|Year : 2022 | Volume
| Issue : 1 | Page : 23-29
Pattern of recurrent pediatric headache: A cohort of 100 children
Naveen Kumar Bhardwaj1, Sanjeev Chaudhary1, Amit Bhardwaj2, Neeraj Gupta3, Vykuntaraju K Gowda4, Ashwin Vivek Sardesai4
1 Department of Pediatrics, Dr. Rajendra Prasad Govt. Medical College Kangra at Tanda, Himachal Pradesh, India
2 Department of Neurology, Dr. Rajendra Prasad Govt. Medical College Kangra at Tanda, Himachal Pradesh, India
3 Department of Neonatology, AIIMS Jodhpur, Rajasthan, India
4 Department of Pediatric Neurology, Indira Gandhi Institute of Child Health Bangalore, Karnataka, India
|Date of Submission||03-Jun-2020|
|Date of Decision||22-Oct-2020|
|Date of Acceptance||20-Dec-2020|
|Date of Web Publication||02-Jul-2021|
Dr. Naveen Kumar Bhardwaj
Department of Pediatric, MM Medical College and Hospital, Kumarhatti Solan, H.P. 173229
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: This study was conducted to provide detailed information about clinical characteristics and short-term treatment outcome of childhood headache. Materials and Methods: This prospective observational study was done over a period of 15 months (January 2013 to March 2014) at a rural tertiary care center in North India. Detailed history, clinical examination, specialty review, and follow-up details were maintained on pretested structured proforma. Final diagnosis of headache type was made as per International Classification of Headache Disorders, 2nd edition. Results: Out of 100 (45 boys) children aged 8–18 years, 52% were diagnosed with migraine, 23% with tension-type headache, and 25% with secondary headache. Diffuse headache was the commonest (41%), and photophobia, phonophobia, and dizziness were the commonest symptoms in all headache subtypes. Sixty-five percentage of migraine headache were triggered by exertion. Lack of sleep and anxiety were triggers in most (65%) of tension type headache. Of 52 migraine children, 21 were started on prophylaxis for migraine and 14 of them reported significant improvement. Secondary causes for headache were found in 25% of children and half of them were having refractive errors. Conclusions: Results of the study show migraine being the commonest type of headache in children followed by secondary headache. This study also highlights the need for long-term follow-up of childhood headache.
Keywords: Migraine, migraine prophylaxis, primary headache, recurrent headache, secondary headache, tension-type headache
|How to cite this article:|
Bhardwaj NK, Chaudhary S, Bhardwaj A, Gupta N, Gowda VK, Sardesai AV. Pattern of recurrent pediatric headache: A cohort of 100 children. J Pediatr Neurosci 2022;17:23-9
| Introduction|| |
Headache is the most frequent neurological symptom and the commonest manifestation of pain in childhood. In terms of the number of people affected headache is the commonest neurological condition. In 1955, Bille provided the first well-conducted population-based study on childhood headache and found that 40% of children by age 7 and 75% by age 15 had already experienced a significant headache. Recurrent headaches can negatively impact a child’s life in several ways, including school absenteeism, decreased academic performance, and impaired ability to establish and maintain peer relationships.
A good number of population-based studies are available on pediatric headache, but they mainly describe the prevalence and proportion of various headache types. There are only few studies,,,, describing parameters like main presenting features, pattern, and treatment outcome of the pediatric headache which are also of equal interest to clinicians.
Therefore, this study was conducted to provide detailed information about distribution, clinical characteristics, and short-term treatment outcome of headache in a tertiary care hospital in Northern India.
| Materials and Methods|| |
This was a prospective observational study conducted at a rural tertiary care teaching hospital in Himachal Pradesh, after getting ethics approval and written informed consent from the parents/guardians of the study participants.
Children aged 8–18 years attending pediatric, ophthalmology, neurology, otorhinolaryngology, and psychiatry outpatient department with a primary complaint of recurrent headache were referred to primary investigator and were included in the study. Recurrent headache was defined as at least two episodes of headache in the last 6 months.
A structured pretested proforma of 45 items including history and thorough general and systemic examination was used to collect the relevant information. Ophthalmology and otorhinolaryngology evaluation was done in every case in concerned department and wherever required dental, orthopedics, psychiatry opinion was taken. Imaging was done wherever indicated which mainly included abnormal or focal neurological signs or symptoms, seizures or brief aura (<5 min), brief cough headache, and headache worst on first awakening. Each child was evaluated by a principal investigator and a single neurologist in a one-to-one setting and the final diagnosis of his/her headache was made according to the International Classification of Headache Disorder II (ICHD-II) criteria of the International Headache Society (IHS). In case of discrepancy in diagnosis, final diagnosis was made by mutual consensus. Children with final diagnosis of primary headache were sub-classified up to 1 decimal point as per ICHD-II. An 11-point (0–10) numerical rating scale (NRS) was used to assess the severity of headache at enrollment and in follow-up.
