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LT causes of headache are found in patients whose clinical history and physical examination reveal
so-called “red flags” ( 36, 55 ) ( Table 6 ). In older children the most frequent disorders are
represented by headache or diplopia. Triptans were more effective than placebo in determining pain
relief in 3 studies involving children and 21 studies involving adolescents and no significant
difference was observed between the subgroups of triptans (including almotriptan, eletriptan,
naratriptan, rizatriptan, sumatriptan, and zolmitriptan). Other symptoms associated are vomiting,
diplopia and papilledema, and convulsions. Non-Responders in Chronic Migraine: Markers of
Disease Reversal. Headaches are common, incapacitating, and often stress inducing for pediatric
patients and parents alike. Management of children and young people with headache. BPT
management is essentially reassurance and supportive care ( 44 ). Another useful element is that
children with arterial ischemic stroke (AIS) are older than those with migraine, and considered at
risk (red flag) up to 8 years of age ( 40 ). The first step is to assess the patient's severity of pain,
which may be indicative of a more serious underlying condition ( 14, 16 ), further to investigate the
clinical features of children presenting to a pediatric ED with headache as the chief complaint and
report in their observational study that all patients with LT secondary headache can present very
intense pain. However, we believe that fundus examination should always be included in the
neurological evaluation of a child with headache even though it does not always exclude dangerous
secondary conditions. MOH typically presents when a bad patch of migraine with or without aura
has transformed into a chronic daily headache, including chronic migraine ( 85 ). Neuroimaging
offers the possibility to identify these sites of action, and how they differ between responders and
non-responders. Association of white matter hyperintensities with migraine phenotypes and response
to treatment. Cetta View author publications You can also search for this author in. Nevertheless, a
study examining 364 children (between 2 and 5 years of age) with headache demonstrated that
diagnostic yield of CT scans is low for children who present no worrying history and a normal
neurological examination ( 23 ). Differential diagnosis includes gastro-esophageal reflux, idiopathic
torsion dystonia, and complex partial seizures, but special concern goes to the posterior fossa and
cranio-cervical junction where congenital or acquired lesions may determine stiff neck ( 28 ). The
authors point out that it is not useful to evaluate routinely the ocular fundus in the emergency room,
especially if the onset of symptoms is 74 ). Odds of AIS are significantly increased in the case of
sudden onset of the following symptoms: weakness, seizures, speech disturbance, ataxia, signs of
face, inability to walk, dysarthria, dysphasia, and altered consciousness. However, their study
compared only 11 responders to 12 non-responders, which is likely too few for generalizable results.
A detailed physical and neurological examination, with attention to abnormalities that could be
associated with a secondary cause of headache, is important for the subsequent diagnostic workup.
According to the evaluated studies results, physiotherapy promotes improvement of headache,
associated symptoms and musculoskeletal disorders related. This is an open-access article distributed
under the terms of the Creative Commons Attribution License (CC BY). Ataxia is seen more
frequently associated in older children ( 28 ). Comparing 18-fluorodeoxyglucose ( 18 FDG) uptake
to controls, migraine patients initially displayed hypometabolism of the orbitofrontal cortex and
ACC, which reverted after treatment. Significant indicators for diagnosis are the absence of
recurrent head pain, especially on initial presentation, and vomiting episodes that are less severe
compared to cyclical vomiting syndrome ( 46 ). Furthermore, a migrainous aura typically develops
within a few minutes and migrates from one area to another ( 36, 42, 43 ). Moreover, the direction of
the amygdala RS FC alterations found in patients who responded to NSAID is difficult to interpret
since different brain areas were found when comparing healthy controls to the two subgroups of
patients. In addition, the number of WMHs increased with age, and age might also affect the
efficacy. Abnormalities in neurological examination are reported in most of the children.
