Chronic and Recurrent Headaches in Children and Adolescents

Symposium on Recurrent Pain in Children

Chronic and Recurrent Headaches in Children and Adolescents Generoso G. Gascon, M.D.*

INTRODUCTION AND PREVALENCE Headache is common in children and adolescents. It often is an incidental symptom during a systemic illness with fever, such as a flu syndrome, or an important symptom in a grave central nervous system acute illness, such as meningitis, encephalitis, or spontaneous subarachnoid hemorrhage. Less commonly, it is a symptom of slowly progressive central nervous system disease, focal, multifocal, or diffuse. The frequency with which this subject is covered in the pediatric literature reflects the frequency with which headache is encountered in the practice of pediatric and adolescent medicine. The study most often quoted about the incidence and prevalence of headache in children is Bille's 1962 study of approximately 9000 school children in Sweden. 6 This study showed that, by age seven years, approximately 40 per cent of children will have experienced headaches. By age 15, 75 per cent have experienced headaches. True migraine occurred in 4 per cent and nonmigrainous headaches of vascular or tension type were reported in 54 per cent. 5 Egermark-Eriksson's recent study21 of 402 Swedish school children in age groups 7, 11, and 15 years confirmed Bille's findings that frequency of headache increases with age. Sex differences are found in older children ages 10 to 15, girls having more headaches than boys, 5· 45 while no significant sex differences are found in 7 year olds. 6• 21 · 55 Several studies report higher prevalence rate of migraine for boys than girls under the age of 10.12,15

Another recent study examined a cohort of 2921 Finnish school children longitudinally, from ages 7 through 14. 54 Migraine and other forms of headache clearly become more prevalent during the school years. Mi-

*Professor of Neurology and Pediatrics, Chairman, Division of Neurology, Department of Neuroscience, University of North Dakota Medical Education Center, Fargo, North Dakota

Pediatric Clinics of North America-Vol. 31, No. 5, October 1984

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graine that begins before age 7 disappears more commonly in boys than girls. If migraine began between ages 8 and 14 years, however, by age 14 it had disappeared in one girl out of three but only in one boy out of five. The prevalence of migraine in 7 year olds was 2. 7 per cent (boys 2. 9 per cent, girls 2.5 per cent) and at age 14 was 10.6 (boys 6.4 per cent, girls 14.8 per cent). Among individual symptoms of migraine, nausea and vomiting decrease while visual auras increase with age. Note that the prevalence rate of migraine in this study (10.6 per cent by age 15) compared with Bille's (4 per cent) is higher. There have been three excellent recent reviews of headaches in childhood49· 51 · 53 as well as several relatively recent articles on specific aspects. 3, 13, 23, 47, 5o The dilemma that concerns the primary care practitioner is whether and when there should be concern about chronic headache and associated symptoms being symptomatic manifestations of underlying systemic, head, face, and neck, or CNS disease, versus whether and when it would be safe to reassure and treat symptomatically. The extremes of omission and commission are watching and waiting too long or overtesting too early and obtaining negative results. At either extreme patients and parents may be falsely reassured. This article will be limited to chronic, intermittent and recurrent headache. Since detailed descriptions of clinically important syndromes are available in the recent reviews mentioned above, this article will assume some familiarity by the average reader with those syndromes and will emphasize a clinical management approach.

DIFFERENTIAL DIAGNOSIS Before adolescence, most chronic, intermittent, or recurrent headache in childhood is migraine, expressed in one form or another. In adolescents, muscle contraction headache becomes a more frequent consideration, along with migrane. Eye strain and sinus problems are overemphasized as causes of headache. Several classifications of headache have been proposed.52 The earliest criteria widely used for migraine was that of Vahlquist60 and has been used as the major definition for inclusion criteria in the Scandinavian prevalence studies, right up to the present. 54 Most of these are based on the symptom complex, the pathophysiology, or the presumed location of the abnormality. A clinically useful classification is that by the temporal pattern: acute, acute and recurrent, chronic and progressive, and chronic nonprogressive. 49 This will be discussed in the section

Interpretation of Symptoms. The approach to differential diagnosis in early school-age children and preadolescents differs from that in adolescents. When acute headaches are eliminated from diagnostic consideration and the question is the differential diagnosis of recurrent chronic progressive or nonprogressive headaches, a division into migrainous versus nonmigrainous headaches is a useful first approximation (see Table 1). Migraine is a paroxysmal disorder of cephalic arteries in' which initial vasoconstriction is followed by vasodilatation15· 62 and is probably inherited as an autosomal dominant with greater

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penetrance in females. 23 In adults a prodrome of hours to days may precede a migraine attack. This is uncommon in this author's experience with children. Common, classic, and complicated migraine syndromes are differentiated primarily by whether or not symptoms are expressed in the vasoconstrictive phase, the vasodilatation phase, or both, and the particular arteries that are involved (see Fig. 1). The migraine syndromes in most preadolescent children fall most commonly into that of common migraine, where there are no early focal neurologic symptoms, the headache is usually bilateral and frontotemporal or bifrontal, and where nausea and vomiting may not be prominent, except in younger children, then to be followed by lethargy or sleep. Usually, the younger the child, the briefer the attack. Classic migraine is reported less in preadolescent children than in adolescent children and consists of visual auras, followed by hemicrania! headache with nausea and vomiting, again tending to be followed by

Table 1.

Differential Diagnosis of Chronic and Recurrent Headaches in Children and Adolescents

VASCULAR DISORDERS

Migraine Common Classic Complicated migraine syndromes Basilar artery migraine Confusional migraine Hemiplegic migraine Ophthalmoplegic migraine Alice-in-Wonderland syndrome Status migrainus Posttraumatic Visual loss Confusional syndrome Common migraine Migraine variants Cyclic vomiting in infancy Benign paroxysmal vertigo Abdominal migraine Cluster Headaches (Histamine Cephalgia, Horton's Headache) Classic cluster syndrome Chronic cluster syndrome PAROXYSMAL DISORDERS

Headaches Associated with Seizures Ictal headaches Postictal headaches MUSCLE CONTRACTION HEADACHES

Common Tension Headaches Psychogenic Depression School phobia syndrome Conversion symptom Prolonged postconcussion syndrome Occipital neuralgia

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Differential Diagnosis of Chronic and Recurrent Headaches in Children and Adolescents (Continued)

SYMPTOMATIC HEADACHES

Hypoglycemia Dental problems Sinusitis Eye Strain Neck Problems and Cervical Spine Temporomandibular Joint (Tl\IJ 1 Syndrome Mass Lesion-Brain Tumor, Abscess, Chronic Subdural Hematoma Arteriovenous Malformation Aneurysm Hydrocephalus Pseudotumor Cerebri Trigeminal Neuralgia Meningeal Leukemia RARE PERIODIC SYNDROMES