After final diagnosis was made, appropriate management including pharmacotherapy and behavioral therapy was started. Children or their parents were asked to make headache diary mentioning the date and time of episode, duration of episode, associated symptoms, trigger and relieving factors for the episode. Children with primary headache were advised acute and preventive treatment as per standard treatment guidelines. Paracetamol 15 mg/kg/dose was used for termination of acute episode and Flunarizine 5 mg daily was used as prophylactic therapy wherever indicated., Secondary headache was managed in concerned department and spectacles were prescribed for refractive errors.
Patients were followed up at the end of 1 month and at the end of 3 months of starting treatment by OPD visit or telephonically. More than two-points improvement on NRS was defined as some improvement and more than four-points improvement was defined as significant improvement at the end of 3 months. Diagnostic algorithm and flow of the study have been mentioned in [Figure 1].
|Figure 1: Diagnostic algorithm and flow of study. ICDH = International Classification of Headache Disorder; TTH = tension-type headache. *Ophthalmology and otorhinolaryngology evaluation in every case and wherever required dental, orthopedics, psychiatry opinion, **cerebrospinal fluid examination in one case, refraction in ophthalmology, X-rays in otorhinolaryngology, etc|
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| Results|| |
Out of 100 children enrolled in the present study, 45 (45%) were boys. The mean age of headache onset was 12.1 ± 2.5 (mean ± standard deviation) years. Primary headache was diagnosed in 75% of children and secondary headache was diagnosed in 25% of children. Distribution of various headache subtypes is shown in [Table 1].
Out of 25 children diagnosed with secondary headache, 19 (76%) were attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structure and of these, refractive errors were most common (13, 52%) followed by sinusitis (4, 16%), otitis media (1, 4%), and dental caries (1, 4%). Headache attributed to psychiatric disorder was present in four children and to nonvascular intracranial disorder was present in two cases.
Forty percent of all secondary headache patients presented within 1 month of onset. Seeing the pattern of presentation of primary headache, only 12% presented within 1 month of onset and most patients presented between 1 and 6 months of headache onset.
Various clinical characteristics of headache are shown in [Table 2]. Primary headache was found to occur with varied frequency while a major proportion of secondary headache (21, 84%) was presenting daily or more than once a week. The duration of headache was less than 4 h in more than two-thirds of children with primary headache whereas it lasted for more than 4 h in almost one half of secondary headache patients. Associated symptoms of headache have been described in [Figure 2].
Family history of headache in the first-degree relative was present in eight (15.3%) children with migraine, three children (13%) with TTH, and in one child with secondary headache.
Sixty-five percent of migraine sufferers reported exertional activity as a trigger for their headache and 65% of TTH were triggered by lack of sleep and anxiety. No specific triggering factor was found in 40% secondary headache; however, 28% of these were increasing on bending forward. Relieving factors for various headache are shown in [Figure 3].
CNS examination was abnormal in six (6%) children and CNS imaging was done in seven cases. Out of these four were showing normal CNS imaging finding, one child was diagnosed with CNS tumor (pilocytic astrocytoma), incidentally posterior fossa cyst was picked up in one child, and one child was diagnosed with chronic meningitis.
Twenty-one children with primary headache were started on flunarizine prophylaxis and 14 of them reported significant improvement and three of them reported some improvement at the end of 3 months. In four children, headache was occurring with the same frequency. Some improvement was seen in one child with refractive error, one with sinusitis and meningitis. Most of the children with secondary headache were awaiting or not taking treatment at the end of 3-months follow-up.
Our study used ICHD II as it was the latest classification available at that time. Later, the IHS published the beta version of the third edition (ICHD-III beta) and now, the third edition of ICHD has come in 2018.,,, We tried comparing our results with newer criteria, as we studied headache subtypes superficially up to one decimal point only, so applying a new classification system would have not altered results much except for coding of migraine headaches.
| Discussion|| |
In this present prospective cohort of 100 children, the mean age of headache onset was 12.1 years. This finding is in accordance with other clinic-based studies where age of headache onset has been reported between 8 and 13 years.,,,,
In this study, migraine was the commonest (52%) type of headache as in previous hospital-based studies where it has been reported between 50 and 75%.,, It has also been reported commonest type of headache in children from various population-based studies.,,, We found TTH in 23% of children of this cohort; a similar proportion is reported in most of the previous studies.,, Few epidemiological studies report TTH much more prevalent than migraine,, reason for which may be that migraine being a severe form of headache results in patients to seeking medical help more commonly compared to TTH, which is usually mild and self-limiting.
