Headache etiology in children: a retrospective study of 125 cases

Retrospective Observational Study Amidst Myriad Conundrums and Myths of Pediatric Headaches: A Critique on Diagnostics and Effectiveness of Interventions

Objective To study the etiological profile of pediatric headaches (PH) in a tertiary child neurology clinic and to determine the utility of diagnostics, interventions, and long-term prognosis. Methods Children (ages 4-15) observed over four years were recruited retrospectively. In primary headaches, the headache frequency and impact on quality of life (QOL) parameters at pre-treatment (T1) were compared post-treatment at follow-up (T2). Results Of the 311 eligible patients, 285 had primary headaches (Tension-Type Headache {TTH}: 156; Migraine: 129), and 26 had secondary headaches. The mean (±SD) onset age was 10 (±3) years with a male-to-female ratio of 2.3:1. Migraine was more common in children aged less than seven years (17/28) and TTH in older patients (146/283). The most common causes of secondary headache were intracranial hypertension (ICH) in 11/26 patients (four idiopathic intracranial hypertension (IIH), four following aseptic meningitis, three with cortical vein thrombosis), and ophthalmologic causes in 7/26 (of these five had convergence insufficiency). Hypertension was a rare cause of secondary headaches (2/26 patients). Neuroimaging was performed in 173/311 (56%), primarily for parental anxiety (160/173; 92%), and was abnormal in only four. At T2 (Median time to follow-up: 29 months; Interquartile range: 22-37 months), data were collected in 207/285 patients with primary headaches (TTH: 109; Migraine: 98). In both migraine and TTH groups, there were statistically significant reductions (p-value <0.0001) in headache frequency and QOL parameters. Conclusion In our study, TTH was the most common cause of PH. Neuroimaging was normal in most cases. Psychological interventions were effective but underutilized. The symptoms of primary headaches improved significantly over time, despite poor adherence to prophylactic medications.

Diagnostic Yield of Neuroimaging and Electroencephalography in Children with Recurrent Headaches

Neuroimaging and electroencephalography (EEG) are commonly used for pediatric recurrent headache evaluation, although not routinely recommended. In this study, data of 517 children with recurrent headaches were analyzed to evaluate the diagnostic yield of neuroimaging and EEG. Neuroimaging was performed in 55% (n = 283) of children, 61% with magnetic resonance imaging and 39% with computed tomography. Abnormal findings were reported in 17% (n = 48), and 5% (n = 13) were significant abnormalities altering headache management. Among children with significant imaging abnormalities, 85% had alarming signs on history, physical, or neurological examination. The diagnostic yield of imaging was 0.7% (n = 2), picking a cavernous hemangioma and a giant arachnoid cyst. EEG was performed in 69% (n = 356) of children, significant findings were reported in 8% (n = 29), with sharp waves/spikes in 4.1% (n = 15), and intermittent focal slow waves in 3.9% (n = 14). EEG was diagnostic for epilepsy in 1.6% (n = 6) of children with recurrent headaches. When there are no red flags on history or physical examination, diagnostic yield of neuroimaging is low for pediatric recurrent headaches. EEG can be helpful in selective cases, and when performed during and at headache-free periods.

Electronic Screen Exposure and Headache in Children

Headache represents the most common neurologic disorder in the general population including children and is increasingly being recognized as a major source of morbidity in youth related to missed school days and activities. Electronic screens are becoming increasingly important in the lives of preteens and teens. In this review, we discussed effects of electronic screens on primary headache in childhood to emphasize the importance of electronic screen exposure in children with headache. Using digital and social media can bring some benefits and risks for mental and physical health. Time spent on screen-based activities contributes to the chance of reporting general physical complaints, in particular, headache and backache during early adolescence. We suggest that all children with primary headache should be evaluated for abuse of electronic screens in neurology practice. We also think that restriction of electronic screen should be advised in children with migraine and tension type headache before initiation of pharmacotherapy. As online classes are a reality, use of electronic screen may be allowed for school age children up to 2 h/day with taking time away from digital media every 20 min for 20 sec. In conclusion, we would like to emphasize that limiting the time spent on the screen is important for the reduction of headache symptoms of children and adolescents.

