosis and appropriate management of TTH are essential. A detailed history and proper examination, as well as a headache diary, are essential for this purpose and help to distinguish secondary causes of headache. Lacking are studies to test the efficacy and safety of pharmacological treatment in children, and a few well-tested drugs are available for this purpose. To date, relaxation techniques and biofeedback are therefore best placed as the first-line therapies.

CONCLUSION

A thorough evaluation of headache in paediatric age is necessary to make a correct diagnosis and start the appropriate treatment. In particular, an appropriate management requires an individually tailored strategy which should include both pharmacological and nonpharmacological therapies. New treatment options for elderly patients with headache including acute, prophylactic and interventional techniques are needed.

Referred pain from myofascial trigger points in head and neck-shoulder muscles reproduces head pain features in children with chronic tension type headache

Our aim was to describe the referred pain pattern and areas from trigger points (TrPs) in head, neck, and shoulder muscles in children with chronic tension type headache (CTTH). Fifty children (14 boys, 36 girls, mean age: 8 ± 2) with CTTH and 50 age- and sex- matched children participated. Bilateral temporalis, masseter, superior oblique, upper trapezius, sternocleidomastoid, suboccipital, and levator scapula muscles were examined for TrPs by an assessor blinded to the children's condition. TrPs were identified with palpation and considered active when local and referred pains reproduce headache pain attacks. The referred pain areas were drawn on anatomical maps, digitalized, and also measured. The total number of TrPs was significantly greater in children with CTTH as compared to healthy children (P < 0.001). Active TrPs were only present in children with CTTH (P < 0.001). Within children with CTTH, a significant positive association between the number of active TrPs and headache duration (r (s) = 0.315; P = 0.026) was observed: the greater the number of active TrPs, the longer the duration of headache attack. Significant differences in referred pain areas between groups (P < 0.001) and muscles (P < 0.001) were found: the referred pain areas were larger in CTTH children (P < 0.001), and the referred pain area elicited by suboccipital TrPs was larger than the referred pain from the remaining TrPs (P < 0.001). Significant positive correlations between some headache clinical parameters and the size of the referred pain area were found. Our results showed that the local and referred pains elicited from active TrPs in head, neck and shoulder shared similar pain pattern as spontaneous CTTH in children, supporting a relevant role of active TrPs in CTTH in children.

Association between blood pressure measures and recurrent headache in adolescents: cross-sectional data from the HUNT-Youth study

The relationship between blood pressure and headache in youth has not been explored and the objective of the present study was to provide data on this association in an adolescent population. Cross-sectional data from a large population-based survey, the Young-HUNT study, on 5,847 adolescents were used to evaluate the association between blood pressure (systolic, diastolic, mean arterial and pulse pressure) and recurrent headache, including migraine and tension-type headache. Increasing pulse pressure was inversely related to recurrent headache prevalence, and both tension-type headache and migraine. For systolic blood pressure such an inverse relationship was present for recurrent headache and tension-type headache prevalence. For migraine, the results were not significant, although there was a tendency in the same direction (p = 0.05). High-pulse pressure has previously been found to be inversely related to the prevalence of migraine and tension-type headache in an adult population. This inverse relationship has now been demonstrated to be present among adolescents also, supporting the results from a previous study in adults, that blood pressure regulation may be linked to the pathophysiology of headache.

Overview of diagnosis and management of paediatric headache. Part I: diagnosis

Headache is the most common somatic complaint in children and adolescents. The evaluation should include detailed history of children and adolescents completed by detailed general and neurological examinations. Moreover, the possible role of psychological factors, life events and excessively stressful lifestyle in influencing recurrent headache need to be checked. The choice of laboratory tests rests on the differential diagnosis suggested by the history, the character and temporal pattern of the headache, and the physical and neurological examinations. Subjects who have any signs or symptoms of focal/progressive neurological disturbances should be investigated by neuroimaging techniques. The electroencephalogram and other neurophysiological examinations are of limited value in the routine evaluation of headaches. In a primary headache disorder, headache itself is the illness and headache is not attributed to any other disorder (e.g. migraine, tension-type headache, cluster headache and other trigeminal autonomic cephalgias). In secondary headache disorders, headache is the symptom of identifiable structural, metabolic or other abnormality. Red flags include the first or worst headache ever in the life, recent headache onset, increasing severity or frequency, occipital location, awakening from sleep because of headache, headache occurring exclusively in the morning associated with severe vomiting and headache associated with straining. Thus, the differential diagnosis between primary and secondary headaches rests mainly on clinical criteria. A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment, bearing in mind that children with headache are more likely to experience psychosocial adversity and to grow up with an excess of both headache and other physical and psychiatric symptoms and this creates an important healthcare problem for their future life.

Overview of diagnosis and management of paediatric headache. Part II: therapeutic management

A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment. In part 1 of this article (Özge et al. in J Headache Pain, 2010), we reviewed the diagnosis of headache in children and adolescents. In the present part, we will discuss therapeutic management of primary headaches. An appropriate management requires an individually tailored strategy giving due consideration to both non-pharmacological and pharmacological measures. Non-pharmacological treatments include relaxation training, biofeedback training, cognitive-behavioural therapy, different psychotherapeutic approaches or combinations of these treatments. The data supporting the effectiveness of these therapies are less clear-cut in children than in adults, but that is also true for the data supporting medical treatment. Management of migraine and TTH should include strategies relating to daily living activities, family relationships, school, friends and leisure time activities. In the pharmacological treatment age and gender of children, headache diagnosis, comorbidities and side effects of medication must be considered. The goal of symptomatic treatment should be a quick response with return to normal activity and without relapse. The drug should be taken as early as possible and in the appropriate dosage. Supplementary measures such as rest in a quiet, darkened room is recommended. Pharmaco-prophylaxis is only indicated if lifestyle modification and non-pharmacological prophylaxis alone are not effective. Although many prophylactic medications have been tried in paediatric migraine, there are only a few medications that have been studied in controlled trials. Multidisciplinary treatment is an effective strategy for children and adolescents with improvement of multiple outcome variants including frequency and severity of headache and school days missed because of headache. As a growing problem both children and families should be informed about medication overuse and the children's drug-taking should be checked.

Guidelines for controlled trials of drugs in tension-type headache: second edition

The Clinical Trials Subcommittee of the International Headache Society published its first edition of the guidelines on controlled trials of drugs in tension-type headache in 1995. These aimed 'to improve the quality of controlled clinical trials in tension-type headache', because 'good quality controlled trials are the only way to convincingly demonstrate the efficacy of a drug, and form the basis for international agreement on drug therapy'. The Committee published similar guidelines for clinical trials in migraine and cluster headache. Since 1995 several studies on the treatment of episodic and chronic tension-type headache have been published, providing new information on trial methodology for this disorder. Furthermore, the classification of the headaches, including tension-type headache, has been revised. These developments support the need for also revising the guidelines for drug treatments in tension-type headache. These Guidelines are intended to assist in the design of well-controlled clinical trials in tension-type headache.