Migraine without aura was the commonest subtype of migraine and frequent episodic TTH was more common as compared to other TTH subtypes; the same pattern was seen in a previously published hospital-based study. In the present study, 20/52 migraine children were having a duration of headache less than 1 h, not fulfilling the desired duration of 2 h as per ICHD-II to be classified as migraine without aura but more than half of them were taking analgesics within 1 h of headache onset. After careful history and careful review of headache diary in follow-up, these children were reclassified as migraine without aura or probable migraine at the end of the study. There are studies stating that a significant percentage of childhood headaches fail to receive migraine diagnosis because of not meeting duration criteria, and further research is ongoing on this issue.
In this study, family history of headache was positive in approximately 15% of primary headache children, which is very low compared to previously reported statistically significant rate of 50–70%.
The proportion of secondary headache was quite high (25%) in the present study as compared to previous studies in a similar setting or other population-based studies,,,; the difference could well be because of the inclusion of patients from other departments along with pediatric and neurology patients. Almost half of the children with secondary headaches were having refractive errors. There is a lack of conclusive evidence between headache and refractive errors in children., in A systemic review, Sheeladevi et al. have found that the overall prevalence of refractive error per 100 Indian children was 8.0 and, in schools, it was 10.8 in less than 15 years. Seeing such high prevalence of both these conditions to pinpoint a single cause is difficult in short-term follow-up.
Although children are remarkably good headache historians, it is difficult for young children to describe all details of headache, so to clinically characterize headache well we included children more than 8 years.
Similar to the previous study by Cuvellier et al., we found that primary headaches tend to occur with daily or more than once weekly frequency and last less than 4 h predominantly.
We found some specific characteristics in various headache types. Secondary headaches were seen to occur with daily and more than once weekly frequency in 84% of children and, in almost half of the cases, it was lasting longer than 4 h. Diffuse headache was reported most commonly followed by frontotemporal headache in all the groups. We found secondary headaches and migraine almost equally disabling in this cohort.
Previous studies have reported a lack of sleep and effort as common aggravating factors for primary headache., However, aggravating factors for various headache types are not discussed separately. In our study, we found exertional physical activity as a trigger for migraine and lack of sleep and anxiety for TTH in up to two-thirds of cases. Sleep was a relieving factor in 65% of migraine cases similar to a previous multicentric French study.
After starting flunarizine prophylaxis in 21 children with disabling migraine, improvement was documented in 66% of cases at the end of 3 months. Very few studies on prophylactic migraine pharmacotherapy are available in children and a similar reduction rate was reported in one of the descriptive study.
Major limitations of the study are convenience sampling and short-term follow-up of treatment. Children with secondary headaches were still awaiting treatment and as half of them were having refractive errors where we are not sure of a component of associated primary headache. We used only a decrease in intensity of headache as improvement criteria, using more objective scores like PedMIDAS for assessment would have strengthened treatment outcome interpretations.
The main strengths of the study were 100% follow-up of enrolled children, interview by a single trained physician in a one-to-one setting, and all patients were also evaluated by neurologist separately to decrease the bias and final diagnosis was made objectively as per ICHD-II. Every possible effort was made to include cases from each department so as to increase generalization of the study. Every case was worked up thoroughly with multidepartment collaboration.
To conclude, the present study has provided insight into the pattern of childhood headache presenting features, triggers, level of associated disability, and short-term treatment outcome. This study also adds that if evaluated thoroughly secondary headache can constitute a significant percentage of childhood headache. This study also highlights the need for long-term follow-up of childhood headache. As we reported, a high association of refractive errors with childhood headache but, seeing a high incidence of both of these conditions, to assign a single cause in short-term follow-up is difficult and the same can happen with other secondary headache. There is still a paucity of data on pediatric headache in India. We need more studies on prevalence, pattern, and treatment outcome with multispecialty collaboration in childhood headache for a better understanding of the problem.
We are thankful to the Department of Ophthalmology, Department of Otorhinolaryngology, Department of Psychiatry, and Department of Dentistry, Dr. Rajendra Prasad Govt. Medical College Kangra at Tanda, Himachal Pradesh for evaluation and management of study participants.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
NKB evaluated and managed all the patients under the guidance of SC and AB, conducted the literature search, collected data, and prepared the initial draft of the manuscript. SC and AB conceived the study, formulated the study protocol, coordinated and supervised data collection, and prepared the final manuscript. NG, VKG, and AS analyzed the data and critically reviewed the manuscript and provided important intellectual inputs in the manuscript. AS provided help in revising the manuscript. All authors approved the final manuscript to be submitted.
The study was approved by the Institutional Ethics Committee.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]