Brain Imaging Findings in Children with Headache

Background:

Headache is a common problem in children, but a small percentage of them have positive findings on CT scan and MRI, and considering that CT scan and MRI is costly and risks of radiation is high for children. Therefore the aim of this study is evaluating CT scans and MRI finding in children with headache.

Materials and Methods:

This cross-sectional study was performed on 353 children with headaches that 217 patients underwent CT and 136 patients underwent MRI. The data collected through the report sheet of CT scan and MRI and analyzed using SPSS software and chi-square test.

Results:

According to the study, 88.9% of MRI and 75.7% of CT scan were normal. Abnormal findings on CT scan was significantly higher in boys (12.2% vs. 9.5%) (P= 0.03) and it was determined that MRI findings was also significantly higher in boys (26.3% vs. 21.5%) (P=0.04). The most common abnormal findings on CT scan was mass (16.6%) and hematoma (16.6%) and the most common abnormal findings on MRI was cysts (26.3%).

Conclusion:

The results of our study showed that the majority of imaging results in patients with headache was normal or benign lesions. Therefore, imaging should be performed only in children with abnormal findings on physical examination.

Primary headaches in pediatric patients with chronic rheumatic disease

OBJECTIVES

To assess the presence, prevalence and clinical characteristics of primary headaches in pediatric patients with chronic rheumatic diseases such as juvenile idiopathic arthritis (JIA) and familial Mediterranean fever (FMF), and to analyze the common pathophysiological mechanisms.

STUDY DESIGN

In this noncontrolled, cross-sectional study, a semi-structured 53 item headache questionnaire was administered to subjects with FMF and JIA, and interviewed a total sample size of 601 patients younger than16years of age. The questionnaires were then analyzed according to the International Headache Society's diagnostic criteria.

RESULTS

Children with FMF (n=378) and JIA (n=223) were studied. Each group was then divided into two subgroups according to whether the subjects reported headache or not. 29.5% of subjects with FMF reported having migraine, 37.6% probable migraine and 32.9% tension type headache (TTH). In JIA group 28.2% were diagnosed with migraine; 41.2% with probable migraine and 30.6% with TTH. No significant difference was found between all subjects with (n=258) and without (n=343) headache for variables such as living in a crowded family (p=0.95), being the first child in the family (p=0.63), academic achievement of the child (p=0.63), high education level (higher than high school) of the mother (p=0.52) and father (p=0.46). The presence of systemic disease was reported not to be effecting the daily life at the time of evaluation by 90.2% of the children with headache and 91.0% of the children without headache (p=0.94). 81.4% of the children reported their headaches were not aggravating with the exacerbation periods of their systemic disease. Family history of hypertension was reported higher by the subjects with headache (13.5% with headache and 4.0% without headache p=0.001). Diabetes mellitus was also reported higher (5.8% with headache; 0.5% without headache; p=0.006). Family history of headache was reported in 28.2% of the patients with headache whereas it was 17.4% of the patients without headache (p<0.001). Family history of headache was reported in 28.2% of the FMF subjects with headache whereas it was 17.4% of the patients without headache (p<0.001). For JIA patients a positive family history for headache was obtained in 25.9% of children with headache notably in migraineurs (81.8%).

CONCLUSION

Patients with JIA and FMF should be asked specifically about accompanying primary headaches particularly migraine headaches as they may be additional disabilities for these patients.

Childhood headaches and brain magnetic resonance imaging findings

BACKGROUND

Headaches are common in children and brain magnetic resonance imaging (MRI) studies are widely used in everyday clinical practice because of increasing demands by parents.

AIM

To determine headache types and to evaluate the frequency and clinical significance of brain MRI abnormalities in children with headache.

METHODS

A total of 449 children (261 male and 188 female with a mean age of 11.16 ± 3.22 years) with headache were included into the study. The criteria defined by International Headache Society were used to classify the headache types.

