What is the impact, prevalence, disability, and quality of life of pediatric headache?

Longitudinal trajectories of posttraumatic headache after pediatric mild traumatic brain injury

OBJECTIVE

This prospective, longitudinal cohort study examined the trajectory, classification, and features of posttraumatic headache after pediatric mild traumatic brain injury.

METHODS

Children (N = 213; ages 8.00 to 16.99 years) were recruited from two pediatric emergency departments <24 hours of sustaining a mild traumatic brain injury or mild orthopedic injury. At 10 days, three months, and six months postinjury, parents completed a standardized questionnaire that was used to classify premorbid and posttraumatic headache as migraine, tension-type headache, or not otherwise classified. Multilevel mixed effects models were used to examine posttraumatic headache rate, severity, frequency, and duration in relation to group, time postinjury, and premorbid headache, controlling for age, sex, and site.

RESULTS

PTH risk was greater after mild traumatic brain injury than mild orthopedic injury at 10 days (odds ratio = 197.41, p < .001) and three months postinjury (odds ratio = 3.50, p = .030), especially in children without premorbid headache. Posttraumatic headache was more frequent after mild traumatic brain injury than mild orthopedic injury, β (95% confidence interval) = 0.80 (0.05, 1.55). Groups did not differ in other examined headache features and classification any time postinjury.

CONCLUSIONS

Posttraumatic headache risk increases after mild traumatic brain injury relative to mild orthopedic injury for approximately three months postinjury, but is not clearly associated with a distinct phenotype.

Tools for Evaluating the Quality of Life of the Paediatric Population with Primary Headaches-A Review of Selected Questionnaires

Primary headaches are a common health issue in the paediatric population. These conditions have a negative impact on the quality of life of patients at the development age in every area of their lives. The aim of this study is to list the tools used to evaluate the quality of life of the paediatric population with primary headaches and to discuss their advantages and limitations. Examining the quality of life of children and adolescents suffering from primary headaches is of particular importance. This is a consequence of a high disease incidence rate and a considerable negative impact of the ailment on the everyday life of this population. It is very important to conduct such examinations with specific and validated tools. It is significant because of the particular features of the areas of patients' lives at the developmental age. Each of the available questionnaires has specific characteristics, advantages and limitations. The data accumulated in this literature review can be of help in designing research on the quality of life of children and adolescents suffering from primary headaches.

Pediatric headache and neuroimaging: experience of two tertiary centers

INTRODUCTION

Headache is a frequent complaint in children and adolescents. Decision-making for neuroimaging should take into account the cost and the need for sedation in young children.

AIM

To evaluate the yield of MRI in pediatric headache patients seen in two large tertiary hospitals.

METHODS

Data were retrospectively collected from patient records (n = 613) and neuroimaging reports. Headache was classified according to International Headache Society guidelines.

RESULTS

There were 346 children with imaging studies (MRI n = 281, CT n = 65). Of patients who had at least one MRI study, 29% demonstrated an abnormal finding. Findings altering the management were obtained in 21 (7%) patients: the majority (n = 17, 80%) had headache for less than 3 months. On the other hand, four patients with headache longer than 3 months (19%) and 12 patients with normal neurological examination (57%) had significant MRI results affecting management. None of the children in whom the diagnosis of migraine could be made on clinical grounds (n = 40) had a significant MRI finding.

CONCLUSION

Neuroimaging should be performed selectively in children with headache seen in pediatric neurology clinics, especially in headache of short duration (< 3 months) and features atypical for migraine. A normal neurological examination should not reassure the clinician.

The influence of allergic rhinoconjunctivitis on migraine disability in children

OBJECTIVE

Migraine is a common condition in the pediatric population and causes a significant impact on the quality of life. Atopic disorders are some of the migraine comorbidities. We hypothesized that allergic rhinitis could aggravate migraine in the pediatric population.

METHODS

This cross-sectional study consecutively evaluated 90 pediatric outpatients (46 children 6-12 years of age; 44 adolescents up to 18 years of age) who sought medical assistance because of migraine at a general neurology clinic in Passo Fundo, RS, Brazil. They, and their parents, were given three questionnaires, to evaluate the diagnosis of current allergic rhinitis, allergic rhinoconjunctivitis and seasonal allergic rhinitis, as well as the disability caused by headache (ISAAC - International Study of Asthma and Allergies in Childhood; CARATkids - Control of Allergic Rhinitis and Asthma Test for Children; PedMIDAS - Pediatric Migraine Disability Assessment). The study was approved by the local ethics committee.