The role of physiotherapy in headache treatment: literature review. Many of these medications have
now been studied in children and adolescents and some have been approved for use in the pediatric
age group. For many treatment approaches, this excludes robust conclusions. In an observational
study, other authors report a reduction in ED access for recurrent headache in those patients for
whom indication was given to contact a specialized Headache Center within 10 days from ED
discharge ( 22 ). An acute and transient malfunction in control of the intracranial vascular tone
causes narrowing and micro-dilatation of a cerebral area, characterized by a mainly favorable
outcome ( 60, 61 ). In children TTH can be triggered by psychosocial stressors and anxiety;
comorbidities frequently present are mood disorders, prevailing if the headache pain is chronic. Five
months after treatment, the GM volume of the left lingual gyrus was normalized only in patients
who received tDCS but not in those treated with sham treatment. Complementary and conventional
medicine use among youth with recurrent headaches. The authors point out that it is not useful to
evaluate routinely the ocular fundus in the emergency room, especially if the onset of symptoms is
74 ). Created by R.M. with BioRender.com Full size image For each individual study, study
population and main results are presented in Tables 1, 2, 3 and 4 and Supplementary Tables 2, 3 and
4. This form of headache can be associated with a considerable number of potentially LT disorders (
28 ) so it is essential to carry out imaging tests to exclude them. We identified 589 articles, of which
19 were included, according to the eligibility criteria. Background information must be investigated,
such as drug use, systemic disease (sickle cell disease, immunodeficiency, malignancy, pregnancy,
neurocutaneous syndrome, or congenital heart disease), associated symptoms, trauma, and family
history. In older children the most frequent disorders are represented by headache or diplopia. All
authors reviewed, approved, and agreed to be accountable for all aspects of the work. It has also
been demonstrated that abnormal activity of the trigeminal cervical complex, insula, cingulate cortex,
frontal and temporal gyrus could predict patients. Residual and persistent adie's pupil after pediatric
ophtalmoplegic migraine. Primary versus secondary headache in children: a frequent diagnostic
challenge in clinical routine. The child's head can be positioned neutrally during attacks, although it
is possible to find resistance during movement. Headache Classification Committee of International
Society. The symptoms of aura of this particular form of migraine are immediately traceable to the
brain stem in the absence of an ischemic etiology. Prevalence of headache at preschool age in an
unselected child population. Results The database search identified 2425 records (PubMed: 948;
Embase:1477). Of these, 54 investigated migraine patients, 4 cluster headache patients and 5 patients
with medication overuse headache. Life-threatening headaches in children: clinical approach and
therapeutic options. To outline the requirements of the Editorial Board, Jason Roberts, PhD, explains
Headache ’s manuscript evaluation process and offers key insights to draft a winning submission for
publication. The search was performed from the inception date up to 21 December 2022. It can also
present in different disorders including epilepsy, drug intoxication, fever delirium, brain injury,
schizophrenia, and hypnagogic states ( 44 ). Secondary headaches manifest differently in children
than in adults and the degree of brain maturation could be the cause of this difference ( 2, 3 ). An
acute presentation could be confused with an acute abdomen or an intracranial mass, though a
detailed history and physical examination should rule them out.
A stepwise approach to pediatric headaches is essential to avoid missing secondary headaches and to
promptly make the correct diagnosis. Pharmacotherapy for acute migraines in children and
adolescents. Imaging studies have provided important information in this regard. Experts' opinion
about the pediatric secondary headaches diagnostic criteria of the ICHD-3 beta. Recurrent and
chronic headaches in children below 6 years of age. Furthermore, a migrainous aura typically
develops within a few minutes and migrates from one area to another ( 36, 42, 43 ). This is
particularly relevant for a thunderclap headache (more frequent in adults), which warrants rigorous
evaluation to exclude a secondary cause. Injuries of the parasellar region or the upper orbital fissure
and aneurysms of intracranial vessels should be excluded with appropriate neuroimaging studies.