RESULTS

The causes of headache were migraine in 247 (55.0%), tension-type in 133 (29.6%), secondary in 48 (10.7%), and unspecified headaches in 21 (4.7%) patients. Overall, 324 (72.2%) patients underwent cerebral MRI, which revealed abnormalities in 68 (21.0%) patients. Two (0.6%) patients had cerebral MRI abnormalities relevant to headache, including tumor and hydrocephalus each 1 (0.3%). Twenty-nine (8.9%) patients had incidental cerebral MRI abnormalities including 14 (4.3%) white-matter hyperintensities, 4 (1.2%) old infarcts, 3 (0.9%) Chiari malformations, arachnoid cysts and demyelinating lesions each 2 (0.6%), and subdural hygroma, fibrous dysplasia, pineal cyst and perivascular widening, each 1 (0.3%). Remaining 36 (11.1%) patients had extra-cerebral MRI abnormalities including 34 (10.5%) sinus disease, and 2 (0.6%) adenoid vegetation. Indications for brain MRI were atypical headache pattern or presence of neurologic abnormalities in 59 (18.2%) patients and parents' concerns in 265 (81.8%) patients. The rates of abnormal MRI findings were similar between these 2 groups.

CONCLUSIONS

The most frequent cause of headache in children is migraine. Despite the high rate of imaging abnormalities, the yield of brain MRI is not contributory to the diagnostic and therapeutic approach.

Primary headache disorders in children under 7 years of age

Background and aim

Research on headache disorders in young children is limited. This study aims to determine causes and clinical presentations of headache in young children attending a specialist clinic.

Methods and results

All children attending the headache clinic over 9-year period were included. Data were collected prospectively on demography and clinical presentations of headache at every attendance. The diagnosis of headache disorders was based on the International Classification of Headache Disorders-II (2004). Of the 921 children (491 male) who attended the clinic, 73 children (8%) were under 7 years of age at presentation; 34 children had migraine, 11 had tension-type headache (4 chronic), 4 had mixed types of headache and 16 children had unclassified headaches. Anorexia, nausea, vomiting, light intolerance and noise intolerance were common during migraine attacks and forehead was the most common site of maximal pain.

Conclusions

Migraine is the most common headache disorder in young children attending a specialist clinic. Headache presentation is often atypical and in 20% of young children headache disorders are unclassified. Chronic tension-type headache, often considered a disease of adolescents and adults, is shown to present in early age.

Profile of children with migraine

OBJECTIVE

To assess the clinical characteristics of patients with migraine.

METHODS

The medical records of 76 patients diagnosed with migraine were reviewed using the ICHD-II 2004 diagnosis criteria. The patients were classified into three age groups: 3-6 yr olds (group I), 7-12 yr olds (group II), and 13-17 yr olds (group III).

RESULTS

Migraine was the most common cause of headache in the patients of present pediatric neurology outpatient clinic (57.1%, 76/133). The mean age of patients was 11.08 ± 3.27 (3.25-17) yrs. The number of girls as the age increased (groups II and III). The mean headache attacks rate was 2.5 ± 1.5 per wk, which resulted in worsening of school performance (n = 26, 34.2%). In the majority of patients (n = 54, 71.1%), there was a family history of migraine or headache in the close relatives. Prophylaxis was found effective for all given medications (flunarizine: 46/54, propranolol: 19/21, topiramate: 10/10, sodium valproate: 1/1).

CONCLUSIONS

These findings indicate that: (a) migraine is the most frequent cause of headache in pediatric patients, (b) it has negative effects on school performance and daily activities, (c) the family history is important for making the diagnosis and (d) prophylaxis is significantly effective.

Off-Therapy Headaches in Pediatric Brain Tumor Patients: A Retrospective Review

To determine the incidence, timing, and characteristics of headaches in a population of off-therapy pediatric brain tumor patients, a retrospective chart review was conducted on 3 subpopulations of children followed in a multidisciplinary neuro-oncology clinic in the Southeastern United States. Data collected included tumor type and location, treatment, associated symptoms, and description and timing of headaches. In all, 81 charts were reviewed from which headaches in 3 subtypes of tumors were identified (29 medulloblastomas, 36 cerebellar juvenile pilocytic astrocytomas [JPAs], and 16 craniopharyngiomas). Off-therapy headaches were noted in 6 (21%) of medulloblastomas, 10 (28%) of JPAs, and 19 (56%) of craniopharyngiomas. Almost half of those patients with prediagnosis headaches had recurrent off-therapy headaches. Given the incidence of this symptom, headache must be highlighted in posttreatment and late effects monitoring.Whether provided by the oncology team or primary care provider, headache assessment, treatment, and prevention counseling can be improved through utilization of newly developed tools and written educational materials. Experienced nurses can play key roles in this aspect of posttreatment pediatric care of brain tumor patients.