RESULTS

According to the ISAAC questionnaire, children with current allergic rhinoconjunctivitis in the last year showed higher scores on the PedMIDAS than those patients without atopy (median and interquartile range 26 [10-58] vs. 5 [1-13], p = 0.008). A significant positive correlation of CARATkids scores with PedMIDAS scores was found (p = 0.007, rho = 0.39). After including other putative predictors of migraine disability (age, body mass index, time since onset of migraine) in a multiple regression analysis, only the scores on the CARATkids remained a significant independent variable correlated with PedMIDAS scores (p = 0.001; R = 0.55; R2 = 0.30).

CONCLUSIONS

Current allergic rhinoconjunctivitis is related to enhanced disability caused by headache in childhood migraine.

Pediatric headache: overview

PURPOSE OF REVIEW

Headache is a common medical complaint in children and adolescents with the majority having experienced some type of headache by their teenage years. Pediatric headache presentations often differ compared to adults, and children may have difficulty describing their symptoms. Thus, a thorough understanding of the approach to the pediatric headache patient is essential to ensure appropriate diagnosis, evaluation, and management.

RECENT FINDINGS

In the following article we will review the components of a comprehensive pediatric headache assessment, as well as discuss primary and secondary headache types seen in children with focus on clinical pearls and 'red flags' necessitating diagnostic testing.

SUMMARY

Headaches in children may be due to primary or secondary etiologies. Common primary headache types include migraine or tension-type headache. Secondary headache causes are broad and include infections, trauma, vascular disorders, substance use/withdrawal, and psychiatric conditions. Current American Academy of Neurology (AAN) guidelines recommend against routine lab studies, lumbar puncture, electro-encephalogram (EEG), or neuroimaging in patients with no headache red flags by history and a normal neurologic examination.

Prevalence of headache and its interference in the activities of daily living in female adolescent students

OBJECTIVE:

To describe the prevalence of headache and its interference in the activities of daily living (ADL) in female adolescent students.

METHODS:

This descriptive cross-sectional study enrolled 228 female adolescents from a public school in the city of Petrolina, Pernambuco, Northeast Brazil, aged ten to 19 years. A self-administered structured questionnaire about socio-demographic characteristics, occurrence of headache and its characteristics was employed. Headaches were classified according to the International Headache Society criteria. The chi-square test was used to verify possible associations, being significant p<0.05.

RESULTS:

After the exclusion of 24 questionnaires that did not met the inclusion criteria, 204 questionnaires were analyzed. The mean age of the adolescents was 14.0±1.4 years. The prevalence of headache was 87.7%. Of the adolescents with headache, 0.5% presented migraine without pure menstrual aura; 6.7%, migraine without aura related to menstruation; 1.6%, non-menstrual migraine without aura; 11.7%, tension-type headache and 79.3%, other headaches. Significant associations were found between pain intensity and the following variables: absenteeism (p=0.001); interference in ADL (p<0.001); medication use (p<0.001); age (p=0.045) and seek for medical care (p<0.022).

CONCLUSIONS:

The prevalence of headache in female adolescents observed in this study was high, with a negative impact in ADL and school attendance.

Headache in school age

Headache, especially migraine and tension-type headache, is one of the most frequently reported somatic complaints by children and adolescents. Different population-based studies have been conducted to study the correlation between headache and lifestyles in pediatric age, nevertheless, the obtained results are often controversial and these relationship still remain unclear. Likewise, is still strongly debated the burden of headache during school age, its impact on school performances and on quality of life of children and their families. Consequently, larger studies are necessary to evaluate the degree of disability due to pediatric headache. We summarize the ongoing knowledge about these concepts, with the intent to provide useful data to neurologists but also to primary care providers, to further improve the management of pediatric headaches by preventing the headache progression, the disabling effects associated and improving the long-term outcome.

Specific Triggers of Migraine Headache in Adolescents

AIM: Purpose of the study was to recognize specific migraine triggers in adolescents.MATERIAL AND METHODS: Study was conducted on 20,917 adolescents in Serbia.RESULTS: Lack of sleep, passive tobacco smoking, alcohol intakes, and "not eating in time" are triggers that provoke migraine in adolescents.CONCLUSION: Avoiding migraine triggers in 68% of adolescents reduced drug therapy for 75%.

