Pediatric Primary Care Case Studies, 1st Ed.

Chapter 20. The Child with a Headache

Ritamarie John

Headache is a common problem in pediatric practice. Parents will bring children in for a headache complaint, concerned that their child has a brain tumor or infectious meningitis. The approach to the history and physical must be systematic and complete. Failing to do one part of the neurological exam can cause a delay in the correct diagnosis. In evaluating the chief complaint of headache, the provider needs to first determine whether the headache is a primary or secondary symptom.

Educational Objectives

1.  Apply evidence-based guidelines to classify the presenting complaint of headache.

2.  Apply shared decision making to develop the treatment plan.

3.  Integrate knowledge of development, pharmacology, and complementary approaches to develop a treatment plan for the young child with primary headache.

  Case Presentation and Discussion

John Brown is a 6-year-old who presents to a private practice with a complaint of headache. He has been having headaches for about 3 months and has seen two other providers without any relief. The child is accompanied by his father. The father explains that he is the primary parent since his 42-year-old wife died of lymphoma 3 years ago. He expresses concern that the child has missed 6 days of school over the past 3 months due to headaches and would like your opinion on the problem.

What questions will you ask John and his father about the “headache” problem? image

Your symptom analysis reveals the following information: The child started with a headache 3 months ago and has been getting between two and three headaches per month. They are described as 5 of 6 on the Wong Pain Scale and are throbbing and bilateral over the top of the head or the forehead, lasting 5–8 hours. The headaches do not have any specific time that they commence; however, they do not wake the child up at night, and he has not had them in the morning. John generally feels nauseated with the headache but has vomited only once. During the headache episode, the child looks like he is sick. The father has not identified any precipitating factors or triggers. He reports that John’s mother had migraines that would last for 2 days, and he does not want John to be as debilitated as his mother was. The headaches are not related to activity. He has been given acetaminophen (Tylenol) for the headaches by the other two providers without much relief. The father was not happy with the care of the other providers because they rushed through the exam and “made light” of his concerns.

What other questions do you need to ask John and his father? image

Before answering this question, here is some information about headaches that you need to consider.

Headaches in Children

Headache is a common pediatric disorder that has become more common in adolescents (Lewis, 2007c). Overall, prevalence is between 37% and 51% in 7 year olds with an increase to as high as 82% in 15 year olds (Lewis, 2007a).

Pathophysiology of Migraine

The pathophysiology of migraine is not fully understood, but is now believed to be a neuronal process (Lewis, 2007b). The current thinking is that the cerebral cortex is hyperexcitable, with genetic influences causing disturbances in the neuronal ion channels (Lewis, 2007b; Lisi et al., 2005). This leads to a lowered threshold for a variety of external and internal factors to trigger episodes of excitation of the neuronal region. Subsequent to this, there is a cortical spreading depression that is likely responsible for the aura seen in migraine and for the activation of the trigeminovascular system (Lewis, 2007b). During the aura phase of migraine, there is regional neuronal depolarization as well as a decrease in blood supply or oligemia.

Because an aura is present in only about 30% of children, there are two mechanisms of pain generation (Lewis, 2007b). The first reason for pain is from the inflammation of the meningeal vessels, and the second reason is the sensitization of peripheral and trigeminal afferents (Lewis, 2007b). Some of the substances involved in the generation of the inflammation and sensitization of the vasculature in the brain include neurokinine, substance P, and calcitonin gene reactive peptide, which cause dilatation with subsequent pain. The vasoreactive neuropeptides act on blood vessels. Serotonin and glutamate may increase the sensitivity to pain in the blood vessel wall (Gunner, Smith, & Ferguson, 2008).

Migraine is now divided into three major subclassifications—migraine with aura, migraine without aura, and childhood periodic syndromes that are commonly precursors of migraine (Headache Classification Subcommittee of the International Headache Society [IHS], 2004). In children, a migraine headache must last between 1 and 72 hours with moderate to severe intensity, with aggravation by usual physical activities, and with behavioral signs of either photophobia or phonophobia (IHS, 2004). The diagnostic criteria for pediatric migraine without aura are not based on one attack. The patient must have five attacks that include the following criteria: 1) headache attacks last between 1 and 72 hours; 2) headaches minimally need two of the four characteristics—unilateral or bilateral, frontotemporal but not occipital location; pulsing quality; moderate to severe pain; and physical activity limitations resulting from the headache; 3) headaches should have one of the following symptoms—nausea and/or vomiting, photophobia, or photophobia inferred from their behavior; and 4) cannot be attributed to another disease (IHS).