Superficial temporal artery-middle cerebral artery bypass surgery in a pediatric giant intracranial aneurysm presenting as migraine-like episodes

INTRODUCTION

Aneurysms of the intracranial arteries in the pediatric population are reportedly rare. There is a male predominance, association with connective tissue disorders, as well as bacterial, mycotic infections, and trauma.

RESULTS AND DISCUSSION

Common sites of presentation are the internal carotid artery bifurcation, posterior circulation, and distal segment of middle cerebral artery. Clinical manifestations can vary from seizures and subarachnoidal hemorrhage to headache, irritability, lethargy, vomiting, or focal motor deficits. Current treatment modalities encompass endovascular or surgical approach.

CONCLUSION

We present a case report on an 11-year-old girl with migraine-like episodes due to an underlying giant fusiform middle cerebral artery aneurysm treated successfully with two superficial temporal artery-middle cerebral artery bypasses.

Psychiatric morbidity in children with medically unexplained chronic pain: diagnosis from the pediatrician's perspective

CONTEXT

There is very little general evidence to support the clinical management, particularly diagnosis, of medically unexplained chronic pain (UCP) in children.

OBJECTIVE

We sought to assess in children with UCP if clinical characteristics held important by general pediatricians help to accurately diagnose psychiatric morbidity and, alternatively, if the same can be achieved using dedicated questionnaires.

METHODS

We used a cross-sectional diagnostic study in a pediatric outpatient clinic of a university hospital. Our participants were 134 patients, aged 8 to 18 years, who were referred for UCP. Performed were (1) diagnostic test reflecting the pediatricians' choice of clinical characteristics and (2) selected questionnaires. Classification was performed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, by a child psychiatrist using the Diagnostic Interview Schedule for Children-Parent Version IV and the Semi-structured Clinical Interview for Children and Adolescents. Results were analyzed by logistic regression.

RESULTS

Psychiatric morbidity was present in 80 of the children. A minority had a medical explanation for the pain (15% definite, 17% probable). The clinical diagnostic model included age, social-problem indicators, family structure, parental somatization, and school problems. In the quintile of children in whom this model predicted the highest risk, 93% indeed had psychiatric morbidity at reference testing. In the quintile with the lowest predicted risk, indeed only 27% had psychiatric morbidity. The Dutch Personality Inventory for Youth and the Child Behavior Checklist matched the pediatricians' choice of clinical characteristics. In the quintile of children with the highest predicted risk based on these questionnaires, 89% had psychiatric morbidity. In the quintile with the lowest predicted risk, only 15% had psychiatric morbidity.

CONCLUSIONS

A pediatrician-chosen set of clinical characteristics of children with UCP proves useful in diagnosing psychiatric morbidity. Using selected questionnaire screening yields similar results.

Prevalence and factors affecting headache in Turkish schoolchildren

BACKGROUND

Headache is a public health problem affecting life quality negatively. The present cross-sectional, selective (2nd-5th grades) study was conducted to determine the prevalence of recurrent headache in schoolchildren in Mersin, a city of Turkey.

METHODS

A stratified sample of 5777 students was selected to be representative of the city's schoolchildren population. After the data quality control process, the study sample was reduced to 5562 schoolchildren.

RESULT

The prevalence of recurrent headache was 49.2% (2739/5562). Among the studied population 24.7% had tension-type headache and 10.4% had migraine. Girls had significantly more frequent headache than boys. Binary logistic regression analysis found that increasing age, female gender, low socioeconomic status of family, low education level of mother, and positive family history of headache (father, mother, siblings, second degree relatives) had a statistically significant effect on the presence of headache in children. Additionally, having travel sickness had a statistically significant effect on schoolchildren headache (P = 0.000).

CONCLUSION

Headache is a common health problem among schoolchildren in Mersin, which merits increased attention and detailed multicentre epidemiological and clinical studies.

Cefaleas agudas recurrentes: características clínicas y epidemiológicas

OBJECTIVE

To analyze the epidemiological and clinical characteristics of migraine and tension-type headache in the pediatric age group with the aim of facilitating their differential diagnosis in clinical practice.

PATIENTS AND METHODS

Information on epidemiological and clinical characteristics, physical examination and complementary examinations, if performed, was collected from the medical records of 225 children with acute recurrent headache. The criteria defined by the International Headache Society (IHS) were used in the diagnosis.