Benign Paroxysmal Torticollis Acute Intermittent Ataxia Intra-abdominal Disorders, e.g., Lead Colic Acute Intermittent Porphyria Other Hereditary Neurologic l\letabolic Disorders Ornithine transcarbamylase deficiency, other urea cycle defects Pyruvate carboxylase deficiency (hyperalaninemia) Hartnup's disease Intermittent variant of maple syrup disease

sleepiness. The visual auras classically are "scintillating scotoma" or fortification spectra. They may also be described as "flashing lights," "like neon signs," or "flash bulbs popping". Rarely, particularly in older adolescents, the visual auras may occur alone without being followed by headache-an aborted classic migraine attack. In this instance, the essential differential diagnostic consideration is whether these are visual seizures or some ophthalmic problem. Complicated migraine syndromes are seen more commonly in children and adolescents than in adults. They are essentially focal neurologic expressions of the vasoconstrictive phase, or of pathophysiology resulting therefrom, such as regional ischemia or edema. Headache is either not prominent or completely absent. Basilar artery migraine4, 31, 35 is manifested by symptoms of vertebralbasilar insufficiency, such as vertigo, ataxia, diplopia, dysarthria, transient hemianopsia, and even loss of consciouness. Its full expression is seen primarily in adolescent females, although partial expressions of the syndrome are probably relatively common and may pose as other syndromes, such as benign paroxsysmal vertigo and confusional migraine or alternating hemiplegia in infancy. 31 A common expression in early school-age children is bisensory symptoms such as perioral and bimanual peresthesias, which may be combined with vertigo. Confusional migraine presents as an acute confusional state and must be differentiated from acute toxic encephalopathies, psychotic states, and nonconvulsive status epilepticus. 26 There is usually partial or complete amnesia of the episode. It ~ now known that attacks may be repetitive in the

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TIME- HOURS Figure 1. The temporal profile of migraine is plotted at the bottom as time versus severity of headache. The presumed pathophysiology of vasoconstriction preceding vasodilatation is plotted above the temporal profile, correlated in time. The symptomatic expression of migraine syndromes is plotted at the top, also correlated in time with the temporal profile and the pathophysiologic sequence.

same patient. 22 Although the symptoms are explainable by ischemia or edema within distribution of the posterior cerebral arteries to medial limbic cortex, 40 there is further evidence from adult neurology that a confusional state can occur from a unilateral hemispheric lesion. 41 Acute confusional migraine probably occurs in adults also, from this author's experience, but there is no definitive literature on the subject. Hemiplegic migraine may present with an initial phase of weakness, but also hemisensory symptoms. These may persist after headache ceases. It is most worrisome when the hemiplegia is on the same side and outlasts the headache, and there is a lack of family history or past history of the syndrome. Essential differential diagnosis includes acute infantile or childhood hemiplegia syndrome, identifiable causes of stroke in children, such as Moya-Moya disease, a postictal Todd's paralysis, intracranial hemorrhage or brain abscess, particularly if the child has cyanotic congenital heart disease. The pathophysiology probably involves the middle cerebral arteries. Ophthalmoplegic migraine is a rare syndrome usually seen in very young children. Although the presumed pathology is edema of the carotid artery and compression of the oculomotor nerve, the presence of a vascular anomaly such as aneurysm must be ruled out, at least the first time the syndrome presents. 48

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The Alice-in-Wonderland syndrome28 is rare and presents as perceptual illusions with distortions of spatial relations and time sense and occasionally micropsia and metamorphosia. They occur before, during, or after the headache, or may occur without a headache. The syndrome is probably secondary to ischemia in the distribution of the posterior branches of the middle cerebral artery. Status migrainous is a state of continual or a prolonged bout of migraine headaches similar to status epilepticus with seizures and is more likely to be seen in older adolescents. The confusion here is whether or not there may be combined migraine and muscle contraction syndrome along with other psychogenic factors. Migraine precipitated by head injury can be termed "posttraumatic migraine" and is an essential consideration when headaches after mild closed head injury seem prolonged and more than can be explained by a concussion. The main characteristics of concussion are brief loss of consciousness and the presence of some anterograde and retrograde amnesia. Migraine precipitated by head injury may present as a common migraine syndrome, as the confusional migraine syndrome, or as transient visual loss. 30 Migraine variants are syndromes which are thought, in some cases, to be either precursors in early childhood of later migraine or a symptomatic expressive "equivalent" of migraine in young children. These include cyclic vomiting in infancy, benign paroxsymal vertigo, and abdominal migraine.53 All the various causes of such symptoms such as posterior fossa tumor, increased intracranial pressure, or abdominal epilepsy are differential diagnostic considerations. Subsequent follow-up with normal neurologic examinations in between episodes as well as normal EEG and CAT scans usually support the diagnosis in retrospect. Cluster headaches are actually rare in children, 16 though they can be seen in adolescent males, and present with sudden onset, usually without aura or prodrome, of retro-orbital pain that rises quickly to a peak. This is sustained for at least a half hour and is usually accompanied by unilateral lacrimation and rhinorrhea and then disappears. In the classic cluster syndrome the headaches may occur several times a week or even several times a day for a period of six weeks or so and then disappear for long periods of time. When the headaches occur frequently and sporadically without long headache-free periods, this is termed a chronic cluster syndrome. Although cluster headaches are a form of vascular headaches, they probably are not migrainous, since the biochemical pathology is different from that of migraine.l 3 • 34 Again, the possibility of vascular malformations must be considered. Though most headaches associated with seizures are postictal headaches, ictal headaches, where headaches are the actual manifestation of seizures, do occur and may be the sole clinical expression of seizure foci in the limbic system and other parts of the cortex. 56 The confusion with migraine is that the majority of these cases are accompanied by nausea and vomiting, followed by lethargy or sleep. The main differentiation is that they are short in duration and the EEGs are more apt to form acceptable epileptiform abnormalities.

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When the physician approaches the adolescent with chronic intermittent or recurrent headaches, most of these are chronic and non progressive, and, as such, are some expression of muscle contraction headache. Of the migraine syndromes previously described, confusional migraine is apt to be seen in juveniles, basilar migraine in adolescent females, and cluster headaches in adolescent males, although common and classic migraine are still the most likely to be encountered in adolescence. Uncomplicated tension or muscle contraction headaches are due to prolonged isometric contraction of either frontalis or occipitalis muscles and may occur in susceptible individuals secondary to the stresses and strains of everyday life. If the greater occipital nerve is compressed by that muscle or by subluxation of C1 and C2, the syndrome of occipital neuralgia may be seen in conjunction with muscle contraction headaches. If these headaches are freqent (several times a week or even daily) and refractory to ordinary analgesics, psychogenic causes such as depression, 37 the school phobia syndrome, or a conversion syndrome should be considered. Finally, if they last after a head injury long beyond the period of concussion and are associated with personality problems or litigation, the postconcussion syndrome should be considered. In Table 1 are listed a number of causes of symptomatic headaches and rare periodic syndromes that may be confused with recurrent headache syndromes, particularly complicated migraine. Limitations of space prohibit discussion of these in detail, but some will be alluded to in the following sections, Interpretation of Symptoms and Methods of