In migraine without aura, there may be autonomic symptoms such as nausea, anorexia, periumbical abdominal pain, diarrhea, pallor, photodysphoria, photophobia, a desire to sleep, cool extremities, goose flesh, increased or decreased blood pressure, or periorbital discoloration (Lewis, 2007b). In migraine with aura, the most common visual phenomena are binocular visual impairment with scotoma, with distortions or hallucinations, or monocular visual impairment occurring much less frequently (Lewis, 2007b).

Pathophysiology of Tension-Type Headache

Tension-type headaches (TTHs) are the most common type of headache and are now felt to have a neurobiological basis (IHS, 2004). Central pain mechanisms are felt to play a role in frequent tension headaches, whereas peripheral pain mechanisms play a role in infrequent episodic tension headaches (IHS). A TTH is described as a symmetrically distributed tightening “band-like” feeling around the head (Rubin, Suecoff, & Knupp, 2006). There may be associated photophobia or phonophobia, but without nausea, vomiting, or exacerbation with activity (IHS). The diagnostic criteria for tension-type headaches require at least 10 episodes of headache. The headaches must fulfill the following criteria: 1) last between 30 minutes and 7 days; and 2) need two of the four characteristics—bilateral location, pressing/tightening of a nonpulsating quality, mild to moderate intensity, and not be increased with routine activity such as walking or climbing stairs. In addition, there can be no associated nausea, vomiting, photophobia, and phonophobia. The headache cannot be the result of another disease process (IHS).

There are three subtypes of TTHs: infrequent episodic TTHs with headaches occurring less than 1 day a month, frequent episodic TTHs with headache episodes occurring 1 to 14 days a month, or chronic TTHs with headaches 15 or more days a month. In children, it may be difficult to distinguish between migraine and tension due to the developmental level of the child (Brna & Dooley, 2006).

Pathophysiology of Cluster Headache and Other Trigeminal Autonomic Cephalalgias It is hypothesized that ipsilateral trigeminal nocioceptive pathways are important in the etiology with the activation of the parasympathetic cranial system and ipsilateral parasympathetic nerves. An inflammation of the cavernous sinus and tributary veins is believed to be the main mechanism involved in cluster headaches (Lampl, 2002). A cluster headache is a unilateral burning pain that is most commonly found around the eye and orbits on the affected side, occurring from one to eight times during the course of the day (Lampl).

Epidemiology of Headaches

Migraine headaches can start at age 6 to 7 years and once puberty occurs, the female to male ratio is 2:1 (Lewis, 2007a). The headache is usually bilateral in children and usually frontotemporal, with occipital headaches being rare and needing immediate evaluation for structural lesions (IHS, 2004). Migraine with aura peaks at 5 to 6 years of age in boys and between ages 12 and 13 years in girls (Lewis, 2007a). Migraine prevalence estimates vary from 1–3% at 7 years of age with an increase to as high as 11% in the later school-age child and mid-adolescent (Brna & Dooly, 2006).

Cluster headaches are rare in the pediatric age group, with prevalence of 0.09% to 0.4% for male patients. From age 11–18, the prevalence of childhoodonset cluster headaches is 0.1% (Lampl, 2002).

Tension headache is more common in older girls. General prevalence is between 30% and 78% in the general population.

Social Factors

Mr. Brown is a single parent and has a full-time job. When questioned about his ethnicity, he denies belonging to any cultural group and feels he is a mixture of races. So in this case, it is important for you to explore what he believes about health care, medications, and complementary medications. Because the father has expressed concern about the management plan that was identified during prior healthcare visits related to John’s headaches, you need to spend time explaining the diagnosis and evaluating Mr. Brown’s acceptance of and desire to be involved in deciding on the management plan. Using the skills of motivational interviewing can be helpful in exploring parental expectations of the healthcare visit.