Safety and tolerability of targeted therapies for pulmonary hypertension in children

The objective of this study is to evaluate the safety and tolerability of the pharmacological treatment of pulmonary hypertension in pediatric patients. It is a retrospective, longitudinal, observational study on pediatric patients undergoing treatment with pulmonary targeted therapies. 63 patients were included (51% male), with a median age of 3.4 years (IQR, 3.6 months-10 years) and a median weight 13 kg (IQR, 6-30 kg). Congenital heart disease was the etiology of pulmonary hypertension in the majority of cases (n = 33) and 28 patients were in NYHA functional class III-IV. The most commonly used drug was sildenafil (n = 79, 56%), followed by bosentan (n = 27, 23%), and a combination of both (n = 14, 41%). 34 patients had adverse reactions (54%) with an incidence rate of 1.02 per patient per year. The most commonly reported reactions were gastrointestinal symptoms (22%) and spontaneous erections (22%) in males. Nine severe adverse reactions (10%) occurred, requiring eight treatment withdrawal and one hospital admission. Treatment with targeted therapies for pulmonary hypertension is safe in the pediatric population. Severe ADRs were uncommon both in monotherapy and in combination therapy. Combination therapy was associated with a higher rate of ADRs. We observed similar survival rates in children receiving sildenafil doses according to the European Medicines Agency (EMA) recommendations or higher.

Monthly variation of United States pediatric headache emergency department visits

OBJECTIVE

The objective of this article is to determine the monthly variation of emergency department (ED) visits for pediatric headache. We hypothesized youth have increased headache-related ED visits in the months associated with school attendance.

METHODS

Using a United States representative sample of ED visits in the National Hospital Ambulatory Medical Care Survey from 1997 to 2009, we estimated number of visits associated with ICD-9 codes related to headache, migraine, status migrainosus, or tension-type headache in 5- to 18-year-olds. Age-stratified multivariate models are presented for month of visit (July as reference).

RESULTS

There was a national estimate of 250,000 ED visits annually related to headache (2.1% of total visits) in 5- to 18-year-olds. In 5- to 11-year-olds, the adjusted rate of headache-related visits was lower in April (OR 0.42, 95% CI 0.20, 0.88). In 12- to 18-year-olds, there were higher rates in January (OR 1.92, 95% CI 1.16, 3.14) and September (OR 1.64, 95% CI 1.06, 2.55).

CONCLUSIONS

In adolescents we found higher ED utilization in January and September, the same months associated with school return from vacation for a majority of children nationally. No significant reduction in the summer suggests that school itself is not the issue, but rather changes in daily lifestyle and transitions.

Headache after pediatric traumatic brain injury: a cohort study

OBJECTIVE

To determine the prevalence of headache 3 and 12 months after pediatric traumatic brain injury (TBI).

METHODS

This is a prospective cohort study of children ages 5 to 17 years in which we analyzed the prevalence of headache 3 and 12 months after mild TBI (mTBI; n = 402) and moderate/severe TBI (n = 60) compared with controls with arm injury (AI; n = 122).

RESULTS

The prevalence of headache 3 months after injury was significantly higher after mTBI than after AI overall (43% vs 26%, relative risk [RR]: 1.7 [95% confidence interval (CI): 1.2-2.3]), in adolescents (13-17 years; 46% vs 25%, RR: 1.8 [95% CI: 1.1-3.1]), and in girls (59% vs 24%, RR: 2.4 [95% CI: 1.4-4.2]). The prevalence of headache at 3 months was also higher after moderate/severe TBI than AI in younger children (5-12 years; 60% vs 27%; RR: 2.0 [95% CI: 1.2-3.4]). Twelve months after injury, TBI was not associated with a significantly increased frequency of headache. However, girls with mTBI reported serious headache (≥ 5 of 10 pain scale rating) more often than controls (27% vs 10%, RR: 2.2 [95% CI: 0.9-5.6]).

CONCLUSIONS

Pediatric TBI is associated with headache. A substantial number of children suffer from headaches months after their head injury. The prevalence of headache during the year after injury is related to injury severity, time after injury, age, and gender. Girls and adolescents appear to be at highest risk of headache in the months after TBI.