Assessment. INTERPRETATION OF SYMPTOMS The single most important tool the physician has when confronting children and adolescents with headaches is history-taking skill. Whether diagnoses are made early and correctly depends on the ability of the physician to elicit and interpret key symptoms. For making diagnostic formulations the following are the most important data: temporal profile; unilaterality or bilaterality; location; duration; presence of nausea and/or vomiting; time of day, week, or month of occurrence; response to ordinary analgesics; relief by sleep; presence of pain-free intervals; focal elementary or behavioral neurologic symptoms; family history of headaches; and past history of motion sickness. In addition, for effective management the physician needs to know the following: triggering factors, frequency and severity, longest spontaneous headache-free period, and patients' and parents' attitude toward taking drugs. Temporal profile refers to the pattern of beginning and cessation of attacks in reference to time. It can be displayed graphically by plotting time on the abscissa and severity of symptoms on the ordinate. A constant flat line (chronic, nonprogressive profile) would be typical of muscle contraction headaches. A graph with spikes separated by return to baseline at periodic intervals (acute recurrent profile) would be typical of vascular headaches, particularly migraine. A chronic and progressive profile would be displayed as a steadily rising slope. 49, so

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When asking about laterality of headache, it is important to distinguish whether headaches are bilateral from the onset, or first unilateral and then secondarily generalize to become bilateral. The former is typical of muscle contraction or common migraine headaches; the latter would support migraine. In classic migraine, headache remains unilateral throughout. If unilateral, do the sides alternate, or are the headaches consistently unilateral? The latter condition would point to suspicion of focal space-occupying lesion. Alternating laterality would be more supportive of classic migraine. Locations of headache are usually frontal, temporal, vertex, occipital, or suboccipital. Common migraine is across the forehead, or is bifrontal. Classic migraine is usually frontotemporal. Muscle contraction headaches are either bifrontal, at the vertex, or bioccipital. Occipital headaches should also call to mind upper neck problems, occipital neuralgia, or basilar migraine. Locations on the face may be due to sinus, dental, or temporomandibular joint problems. The latter may be associated with bruxism. A trigeminal neuralgia-like syndrome in adolescents may be the first presentation of multiple sclerosis. Eye strain headaches usually occur in hyperopics and should be temporally related to prolonged close eye use. Retroorbital pain occurs in cluster headache syndromes, and in optic or retrobulbar neuritis. Duration of headaches is primarily useful for distinguishing between periodic headache syndromes versus other paroxysmal disorders. Seizures are measured in minutes while migraine and muscle contraction headaches are measured in hours, and sometimes days. Cluster headaches are usually brief, averaging 20 to 30 minutes at a time, though they may last longer. Other brief headaches, lasting minutes, may be due to overinterpretation of various physiologic aches and pains by young adolescents overaw~re of their bodies, and need not occur only in hypochondriacal personalities. Neuralgias are brief, shooting pains lasting seconds. A headache that is "always there" is most likely psychogenic in origin. The presence of nausea and vomiting with headache almost always points to migraine, if there are no other symptoms suggestive of increased intracranial pressure. It may be the sole symptom preceding recognizable migraine syndromes, such as in the syndrome of cyclic vomiting of infancy. In young children, it may signify motion sickness, especially if vomiting consistently occurs while riding in cars. Headaches upon awakening, if not due to increased intracranial pressure or hypertension, again are most commonly due to migraine. Some are secondary to nocturnal bruxism. Onset in the afternoon on school days is typical for school children, although migraine also occurs on weekends and holidays. Consistent worsening as the day goes on is typical of muscle contraction headaches. Headaches that wake patients up from a sound sleep at night are most commonly cluster headaches, rarely migraine or serious CNS disease. Adolescent females may have headaches regularly preceding their menstrual periods. These are usually menstrual migraine, rather than nonspecific headaches that accompany painful menses. Migraines may occur as frequently in summer as during the school year. Ordinary analgesics usually help uncomplicated muscle contraction

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headaches and mild migraines. Intensity, however, is not a crucial characteristic for the diagnosis of migraine, even though it is a common belief that headaches have to be severe to qualify as migraine. The interpretation of whether relief is obtained by ordinary analgesics is complicated by the fact that patients then follow that with sleep, and report disappearance of headache when they awaken. Often it is the period of sleep, rather than the analgesic, that relieves the pain, which is characteristic of migraine. If there is persisting dull ache upon awakening, it is possible that a muscle contraction headache succeeds a migraine. Some patients may have both kinds of headaches, particularly "refractory" adolescents. The presence of pain-free intervals is necessary for the definition of chronic and recurrent headaches. What is important is whether neurologic functioning is intact during those pain-free intervals. If not, serious CNS disease must be suspected. Serious CNS disease must be suspected whenever any symptoms of focal elementary motor, coordination, or sensory neurologic function are described and persist in the pain-free intervals, even though complicated migraine syndromes may present in this way. More subtle, but just as important, is to determine whether there has been change in behavior, emotions, cognition, or learning. It is important to obtain histories from peers and teachers to confirm these changes. The way to ask about a family history of headaches, especially if one suspects migraine, is not "are there any members of the family with headaches?" but "who in the family has headaches?" Approximately 75 to 95 per cent of children have family histories of migraine. Headaches may have long stopped, and are therefore forgotten, or, not uncommonly, they have not been diagnosed, either because family members have learned to live with them or because they have been told they have sinusitis or allergies. The physician will have to take as detailed a history from family members with headaches as he does from the proband. A past history of motion sickness is highly associated with migraine. 2 This usually occurs when riding in the back seat on long rides, although short rides with much stop and start motion may also provoke this. Although migraines are classically described as throbbing or pulsatile and muscle contraction headaches as steady or band-like, depending on a description of the quality of a headache from a child can be misleading to the physician. If children do say it is throbbing and reinforce it with gestural language, then quality may be useful. However, if they do not, this does not rule out migraine, since other symptoms and the temporal profile may be compelling. Other considerations in history taking are presence of other paroxysmal disorders, organic versus psychogenic, and whether there is a new, acute problem or the same chronic, recurrent one with a different symptomatic expression. The presence of other paroxysmal disorders, either concurrently or in the past, can be helpful in supporting diagnoses or in leading one to decisions about further neurodiagnostic evaluation. The concurrence of seizures and migraine in the same person, whether as separate attacks or part

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of the same attack, should make the physician suspicious of underlying arteriovenous malformation as the cause for both. A past history of syncope or even childhood breath-holding spells can. be supportive of migraine, since these disorders of vascular instability tend to be associated. 25 Psychogenic headaches are a subset of muscle contraction headaches. If muscle contraction headaches are persistent and refractory to ordinary analgesics, a psychogenic factor must be considered. If there is a difference in the way pain is described and the way a patient appears, conversion reaction should be suspected. For example, severe constant pain is described, but the patient does not appear in distress. If there is decreased vigor, appetite disturbance, or sleep disturbance with early morning awakening, depression should be suspected. School phobia is suspected if the symptoms seem to serve the function of keeping the patient from attending school. Finally, there is the problem of whether there is a new, acute problem (a qualitative change) or the same chronic, recurrent one with an increase in severity (a quantitative change). If there is a change toward consistent unilaterality, persistent gastrointestinal symptoms, loss of relief from previous measures, or, in particular, new neurologic or behavioral symptoms during pain-free intervals, a qualitative change must be suspected. Qualitative change suggests new, possibly unrelated, disease or old static disease now malignantly degenerating.

