Phenotypes May Aid Diagnosis and Treatment of Pediatric Headache

Researchers posit that adult studies on headache can help to create a multidisciplinary treatment plan.

Headaches in children are among the most frequent complaints leading to pediatric office and urgent care visits. According to a 2015 editorial in Headache by Andrew D. Hershey, MD, PhD, FAAN, FAHS, director of neurology at the Headache Center at Cincinnati Children’s Hospital Medical Center in Ohio, as many as 75% of children will experience a “notable” headache by the time they are teenagers.1

Headache Prevalence in Children

The estimated prevalence of migraine in children aged 4 to 11 years is approximately 10%, increasing substantially in adolescence.1,2 Up until just before puberty, migraine prevalence is similar in girls and boys, when it shifts in favor of girls. Epidemiologic studies in school children by Split and Neuman3 in the 1990s reported 3 times higher rates of migraine in girls compared with boys, which was supported in a review by Gofshteyn and Neuman4 that reported a prevalence of 27% in girls vs 20% in boys. Young children are not spared from headache, either. Colic in infants is now believed to be an early manifestation of migraine.5 

Diagnosing Headache in Children
The headache phenotypes in children differ from adults, reflecting growth activity of the brain during childhood and adolescence.2 Evaluation of the variations in temporal patterns in children may be useful for headache diagnosis, especially since children are often unable to clearly describe what their pain feels like or where it comes from.2 “It is essential to include the child in the description of their headaches as parents may introduce their own headache bias,” Dr Hershey told Neurology Advisor.

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The first occurrences of headache in young children tend to be episodic and do not clearly point to a headache syndrome, Dr Hershey said. This led to a reclassification of these conditions as “Episodic Syndromes That May Be Associated With Migraine” in the 2013 International Classification of Headache Disorders (ICHD-3beta).5

Multiple secondary phenotypes have been identified in children, including2:

Acute headaches – Headaches of increasing frequency and/or severity may be secondary to brain injury or infection.

Abrupt onset of unremitting headaches points to a secondary cause or new daily persistent headache (NDPH). This type of headache in  children often occurs at the start of the school year.

Unilateral headaches in children tend to suggest a secondary pathology, or trigeminal autonomic cephalgia, which is a rare condition.

Occipital Headache may be a sign of serious intracranial pathology, although not a common occurrence in children.

Medication Overuse Headache is a particularly common occurrence in adolescence, generally associated with simple analgesics such as ibuprofen and acetaminophen. Dao and Qubty reported a frequency from one-third to one-half of all cases seen in their clinic.2

Primary Headaches in Children

Unlike adults, however, most headaches in children are primary rather than secondary to other diseases.4 The 2 most common recurrent types of headache observed in children are tension-type headache (TTH) and migraine. 2,4 Although ICHD-3 beta describes these 2 conditions as discrete types of primary headaches in children, the presentations often tend to overlap to include any combination of nausea, vomiting, photophobia, and phonophobia. Both pediatric headache phenotypes report hypersensitive reactions to odors (at rates of 33.4% in migraine and 18.1% in TTH).2

In children, TTH may last from 30 minutes to 7 days, with more diffuse pain than in adults. Migraines in children also tend to have shorter durations than in adults.2,4,6 Criteria for diagnosis in adults is a minimum of 4 hours, but in children it is only 2 hours.4

Migraine pain in adults is usually unilateral, while in children it is more likely to be bilateral and isolated to the frontotemporal region. 2,4,6  Occipital involvement is rare.2,4,6 Photosensitivity, which is often present in adult migraine, is less likely in children.7 Migraines in children tend to be milder in intensity; however, an estimated 19% of children experience disability due to migraine that interferes with school work and after-school activities.6 “Migraine is genetic, so the genes don’t change,” Dr Hershey explained. “However, with early intervention, the impact of the headaches can be reduced and outcomes improved.”

Due to the many challenges to the appropriate distinction between primary and secondary headache in children, careful consideration of headache location and family and personal medical history is important.2  Dau and Qubty wrote that, “Common thought is that increased frequency of severity of headache may reflect secondary pathology; however, headache phenotype may not be fully developed and can evolve in adolescence or adulthood.” They also noted specific premonitory symptoms in children, other than aura, that help to predict migraines hours or days before onset. These signs, including sudden irritability, anxiety, depression, yawning, lack of concentration, and neck stiffness, can be recognized in children as young as 18 months.2

Treatment of Pediatric Headache

Treatment approaches to pediatric headache include the same abortive and preventive therapies used in adults, with the goal of preventing escalation to chronic headache patterns that persist later in life. Dr Hershey suggested “a focus on acute treatment avoiding medication overuse, healthy life-style habits and consideration of prevention therapy (pharmacologic or behavioral – CBT) when headaches are frequent or disabling.” He specified that healthy lifestyle habits, including regular exercise, a good diet, adequate hydration, and getting enough sleep are essential to manage pediatric headache and reducing the risk for chronic headache patterns throughout life. 

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1. Hershey AD. Pediatric hHeadache. Continuum (Minneap Minn). 2015 Aug;21(4 Headache):1132-1145.

2. Dao JM, Qubty. Headache diagnosis in children and adolescents. Curr Pain Headache Rep. 2018;22:17.

3. Split W, Neuman W. Spontaneous headaches among secondary school students. Abstract. Neurol Neurochir (Polish) 1999;33(Suppl 5):97-109.

4. Gofshteyn JS, Stephenson DJ. Diagnosis and management of childhood headache. Curr Probl Pediatr Adolesc Health Care. 2016;46:36-51.

5. International Classification of Headache Disorders (ICHD-3beta).  2013 Accessed August 1, 2019.

6. Langdon R, DiSabella MT.  Pediatric headache: an overview. Curr Probl Pediatr Adolesc Health Care. 2017;47:44-65.

7. Straube A, Andreau A. Primary headaches during lifespan. J Headache Pain. 2019:20;35.

This article originally appeared on Neurology Advisor