RESULTS

A total of 98.2 % of the patients had primary headache: migraine (48.9 %), tension-type headache (48.4 %) and mixed (0.9 %). Thirty percent of those with migraine had migraine with aura. The mean age at onset was 8.6 6 2.9 years in migraine and 9.7 6 2.5 years in tension-type headache (p < 0.05), with no differences between sexes. Children with tension-type headache showed a greater prevalence (p < 0.05) of female sex, urban origin and excellent academic performance. Children with migraine had a greater prevalence (p < 0.05) of positive family history. Migraine headaches were unilateral (44.1 %) or bilateral (55.9 %), pulsating (77.1 %), aggravated by physical activity (68.8 %), caused lost days at school (65.3 %) and were usually accompanied by vomiting (71 %) and photophobia/sonophobia (67 %). Tension-type headaches were bilateral (81.8 %) and oppressive (85.3 %), were less frequently aggravated by physical activity (11.8 %) or interrupted activities (11.8 %) and were occasionally accompanied by vomiting (7.3 %) and photophobia/sonophobia (21.8 %). Electroencephalogram and brain computed tomography scan were performed in 21 % and 39.1 % of the patients, respectively, without changing their diagnosis.

CONCLUSIONS

Migraine and tension-type headaches are a common cause of recurrent headache in the pediatric age group. Onset usually occurs in school-aged children. The IHS criteria for the differential diagnosis of headache in children are useful, although follow-up is the gold standard to validate diagnostic criteria.

Nasal obstruction and headache. A real correlation?

OBJECTIVE

to evaluate the relationships between headache and nasal obstruction or nasal allergy on a group of Italian school children.

METHODS

One hundred twenty-six children suffering from headache, were enrolled in the study. All patients underwent an accurate clinical history, a complete ENT objective examination, an Anterior Active Rhinomanometry, an analysis of nasal mucociliary transport time and a skin test on the inner forearm.

RESULTS

Nasal resistances were increased in 101 out of 105 of children (96.2%) affected by severe headache (group A) and in 5 out of 21 (23.8%) of those affected by sporadic headache (P < 0.0001), for an odds ratio of 80.0 (95% CI, 19-343). The analysis of mucociliary transport time offered results comparable with those of the Anterior Active Rhinomanometry.

CONCLUSIONS

Dysfunctions of nasal physiology, as stated by the alteration of nasal resistances and nasal mucociliary transport, seem to be able to affect the development and the characteristics of headaches; specifically we found that children with an altered nasal physiology have more severe and more frequent attacks of headache.

Children with unexplained chronic pain: do pediatricians agree regarding the diagnostic approach and presumed primary cause?

OBJECTIVE

To investigate the opinions of general pediatricians regarding children with unexplained chronic pain (UCP), with respect to the presumed cause of the pain and the optimal diagnostic approach for these children.

DESIGN

Diagnostic follow-up study.

SETTING

Outpatient clinic of a university children's hospital.

PARTICIPANTS

A total of 134 consecutive patients, 8 to 18 years of age, referred for pain of > or =3-month duration without a satisfactory explanation at presentation.

METHODS

A full copy of the patient records from routine medical practice and data from standardized psychiatric assessments, standardized questionnaires, and standardized follow-up assessments were provided to 17 pediatricians assigned to 3 panels.

MAIN OUTCOME MEASURES

Agreement regarding the presumed primary cause and diagnostic approach for children with UCP, with consensus being defined as > or =80% agreement among the pediatricians.

RESULTS

The mean age of the children (73% girls) was 11.8 years (SD: 2.6 years). Psychiatric (co)morbidity was present for 60% of the children. Consensus regarding the presumed primary cause was reached for 43% of the patients (58 of 134 patients), ie, 72% (42 of 58 patients) primarily dysfunctional, 17% (10 of 58 patients) primarily psychologic, and 10% (6 of 58 patients) primarily somatic. Consensus regarding the diagnostic approach was reached for 63% of the children (84 of 134 children), leaving more than one-third of the children (37%) without diagnostic consensus.

CONCLUSIONS

The relatively high rates of disagreement regarding the optimal diagnostic approach and presumed primary cause illustrate the difficulties of diagnostic evaluation and subsequent therapeutic strategy design for this patient group. Therefore, children with UCP might be at risk for suboptimal care.