METHODS OF ASSESSMENT Correct diagnosis can be made on the first visit in 80 to 90 per cent of patients from careful history and the presence of a normal physical and neurologic examination. With careful follow-up, initial diagnostic impressions can probably be confirmed in two or three visits by the time course and the findings of a thorough neurologic examination. In the physical examination, head circumference should be measured, blood pressure taken, and a careful inspection of the skin ·done for neurocutaneous stigmata. These maneuvers would lead one to suspect hydrocephalus, hypertension, and neurocutaneous syndromes such as tuberous sclerosis or neurofibromatosis, conditions in which brain gliomas, meningiomas, or other tumors may develop. Various maneuvers are done to get at the source of pain from head, face, and neck structures. The frontal and maxillary sinuses are percussed (see Fig. 2), and bruits are listened for over the temples and orbits (see Fig. 3). Mobility of the temporomandibular joint can be tested by opening and closing the mouth and testing pterygoids and masseters. The posterior cervical muscles should be palpated for spasm with the patient lying down (see Fig. 4) since they are normally contracted in the upright position. Mobility of the neck is tested by rotating laterally, bending forward and backward, and eliciting Lhermitte"s sign (see Fig. 5). This hyperffexion of the neck elicits painful paresthesias down the spinal column when there are various kinds of upper cervical lesions, either extraaxial or intraaxial.

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Figure 2. In clinically significant sinusitis, there should be tenderness on percussion over the frontal, maxillary, and nasal sinuses. Percussion is performed with the middle finger on the spots marked by X's.

Tenderness over the suboccipital and occipital muscles over the pathway of the greater occipital nerve may be seen in occipital ne~ralgia. If, after initial history and physical, the evidence strongly supports either muscle contraction or vascular headaches, there is no need for special neurodiagnostic evaluations. If the history brings out a "red flag" such as consistent unilaterality, or a complicated migraine syndrome is being

Figure 3. In any case where vascular headaches are suspected, the examiner should listen for bruits, using the bell of the stethoscope, over frontotemporal areas, and over the orbits. Asymmetric cranial bruits require further neurodiagnostic evaluation.

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Figure 4. Palpation for cervical muscle spasm should be done with the patient in the supine position.

considered, then further diagnostic studies are warranted. Further indications for such evaluation are (1) symptoms and/or signs of increased intracranial pressure, (2) symptoms and/or signs of subarachnoid hemorrhage, or (3) suspicion of focal lesions by history or localizing abnormalities on physical and neurologic examination. Skull X-Rays. Skull x-rays are indicated in headache after head trauma, either accidental or when child abuse is suspected. Though tran-

Figure 5. Lhermitte's sign is present when there are painful paresthesias shooting down the shoulders or back upon hyperflexion of the neck.

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sient blindness, confusional syndrome, or even headache and vomiting may turn out to be some form of migraine, the possibility of epidural hematoma, cerebral contusion, or other serious traumatic complications can be foreseen by the presence of, for example, linear skull fractures across the middle meningeal artery, the occipital bones, or the base of the brain. Cervical Spine X-Rays. These may be helpful in the suspicion of upper cervical lesions, such as the Arnold-Chiari malformation, where there may be associated cervical vertebral anomalies. Subluxation of C1 and C2 may be seen in occipital neuralgia. Evidence of inflammation may be seen in juvenile rheumatoid arthritis. Lumbar Puncture. Lumbar puncture should be considered primarily if headache due to CNS infection is being considered such as in bacterial or viral meningitis, meningoencephalitis, or in encephalitis, or recurrent meningitis syndromes such as Behcet's. The CSF protein may be transiently elevated in migraine. When a lumbar puncture is done for any other reason, it should be preceded ordinarily by CT scan of the brain, because of the danger of brain herniation. Many patients with chronic headache syndromes, either vascular or muscular contraction, are prone to develop post-lumbar puncture headache, in this author's experience, so it should be done only if imperative. Computerized Axial Tomography (CAT Scanning). When there are indications as above for neurodiagnostic evaluation, CAT scanning is the procedure of first choice. This is the most reliable test for screening for brain tumors, though it may miss early infiltrating isodense tumors or early meningeal neoplastic infiltrations. CAT scanning with contrast material in particular is a good screening instrument for vascular malformations (see Fig. 6). The presence of asymmetric cranial bruits or consistently unilateral headache would lead to suspicion of vascular anomalies. The procedure may miss small "cryptic" malformations but these are apt to present with hemorrhage, rather than recurrent headache, if they are symptomatic at all. Electroencephalography (EEG). This author believes that the EEG can be helpful in the diagnosis of headaches in certain situations. Perhaps it is most helpful when it is not clear whether a paroxsymal disorder is migrainous or epileptic. There are headache syndromes that may appear like vascular headaches but that in fact are ictal. 56 The EEG is necessary in distinguishing confusional migraine from subclinical epileptic encephalopathy or nonconvulsive status epilepticus. If one is not sure whether the problem is common migraine or muscle contraction headaches, the presence of reported EEG findings in migraine can be supportive. The most common finding in EEG in patients subject to migraine is actually within the limits of normal-namely, marked following responses at all flash frequencies starting from lower flash frequencies during stroboscopic stimulation29 (see Fig. 7). Normally, most children will have following responses to either the alpha frequences (10 to 11 flashes per second) or at about 17 to 18 flashes per second; that is, the flash response has one or two peaks. Another finding that is not abnormal but commonly seen in migraine patients is a large slow-wave response to hyperventilation. 58 This finding is most helpful when seen in adolescents, less so in younger children. Vary-

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Figure 6. An arteriovenous malformation is demonstrated by the collection of increased scattl'll'd but regional densities over the left frontoparietal area in this CT scan with contrast.

ing degrees of delta slowing are seen if an EEG is recorded in proximity to an attack. This is also sometimes seen during the interheadache period. 32• 61 This slowing must be distinguished from a normal finding of "delta de jeunesse" or the posterior slow waves of youth and the kind of polymorphic, arrhythmic slowing seen in posterior fossa mass lesions. Digital Intravenous Subtraction Angiography (DISA). Although there are no series reported on children with headaches yet, this is a technique that is becoming widespread and has proven diagnostic screening efficacy in adults with arteriovenous malformations. 24 Anteroposterior, lateral, and, sometimes, oblique views are obtained. Angiocatheters are usually inserted into an antecubital vein, although the femoral vein can also be used and attached to a pressure injector. In Gardeur's series, DISA was 100 per cent diagnostic for AVM in 21 patients. Selective arteriography was needed, however, for preoperative evaluation. In this series, four associated aneurysms were also visualized. The advantages over conventional cerebral arteriography are that it is safer, it can be performed on outpatients without hospitalizing them, it is faster and less costly, it requires less physician training, and it can be easily repeated. The main limitations are poor spatial resolution, superimposition of vessels, limitation of number of projections per study because of the higher bolus iodine IV injection, and possible image degradation resulting from patient movement. In adults its use alone has been sufficient in diagnostic screening when there is surgical abstention, and in follow-up of postoperative AV malformations. The technique may not be widely applicable to young children, however, because of the large amount of contrast material that has to be injected at a relatively fast rate and then washed out with 5 per cent dextrose solutions.

