Pain and disability in migraine or other recurrent headaches as reported by children

Can flunarizine be used routinely as the first option for childhood headache treatment?: Flunarizine and childhood headache

The prevalence of headache in childhood increases due to environmental factors. Various risk factors in children whose playgrounds are restricted outside and therefore remain inactive. So diagnosis and treatment can be challenging. The aim of this study was to evaluate the experience of flunarizine in childhood headache with a focus on efficacy and success. We conducted a retrospective observational study of 185 pediatric patients at the tertiary pediatric emergency and pediatric neurology unit between May 2018 and May 2020. Patients with headache for >15 days of a month for at least 3 months were included in the study, whether or not receiving treatment. Also, all patients who had an adequate follow-up period were included in the study. All patients were evaluated by history, physical-neurological examination, blood tests, blood pressure, eye examination, and cranial magnetic resonance imaging. All data were evaluated statistically. Ninety-eight (53%) of 185 cases were female and 87 (47%) were male. Average age was 11.4 years (min-max, 4-17). There was family history in 51.3% of the cases. The most frequent applicants were in the autumn season (43%), when schools were opened. Organic causes were hypertension in 1 case, brain tumor in 1 case, and papilledema due to idiopathic intracranial hypertension in 2 cases. The other cases were asked to make a 1-month pain chart and grading according to the visual analog scale. In this process, it was stated that painkillers could be used if needed. At the end of the first month, these patients were reevaluated. Flunarizine treatment was initiated in 95 patients who had to use painkillers for >4 times and who described ≥6 pain score according to the visual analog scale. The treatment was discontinued due to sleepiness and weakness in 2 patients. At the end of the third month, a 50% reduction in headache was observed in 82 cases (86.3%). We used flunarizine as the first choice in all patients and we achieved a high rate of treatment success. Flunarizine can be considered as an alternative option for headache management in terms of low side effects, easy accessibility, and compliance with treatment.

Management of Childhood Headache in the Emergency Department. Review of the Literature

Headache is the third cause of visits to pediatric emergency departments (ED). According to a systematic review, headaches in children evaluated in the ED are primarily due to benign conditions that tend to be self-limiting or resolve with appropriate pharmacological treatment. The more frequent causes of non-traumatic headache in the ED include primitive headaches (21.8–66.3%) and benign secondary headaches (35.4–63.2%), whereas potentially life-threatening (LT) secondary headaches are less frequent (2–15.3%). Worrying conditions include brain tumors, central nervous system infections, dysfunction of ventriculo-peritoneal shunts, hydrocephalus, idiopathic intracranial hypertension, and intracranial hemorrhage. In the emergency setting, the main goal is to intercept potentially LT conditions that require immediate medical attention. The initial assessment begins with an in-depth, appropriate history followed by a complete, oriented physical and neurological examination. The literature describes the following red flags requiring further investigation (for example neuroimaging) for recognition of LT conditions: abnormal neurological examination; atypical presentation of headaches: subjective vertigo, intractable vomiting or headaches that wake the child from sleep; recent and progressive severe headache (<6 months); age of the child <6 years; no family history for migraine or primary headache; occipital headache; change of headache; new headache in an immunocompromised child; first or worst headache; symptoms and signs of systemic disease; headaches associated with changes in mental status or focal neurological disorders. In evaluating a child or adolescent who is being treated for headache, physicians should consider using appropriate diagnostic tests. Diagnostic tests are varied, and include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography or magnetic resonance neuroimaging. The management of headache in the ED depends on the patient's general conditions and the presumable cause of the headache. There are few randomized, controlled trials on pharmacological treatment of headache in the pediatric population. Only ibuprofen and sumatriptan are significantly more effective than placebo in determining headache relief.

Primary headache in yemen: prevalence and common medications used

Background and Objective. Primary headaches is a major medical concern in certain Arabic countries, for example Oman, Jordan, and Qatar. This study was aimed at increasing understanding of the prevalence of headache in Arabic countries and identifying common medications used for treatment because of the lack of research done in this field in Yemen. Methods. This is a cross-sectional observational study conducted by recruiting case-series of adults and elderly who have primary headache within the age group from 18 to 85 years. 12640 subjects received a simple explanation for the aim of the study as ethical issue. The subjects were allowed to complete a self-conducted screening questionnaire. The data were diagnosed according to the International Headache Society's diagnostic criteria (2004). Results. The results showed that 76.5% of the primary headache is prevalent at least once per year, 27.1% of the tension type headache (TTH) was the maximum percentage of type of headache, and 14.48% of the migraine headache (MH) was the minimum percentage. On the other hand, the relationship between the primary headache and age of subjects was statistically significant (P < 0.05), while between primary headache and sex was not (P > 0.05). In addition, 70.15% of the subjects said that headache attacks affected their activity of daily livings (ADL). 62.26% of the subjects used the medications without medical advice regarding their headache. 37.73% of the subjects relied on medical professionals (physicians and pharmacist) regarding analgesics use. The most common agent used among the medications was paracetamol (38.4%). Others included ibuprofen, aspirin, diclofenac sodium, naproxen, mefenamic acid, ergotamine and (11.45%) were unknown agents. Conclusion. We concluded that absence of health attention from the Yemeni Community and education from the health system in the country regarding analgesics use and their potential risk led to abuse of such medications and could be a reason beyond high prevalence of headache in Yemen.

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.