Further Assessment Data Required for the Differential Diagnosis?

The differential diagnosis is vast but needs to be approached systematically by first deciding whether the headache is a primary problem or a secondary symptom to another problem. A complete history and physical examination are the first steps in making the decision. Table 20-1 reviews possible differential diagnoses for headaches in children. The key to confirming the diagnosis is compliance with the treatment plan and good follow-up with the family.

From the above review, what additional questions should you ask? image

History

•  When did the headaches begin? If the problem has been going on for years, make sure there are no recent changes in the headache presentation.

•  How often are the headaches, and has there been a change in frequency? What is the interval between the headaches? Migraines are not daily whereas TTHs can be daily or several times a week. Cluster headaches occur in clusters of two to three per week over a few weeks and then do not occur for a period of time (Brna & Dooley, 2006).

Table 20–1 Differential Diagnoses for Headache

image

•  How did the headache begin? Asking about head trauma or recent changes in the child’s social situation is an important part of this question.

•  What is the time of onset of headache during the day? Ask about night waking due to headache, relationship to activity, or coughing causing the headache. Headache associated with coughing is an ominous sign (Gunner & Smith, 2007). Headaches that are predominantly nocturnal or early morning and associated with vomiting deserve neuroimaging (Brna & Dooley, 2006).

•  How long does the headache episode last? Cluster headaches tend to be brief; migraines can last as short as 1 hour and as long as 72 hours; and TTHs can last the entire day (Brna & Dooley, 2006).

•  Where is the headache located on the head? Bitemporal frontal headache is common in migraine whereas tension headache is around the head. Occipital headaches are an ominous sign and may indicate structural lesions (Gunner & Smith, 2007).

•  What makes the headache better or worse?

•  What are the characteristics of the pain? Younger children may describe migraine as pressing or heavy rather than throbbing (Brna & Dooley, 2006). The inability to locate the pain is more disturbing than not being able to describe it (Brna & Dooley).

•  Are there any warning signs that the headache is coming? Auras that are persistently unilateral on the same side should have neuroimaging to rule out structural lesions (Brna & Dooley, 2006). Parents may be able to note changes in the child’s appetite, mood, or thirst.

•  What are the associated symptoms? Are there associated autonomic symptoms such as nausea, vomiting, numbness, or weakness? If the child complains of dizziness, you will need to ask more questions. Is the patient describing lightheadedness, unsteadiness, or vertigo? Lightheadedness suggests cerebral hypoperfusion or orthostasis (Lewis, 2007b). Unsteadiness or vertigo is associated with balance disorders, suggesting the need for neuroimaging to rule out vestibular or cerebellar pathology (Lewis, 2007b). Dizziness and vertigo at the onset of a throbbing headache suggest basilar-type migraine, which is a more complex type of migraine requiring referral (Lewis, 2007b).

•  Do the headaches occur under any specific circumstances or after eating any particular food? Migraines may have a trigger.

•  What makes the headache better or worse? Aggravating factors can include activities, light, noise, and smell. Headaches caused by increases in intracranial pressure will get worse when the child lies down (Brna & Dooley, 2006).

•  What does the child do during the headache? Ask the child what he does if he gets the headache during playtime.

•  What medications are taken for the headache? What other medications is the child taking? Asking specifically about alternative medications is also important. Headaches can be the side effects of other medications.

•  Does the child have any other medical/psychiatric problems? Make sure there is no chronic health condition that may be causing headache or stress

•  Would I as a healthcare provider know your child has a headache if I saw him?

•  Has the child had a change in personality with the onset of the headache?

•  Does anyone in the family have headaches? The genetics of migraine need to be explored.

•  What does the parent think is causing the headaches?

•  Is there any drug or alcohol use?

•  What is the child’s sleep pattern? Does the child snore? Is there daytime sleepiness? Children with migraine have increased sleep disturbances (Heng & Wirrell, 2006; Isik et al., 2007).

