Steven, a 13-year-old boy, experienced his first headache at age 7 years. The frequency, intensity, and duration of his headaches have been increasing over the past 6 months. Steven now experiences 7 to 10 headaches each month that last up to 8 hours. The headaches are associated with mild nausea, light and sound sensitivity, dizziness, fatigue, occasional abdominal discomfort, and difficulty in concentrating. Last year, he had a vomiting episode because of a headache. The pain is usually more prominent in the forehead and does not favor either side of the head. The headaches usually begin in the morning before he leaves for school. As a result, Steven has missed nearly 25% of his school days this semester; his parents are considering home tutoring for "sick children who are unable to attend school."
Steven's mother has treated the headaches with various over-the-counter medications. The pain typically resolves slowly and often recurs the next day. Steven would like to study martial arts but was advised against participation because exercise exacerbates his headaches. Steven's mother suffers from "terrible sinus headaches" that worsen during menstruation. She is very concerned that her son may have a brain tumor or chronic infection.
On presentation, Steven complained of a mild headache and photophobia. His vital signs were stable. Results of the physical and neurologic examination were normal. He had no evidence of meningeal signs.
By age 15 years, 75% of children will have had a significant headache.1 Ten percent of children aged 5 to 15 years and 28% of adolescents aged 15 to 19 years report experiencing migraine headaches.2 Those who experience recurrent headaches are challenged with issues related to school attendance. Within a typical 2-week period in the United States, an estimated 975,000 children reported having a migraine; this resulted in 164,454 missed school days.3 Recurrent headaches also affect a child's participation in social and sporting events, as Steven's case attests. The child's health status can also influence family dynamics.
Here I review the salient details of the history that offer diagnostic clues, discuss the latest diagnostic criteria for migraine in children under 16 years old, describe pediatric migraine precursors, and offer therapeutic recommendations.CLINICAL EVALUATION
Headache specialists agree that the vast majority of pediatric patients who seek consultation for recurring, disabling headache are migraineurs.3 In a study by Ward and colleagues,4 meningitis, shunt malfunction, and hydrocephalus were diagnosed in only 6% of all emergency department visits prompted by severe headache.All cases of secondary headache disorders in that study were associated with abnormal physical and neurologic findings.4
The diagnosis of pediatric headache disorders is best accomplished by taking a detailed history from the patient and the patient's parents. Key features in children with intracranial disease include altered mental status, abnormal eye movements, optic disc distortion, motor or sensory asymmetry, balance disturbances, and abnormal deep tendon reflexes. Those patients who have abnormalities on examination should undergo additional diagnostic testing.
Focus the history on the patient's headache patterns. Intermittent, disabling headaches in an otherwise healthy and fully functioning person are typical of a primary headache disorder such as migraine. An acute headache that gradually increases in severity over time warrants further investigation to identify possible intracranial disease.
MRI scanning is warranted for those patients who have a chronic-progressive headache pattern or any worrisome features (Table 1). An electroencephalogram is indicated only when the child's headaches are associated with alterations in consciousness or with abnormal involuntary movements.5
Lumbar puncture should be performed in patients in whom acute CNS infection is suspected or in those patients with signs of meningeal irritation or lateralizing signs on neurologic examination. Opening and closing pressures should be measured when pseudotumor cerebri, subarachnoid hemorrhage, or meningitis is suspected.
A useful tool for evaluating the impact of migraine on a child's quality of life is the Pediatric Quality of Life Inventory (Peds QL 4.0) generic core scales.6 This age-specific, 23-question document is divided to address 4 age groups and offers questions for parents and children. Evaluated domains include physical, emo- tional, social, and school health.