Different imaging modalities were combined in eight studies. The role of physiotherapy in headache
treatment: literature review. Unleashing the Power of AI Tools for Enhancing Research, International
FDP on. Yield and clinical efficacy of funduscopic examinations performed in the pediatric
emergency room. Common features of these disorders are: complete well-being between episodes,
stereotypy of episodes, familiarity for migraine or headache ( 2 ). This study found a decreased T2-
weighted signal in the periaqueductal grey (PAG) in 47 responders compared to 15 non-responders,
suggesting increased iron accumulation in responders. In this age group it would seem that headache
may be the only symptom. During the disorder, the EEG can detect a generalized slowdown and
sometimes an intermittent frontal rhythmic delta activity ( 44 ). Figure 3 outlines the main central
structures targeted by treatments described in the included studies. Imaging might help to identify
responders to anti-CGRP mAbs. Opioids are not part of the American Academy of Neurology
practice parameter for pediatric pharmacological treatment of headache ( 71 ). Conclusion Several
aspects of headache treatments remain to be elucidated using imaging approaches, such as how
pharmacological preventive therapies work, whether treatment-related brain changes may influence
therapy effectiveness, and imaging biomarkers of clinical response. An interesting goal of future
imaging studies would be to examine how triptans with different efficacy and tolerability cross the
BBB. In younger patients, it may be useful to evaluate the head circumference. RCVS treatment is
the elimination of possible triggering factors, together with symptomatic measures. Distinct patterns
of brain functional activity have been found in patients treated with erenumab and galcanezumab. In
particular, neuroimaging must always be sought in order to exclude life-threatening headaches. A
previous analysis of data regarding more than 3,000 children with brain tumors showed that 98% had
one of the following five signs: papilledema, ataxia, hemiparesis, abnormal eye movements, or
depressed reflexes ( 80 ). One of many initiatives to support that mission is our publication of
Headache: The Journal of Head and Face Pain, published ten times per year, which highlights the
latest findings in the realm of headache medicine research. The authors point out that it is not useful
to evaluate routinely the ocular fundus in the emergency room, especially if the onset of symptoms is
74 ). Side effects, usually mild, included fatigue, dizziness, asthenia, dry mouth, and nausea or
vomiting with oral preparations, and taste disturbance, nasal symptoms, and nausea with intranasal
preparations. Intravenous sodium valproate for acute pediatric headache.
In our experience it is useful to evaluate serum electrolytes in patients with suspected IIH as this
condition can be associated with underlying hypocalcemia. Association of white matter
hyperintensities with migraine phenotypes and response to treatment. Failure to do so may have
devastating consequences for children. Headache has a particularly rigorous approach to peer review
in order to maintain the standard of the publication. LT causes of headache are found in patients
whose clinical history and physical examination reveal so-called “red flags” ( 36, 55 ) ( Table 6 ).
Article types Author guidelines Editor guidelines Publishing fees Submission checklist Contact
editorial office Frontiers in Neurology. RCSV may be primitive or a complication of other clinical
conditions such as cerebral infarctions, intracranial hemorrhages or cerebral edema. MOH typically
presents when a bad patch of migraine with or without aura has transformed into a chronic daily
headache, including chronic migraine ( 85 ). However, the study examined only 10 patients and
results were uncorrected for multiple comparisons. Eleven additional studies related to the topic were
included. Trends in prescription opioid use in pediatric emergency department patients. In patients
with headache it is essential to treat the acute episode immediately according to evidence based
medicine. Compared with other mid-sized journals, Headache has a particularly rigorous approach to
peer review, resulting in sufficiently validated, well-written reports of some of the most recent on
going research in Headache Medicine. Significant features associated with decreased odds of AIS
include older age, vomiting, visual or sensory aura, other symptoms, and absent focal signs on
assessment ( 40 ). Cephalalgic phase is typically not present during the attacks ( 28 ). Patients with
this group of disorders can present with migraine (with or without aura) or are likely to develop
them. The emergency physician should ask about headache description (onset, duration, quality, and
pain severity), triggers and exacerbating factors (stress, sleep pattern changes), alleviating factors (
Table 7 ), and specifically search for warning signs ( Table 6 ). In addition, the number of WMHs
increased with age, and age might also affect the efficacy. Often the child or adolescent has already
taken analgesics without apparent benefit, so one should check that the drug has been taken with the
correct dosage and give indications for repeat administration. All authors reviewed, approved, and
agreed to be accountable for all aspects of the work. Unleashing the Power of AI Tools for
Enhancing Research, International FDP on. Although an acute TCH is the classic presenting
symptom of ICH, most children who have ICH or ischemic stroke have additional signs or
symptoms by the time they present to a medical facility. Dysphasia may occur either at the same time
or sequentially. In these patients ophthalmic assessment shows bilateral papilledema while
neuroimaging is found to be within normal limits. Diagnosis and treatment can be challenging due to
its varying presentation, etiology, and triggers. The average frequency of the attacks is about two per
month and the duration about 2 h per single episode. A meta-analysis of about 400 pediatric patients
with brain tumors reported the presence of papilledema in only 13% of patients ( 73 ). The authors
point out that it is not useful to evaluate routinely the ocular fundus in the emergency room,
especially if the onset of symptoms is 74 ). Often the symptoms of TTH can overlap with those of
migraine and a migraine may transform over time to a tension type of episodic headache.