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Figure 7. Marked following responses throughout all the flash frequencies used in routine stroboscopic stimulation, termed the H-response of Golla, are commonly seen in patients with migraine. Note following responses at 3, 6, and 8 flashes per second in derivations C3-0l and C4-02 in this 10-year-old boy.

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Cerebral Arteriography. This is the definitive technique when there is a question of abnormality of vascular anatomy of the brain that might need surgical intervention. It will pick up aneurysms, details of feeding and draining of malformations, Moya-Moya disease, and other arteritides. The main indications are the complicated migraine syndromes, a history or exam suspicious for AVM or aneurysms, and suspicion of neoplasm. Although there is no definitive literature on the risk of provoking infarction if arteriography is done during a migraine attack, particularly in complicated migraine syndromes, it is wise to defer the study until the attack is over. Other Techniques. There are other diagnostic techniques that are applicable to the elucidation of pathophysiologic mechanism in migraine such as brain electrical activity mapping (BEAM), 20 positron emission tomography (PET scanning), and cerebral blood flow techniques. 36 However, at this point there is no widely accepted clinical applicability. TREATMENT APPROACHES Most management and treatment of migraine and muscular contraction headaches in children and adolescents can be handled by the pediatrician or family practitioner. Referral to a pediatric neurologist is helpful if there is doubt about a diagnosis, if there is a history of neurologic, cognitive, behavioral, or personality change, focal neurologic signs, or signs of increased intracranial pressure. An overlooked reason for referral is that the primary physician may have too busy an office practice to engage in the patient and parent education necessary for compliance with regimens in any chronic or recurrent medical condition. The steps in therapeutics are: (I) reassurance, (2) patient or parent education, (3) general nonpharmacologic management, (4) pharmacologic management, (5) specific nonpharmacologic management, if appropriate. Reassurance The family should know that the headaches are real, not imagined, and that headaches are not uncommon in children. If patients have migraine or uncomplicated muscle contraction headaches, they should be reassured that there is no serious medical or neurologic disease, and no further specialized diagnostic studies indicated. There is no one diagnostic laboratory test for migraine. Patients and parents now are "test-conscious" and may cajole vulnerable doctors sensitized to the medicolegal climate into ordering tests that are unnecessary, costly, and possibly falsely reassuring. If any further reassurance is desired or wanted, a more favorable cost-benefit ratio can probably be obtained from a consultation with a pediatric neurologist. Families should know that migraine is a life-long condition. No cures therefore can be promised, but only relief from especially bad bouts of pain. The condition will not kill; for some people it might cause occasional dysfunction, but for most it is a nagging discomfort that must be put up with.

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Parents should be made aware that the headaches should not be used for secondary gain at home or school, a trap that some parents fall into, especially if they tend to be overprotective and therefore inadvertently nudge their children to overdependency. What is sometimes reassuring to parents, especially if the child or adolescent fits that of the compulsive and meticulous migraine personality, is to point out that, although not invariably true, migraine tends to be a disorder in overachievers rather than underachievers. The dispensing of clearly written articles in lay language is a valuable supplementary aid to patient education. General Nonpharmacologic Management These are general measures directed primarily toward avoiding triggers; instilling balanced health habits of sleep, exercise, and diet; and identification of stresses and development of stress management strategies. If bright sunlight triggers migraine in the summer, dark glasses help. If birth control pills seem to be a trigger, some other form of birth control might be suggested. If certain foods, such as wine or cheese, trigger migraine, they should be avoided. More problematic is the case when exertion or exercise seems to be a trigger-that is, whether to advise excusing from physical education classes or athletic participation. Probably contact sports should be discouraged, because of the possibility of triggering migraine by mild closed head injury. If associated with menstrual periods, headaches could be anticipated for effective abortive drug treatment. Pharmacologic Management In these days of "natural food" consciousness, and a national preoccupation with fitness, the physician must assess parents' and patients' attitudes toward taking of drugs before blithely prescribing them. Pharmacologic management is aimed at the relief or prevention of pain, and therefore is symptomatic therapy. The physician must always keep that in mind and consider the possibility, during follow-up, of undiagnosed etiologies for the headache, particularly if headache pattern changes or if there is lack of response to medications. If the physician decides on pharmacologic treatment, there are three approaches: (1) symptomatic treatment with common analgesics and antiemetics, (2) abortive therapy at the time of the headache, and (3) prophylactic therapy. The simple analgesics used are salicylates and acetaminophen and will suffice for mild migraines and the usual muscle contraction headache. Abortive treatment works best in classic migraine, where there is a sufficient warning period before the headache that the patient can easily recognize. Unfortunately, most children do not recognize that period, and, even then, abortive therapy is often not helpful in adolescents. Abortive therapy is used when headaches are relatively infrequent, but not relieved by common analgesics, and severe enough for the patient to wish relief. The common abortive medications used in migraine are the ergotamine derivatives, delivered orally, sublingually, per rectum, or via inhalation. The usual oral dose for children is 1 or 2 tablets at the beginning with a maximum of 4 tablets taken a half hour apart in any 24-hour

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period. The earlier in the attack the medication is administered the better the chance of aborting the headache. Oral medications are not effective if vomiting is a prominent part of the attack. The rectal route is not acceptable for older children and adolescents. Inhalation is the fastest way to selfadminister abortive medications and can be taken as one inhalation ten minutes apart. However, patients must be taught, so that they actually inhale, rather than spray the back of their throats. Inhalation is easiest taught to adolescents. Other medications for abortive treatment are the isometheptene preparations. They are less effective than the ergotamine preparations but also have fewer contraindications and adverse reactions. In combination form, 1 or 2 capsules are given at the beginning of an attack, followed by 1 capsule per hour to a maximum of 2 to 4 per attack. In severe, prolonged migraine-status migrainus-prednisone at 40 to 60 mg daily over a short period may provide relief. The indications for prophylactic therapy are attacks frequent enough and/or severe enough to cause significant dysfunction in school, on the job, or socially. Practically this usually means at least weekly attacks. Ask for the attack frequency-"what' s the most often they've occurred," and the best spontaneous headache-free period-"what's the best you've done?" The reason for these questions is that there has to be some criterion for how long prophylactic treatment will take place. No controlled studies have been published establishing clear superiority of one regimen over another. Some prefer to leave children on medication through the school year, and attempt weaning over the summer. Others recommend at least a four- to six-month period of prophylactic treatment. This author arbitrarily picks a criterion of at least 50 per cent decrease in headache frequency to mean effectiveness of the prophylactic drugs, and then leaving patients on until they reach a headache-free time period at least twice that of their best spontaneous headache-free period. The drugs used are phenobarbital, mephobarbital, phenytoin, propranolol, methysergide maleate, cyproheptadine, and amitriptyline. Anticonvulsants are used effectively in preadolescent children. There seems to be no clear advantage of phenobarbital over phenytoin, and viceversa. There also is no clear indication that the presence of epileptiform abnormalities in the EEG in children with migraine makes it more likely that anticonvulsants will improve headaches, since many children with no such abnormalities also improve. The exact mechanism is unknown, and there are no double-blind controlled studies. 10• 43 Choice of drugs is therefore arbitrary. Side effects to watch for with phenobarbital are inducement of disorders of attention/activity, sedation, irritability, and decline in school work. With phenytoin, inducement of the Stevens-Johnson syndrome is the worst idiosyncratic reaction. Patients will not be on phenytoin long enough to consider hirsutism or gum hypertrophy a significant factor in therapeutics. Propranolol is probably now the most commonly used prophylactic medication in adolescents for all migraine syndromes. 38 • 64 It probably should be used for any of the complicated migraine syndromes, since vasoconstrictors are contraindicated in those syndromes. They should be used particularly in those complicated migraine syndromes that are more