•  Are there any behavioral problems with the child? Children with headaches were initially thought to have psychopathology. However, recent reviews and studies have failed to show that a majority of children with headache have any psychopathology (Laurell, Larsson, & Eeg-Olofsson, 2005; Powers, Gilman, & Hershey, 2006; Vannetta et al., 2008)

•  If the child is a female adolescent, does she use oral contraceptives?

•  Does the child have a history of 2 weeks or more of purulent nasal discharge?

•  When was the child’s last visit to the dentist?

In addition to the data described earlier, you now learn on further questioning that with the first headache, there was no nausea reported but now Mr. Brown reports that John does not look well during the headache episodes. He does not feel the child has any aura. The headache is improved by lying down, but Tylenol provides only minimal relief. After sleeping, John is generally better. He has had about two to three headaches a month.

After the first headache, Mr. Brown took John to the doctor, and the child was diagnosed with a tension headache. The father was advised to use Tylenol. After 6 weeks and three more headaches, John was seen by a second provider who did a CT scan, CBC, lead level, and thyroid screen. The results were all normal by the father’s report and the family was given no further follow-up visits. Mr. Brown has not been able to identify a precipitating cause but has not done a headache diary. John has had no associated head trauma or change in social situation. There are no other medical problems, and the father has not noted John to have purulent rhinitis. John’s behavior and school performance is the same. He sees a dentist regularly. He generally sleeps 10 hours a night, but does report variability in sleep time. John eats three meals per day, and there has been no change in bowel or bladder habits. The maternal grandmother has babysat for the child for the past 3 years since the death of the mother. The previous medical record was not available at the time of the initial visit, but was later obtained and confirmed the father’s history.

Physical Examination

John is at the 75th percentile in height and the 50th percentile in both head circumference and weight. His body mass index (BMI) is between the 50th and 75th percentile and his BP is normal. Developmentally, the child is able to answer questions and draw a diamond. He is able to read on grade level and do simple math and reading.

From the general physical examination, the following observations were made: There is one 1.5 cm café au lait spot on the right trunk but no other neurocutaneous manifestations. There is no tenderness over the maxillary sinus, and the nasal mucosa is pink with exudate. The mouth opens without clicking or popping of the temporomandibular joint. No caries are seen and there is no evidence of gingivitis. The cervical spine has full range of motion. Heart, lung, and abdomen examinations are normal.

A complete neurological exam was done. No cranial bruit was identified. Visual fields: grossly intact by confrontation. Visual acuity is 20/20, and extraocular movements are intact without nystagmus. The optic disc is sharp with normal disc to cup ratio. There is no blurring of the vessels along the disc margins. Pupils are equal, round, and reactive to light and accommodation. Fifth (trigeminal) nerve: intact bilateral masseter strength. Seventh (facial) nerve: face bilaterally symmetric; eighth (auditory) nerve: intact bilateral hearing; ninth (glossopharyngeal) nerve: normal gag; 11th (spinal accessory) nerve: full strength in bilateral trapezius and SCM; 12th (hypoglossal) nerve: tongue midline. Reflexes +2 symmetrical on all four extremities without clonus and with downgoing toes. Motor: right upper extremity muscle: normal; left upper extremity muscle: normal; right lower extremity muscle: normal; left lower extremity muscle: normal. Other: Able to walk on heels and hop three times on each foot. Right hand, right foot preference, able to do tandem gait. Sensory primary: Light touch: intact; Pinprick: intact. Secondary: Graphesthesia: able to perform; Stereognosis: able to perform. No neurological soft signs such as hyperactivity, poor attention span, or impulsivity demonstrated during exam. Coordination: dysdiadochokinesis (i.e., inability to quickly substitute antagonistic motor impulses) attempted. Gait: normal for age without ataxia.

In summary, no abnormal findings were identified in the physical examination.

Making the Diagnosis

The history and physical examination are consistent with the diagnosis of migraine headache. The need for neuroimaging should be considered when there are either historical features of recent onset of severe headache, changes in type of headache, or changes in neurological function (Lewis, 2007b). The need for neuroimaging should be considered if there are physical examination features of focal findings, increased intracranial pressure, or new onset of seizures. (See Table 20-2.) The child’s history and physical have no worrisome characteristics and meet the criteria for pediatric migraine rather than tension-type headaches.

