Typical and atypical cluster headache in childhood

Pediatric Cluster Headache Case Series: Symptomatic Cases and the Migraine Relationship

BACKGROUND

Current criteria help differentiate cluster headache from migraine. However, children may have overlapping features making it difficult to distinguish the 2 conditions, which may delay diagnosis. Differentiating cluster headache from migraine is important regarding treatment as well as diagnostic workup of secondary headache etiologies.

METHODS

Cases at a single pediatric children's hospital from 2015 to 2023 diagnosed with cluster headache before the age of 18 years were reviewed.

RESULTS

Twenty-five cases were identified of which 22 cases met criteria for either chronic, episodic, or probable cluster headache. Three cases were diagnosed with cluster headache by their provider, but documentation was insufficient to meet criteria for cluster headache. There were 16 females and 9 males between ages 6 and 17 years. Five cases were identified as symptomatic, 2 cases as chronic, 7 cases as episodic, and 13 cases as probable cluster headache. Symptomatic etiologies include Graves disease, optic neuritis, prolactinoma, hypothalamic pilocytic astrocytoma with carotid stenosis, and congenital right eye blindness. Migrainous features were common, including 76% with nausea, 36% with vomiting, 68% with photophobia, and 56% with phonophobia. Patients with cluster headache also had an independent diagnosis of migraine in 64%.

CONCLUSION

Children with cluster headache have a high frequency of migrainous symptoms and co-occurrent diagnosis of migraine. A careful history may differentiate cluster headache from migraine and treated accordingly. Children with cluster headache features should undergo screening for secondary causes with appropriate imaging and other studies. Except for prolactinoma, the symptomatic associations noted in this case series have not been reported before.

Feasibility, Utility, and Interrater Reliability of the Cluster Headache Severity Scale, Cluster Headache Quality of Life, Cluster Headache Index, and 6-Item Headache Impact Test in Pediatric Cluster Headache

Introduction: Cluster headache is rare in children and only a few clinical studies have systematically evaluated cluster headache in children. Methods: This study was conducted between August 2019 and December 2021 with the primary aim to evaluate the feasibility and utility of the Cluster Headache Severity Scale in determining the severity of cluster headache in patients aged less than 18 years and monitoring response to prescribed treatment. Secondary objectives were to evaluate the feasibility and utility of Cluster Headache Quality of Life, Cluster Headache Index, and 6-item Headache Impact Test in pediatric cluster headache patients to assess the quality of life, severity, and impact of cluster headache. Results: A total of 32 children (age of onset 11.9 ± 2.3 years, age of diagnosis 13.7 ± 2.4 years, 68% boys) were enrolled. Although 30 cases had their headache episodes occurring during nighttime, only 16 children had a Children's Sleep Habits Questionnaire (CSHQ) score >41 at baseline. All children responded to prednisolone as bridging therapy and 23 of 32 showed adequate pain relief after sumatriptan nasal spray for an acute attack. The average time taken for completion of Cluster Headache Index, Cluster Headache Severity Scale, Cluster Headache Quality of Life, and Headache Impact Test-6 scores were 5.2 ± 0.7, 5.1 ± 0.8, 27.4 ± 3.5, and 6.2 ± 0.8 minutes, respectively. The interrater reliability was good for Cluster Headache Severity Scale, Cluster Headache Quality of Life, and Headache Impact Test-6 (Cronbach α 0.93, 0.81, and 0.89, respectively). There was a strong positive correlation between the Cluster Headache Severity Scale score with Headache Impact Test-6 score and Cluster Headache Quality of Life score (correlation coefficient r = 0.90 and 0.98). Conclusion: Majority of pediatric cluster headache patients are likely to respond to prednisolone and sumatriptan. Cluster Headache Severity Scale, Cluster Headache Quality of Life, and Headache Impact Test-6 can be used for pediatric cluster headache patients for treatment monitoring.

Childhood-Onset Cluster Headache: Observations From a Personal Case-Series and Review of the Literature

BACKGROUND/OBJECTIVES

Puberty seems to be a turning point in cluster headache (CH) onset. To verify its influence on CH phenotype, we focused on cases with onset ≤13 years. A review of the literature follows.

METHOD

We considered CH cases with age-of-onset ≤13 years evaluated at our center between 1975 and 2015; these cases were matched by sex to two consecutive patients with age-of-onset as close as possible (±2 years) to the median age-of-onset of the overall CH population.

RESULTS

Of the overall 808 cases (585 men and 223 women, M:F ratio = 2.6), 38 patients (20 men and 18 women, M:F ratio = 1.1) had pediatric onset (PO). The diagnostic delay was significantly higher among cases with PO (21.2 ± 12.4 years, P < .0001). In this group, females had more frequently a chronic course and a familiarity for CH. Men with PO had some significant distinctive features, including higher frequency and longer duration of headache attacks, and higher proportion of various cranial autonomic and migraine-like symptoms.

CONCLUSIONS

We confirmed that CH with childhood onset does not show a male predominance, which was actually inverted for chronic cases. Furthermore, males with PO seem to have a specific clinical phenotype.

Cluster headache in children and adolescents: Ten years of follow-up in three pediatric cases

Background: Cluster headache (CH) is a rare cause of headache in children. Onset before 12 years of age is unusual, and long-term follow-up of pediatric cases has been not reported.