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likely to be repetitive, such as basilar artery migraine. Asthma and depression are contraindications. In adolescents start with 20 mg b.i.d. and titrate to desired therapeutic effect or toxicity. In preadolescents, 10 mg b.i.d. is a safe starting dose. Cyproheptadine7 has the disadvantage of sedation and having to be given more frequently (t.i.d. or more), and therefore harder for compliance. Dose is 2 to 4 mg t.i.d. to q.i.d. Amitriptyline 14 can be used when headaches occur upon awakening, in the presence of sleep disturbance, or migraine with a depressive component, or frank childhood depression. For the latter, a child psychiatrist must confirm the diagnosis. The starting dose is 25 mg h.s. and titrate up to effectiveness or toxic effects. The therapeutic blood levels for depression should be 50 to 200 ng/ml. Methysergide maleate is still very effective, but it should not be used more than three to four months at a time without at least a one-month drug holiday. To this author's knowledge, no further cases of retroperitoneal fibrosis have been reported since the 1960's. In adolescents, start with 2 mg t.i.d. with meals for 3 weeks; if not effective, go to q.i.d. for 3 weeks. At that point, if it is not effective, stop. Methysergide maleate should be considered in refractory migraine. Ergonovine maleate 3 is also given in refractory headache. Dose is 0.2 mg b.i.d. to t.i.d. for 8 weeks, with a two-week drug holiday. Efficacy is usually established in 6 weeks. 44 In summary, for prophylactic therapy of migraine in preadolescents, the anticonvulsants are the usual first drugs; in adolescents, propranolol. If propranolol is ineffective, anticonvulsants can be tried in the younger adolescents. Second-line drugs would be amitryptiline and cyproheptadine. If headaches are still refractory, the choices are methysergide maleate and ergonovine maleate. Classic cluster headaches are best treated with a course of methysergide maleate. Cyproheptadine, propranolol, and prednisone may be selectively beneficial when methysergide is not. Chronic cluster headaches are effectively treated with daily lithium carbonate, to a serum level of 1 to 1.5 mg/dl. There are recent reports that in adults tne new calcium channel blockers are effective in vascular headaches, including cluster (verapamil), 42 though they are largely untried in children. In muscle contraction headaches, simple analgesics, such as salicylates or acetaminophen, are usually effective. If recalcitrant, or coupled with occipital neuralgia syndrome, muscle relaxants (cyclobenzapine, diazepam) can be tried. If simple pharmacologic measures and general nonpharmacologic hygiene measures do not relieve or prevent headaches, then referral for specific nonpharmacologic approaches (see next section) or a multidisciplinary pain clinic approach may be indicated. If muscle contraction headaches are felt to be of psychogenic origin (Table 1), referral to a child psychiatrist for diagnostic confirmation should precede any consideration of pharmacologic management. Drugs may be only one aspect, then, of a total therapeutic management plan. For headaches of symptomatic etiology, the treatment is to discover the cause (Table 1) and remediate that. This subject is beyond the scope of this article.

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Specific Nonpharmacologic Treatment The main nonpharmacologic treatment approaches that have been applied in migraine and muscle contraction headaches are those used in physical therapy, those used by behaviorally oriented clinical psychologists and psychiatrists (relaxation therapy, biofeedback, and hypnosis), and those used by dynamically oriented psychotherapists. Physical therapy approaches to symptomatic relief of muscle contraction headaches, particularly if neck muscle spasm is palpated, consists of application of local wet heat, sometimes alternating with cold, for at least 20 to 30 minutes, followed optionally by local massage. An application of local ice packs is anecdotally said to relieve cluster headaches, and occasionally migraine, in some patients, presumably by causing vascoconstriction in dilated painful extracranial arteries. Oxygen inhalation to abort cluster headaches also works presumably by the same mechanism. Transcutaneous nerve stimulation (TNS) for chronic pain syndrome including face and neck pain is widely used in adults often as part of a total pain clinic approach, but no definitive literature on TNS for chronic headache syndromes in children or adolescents is known to this author. Immobilization of the neck with stiff collars is sometimes helpful in occipital neuralgia. There is a large recent literature on nonpharmacologic treatment approaches to headache. 8 • 9• 33 What these techniques have in common is a behavior therapy approach-an attempt to teach patients control of their own physiologic processes, such as muscle contraction and relaxation and vasoconstriction and vasodilatation. These techniques can be divided, for purposes of discussion, into nonbiofeedback and biofeedback techniques. Nonbiofeedback Techniques. In autogenic relaxation training, 39 the patient repeats relaxing phrases to himself-"! am beginning to feel relaxed ... " With progressive relaxation exercise, 57 • 63 patients practice tensing and relaxing various muscles, similar to what is done in the early stages of training in the Lamaze method for painless childbirth. In both techniques warm and relaxing imagery is often coupled. Finally, hypnosis has also been used. 1 All of these methods have in common the use of suggestion: either autosuggestion or suggestion by a therapist. Psychotherapy, individual or family therapy, may be indicated in psychogenic headaches. Depression is of particular concern, because of the risk of adolescent suicide. Biofeedback Techniques. Feedback was a term coined by Norbert Weiner about a quarter century ago and is defined as a method for controlling a system by reinstating into it the results of past performance. Biofeedback means the bringing into consciousness of voluntary control processes which are ordinarily unconscious and involuntary and often subserved by the autonomic nervous system. In biofeedback, the feedback is artificially mediated by man-made detection, amplification, and display instrumentation rather than by an inborn feedback loop. 18 Operant conditioning forms the psychological basis of biofeedback techniques. A conditioned stimulus (in Pavlovian terms) is provided along with an opportunity for multiple varied responses. The desired response-

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such as relaxation of muscle, or increase in hand temperature-is then reinforced. After several reinforcements, the conditioned stimulus serves as a signal for performing the learned response. The principal techniques in use are EMG biofeedback of contracted muscles 11 • 46 and hand-warming or temperature biofeedback in migraine. 59 In EMG biofeedback the state of isometric contraction of frontalis muscles is signaled to the patient, who then tries to "quiet" the EMG. In temperature biofeedback, increases in temperature of the hand are reinforced, because there is then reciprocal vasoconstriction of extracranial arteries. Studies done so far in adults lack proper no-treatment or placebo control groups. They confound biofeedback with other strategies and have sample sizes too small to make reasonable conclusions about efficacy. It appears that biofeedback is no more effective than relaxation training in muscle contraction headaches. The application of biofeedback to migraine remains of unproven value. Many extraneous variables linked to the therapeutic situation pervades these studies, but their role in symptom reduction is largely unexplained. 33 Although many therapists have an occasional adolescent in their practices, there is no definitive literature on nonpharmacological approaches to children.l9 Most adolescents referred in clinical practice are those who have become refractory to conventional pharmacologic agents. It is of interest to develop nonpharmacologic approaches to children for at least two reasons. First, it is commonly said that children seem to learn biofeedback techniques easier than adults. Second, these techniques may provide an alternative treatment method at the beginning of therapeutic intervention for patients and parents with strong feelings against drugs, who are also willing to undertake the costs of behavior therapy approaches.

