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Children are not young adults; thus, we have to take a different approach with caring for this population. Children may have similar pathophysiology as adults, but they respond differently to psychosocial variants and may have some clinical variants that are not present in adults. For example, pain itself is a subjective feeling that is objectively measured with specific pain scales, but this can be challenging to assess in younger children who have difficulties expressing symptoms they are experiencing. Standard pain-related questions may not capture the full picture, as children may have a difference in perception of pain. It is important to note that most of the information collected may be primarily provided by parents or guardians. When taking the history, it is advantageous to direct specific questions to the child at a level they understand. The primary goal is to gather relatively a good history and description of the symptoms using clues or even drawings (this has shown to be a very sensitive tool in younger children). It is the only way to discover what the child is feeling without having the clinical symptoms translated through an interpreter (ie, parents or guardians). Clues could include when a little boy goes into a dark room and stops playing (photophobia) or when a 5-year-old girl draws herself with a hammer hitting her head (throbbing).

This chapter will review key differences in childhood primary headache presentations and summarize different strategies used in treating those headaches including acute, preventive, and behavioral therapies.


The International Classification of Headache Disorders, Third Edition (ICHD-3) helps to classify different headache disorders including migraine. The diagnostic criteria for children and adolescents are generally similar as adults with few exceptions.1

Temporal Criteria

As per the ICHD-3, a migraine lasts between 4 and 72 hours. In children and adolescents, this criterion has been revised to include a shorter duration of headache lasting from 2 to 72 hours. This allowance for a shorter duration of headache has many practical implementations. Time, much like pain, may be very subjective from a younger child’s perspective. When asked the duration of headache, they may not be able to accurately describe it. Many children only report headaches to their caregivers when the intensity reaches a moderate or severe level and not necessarily at onset of headache.

Location Criteria

Unilateral location of migraine has been described since antiquity. Pain may not be strictly unilateral in children and adolescents presenting with migraine. ICHD-3 recognizes frontotemporal location of pain in the diagnostic criterion of migraine in adolescents and children. Many younger children report more frontal pain. Location of pain also helps to identify other headache disorders, including occipital neuralgias and trigeminal autonomic cephalgias.

Associated Symptoms

Given the polygenic nature of migraines and the ...

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