The primary headache disorders, especially migraine, occur in children and adolescents more commonly than is recognized, and may be under-treated. Since migraine is more common in women than in men, and since it often begins for the first time in childhood, it is important to be alert to the possibility of this diagnosis in girls with headache. Headache diagnosis in the pediatric population can be challenging because of differences in headache presentation in children as compared to adults.

Many girls assume having headaches is a normal part of life, especially when they have family members who also report headaches. As with adult headaches, there are important gender differences identified in pediatric headaches. One study followed about 300 school-age children and questioned them about headache at ages 7 and 14. At age 7, boys reported more frequent headache than girls. At age 14, girls were reporting more frequent headache than boys. A larger sample of 4,000 Finnish students confirmed higher headache prevalence in girls (71%) than boys (65%). Thus, in early childhood, migraine equally affects both boys and girls, with a prevalence of 4% to 5% for all children between ages seven and ten. Boys begin to experience migraine earlier than girls, with a peak age of onset of headache in boys at five years and in girls at 12 years. The onset of migraine in girls is closely linked to menarche, explaining the peak incidence in girls at 12 years. In fact, girls are more likely to begin having migraine during the same year of their menarche than at any other age. Once girls begin to develop migraine, their prevalence is greater than that in boys. After age 11, girls are more likely to experience migraine than boys, and this continues for the rest of the life cycle. These studies show that recurring, primary headache, especially migraine, is common in children and adolescents. School-aged girls who are missing school or other activities should be questioned about headache. In addition, questions about headache should be a routine part of the pediatric screening for girls at or around the time of menarche.

The International Headache Society (IHS) criteria for the diagnosis of migraine recognize the typically shorter pediatric headache duration of 1 to 72 hours and the fact that in children the pain is often generalized or over both sides of the head, rather than on one side of the head. In addition, sensitivity to light and noise do not have to be directly reported by the child, but can be assumed based on their behavior (such as retiring to a dark room or complaining about noise from a radio.)

Children with headache lose an average of 7.8 days per school year, compared to 3.7 days lost per year for children without headaches. Low self-esteem and depressive symptoms are pre-morbid predictors of adolescent headache in girls. The longer school absence is maintained, the more difficult it is for children to return to school because of failure to maintain academic work and fear of isolation from peers on return to school. Treatment begins with resuming a regular routine. Good school participation must be the top priority because regular school attendance and interaction with peers is important for social development.

The same type of acute care and preventive medications used in adults are often effective in older children and adolescents. Medication dosage, however, must be adjusted in children and small teenagers. Although many standard adult migraine therapies have been used clinically in pediatric patients, few studies have directly evaluated efficacy, tolerability, and safety in a pediatric population.

Nonpharmacological treatments, such as relaxation and biofeedback, are extremely effective in pediatric populations. Psychologists, nurses, and physical therapists are often trained to teach pain management techniques. In addition, lifestyle modification, such as regular eating and sleeping habits, avoidance of caffeinated beverages and alcohol, and regular exercise are also beneficial preventive headache measures.

Headache in girls may be more likely to go unrecognized and untreated than headache in women. Migraine, in particular, is often under-diagnosed in children because many of the hallmark features of adult migraine (unilateral pain, longer duration of headache, and verbalized sensitivity to noises and lights) are not reported by children with migraine. Modifications to the IHS diagnostic criteria for pediatric migraine should improve recognition and identification of this important syndrome.

Reprinted from the website of the American Council for Headache Education