Management

How do you plan to treat his migraine headaches? image

Do you need to do anything to confirm the diagnosis, such as laboratory studies? image

No laboratory studies are recommended in the management of pediatric migraine (Guidetti & Galli, 2004; Gunner & Smith, 2007; Lewis, 2007a, b, c). Neuroimaging or lumbar puncture should be done if there are abnormalities during the history or physical examination that indicate the need for further testing.

Therapeutic plan: What will you do therapeutically? image

Table 20–2 Worrisome History and Physical Examination Findings

History

Headache that increases on coughing or Valsalva maneuver

 

Increasing frequency of or changes in type of headaches

 

Changes in child’s personality, behavior, or school performance

 

Developmental delay

 

Pubertal delay

 

Headache with acute onset, associated with fever, neck stiffness, or vomiting

 

Headache that gets worse when laying down

 

Headache that wakes up the child at night, with morning headache

 

Occipital headache

 

Explosive onset of headache

 

Epilepsy

 

Changes in mental status including confusion or drowsiness

 

Physical examination

Signs of head trauma

 

No increasing head circumference

 

Normal level of consciousness

 

Abnormalities of cranial nerves

 

Anisocoria that varies in light and dark

 

Abnormal growth parameters

 

Cranial bruit

 

Papilledema or optic pallor

 

Visual disturbances

 

Tenderness over maxillary or frontal sinuses

 

Meningeal signs: neck stiffness, positive Brudzinski’s sign or Kernig’s sign

 

Cervical spine with limitation of range of motion

 

More than six café au lait spots on skin with axillary freckling

 

No sensory or motor asymmetry

 

Normal deep tendon reflexes: hyperreflexia indicates upper motor neuron lesion

 

Weakness or paralysis on a side

 

Ataxia

 

No graphesthesia or stereognosis perceptions

 

Gait disturbance

 

Sources: Adapted from Brna, P., & Doodley, J. (2006). Headache in the pediatric population. Seminars in Pediatric Neurology, 13, 222–230; Guidetti, V., & Galli, F. (2004). Headache in children: diagnostic and therapeutic issues. Seminars in Pain Medicine, 2(2), 106–114; Gunner, K. B., & Smith, H. D. (2007). Practice guidelines for diagnosis and management of migraine headaches in children an adolescents: part one. Journal of Pediatric Healthcare, 21, 327–332; Lewis, D. W. (2007b). Headaches in children and adolescents. Current Problems in Pediatric and Adolescent Health Care, 37, 207–246.

The plan is thoroughly discussed and decided with Mr. Brown’s input. This is particularly important because the father had expressed his lack of satisfaction with the other two providers who did not schedule follow-up visits. The treatment plan you identify incorporates the goals outlined in the American Academy of Neurology Practice Parameters (Lewis et al., 2004) and the Guidelines of the National Association of Nurse Practitioners (Gunner et al., 2008) for the treatment of pediatric migraine. They include:

•  Reduce the frequency, duration, severity, and disability from the headache.

•  Reduce reliance on medication for acute migraine treatment that is ineffective or poorly tolerated.

•  Improve the quality of life of migraine sufferers.

•  Avoid overuse and escalating use of medication for acute migraine treatment.

•  Educate patients to help them self-manage and self-control their migraine headache.

•  Reduce headache-related distress and emotional symptoms in migraine sufferers.

Treatment Options

In order to develop a treatment plan, the options need to be explored with the father. First, it is important to assess the degree of headache disability. The PedMIDAS tool was developed at Cincinnati Children’s Hospital and is available online at http://www.cincinnatichildrens.org/svc/alpha/h/headache/pedmidas.htm. The scoring information and PDF of the document are available at the Web site.

The next step would be to discuss nonpharmacological approaches because the family has not had a good experience with medication (see Table 20-3).

John’s PedMIDAS score is 24, indicating a mild disability from the headache. A headache diary has not been done before, so you explain the reasons for the diary to Mr. Brown. Headache diaries can help identify triggers, allow for the child to express the headache symptoms, and help identify whether the treatment regimen is working. Headaches can be precipitated by different things including sleep, nutritional intake, physical activity changes, hormonal changes, lights, types of food, and stress. Minor stress can be missed by the parent, and a headache diary can help the child point out the problems to the father, who will share in the responsibility of keeping the diary.

