• Chronic or recurrent: recurring repeatedly over years or persisting relentlessly over days
• Acute: rapid onset or progression
• Tension headaches, also known as muscle contraction headaches, are thought due to simple traction on pain sensors during prolonged contraction of the scalp and neck.
• Migraine is a recurrent, throbbing headache of vascular origin, usually bilateral in children and unilateral in adults. The majority of primary pediatric headaches are migraine headaches.

• Classic migraine
  • A visual aura consisting of scintillations, scotomata, or blurred vision precedes the headache followed by a unilateral or bilateral throbbing headache that intensifies over a few hours, can last several hours to a day, and is generally relieved with rest or sleep.
  • Nausea, vomiting, anorexia, abdominal pain, irritability, malaise, fatigue, and photophobia are all common associated symptoms.
• Common migraine
  • Is the most common form of headache in children and adolescents
  • Has the characteristic throbbing headache but without the visual prodrome of classic migraine. All other symptoms noted here are frequently seen.
• Complicated migraine
  • Is the association of migraine with transient neurological deficits such as ophthalmoplegic migraine, hemiplegic migraine, and migraine with aphasia
  • Basilar artery migraine is the combination of occipital headache with neurological dysfunction referable to the brainstem, cerebellum, inferior temporal, and occipital lobes.
  • Symptoms may include blurred vision, dizziness, vertigo, ataxia, sensory and motor abnormalities, obtundation, and loss of consciousness.
  • Acute confusional migraine begins with headache and is followed by confusion, agitation, and altered sensorium and is confused with the confusional state of illicit drug use in adolescents.
• Migraine variants: include paroxysmal vertigo, paroxysmal vertigo, and cyclic vomiting or periodic syndrome.
  • Are episodes of transient neurological dysfunction in a patient with known migraine, a patient who develops migraine later, or in a patient who has a family predisposition to migraine.

• Migraine occurs in 3% to 5% of children before puberty and increases to 10% to 20% during the second decade.
• Female:male ratio is approximately equal before puberty and increases to 2:1 after puberty.
• Migraine has a strong genetic component; may be autosomal dominant in many families.

• Acute diffuse: trauma, infection (systemic), stress, meningitis, encephalitis, stroke (thrombotic, embolic, hemorrhagic), subarachnoid hemorrhage, toxins (e.g., lead), hypertension, hypoglycemia, post-lumbar puncture, collagen vascular disease (arteritis), drug abuse
• Acute focal: trauma, infection (otitis, sinusitis, brain abscess, encephalitis, meningitis), dental process, orbital disease, cranial neuralgias
• Subacute recurrent/progressive: migraine (common and classic), complicated migraine, migraine variants
• Chronic progressive: benign intracranial hypertension, abscess, tumor, hydrocephalus, subdural hematoma, drug abuse
• Chronic, non-progressive: chronic myositis, psychogenic or tension headache, post-concussive syndrome, depression, conversion disorder, cervical osteoarthritis, temporomandibular joint syndrome, atypical facial pain

• Sinusitis
• Trigeminal neuralgia
• Atypical facial pain and factitious pain disorders
• Systemic features of migraine may lead to evaluation for metabolic or cerebrovascular disorders: episodic vomiting-hyperammonemias, transient hemiparesis-stroke, acute/recurrent ataxia-amino acidopathy, mitochondrial disorders, epilepsy

• Chronic: A minority of children with chronic headache have structural brain lesions: brain tumors, hydrocephalus, abscess.
• Benign intracranial hypertension usually accompanied by papilledema, normal imaging, and cerebrospinal fluid analysis.
• Post-concussive syndrome should be considered in appropriate setting.
• Children with psychogenic or tension headaches often lack associated history of social/emotional stress.
• Occipital neuralgia from trauma, shingles, or Lyme disease
• Acute: meningitis, encephalitis, intracranial hemorrhage, sinus thrombosis, dental infection, hydrocephalus

Question: Background?
Significance: Important features include duration of the problem, location of the headache, time of onset, mode of onset, associated symptoms, response to therapy, and familial history.

Question: Migraine?
Significance: The mode of onset is usually gradual, rarely paroxysmal. The location of the headache is typically bilateral either bifrontal, bitemporal, or bioccipital or diffuse and ill-defined. The quality of the pain may be aching/steady or throbbing.

Question: Stress?
Significance: May exacerbate either migraine or tension headache. Although many adults with migraine are depressed, the prevalence of depression in children with chronic headaches is not known.

Finding: Blood pressure measurement
Significance: Hypertension

Finding: Auscultation for bruits
Significance: A-V malformations

Finding: Signs of meningeal irritation
Significance: Fundoscopy for papilledema

Finding: Examination of jaw (range of motion), teeth/oral cavity, otoscopy, and palpation of maxillary, frontal, and mastoid sinuses.
Significance: TMJ syndrome; sinusitis

Finding: Neurological examination
Significance: Should be normal in primary headache syndromes (migraine, tension), except perhaps during a migraine ictus; focal neurological deficits suggest a structural (symptomatic) basis of headache.

Test: Sinus films
Significance: Indicated if symptoms point to sinusitis. These may not be obvious in sphenoid sinusitis, which may produce unremitting, chronic frontal headache.

Test: Chronic anemia
Significance: May be associated with headache, although it rarely presents in children as headache.

Test: Neuroimaging studies (CT/MRI)
Significance: Indicated when neurological examination indicates a focal abnormality; if the history suggests a specific diagnosis such as a brain tumor; or, if headaches are associated with persistent vomiting. Neuroimaging may also be indicated for atypical headaches, persistently unilateral headaches, and headaches that are increasing in frequency and severity, or that are refractory to treatment.

Test: EEG
Significance: Should be obtained when the headache is paroxysmal and/or focal.

Test: Lumbar puncture
Significance: Examination of cerebrospinal fluid to detect infection may occasionally be indicated. Opening pressure necessary in diagnosis of pseudotumor cerebri.

• Evaluation and treatment is similar to that of adult migraine. Treatment may be categorized as symptomatic, abortive, or preventive. Rare to occasional migraines may be treated symptomatically with aspirin or acetaminophen.
• Abortive therapy: ergotbomine, sumatriptan
• Prophylactic therapy includes beta blockers, cyproheptadine, tricyclic antidepressants, calcium channel blockers, anti-inflammatory drugs, and occasionally anticonvulsants.
• Other treatment modalities may include behavior therapy, relaxation training including biofeedback, avoidance of specific foods or substances that may be migraine triggers. Treatment may also include appropriate psychological counseling.

• Headaches with vomiting may suggest elevated intracranial pressure, not just migraine.
• Depression and migraine may be due to temporal lobe tumor.
• Arteriovenous malformation may mimic migraine and should be considered if headache is persistently on the same side of the head or if response to therapy is poor.

Q: When should migraine be treated?
A: Many children with migraine headaches have attacks so infrequently that prophylactic medical therapy is not warranted. Treatment should be considered when attacks occur at least once a month.

Q: What about allergy and headache?
A: Many believe that headache may represent a symptom of hypersensitivity. Headache in the setting of allergic rhinitis/asthma may be due to associated sinusitis/sinus congestion, side effect of treatment (especially theophylline), or muscle tension.

Q: At what age may migraine begin?
A: Even 2 to 3 year olds may present with headache or migraine equivalent symptoms: episodic vomiting, episodic ataxia that improves after sleep.