Objectives: To report three cases of CH with onset at childhood and at least ten years of follow-up.

Methods: Case report.

Results: The first case is that of a 12-year-old boy with episodic CH with unilateral pain and striking, bilateral autonomic manifestations, remitted for over eight years. The second case is unique in that it reports a case of chronic CH in a 13-year-old boy with Down syndrome. The third case is that of a 9-year-old girl with episodic CH with remissions of 2 and 5 years. All cases had prominent autonomic features. The frequency and duration of the attacks were similar to those that have been reported in adults. Good response to indomethacin was obtained in two cases, although tolerability issues occurred in one.

Conclusion: Sustained, long-term, medical and/or spontaneous remission occurs in CH of early onset. The phenotype and response to therapy in children, at least in these case examples, are similar to equivalent observations in adult patients with CH.

Overview of diagnosis and management of paediatric headache. Part II: therapeutic management

A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment. In part 1 of this article (Özge et al. in J Headache Pain, 2010), we reviewed the diagnosis of headache in children and adolescents. In the present part, we will discuss therapeutic management of primary headaches. An appropriate management requires an individually tailored strategy giving due consideration to both non-pharmacological and pharmacological measures. Non-pharmacological treatments include relaxation training, biofeedback training, cognitive-behavioural therapy, different psychotherapeutic approaches or combinations of these treatments. The data supporting the effectiveness of these therapies are less clear-cut in children than in adults, but that is also true for the data supporting medical treatment. Management of migraine and TTH should include strategies relating to daily living activities, family relationships, school, friends and leisure time activities. In the pharmacological treatment age and gender of children, headache diagnosis, comorbidities and side effects of medication must be considered. The goal of symptomatic treatment should be a quick response with return to normal activity and without relapse. The drug should be taken as early as possible and in the appropriate dosage. Supplementary measures such as rest in a quiet, darkened room is recommended. Pharmaco-prophylaxis is only indicated if lifestyle modification and non-pharmacological prophylaxis alone are not effective. Although many prophylactic medications have been tried in paediatric migraine, there are only a few medications that have been studied in controlled trials. Multidisciplinary treatment is an effective strategy for children and adolescents with improvement of multiple outcome variants including frequency and severity of headache and school days missed because of headache. As a growing problem both children and families should be informed about medication overuse and the children's drug-taking should be checked.

Cluster headache in children--experience from a specialist headache clinic

BACKGROUND

Cluster headache is a primary headache disorder with the distinct clinical features: unilaterality, extreme pain, cranial autonomic features and periodicity. The prevalence of the disorder is 0.1% in adults and with a male predominance. The age of onset is usually in the second and third decade of life but the onset in the first decade is recognised. We describe our experience of cluster headache in children and review the literature. We have attempted to define the clinical features of cluster headache in children as compared to adults, the role of clinical investigations, reliability of clinical diagnosis, effective treatment and management options.

METHODS

A retrospective casenotes review was conducted on all children with suspected cluster headache seen in our centre from 2000 to 2005. Case ascertainment was conducted using International Headache Society guidelines, and by telephone interviews with the parents.

RESULTS

Eleven children were identified, (seven male and four female). The median age of onset was 8.5 years (range 2-14). The median age at diagnosis was 11.5 years (range 7-17). Eight children had episodic and 3 children had chronic cluster headaches. The average attack duration was 72 min. The commonest reported bout frequency was one per day. Several children had circadian and circumannual periodicity and most displayed the other features of the disorder, such as agitated movement and cranial autonomic activation. Oxygen, methysergide, verapamil, zolmitriptan and dihydroergotamine were the drugs which were effective in terminating the headache. Paracetamol, ibuprofen and paracetamol/codeine combinations were not.

CONCLUSION

We describe our experience with cluster headache in eleven children who all presented before the age of 16.

Therapy-resistant cluster headache in childhood: Case report and literature review

The mean age of onset of cluster headache (CH) is in the late third decade. Only few cases of childhood-onset (< 14 years) CH have been reported in the literature. We report the case of an 11-year-old boy who suffered from sudden attacks of shock-like, intense pain, localized in the right orbital region, with associated photophobia, phonophobia, conjunctival injection, lacrimation, nasal congestion, rhinorrhoea and psychomotor agitation. The episodes lasted 60–180 min, and the headache frequency was one to three per day. Physical and neurological examinations, magnetic resonance imaging and blood examinations were normal. The first bout lasted 8 months. Attacks were resistant to every symptomatic and partially to prophylactic treatment that has been tried. The second bout lasted approximately 2 months.

Chronic paroxysmal hemicrania-like headaches in a child: response to a headache diary

Chronic paroxysmal hemicrania and cluster headache are both characterized by recurrent, severe, unilateral headaches accompanied by symptoms and signs of autonomic dysfunction. They are differentiated by the frequency, duration, and medication responsiveness of the headaches. Both occur in childhood, although such reports are rare. A 6-year-old boy presented with chronic paroxysmal hemicrania-like headaches. Through the use of a headache diary, his headaches were found to follow stressful events and resolved shortly after the introduction of the diary. Precipitation of chronic paroxysmal hemicrania-like headaches by stress has not been previously reported. We recommend the use of a headache diary as both an aid to diagnosis and an initial nonpharmacological therapeutic intervention for children with such headaches.