Mr. Brown and John are interested in increasing John’s amount of daily physical activity; however, it was more problematic for Mr. Brown because John is with a grandmother who is very protective of the child and does not allow playtime outside of the house. You ask Mr. Brown how he thinks he could increase John’s daily exercise, and he decides that he will play catch with John after dinner.

Regular meal times, good hydration, and avoiding caffeine are discussed. Mr. Brown feels that John gets enough fluids in school, but he says he will talk with the teacher about allowing extra fluids during the school day. You give Mr. Brown a list of caffeine-containing fluids, including sodas. After further discussion, Mr. Brown decides to try relaxation techniques because this is something he feels he could do with his son at home. The family is introduced to the technique in the office setting.

Table 20–3 Biobehavioral Treatment in Pediatric Migraine

Sleep hygiene

Good sleep hygiene

 

Going to bed and getting up at the same time, including on the weekend

 

Avoidance of excess, inadequate, or irregular sleep patterns

 

Healthy lifestyle

Regular exercise

 

Adequate amounts of fluids

 

Avoiding caffeine

 

Increasing fruits and vegetables

 

Progressive muscle relaxation

Involves tensing and relaxing a variety of muscles

 

Teaching diaphragmatic and deep breathing

 

Guided imagery by having the child visualize a pleasant scene

 

More appropriate after 7 years, but can be used in younger children

 

Biofeedback

Needs to be done in a biofeedback lab

 

Electromyographic activity or peripheral skin temperature is monitored and feedback given during a visual display.

Other techniques

There is no clinical evidence for the use of acupuncture, chiropractic treatment, hypnosis, osteopathic cervical adjustment, or hyperbaric oxygen in children.

 

Sources: Adapted from Gunner, K. B., Smith, H. D., & Ferguson, L. E. (2008). Practice guidelines for diagnosis and management of migraine headaches in children and adolescents: part two. Journal of Pediatric Healthcare, 22, 52–59; Lewis, D. W. (2007b). Headaches in children and adolescents. Current Problems in Pediatric and Adolescent Health Care, 37, 207–246; Powers, S. D., & Andrasik, F. (2005). Biobehavioral treatment, disability, and psychological effect of pediatric headache. Pediatric Annals, 34, 461–465.

Pharmacological management of acute headache involves taking the medication as prescribed in the right dose at the onset of the headache.

Teaching Mr. Brown to identify and treat the pain early is a key point to abort the pain. John needs to have the medication with him so he can take it within 20–30 minutes of onset of the headache (Lewis, 2007b). You give Mr. Brown a note for the school. You discuss changing medication from Tylenol to ibuprofen at 10 mg/kg. Ibuprofen is an effective first line drug for migraine (Gunner et al., 2008; Lewis et al., 2004). Mr. Brown is happy about a change in medication.

Mr. Brown raises the issue of complementary medications such as feverfew, ginkgo, valerian root, or magnesium, so you discuss the lack of evidence of the efficacy of these medications. Mr. Brown also raises the issue of a multivitamin with a daily dose of magnesium as an alternative to a specific supplement. You agree to this as part of the treatment plan.

In addition, Mr. Brown has heard about medications to prevent migraines. It is important to explain that prevention medication would not be the first step in treatment. Medications for migraine prevention would be used only if the plan did not work. In addition, migraine prophylaxis does not have FDA approval (Eiland, 2007; Gunner et al., 2008; Lewis, 2007a, b, c).

When do you want to see this patient back again? image

Generally, you would want to see this patient back in a month. You would want to review the diary, discuss the effectiveness of the treatment plan, and support the family in the new treatment management. As the family develops self-care skills, these appointments can be spread further apart.

John and his father agree on the treatment plan. You give them written instructions that go over the key points of the treatment plan. Mr. Brown is able to show you the dosage of ibuprofen to give the child, and a measurer is dispensed by the pharmacy. John likes the idea of doing imagery to help control his headaches. Mr. Brown schedules the 1-month follow-up appointment before leaving the office.