SUMMARY

Headache is a common chronic and recurrent symptom in children and adolescents. Prior to adolescence most such headaches are migraine, complicated migraine, or migraine variants. In adolescence, muscle contraction headaches become a relevant differential diagnostic entity, although migraine is even more prevalent in this age group compared with early school-age children. Indications for neurodiagnostic evaluation are (1) signs and symptoms of increased intracranial pressure, (2) signs and symptoms of subarachnoid hemorrhage, (3) suspicion of focal brain lesions by history or localizing abnormalities on physical and neurologic examinations, (4) complicated migraine syndromes. The single most important screening diagnostic test is CT scan, with contrast. Although DISA (digital intravenous subraction angiography) may prove to become more definitive in time, at present, cerebral arteriography is the definitive technique when vascular anomalies are suspected, and neurosurgical intervention is contemplated. The most effective pharmacologic approach to children and adolescents with migraine is prophylactic treatment. In children, anticonvulsants-phenobarbital and phenytoin-are most commonly used. In adoles-

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Table 2.

Summary of Clinical Management of Chronic Headaches in Children and Adolescents TREATMENT

DIAGNOSTIC WORKUP

Type Migraine Common Classic Variants

History *F. H. migraine tP. H. motion sickness Bilateral. no prodrome Unilateral, 2-phase Prominent focal neurologic symptoms

Cluster

Brief retro-orbital, unilateral lacrimation and rhinorrhea

Muscle Contraction Depression

Temporal profile flat, relieved by common analgesics Sleep disturbance, F. H. of depression

Exam

Normal, listen for bruits Normal Focal signs during attack

Tight neck muscles Depressed affect

Pharmacologic

Non-Pharmacologic

Phenobarbital Phenytoin Propranolol Cyproheptadine Amitriptyline

Finger warming biofeedback, relaxation therapy

Methysergide, maleate, lithium

Oxygen inhalation, local cold

Common analgesics, muscle relaxants Tricyclic antidepressants

EMG biofeedback, relaxation therapy, hypnosis, local heat and massage. Psychotherapy

CJ *F.H. =Family History. tP. H.= Past History.

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CHRONIC AND RECURRENT HEADACHES IN CHILDREN AND ADOLESCENTS

1049

cents, propranolol, cyproheptadine, amitriptyline, methysergide maleate, and ergonovine maleate are recommended. In muscle contraction headaches simple analgesics and muscle relaxants usually suffice, although in prolonged courses of muscle contraction headaches, pharmacologic treatment is only part of a total multidisciplinary therapeutic plan. Nonpharmacologic treatment approaches, such as relaxation training and biofeedback techniques, have not been used widely enough to ascertain their effectiveness in children and adolescents. ACKNOWLEDGMENTS The author wishes to thank Sandy Amundson for manuscript preparation, Gary Baune for the illustrations, Dale Shook, M.D., for advice on neuroradiologic procedures, and Robert Ivers, M.D., and Larry Fisher, Ph.D., for review of the manuscript. The author also wishes to thank the Pediatric Departments of Dakota Clinic, Fargo Clinic, and the University of North Dakota School of Medicine for their commentary and support.

REFERENCES 1. Andreychuk, T., and Skriber, C.: Hypnosis and biofeedback in the treatment of migraine headaches. Int. J. Clin. Exp. Hypn., 23:172-183, 1975. 2. Barabas, G., Matthews, W. S., and Ferrari, M.: Childhood migraine and motion sickness. Pediatrics, 72:188-190, 1983. 3. Barlow, C.: Migraine in childhood. Res. Clin. Stud. Headache, 5:34-36, 1978. 4. Bickerstaff, E. R.: Basilar artery migraine, Lancet, 1:15-17, 1961. 5. Bille, B.: Juvenile headache. The natural history of headache in children. In Friedman and Harms: Headaches in Children. Springfield, Charles C Thomas, 1967, pp. 10-28. 6. Bille, B.: Migraine in schoolchildren. Acta Paediatr. Scand., 51 (Suppl. 136):1-151, 1962. 7. Bille, B., Ludvigsson, J., and Scanner, G.: Prophylaxis of migraine in children. Headache, 17:61-63, 1977. 8. Blanchard, E. B., Andrasik, F., Arena, J. G., eta!.: Non-pharmacological treatment of chronic headache: Prediction of outcome. Neurology, 33:1596-1603, 1983. 9. Blanchard, E. G., Andraskik, F., Neff, D. F., eta!.: Biofeedback in relaxation training with three kinds of headache: Treatment effects and their predictions. J. Consult. Clin. Psycho!., 30:562-575, 1982. 10. Buda, F. B., and Joyce, R. P.: Successful treatment of atypical migraine of childhood and anticonvulsants. Milit. Med., 144:521-523, 1979. 11. Budzynski, T. H., Stoyva, J. M., Adler, C. S., eta!.: EMG biofeedback and tension headache: A controlled study. Psychosom. Med., 35:6, 1973. 12. Burke, E. C., and Peters, G. A.: Migraine in childhood: A preliminary report. Am. J. Dis. Child., 92:330-336, 1956. 13. Chutorian, A. M.: Migrainous syndromes in children. In Thompson, R. A., and Green, J. R. (eds.): Pediatric Neurology and Neurosurgery, Medical and Scientific Books, New York, 1978. pp. 183-204. 14. Couch, J. R., Ziegler, D. K., and Hassanein, R.: Amitriptyline in the prophylaxis of migraine. Neurology, 26:121-127, 1976. 15. Congdon, P. J., and Forsythe, W. I.: Migraine in childhood: A study of 300 children. Dev. Med. Child. Neurol., 21:209-216, 1979. 16. Curless, R. G.: Cluster headaches in childhood. J. Pediatr., 101:393-395, 1982. 17. Dexter, J. D.: Biochemical and pathophysiology of migraine. Neurologic Clinics, 1:527531, 1983. 18. Diamond, C.: Biofeedback and headache. Headache, 19:180-184, 1979. 19. Diamond, S., and Medina, J. L.: Autogenic training with biofeedback in children with migraine. In Luthe, W., and Antonelli, F. (eds.): Therapy in Psychosomatic Medicine, Proceedings of the 3rd Congress of the International College of Psychosomatic Medicine, Rome, 1975.