Parent-child agreement in the reporting of headaches in a national sample of adolescents

The aim of this article is to assess the concordance between parent and adolescent headache ratings in a representative sample of 6483 US adolescents (aged 13-18 years). Headaches were assessed using modified criteria from the International Headache Society's International Classification of Headache Disorders, Second Edition. Caregiver report was based on a self-administered questionnaire. Overall concordance between caregivers and adolescents on the presence or absence of headaches was quite low (κ = 0.39). Female caregivers were twice as likely as male caregivers to report headaches in their offspring. Positive endorsement of headaches in offspring by caregivers was associated with adolescent-reported chronic headaches, longer headache duration, and photophobia or phonophobia. These findings suggest that relying solely on parent report may result in an underestimate of the true prevalence of headaches in the general population. In addition, collecting information from both parents and adolescents could be critical to effective treatment and prevention of the severe consequences of migraine.

Identification of abnormal neuromagnetic signatures in the motor cortex of adolescent migraine

OBJECTIVE

To investigate the functional abnormalities of the motor cortices in children with migraine using magnetoencephalography (MEG) and a finger-tapping task.

BACKGROUND

Cortical hyperexcitability has been reported in adults with migraine using MEG. Many children with migraine report difficulty with motor functioning. There is no report on motor-evoked magnetic activation in children with migraine using MEG and the latest signal processing methods.

METHODS

Ten children with migraine (all female, 9 right-handed and 1 left-handed, aged 13-17 years) and 10 age- and gender-matched healthy children were studied with a 275-channel MEG system. After hearing a unilateral, randomly presented sound cue (500 Hz, 30 milliseconds square tone), each subject immediately performed a brisk index finger tapping with either the right or the left index finger. The auditory stimuli consisted of 200 trials of square tone, 100 trials per ear, randomly distributed. The latency and amplitude of neuromagnetic responses were analyzed with averaged waveforms. Neuromagnetic sources were estimated using synthetic aperture magnetometry (SAM). SAM images were normalized for each participant for group comparison.

RESULTS

In comparison with healthy children, children with migraine had prolonged latency of motor-evoked magnetic response in the right hemispheres during left finger movement (62.33 +/- 34.55 milliseconds vs 34.9 +/- 17.29 milliseconds, P < .05). In addition, children with migraine had stronger activation in the motor cortex during right finger movement (8097.46 +/- 5168.99 vs 4697.54 +/- 3194.74, P < .05).

CONCLUSIONS

The results suggest that there are neurophysiological changes in the motor cortices of children with migraine that can be measured with neuromagnetic imaging techniques. The findings expand the ability to study the cerebral mechanisms of migraine using MEG and may facilitate the development of new therapeutic strategies in migraine treatment via alterations in cortical excitability.

MIPAS-Family-evaluation of a new multi-modal behavioral training program for pediatric headaches: clinical effects and the impact on quality of life

Several meta-analyses have demonstrated that the combination of electrical muscle activity and Temperature Biofeedback could be regarded as gold standard in chronic pediatric headaches. However, these techniques seem to be uneconomical and furthermore they are not directed to improve the social competence as well as resolve possible impairments in daily activities of the child. Therefore, multi-modal behavioral techniques have been proposed, but no studies comparing these with the gold standard were conducted. The present study compared the impact of a new multi-modal behavioral education and training program--MIPAS-Family--with a combined Biofeedback treatment, evaluating clinical efficacy as well as the effect on the quality of life (QoL) of children with chronic headaches. Thirty-four children and adolescents with recurrent headache, ranging from 7 to 16 years, were randomly assigned to the MIPAS-Family (N = 19) or the Biofeedback (N = 15) condition. All patients were diagnosed by the criteria of the International Headache Society. The children and their parents completed headache diaries, diaries of daily living activities and a QoL questionnaire (KINDL). Both groups showed significant improvements concerning the headache intensity and headache duration. We found no significant differences in the main headache parameters between both treatments. After the treatments, the children were less disturbed by their headaches in the domains school, homework, and leisure time. In conclusion, MIPAS-Family is as effective as Biofeedback but it is more cost-effective and addresses the whole family and the daily activities.

