Experts’ opinion about the primary headache diagnostic criteria of the ICHD-3rd edition beta in children and adolescents

DOI: https://doi.org/10.1186/s10194- 017- 0818- y

Abstract-Summary The 2013 International Classification of Headache Disorders-3 (ICHD-3) was pub- lished in a beta version to allow the clinicians to confirm the validity of the criteria or to suggest improvements based on field studies.

The aim of this work was to review the Primary Headache Disorders Section of ICHD-3 beta data on children and adolescents (age 0–18  years), and to suggest changes, additions, and amendments.

Based on their personal experience and the literature available on pediatric head- ache, they made observations and proposed suggestions for the primary headache disorders section of ICHD-3 beta data on children and adolescents.

Some features in children were found to be age-dependent: clinical characteris- tics, risks factors and etiologies have a strong bio psycho-social basis in children and adolescents making primary headache disorders in children distinct from those in adults.

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Background Headache is a frequent cause of pain and of significant disability in children and adolescents.

Primary headache disorders in childhood are different from their adult manifes-

tations, but the cause for this difference is unknown.

Owing to the high prevalence of childhood headache and the absence of specific objective diagnostic criteria for children, accurate clinical diagnostic criteria are needed.

Review The aim of this study was to receive comments and suggestions from pediatric head- ache specialists around the world about the accuracies and deficiencies of ICHD-3 beta, and to provide a summary of them.

Each of them was asked to search the literature written prior to and after the

publication of ICHD-3 beta, and to provide their comments and suggestions.

The primary source of literature was Pubmed, and the paper also benefited from other widely used search engines, such as Google Scholar, and reference lists from single articles, reviews and editorials.

Migraine Frontal Headache is common in children with migraine without aura and should be acknowledged.

The autonomic symptoms associated with children and adolescent migraine should not be considered as exceptions because there are substantiated data that suggest that they can be observed in the presence of reported aura or without aura symptoms, on its own.

One study on 1134 children and adolescents with chronic headache (73.2% with migraine) revealed that migraine equivalents (abdominal migraine, cyclical vomiting, benign paroxysmal vertigo, and benign paroxysmal torticollis) are so common that these should potentially be considered as part of the migraine syndrome.

Benign paroxysmal vertigo of childhood begins between ages 2 and 5 years, with some children outgrowing the disorder and others showing persistent symp- toms into adolescence; cyclic vomiting syndrome begins on average at age 5 (about 40% rate of headache); and abdominal migraine usually begins latest, at school-age.

Tension-Type Headache In clinical studies, chronic tension-type headache was found in 5–20.5% of children.

Episodic tension-type headache may have particular features in children. The symptoms of tension-type headache may also overlap with migraine and a diagnosis of migraine can change to episodic tension-type headache over time [2–5].

Given that migraine in children may be characterized by non-pulsating (not a rule), bilateral pain, most young migraineurs can easily meet the first two criteria of tension-type headache (point C).

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In tension-type headache (TTH), by contrast, there is no photophobia, no nausea, and no aggravation after physical activity; the pain is usually of mild or moderate in intensity and non-pulsating.

The most specific features distinguishing migraine from tension-type headache are improvement after sleep, presence of nausea and vomiting, worsening with physical activity and photophobia- phonophobia- or osmophobia [6].

There are clinical findings that suggest that tension-type headache in childhood

may become migraine later in life.

Trigeminal Autonomic Cephalalgias Trigeminal autonomic cephalalgias (TACs) are divided into five different head- ache syndromes: cluster headache (CH), paroxysmal hemicranias (PH), short- lasting unilateral neuralgiform headache attacks with conjunctival tearing and injection (SUNCT), and short-lasting unilateral headache attacks with cranial autonomic symptoms (SUNA) that moved from the appendix section of ICHD-II.

The clinical features of pediatric-onset cluster headache seem to be similar to the

adult-onset type.

Lacrimation is reportedly the most common symptom of pediatric cluster head-

ache, followed by conjunctival injection and nasal discharge.