Nevertheless, a recent study of Ahmed et al. ( 68 ) reported that neuroimaging among 4% of patients
with headache sleep interruption or on awakening revealed intracranial abnormalities that were
unlikely to have caused the awakening and none of them required prompt intervention.
It occurs predominantly in late childhood and adolescence (50% of cases) and there is often a
positive family history for migraine. Enjoy access to the full catalogue of content plus a print
subscription included with an American Headache Society Membership. MRI provides superior
quality images but is more expensive and children under 6 years of age may need sedation or
anesthesia to perform it ( 24, 70 ). Some authors ( 14, 55 ) aimed to identify clinical clues for
headaches associated with serious LT intracranial disorders. Dr. NN Chavan Keynote address on
ADNEXAL MASS- APPROACH TO MANAGEMENT in the. Headache 1. Headache. Proper
neuroimaging of children with headache is very specific to the headache type. Unleashing the Power
of AI Tools for Enhancing Research, International FDP on. These experiences can precede or
accompany a headache or occur without headaches. The accuracy of the verapamil responsiveness
prediction was marginally increased (from 66 to 68%) when clinical features were combined with the
cerebellar GM volume. At present they do not have a scientific evidence of efficacy in the pediatric
population and they seem to be associated with an increase in hospitalization time ( 108 ). After
duplicates were removed, the title and abstract of 2169 studies was screened yielding 84 articles for
full-text screening. Usually the therapies aim to eliminate head pain and reduce the associated
symptoms, such as nausea, phonophobia, and photophobia. However, these studies did not describe
their statistical approach in detail, making the findings difficult to interpret. These patients often
undergo intensive diagnostic workup, including neuroimaging, and frequently require access to ED
as well as hospital admissions. Headache is unusual as an isolated complaint and is most often
associated with other symptoms such as fever, sore throat, neck pain, and vomiting ( 15 ). When
performing an uncorrected exploratory analysis, metoprolol increased the hypothalamic BOLD
response after treatment. This approach also minimizes parents' and children's anxiety, reduces
interruption of leisure time and school activities, and prevents the development of VM. CO, MP,
MV, and AR approved the design of the study. Despite this, some coherent findings have been
reported for triptans as abortive treatments for migraine attacks, non-pharmacological approaches
employed in migraine and cluster headache prevention and for central effects of medication
withdrawal in patients with MOH. This study also showed that, compared to non-responders,
responders to 4-week of acupuncture treatment developed an increased GM volume of the left
cuneus after treatment. Vestibular migraine in children and adolescents: clinical findings and
laboratory tests. Episodic syndromes can be difficult to recognize and treat. Ergotamine use,
however, is hampered by potentially serious side effects. Six weeks after twice weekly treatment, the
studies reported an increased volume of the left nucleus accumbens, a decreased volume of the right
hippocampus and pallidum, and decreased cortical thickness of the left temporal pole and lateral
occipital-temporal sulcus cortex, as well as an altered FC of several regions of the salience and
executive networks. The findings should be confirmed in a separate cohort and adjusted for age
before clinical inferences can be made. The ACC is known to be involved in the descending
antinociceptive pathway and the orbitofrontal cortex is implicated in cognitive aspects of pain
modulation. Likewise, the analysis was not corrected for multiple comparisons. Only one study
explored whether dihydroergotamine (DHE) has central effects. Headache on awakening or sleep
interruption due to headache have been commonly regarded as a potential sign of raised intracranial
pressure and, therefore, significant underlying pathology, but this issue is debated and warrants
further investigation.