On the follow-up visit in one month, the family brings the diary. They have identified that lack of fluid was a trigger for the first migraine during the previous month. They increased fluid intake before school and at lunch because the teacher felt she could not allow fluids in the classroom. Ibuprofen was more effective than Tylenol in relief of migraine pain, and imagery seemed to help John relax. Mr. Brown wants to come back in a month and continue the diary.

Key Points from the Case

1. The management of pediatric migraine requires family education, use of biobehavioral measures, medications for acute treatments, and if needed, daily preventive medications.

2. The treatment requires a stepwise approach. This involves determining how much of an impact the headache has on the child’s life, determining and then eliminating possible triggers, instituting a healthy lifestyle, teaching biobehavioral methods to control pain, and starting pain medication for acute headache early.

3. Offering treatment options and involving the family in the treatment decisions allows the patient and the family to practice self-care and manage the problem.

REFERENCES

Brna, P., & Doodley, J. (2006). Headache in the pediatric population. Seminars in Pediatric Neurology, 13, 222–230.

Eiland, L. S. (2007). Anticonvulsant use for prophylaxis of pediatric migraine. Journal of Pediatric Healthcare, 21, 392–395.

Guidetti, V., & Galli, F. (2004). Headache in children: diagnostic and therapeutic issues. Seminars in Pain Medicine, 2(2), 106–114.

Gunner, K. B., & Smith, H. D. (2007). Practice guidelines for diagnosis and management of migraine headaches in children and adolescents: part one. Journal of Pediatric Healthcare, 21, 327–332.

Gunner, K. B., Smith, H. D., & Ferguson, L. E. (2008). Practice guidelines for diagnosis and management of migraine headaches in children and adolescents: part two. Journal of Pediatric Healthcare, 22, 52–59.

Headache Classification Subcommittee of the International Headache Society. (2004). The International Classification of Headache Disorders. Cephalagia, 24(Suppl 1), S1–S160.

Heng, K., & Wirrell, E. (2006). Sleep disturbance in children with migraine. Journal of Child Neurology, 21, 761–766.

Isik, U., Ersu., R. H., Ay, P., Save, D., Arman, A. R., Karakoc, F., et al. (2007). Prevalence of headache and its association with sleep disorder in children. Pediatric Neurology, 36(3), 146–151.

Lampl, C. (2002). Childhood-onset cluster headaches. Pediatric Neurology, 27(2), 138–140.

Laurell, K., Larsson, B., & Eeg-Olofsson, O. (2004). Headache in schoolchildren: association with other pain, family history and psychosocial factors. Pain, 119, 150–158.

Lewis, D., Ashwal, S., Hershey, A., Hirtz, D., Yonker, M., & Silberstein, S. (2004). Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Society Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology, 63, 2215–2224.

Lewis, D. W. (2007a). The epidemiology and treatment of pediatric migraine. Current Medical Literature: Neurology, 22(3), 65–74.

Lewis, D. W. (2007b). Headaches in children and adolescents. Current Problems in Pediatric and Adolescent Health Care, 37, 207–246.

Lewis, D. W. (2007c). Pediatric migraine. Pediatrics in Review, 28(2), 43–53.

Lisi, V., Garbo, G., Micchiche, F., Stecca, A., Terrazzino, S., Franzoi, M., et al. (2005). Genetic risk factors in primary paediatric versus adult headache: complexities and problematics. Journal of Headache Pain, 6, 179–181.

Powers, S. D., & Andrasik, F. (2005). Biobehavioral treatment, disability, and psychological effect of pediatric headache. Pediatric Annals, 34, 461–465.

Powers, S. W., Gilman, D. K., & Hershey, A. D. (2006). Headache and psychological functioning in children and adolescents. Headache, 46(9), 1404–1415.

Rubin, D. H., Suecoff, S. A., & Knupp, K. (2006). Headaches in children. Pediatric Annals, 35(5), 345–353.

Vannetta, K., Getzoff, E. A., Gilman, D. K., Noll, R. B., Gerhardt, C. A., Powers, S. W., et al. (2008). Friendships and social interactions of school-aged children with migraine. Cephalalgia, 28, 734–743.