Headache and facial pain in children and adolescents

Headaches commonly affect children and adolescents. Proper diagnosis and management is dependent on thorough history taking and a comprehensive physical and neurological examination. Additional diagnostic testing is indicated in some cases. The second edition of the headache classification system by the International Headache Society has recently become available. The classification system is primarily based on adults, but we discussed the subtle distinctions made regarding children. In addition to the primary headache types of migraine, tension-type, and cluster headaches, we discussed selected symptomatic headaches. Emphasis was placed on migraine and tension-type headaches because these are the most common pediatric headache types. We briefly discussed genetic aspects of headaches. Genetic factors have been hypothesized for chronic tension headache and other forms of migraine, but genetic linkage has only been established for familial hemiplegic migraine. We reviewed the nonpharmacologic and pharmacologic therapies, including abortive and prophylactic medications for various age groups. Unlike headaches, facial neuralgias are rare in otherwise healthy children. Facial pain may be neurological, vascular, or dental in origin. We focused on trigeminal neuralgia, glossopharyngeal neuralgia, occipital neuralgia, and Bell's palsy as neurological causes of facial pain in children.

The sensitivity and specificity of the case definition criteria in diagnosis of headache: a school-based epidemiological study of 5562 children in Mersin

The objectives of the present study were to estimate the prevalence of recurrent headaches in schoolchildren (ranging from 2nd to 5th degrees) in Mersin city of Turkey and to determine the sensitivity, specificity, positive predictive value and positive likelihood ratio of the diagnostic headache characteristics in children with migraine and Tension Type Headache (TTH) using neurologist's diagnosis as the gold standard. The stratified sample of study was composed of 5562 children. The prevalence of recurrent headache was 49.2% (2739 of 5562) and the prevalence of current headache was 31.3% (859 of 2739). TTH was more common than migraine (24.7% vs. 10.4%). The most sensitive headache characteristic for migraine was 'severity of pain' and the most sensitive definitive symptom is 'duration of headache' in children with TTH. IHS-based symptom definition criteria are highly beneficial in diagnosis of childhood headache, if used together with detailed clinical assessment.

The sensitivity and specificity of the case definition criteria in diagnosis of headache: a school-based epidemiological study of 5562 children in Mersin

The objectives of the present study were: (i) to estimate the prevalence of recurrent headaches in schoolchildren (ranging from 2nd to 5th degrees) in Mersin city of Turkey; (ii) to determine the sensitivity, specificity, positive predictive value and positive likelihood ratio of the diagnostic headache characteristics in children with migraine and tension-type headache (TTH) using neurologist's diagnosis as the gold standard. The stratified sample of study was composed of 5562 children. The prevalence of recurrent headache was 49.2% (2739 of 5562) and the prevalence of current headache was 31.3% (859 of 2739). TTH was more common than migraine (24.7% vs. 10.4%). The most sensitive headache characteristic for migraine was 'severity of pain' and the most sensitive definitive symptom was 'duration of headache' in children with TTH. International Headache Society-based symptom definition criteria are highly beneficial in diagnosis of childhood headache, if used together with detailed clinical assessment.

Migraine attacks and sleep in children

Falling asleep as a means of ending migraine attack was studied in 133 4-16-year-old children in out-patient settings. Children registered 999 migraine attacks in headache diaries using a visual analogue scale (VAS) in 409 attacks and a five-face scale in 590 attacks. The distribution of maximal pain intensity was similar on both scales; on VAS 88% assigned grades between 63 and 100, and on the face scale 93% assigned grades of 4 or 5. Children fell asleep during 33% of the attacks (n = 329), in 64% of these within the first hour (n = 209). Of the children, 68% (n = 91) had fallen asleep at least once during an attack. Falling asleep was more common in children under 8 years of age than in older children. In those under 8 years, 62% (95% confidence interval (CI) 49-75%) of attacks were resolved by sleep, in those aged 8-12 years 34% (26-41%), and in children >12 years 24% (15-33%) (ANOVA, P<0.0001). Pain was relieved without sleep in 43% (n = 431) of attacks, in 38% of these (n = 383) within the first 4 h. The data on migraine resolution were missing for 24% (n = 239) of the attacks, most often because the attack exceeded the 5-h observation period. This study confirms that migraine attacks in children are extremely painful and often resolve during an interval of sleep in children under 8 years of age.

Migraine and headache in childhood and adolescence

Headache is one of the most common physical complaints of children and adults. The authors have provided definitions of headache, a classification system, diagnostic evaluations appropriate for children, and treatment options for patients with acute and chronic headache. Also, this article has emphasized the importance of diagnosing and treating migraine headache, a painful malady that is extensively underestimated and misdiagnosed in the pediatric population and one that can be treated acutely and when appropriate prophylactically with great success. Lack of a specific biologic marker, specific investigation, or brain imaging reduce these clinical entities too often to a psychological illness. Nonpharmacologic treatments are pivotal to manage chronic headaches. Migraine therapy, if administered early and through the appropriate route, could provide important and rapid relief.

Intranasal sumatriptan for the acute treatment of migraine in children

Sumatriptan is a highly effective treatment for migraine in adults but its efficacy in children has not been determined. Fourteen children with migraine (6.4 to 9.8 years of age; seven girls, six with aura) participated in a randomized double-blind placebo-controlled crossover study to evaluate the efficacy of sumatriptan nasal spray. After sumatriptan, 12 of 14 (versus 6 of 14 after placebo) reported a decrease in pain intensity (p = 0.031); complete headache relief was obtained in 9 of 14 after sumatriptan versus 2 of 14 after placebo (p = 0.016). Migraine-associated symptoms were also significantly reduced by sumatriptan.