Topiramate in the prevention and treatment of migraine: efficacy, safety and patient preference

Migraine is a very common disorder characterized by the combination of typical headache with associated autonomic symptoms and/or the presence of aura. Considerable advances have been made in recent years to understand the pathophysiology of migraine, which has led to improved treatment options for the acute migraine attack as well as migraine prophylaxis. Unfortunately, preventive treatment is often insufficient to decrease migraine frequency substantially or is not well tolerated. Topiramate is an antipileptic drug with a complex mode of action which has proven its efficacy and safety in the prophylactic treatment of episodic migraine in a number of randomized controlled clinical trials. Topiramate is also effective in treating patients with chronic migraine. It has little pharmacological interaction with other drugs and is generally well tolerated by patients.

Headache disability among adolescents: a student population-based study

OBJECTIVE

To examine the extent and to identify the relevant predictors of headache disabilities in adolescents.

BACKGROUND

Headaches are common in adolescents but their impact and related factors have not been extensively studied in adolescent communities.

METHOD

We recruited and surveyed 3963 students aged 13-15 from 3 middle schools using self-administered questionnaires. The questionnaires were used to make 3 assessments: (1) headaches were diagnosed using a validated headache questionnaire; (2) headache disabilities were evaluated using the 6-question Pediatric Migraine Disability Assessment; (3) depression was measured using the Adolescent Depression Inventory.

RESULTS

The student response rate was 93%. In total, 484 students (12.2%) had migraines with or without auras, 444 (11.2%) had probable migraines, and 1092 (27.6%) had tension-type headaches. The students with migraine had the highest Pediatric Migraine Disability Assessment scores (10.7 +/- 20.0); whereas, the students with tension-type headaches had the lowest scores (2.0 +/- 4.4). Logistic regression analyses indicated that there were a number of independent predictors for moderate to severe headache-related disability (Pediatric Migraine Disability Assessment score > or =31), including a migraine or probable migraine diagnosis, a higher depression score, severe headache intensity, and frequent headaches.

CONCLUSIONS

The Pediatric Migraine Disability Assessment provides a simple tool to measure the impact of headaches in adolescents. Adolescents with migraine headaches suffered the greatest level of disability. Higher depression scores were associated with more severe headache-related disabilities in adolescents, independent of headache frequency and severity.

Randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of topiramate for migraine prevention in pediatric subjects 12 to 17 years of age

OBJECTIVE

Currently, no drugs are Food and Drug Administration-approved for migraine prophylaxis in pediatric patients. The objective of this study was to evaluate the efficacy and safety of topiramate for migraine prevention in adolescents.

METHODS

Adolescents (12-17 years of age) with a >/=6-month history of migraine were assigned randomly to receive 16 weeks of daily treatment with topiramate (50 or 100 mg/day) or placebo. The primary efficacy measure was the percent reduction in monthly migraine attacks, with the use of the 48-hour rule, from the prospective baseline period to the last 12 weeks of the double-blind phase. The 48-hour rule defined a single migraine episode as all recurrences of migraine symptoms within 48 hours after onset. Several secondary efficacy measures were evaluated, including the reduction from baseline in the monthly migraine day rate and the 50% responder rate. Safety and tolerability were also assessed.

RESULTS

A total of 29 (83%) of 35 subjects treated with topiramate at 50 mg/day, 30 (86%) of 35 subjects treated with topiramate at 100 mg/day, and 26 (79.0%) of 33 placebo-treated subjects completed double-blind treatment. Topiramate at 100 mg/day, but not 50 mg/day, resulted in a statistically significant reduction in the monthly migraine attack rate from baseline versus placebo (median: 72.2% vs 44.4%) during the last 12 weeks of double-blind treatment. Topiramate at 100 mg/day, but not 50 mg/day, also resulted in a statistically significant reduction in the monthly migraine day rate from baseline versus placebo. The responder rate favored topiramate at 100 mg/day (83% vs 45% for placebo). Upper respiratory tract infection, paresthesia, and dizziness occurred more commonly in the topiramate groups than in the placebo group.

CONCLUSIONS

The 100 mg/day topiramate group demonstrated efficacy in the prevention of migraine in pediatric subjects. Overall, topiramate treatment was safe and well tolerated.

Behavioral assessment and treatment of pediatric headache

Headaches are quite common in children and adolescents, and they appear to persist into adulthood in a sizable number of individuals. Assessment approaches (interview, pain diaries, and general and specific questionnaires) and behavioral treatment interventions (contingency management, relaxation, biofeedback, and cognitive behavior therapy) are reviewed, as is the evidence base for their use. The article concludes with practical suggestions for headache management.