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20. Duffy, F. H.: Brain electrical activity mapping (BEAM): Computerized access to complex brain function. Int. J. Neurosci., 13:55--65, 1981. 21. Egermark-Eriksson, I.: Prevalence of headache in Swedish school children. Acta Paediatr. Scand., 71:135-140, 1982. 22. Ehyai, A., and Fenichel, G. M.: The natural history of acute confusional migraine. Arch. Neurol., 35:368--369, 1978. 23. Fenichel, G.: Migraine in children. In Pediatrics Update, New York, Elsevier, 1981. 24. Gardeur, D., Seurot, M., Fonda, C., eta!.: Digital intravenous subtraction angiography of intracranial arteriovenous malformations. Neuroradiology, 25:307-313, 1983. 25. Gascon, G. G.: Breathholding spells, syncope, and related paroxysmal disorders. In Pediatrics Update, New York, Elsevier, 1981. 26. Gascon, G. G., and Barlow, C.: Juvenile migraine presenting as an acute confusional state. Pediatrics, 45:628--635, 1970. 27. Golden, G.: The child with·headaches. J. Dev. Behav. Pediatr., 3:114-227, 1982. 28. Golden, G.: The Alice-in-Wonderland syndrome in juvenile migraine. Pediatrics, 63:517519, 1979. 29. Golla, F. L., and Winter, A. L.: Analysis of cerebral response to flicker in patients complaining of episodic headache. Electroencephalogr. Clin. Neurophysiol., 11:539-549, 1959. 30. Greenblatt, S. H.: Post-traumatic transient cerebral blindness. Association with migraine and seizure diathesis. J.A.M.A. 225:1073-1076, 1973. 31. Hockaday, J. M.: Basilar migraine in childhood. Dev. Med. Child. Neurol., 21:455-463, 1979. 32. Hockaday, J. M., and Whitty, C. W. M.: Factors determining the electroencephalogram in migraine. A study of 560 patients according to clinical type of migraine. Brain, 92:769-788, 1969. 33. Jessup, B. A., Neufeld, R. W. J., and Merskey, H.: Biofeedback therapy for headache and other pain: An evaluative review. Pain, 7:225-270, 1979. 34. Kudrow, L.: Cluster headache: New concepts. Neurologic Clinics, 1:369-383, 1983. 35. Lapkin, M. L., and Golden, G. S.: Basilar artery migraine, a review of30 cases. Am. J. Dis. Child., 132:278--281, 1978. 36. Lauritzen, M., Olsen, T. S., Lassen, N. A., eta!.: Relation of regional cerebral blood flow during the between migraine attacks. Ann. Neurol., 14:569-572, 1983. 37. Ling, W., Oftedal, G., and Weinburg, W.: Depressive illness in childhood presenting as severe headache. Am. J. Dis. Child., 120:122--124, 1970. 38. Ludvigsoon, J.: Propranolol used in prophylaxis of migraine in children. Acta Neurol. Scand., 50:109-115, 1974. 39. Luthe, W., and Schultz, J. H. Autogenic Therapy, Vol. 2, Medical Applications. New York, Grune and Stratton, 1969. 40. Medina, J. L., Rubino, F. A., and Ross, E.: Agitated delirium caused by infarction of the hippocampal formation and fusiform and lingual gyri. Neurology, 24:1181-1183, 1974. 41. Mesulam, M. M., Waxman, S. G., and Geschwind, N. eta!.: Acute confusional state with right middle cerebral artery infarction. J. Neurol. Neurosurg. Psychiatry, 39:8489, 1976. 42. Meyer, J. S., and Hardenberg, J.: Clinical effectiveness of calcium entry blockers in prophylactic treatment of migraine and cluster headaches. Headache, 23:266-277, 1983. 43. Millichap, J. G.: Recurrent headaches in 100 children: Electroencephalographic abnormalities and response to phenytoin. Child's Brain, 4:95-105, 1978. 44. Olson, W. H., Brumack, R. A., Gascon, G. G., and Christoferson, L. A.: Practical Neurology for the Primary Care Physician. Springfield, Charles C Thomas, 1981, p. 35. 45. Oster, J.: Recurrent abdominal pain, headache, and limb pains in children and adolescents. Pediatrics, 50:429-436, 1972. 46. Peck, C. L., and Kraft, G. H.: Electromyographic biofeedback for pain related to muscle tension. Arch. Surg., 112:889-895, 1977. 47. Prensky, A. L., and Sommer, D. Diagnosis and treatment of migraine in children. Neurology, 29:506-510, 1979. 48. Robertson, W. C., Jr., and Schnitzler, E. R.: Ophthalmoplegic migraine in infancy. Pediatrics, 6:886-888, 1978. 49. Rothner, A. D.: Diagnosis and management of headaches in children and adolescents. Neurologic Clinics, 1:511-526, 1983.

CHRONIC AND RECURRENT HEADACHES IN CHILDREN AND ADOLESCENTS

1051

50. Rothner, A. D.: Headaches in children: A review. Headache, 19:156--162, 1979. 51. Rothner, A. D.: The diagnosis and treatment of headache syndromes in children. Pediatrics Update, New York, Elsevier, 1980, pp. 55-77 . 52. Saper, J. R.: Migraine. I. Classification and pathogenesis. J.A.M.A., 239:2380--2383, 1978. 53. Shinnar, S., and D'Souza, B. J.: The diagnosis and management of headaches in childhood. Pediatr. Clin. North Am., 29:79-94, 1981. 54. Sillanpaa, M.: Changes in the prevalence of migraine and other headaches during the first seven school years. Headache, 23:15-19, 1983. 55. Sillanpaa, M.: Prevalence of migraine and other headache in Finnish children starting school. Headache, 15:288--290, 1976. 56. Swainman, K. F., and Yizchak, F.: Seizure headaches in children. Dev. Med. Child. Neurol., 20:580--585, 1978. 57. Tasto, D. L., and Hinkle, J. E.: Muscle relaxation treatment for tension headaches. Behav. Res. Ther., 11:347-349, 1973. 58. Towle, P. A.: The electroencephalographic hyperventilation response in migraine. Electroencephalogr. Clin. Neurophysiol., 19:390-393, 1965. 59. Turin, A., and Johnson, W.: Biofeedback therapy for migraine headaches. Arch. Gen. Psychiatry, 33:517-519, 1976. 60. Vahlquist, B.: Migraine in children. Int. Arch. Allergy, 7:348-355, 1955. 61. Whitehouse, D., Pappas, J. A., Escala, P. A., et al.: Electroencephalographic changes in children with migraine. N. Engl. J. Med., 276:23-27, 1967. 62. Wolff, H. G.: Headache and Other Head Pain. 2nd ed. Oxford University Press, 1963. 63. Wolpe, J.: The Practice of Behavior Therapy. New York, Pergamon, 1969. 64. Weber, R. B., and Reinmuth, 0. M.: The treatment of migraine with propranolol. Neurology, 22:366--369, 1972. University of North Dakota Medical Education Center 1919 Elm Street North Fargo, North Dakota 58102