The attacks often last longer than the maximum 30 min noted by the ICHD-3 but the duration of the attacks has been reported up to 45  min in very young children.

Children with PH, who had less than five attacks per day for more than half of

the time, as specified by the ICHD-3, have been reported before.

SUNCT The syndrome of short-acting unilateral neuralgiform headache attacks with conjunc- tival injection and tearing (SUNCT) is characterized by three different types of pain: single stabs, groups of stabs, and a saw-tooth pattern in which repetitive spike- like paroxysms occur without reaching the pain-free baseline between the individ- ual spikes.

Pediatric-onset SUNCT is very rare, with only four cases (3 idiopathic, 1 second-

ary) reported in the literature.

In all the affected children, the clinical phenotype of the headache resembled

adult-onset SUNCT [7, 8].

Other Primary Headache Disorders In children less than 12 years old, diagnoses of primary cough headache, primary exercise headache, primary headache disorders associated with sexual activity, pri- mary thunderclap headache, and hypnic headache should be made only after the exclusion of other causes of headache.

A case report of a 12-year-old boy described an association between primary

exertional headache and primary sex headache.

The following might be added to the text: “There is a phenomenological associa-

tion between primary exertion headache and migraine attacks”.

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There is a case report in the literature of a four-year-old boy who presented with nummular headache co-localized with a patch of discolored hair and a common etiology is proposed [9].

We need more cases of nummular headache in children and adolescents to make

good recommendations.

Reports of hypnic headache in children are scarce. A recent literature review of six children with hypnic headache (HH), was used

to evaluate the validity of the ICHD-3 criteria in children.

Primary Headache and Comorbidities in Children and Adolescents Primary headache is strictly correlated to psychiatric comorbidities, especially in children and adolescents.

Children with migraine seem to have lower attachment security than children

without the disorder.

Children with primary headache seem to have a reduced ability to identify and

describe feelings (that is called alexithymia).

It is essential to deepen the presence of comorbidities in children and adolescents with primary headache to choose the correct therapy directed not only to improve headache but also the patient’s quality of life.

Limitations of this Paper This paper is based on the data reported in the literature and the personal experience of pediatric headache specialists.

The use of interviews, standardized questionnaires and diaries is another impor- tant source of variation in the assessment of headache in children and adolescents.

We are planning to organize a prospective, language-adapted study supported by

clinical assessments of video-taped interviews.

Some of our comments were restricted by a sparsity of data or absence of knowl-

edge on the applicability of specific aspects/points to the pediatric population.

Implications of the Paper All authors based their comments and recommendations on their personal experi- ence, with support from the data in the literature specifically pertaining to the pedi- atric population, even after the publication of ICHD-3 beta.

This paper supports the distinction between pediatric and adult headache. We trust that with the accumulation of data, the next version of the ICHD will include specific subsections with separate definitions/criteria of pediatric headache.

Conclusions Children are not simply small adults; they have distinct biopsychosocial attributes that play a clear role in the pathogenesis and presentation of headache disorders, with important differences from adults.

Different characteristics of headaches between children, adolescence and adults reflect the degree of brain maturation including myelination, brain plasticity, new synapse formation and synaptic reorganization.

Different characteristics of headaches between children, adolescence and adults

reflect the degree of cognitive development.

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Acknowledgement A machine generated summary based on the work of Özge, Aynur; Faedda, Noemi; Abu-Arafeh, Ishaq; Gelfand, Amy A.; Goadsby, Peter James; Cuvellier, Jean Christophe; Valeriani, Massimiliano; Sergeev, Alexey; Barlow, Karen; Uludüz, Derya; Yalın, Osman Özgür; Lipton, Richard B.; Rapoport, Alan; Guidetti, Vincenzo 2017 in The Journal of Headache and Pain.

ICHD-3 is significantly more specific than ICHD-3 beta for diagnosis of migraine with aura and with typical aura