Furthermore, it is essential to know the characteristics of the primary forms of migraine in order to
avoid unnecessary, expensive, and potentially dangerous investigations (for example
neuroradiological imaging ). In fact, the American Academy of Neurology published a statement
recommending against the use of opioids for primary headache ( 102 ). LT causes of headache are
found in patients whose clinical history and physical examination reveal so-called “red flags” ( 36, 55
) ( Table 6 ). Given the clinical worsening observed after five months from treatment start, these
morphometric results are difficult to reconcile with a treatment effect. Other limitations of the
currently available literature are the small sample size and the frequent use of inadequate statistical
approaches that introduce a considerable risk of false positive findings. Nevertheless, these studies
were weakened by prior treatment of the subjects with dopamine agonists. The study found no
significant functional brain changes after treatment. Another useful element is that children with
arterial ischemic stroke (AIS) are older than those with migraine, and considered at risk (red flag) up
to 8 years of age ( 40 ). Prevalence of headache at preschool age in an unselected child population.
The vertigo is maximum at the onset of the attack and resolves spontaneously after a few minutes or
a few hours without loss of consciousness. In ED, the headache characterization is mandatory in
order to identify patients who would benefit from neuroimaging. In these patients ophthalmic
assessment shows bilateral papilledema while neuroimaging is found to be within normal limits. The
authors concluded that awakening or sleep interruption due to headache among clinically well and
neurologically normal pediatric patients was most likely to be caused by primary headaches,
particularly migraine or tension type headaches, and this needs to be more widely recognized in
order to avoid unnecessary brain imaging. RHC and IC contributed to drafting and revising the work.
The duration of each session ranged from 1 up to 30 min, the number of treatments per weeks was
inconstant and the treatment period could range from 4 to 16 weeks. Ataxia is seen more frequently
associated in older children ( 28 ). The abdominal pain resolves in 61% of patients, but 70% develop
migraine with or without aura ( 47 ). These findings suggest that structural MRI has a minimal role in
predicting response to verapamil apart from what can be clinically deduced. Prevalence of brain
tumor in pediatric patients accessing the ED varies from 0.4 to 3% in relation to the studies
examined ( Table 1 ). However, it should be noted that the T2 weighted signal is not specific for iron
accumulation. Principle 6 Practice. Fourth Ed. Philadelphia, PA: Mosby Elsevier (2006).
Abnormalities in neurological examination are reported in most of the children. Vomiting can
sometimes be a very important part of a migraine attack in young children. Acute headaches which
evolve suddenly can be considered suggestive of organic disease and must be evaluated very
carefully. Six weeks after twice weekly treatment, the studies reported an increased volume of the
left nucleus accumbens, a decreased volume of the right hippocampus and pallidum, and decreased
cortical thickness of the left temporal pole and lateral occipital-temporal sulcus cortex, as well as an
altered FC of several regions of the salience and executive networks. Experts' opinion about the
primary headache diagnostic criteria of the ICHD-3rd edition beta in children and adolescents.
Symptoms can be so intense as to require ED management ( 45 ) and hospitalization for intravenous
rehydration ( 44 ). Ashina View author publications You can also search for this author in. Seven
days after the blockade, the regional CBF increased in the right secondary visual cortices and
decreased in the left medial temporal gyrus, cerebellum, caudate and putamen. Dysphasia may occur
either at the same time or sequentially.