Primary Headaches in Preschool Age Children

Abstract & Commentary

By Dara G. Jamieson, MD, Associate Professor, Clinical Neurology, Weill Medical College, Cornell University. Dr. Jamieson is a consultant for Boehringer Ingelheim and Merck, and is on the speaker's bureau for Boehringer Ingelheim, Merck, Ortho-McNeil, and Pfizer.

Source: Battistella PA, et al. Primary Headaches in Preschool Age Children: Clinical Study and Follow-Up in 163 Patients. Cephalalgia. 2006;26:162-171.

Primary headaches in preschoolers include migraine without aura and tension-type headaches. The migraine can last < 1 hour with nausea, but generally without other accompanying symptoms. Primary headaches are more common in preschool boys than girls, but the prognosis is relatively benign. Children with early-onset headaches have parents with early-onset headaches.

Primary headaches, including migraines, are a major adult affliction, but even young children suffer from chronic headaches. Headaches and migraines are common in childhood, with 4-11% of children between the ages of 5 and 15 years having headaches consistent with migraine. One to 3% of even younger children, ages 3 to 7 years, have migraines, with a slight male predominance. The impact of chronic headaches, including migraines in children, is significant with missed school and social activities and compromised quality of life.

The International Classification of Headache Disorders, Second Edition (ICHD-II), the current guide to the identification of primary headaches and migraines in adults and children, was revised from the earlier addition but has yet to be validated in the diagnosis of primary headaches in children (Headache Classification Committee of the International Headache Society (IHS): International Classification of Headache Disorders II. Cephalalgia. 2004;24:1-160). Pediatric migraine does not fit easily into the criteria for diagnosis of migraine in adults. In younger children, the diagnosis may be hampered by difficulty describing the quality and localization of the pain, and the accompanying non-pain migraine symptoms, such as photophobia and phonophobia, may have to be inferred from the child's behavior. Children have distinctive migraine symptoms and syndromes. The ICHD-II recognizes the shorter headache duration (1-72 hours) in children younger than age 15 years as compared to older children (2-72 hours). In some children with migraine, gastrointestinal symptoms, including nausea, intractable vomiting, and abdominal pain, may be more prominent than head pain. The head pain in migraine, generally unilateral in adults, is commonly bilateral in young children. Localization of the migraine head pain, relatively variable in adults, is usually fronto-temporal in children. Children have periodic syndromes or migrainous disorders, such as cyclic vomiting syndrome, abdominal migraine, and benign paroxysmal vertigo, which may overlap with migraine headache disorders.

The goals of this retrospective study were to verify the applicability of the current diagnostic criteria for pediatric primary headache to 2 different age groups (< 6 years and 12-18 years), and to evaluate the predictive factors in the evolution of headache onset at a preschool age. The 243 children in the study were recruited during the period from 1992 to 2001 from the pediatric headache practices of Battistella and colleagues. In the cross-sectional phase of the study, headache questionnaires were filled out by specialty clinic doctors for children with early age (< 6 years old) and late age (12-18 years) onset of headache. In the longitudinal phase of the study, a follow-up analysis was carried out by a brief questionnaire sent to the parents of the children in the cross-sectional phase of the study. The attack frequency was categorized as favorable or unfavorable, and the clinical evolution was assessed. In the preschool headache group (n = 163), the mean age of onset of headaches was 3.8 years, ranging from 1.0-5.8 years, with 58% males. In the pubertal headache group (n = 80), the mean onset age was 13.1, with a range from 12-16.5 years, with 39% males. There was no difference in frequency of attacks, pain intensity, or pain quality in the 2 age groups. The duration of attacks was significantly shorter in younger patients, at < 1 hour of headache in 52% of the younger children and in 15% of the older children. Attack duration was > 5 hours in 10% of the younger and 27% of the older patients. Pain localization was unilateral in 24% and bilateral in 76% of children of both age groups, without significant difference with age. Pain exacerbation with exercise was more frequent in older children. While there was no difference in the incidence of vomiting between the 2 age groups, nausea, phonophobia, and photophobia were more frequent in the older children.

Battistella et al used data from the questionnaire to classify headache type based on the ICHD-I published in 1988, now supplanted by the more recent version published in 2004. Younger primary headache patients were diagnosed with migraine (36%), tension-type headache (42%), idiopathic stabbing headache (10%), or not-classifiable headache (12%). Migraine with aura was less common, but migrainous disorders were more common in the younger subjects. The older, primary headache patients were all classified as having migraine (58%), tension-type headache (41%), or idiopathic stabbing headache (1%). Use of the Winner IHS-R classification for pediatric migraine shifted some patients within the migraine category from the migrainous disorders subcategory into the migraine without aura subcategory (Winner P, et al. Classification of Pediatric Migraine: Proposed Revisions to the IHS Criteria. Headache. 1995;35:407-410). Family history of headache was common in both groups (75% in the younger group and 59% in the older group), with early-onset headaches in the children predicting a history of an earlier onset of headaches in the parents.

The longitudinal questionnaire study had a 71% response rate and a mean follow-up of 3.5 ± 2.7 years. The initial headache diagnosis persisted for 61% migraine patients and 46% patients with tension-type headache, but only 20% of idiopathic stabbing headache patients continued with their initial diagnosis. The overall evolution of headache was favorable in 67% of patients and unfavorable in 33% of patients. Patients with tension-type or idiopathic stabbing headaches were more likely to have a favorable response than migraine patient (80% vs 49%; P < 0.05). Patients with migraine without vomiting were more likely to go into headache remission than patients who had vomiting with migraines.

Commentary

This study demonstrated that boys were more likely than girls to have preschool onset of primary headaches including migraine, but that they had a higher remission rate. Preschool children had shorter duration migraine and a higher frequency of positive family history of early onset headache than did older children. Children with a preschool age onset of headache had a relatively benign prognosis for remission (21%) or improvement (46%), with the type of primary headache predicting outcome. Improved recognition and diagnosis of primary headache disorders in children, including preschoolers, will lead to improved treatment and decreased disability for these youngest of headache sufferers.