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8 Articles in this Series
Are Botox Injections Safe for Younger Patients?
Chronic Daily Headache Prevalent Among Younger Patients
Depression and Disability, Problems for Children with Migraine
Dropping Caffeine May Enhance Acute Migraine Treatment
Migraine with Aura More Common at Higher Altitudes
New Insights Into Botox for Preventive Migraine Treatment
Triptans Worsen Visual Snow in Migraine Patient
Vitamin Deficiency Common in Migraine Patients

Chronic Daily Headache Prevalent Among Younger Patients

Chronic daily headache (CDH) with migraine is the most common type of headache seen among children and adolescents, according to researchers from the Cleveland Clinic Foundation (CCF), Cleveland, Ohio.

In a recent review, the research team of Emine Tunc and David A. Rothner found that between 8% and 30% of pediatric patients are diagnosed with CDH. In addition, a large percentage of these CDH cases involved patients under 12 years of age, ranging from 28% to 56%.1   

“This is the first and largest study specifically dealing with CDH in children under age 12,” the researchers stated. In addition to the literature review, the team also studied 327 patients with primary headache at the CCF. Fifty-seven percent of these patients were diagnosed with CDH. Of those, over a quarter (28%) were under the age of 12.

Many of the characteristics these young patients showed were “surprisingly similar” to what is seen in older children, and many of the same issues—like excessive absenteeism from school and over-usage of medication—were important factors that practitioners should address, noted the researchers.

CDH is defined by headaches occurring on a daily or near daily basis for 3 months or longer, or no less than 15 days per month and 4 hours per day. While the condition comes in all varieties of headaches, all headaches appear to increase in frequency from childhood, through puberty, and into adulthood.2-5

Both the literature review and CCF cohort study found a male to female ratio of 1:1 for patients under 12-years-old diagnosed with CDH, which increased to a 1:2 ratio for patients over 12-years-old. This is in line with past research, where the incidence of migraine is similar in boys and girls before puberty.5 By adulthood though, the male to female ration is 1:3.6

While not all research supports the notion pubescent changes can modulate the frequency of headache,7 the hormonal fluctuations in estrogen and progesterone8 seen in a young woman’s first years of menarche are typical,9 and the decrease in estrogen that occurs before menses could precipitate migraine.6

Treating CDH in Adolescents

The researchers also pointed out data illustrating some significant challenges associated with treating CDH in pediatric patients.

For instance, treatment of CDH can be complicated by comorbid symptoms, like abdominal pain, muscle aches, and fatigue. But despite the fact no real pathophysiology to the condition has been proven, parents of patients typically insist there is an organic etiology.2

“Diagnosis of CDH patients depends mostly on comprehensive history and physical exam. Imaging studies such as MRI and laboratory test are seldom helpful,” the authors noted, and indeed, brain magnetic resonance imaging (MRI) was performed on a strong percentage of both younger and older patients, at 38% and 59% (P=0.013), all of which were unremarkable.

Also, there is a possibility MRI could reveal unrelated abnormalities (Chiari malformations or arachnoid cysts), which may cause parents to have serious concerns.11

On the other hand, children and their parents may ignore symptoms or wait a length of time before seeking medical care. Younger patients had a significantly longer duration of illness prior to their initial evaluation (P=0.002). This could be worrisome, since there is a trend patients will miss significant amounts of school and overuse medications to try and get themselves better.

Indeed, 30% of younger patients and 41% of older patients were missing significant amounts of school days. Older children appeared to have higher PedMIDAS disability scores (P=0.039), and 61% of younger and 52% of older patients were overusing medications.

Important Factors to Consider

Stress can be a major, overlooked component affecting the child and can come from many directions – whether it be parental- or self-pressure to perform well in school, or athletics, or social pressure at school or home. The study found over a quarter (27%) of both younger and older patients showed behavioral concerns, a sign that other issues are affecting the patient’s life.

“Because younger children present later in the disease process, earlier diagnosis would decrease morbidity. Since this headache tends toward chronicity, greater effort is needed to decrease both medication overuse and excessive school absenteeism. Innovative approaches to deal with these long term headaches are needed.”

Many doctors recommend a multimodal approach to therapy, working to get the child back in school and limit their use of analgesics.12 Addressing factors like diet, exercise, and emotional problems can be significant steps, too.

Sleep in particular could be a serious factor in the patient’s lifestyle. Another study presented at the AHS meeting found that pediatric patients suffering from daily persistent headache commonly had greater sleep disturbance.13 While it may be difficult to tell which came first for these patients – the pain or the lack of sleep – researchers believe that assessing and treating sleeping problems is important, as well.


  1. Tunc EM, Rothner A. (June, 2016). Chronic daily headache: Focus on younger children age 3-11. Presented as part of the American Headache Society annual meeting, San Diego, California.
  2. Gladstein J, Rothner DA. Chronic daily headache in children and adolescents. Seminars in Pediatric Neurology. 2010;17(2):88-92.
  3. Castillo J, Muñoz P, Guitera V, et al. Epidemiology of chronic daily headache in the general population. Headache. 1999;39:190-196.
  4. Anttila P, Metsähonkala L, Aromaa M, et al. Determinants of tension-type headache in children. Cephalalgia. 2002;22:401-408.
  5. Abu-Arafeh I, Russell G. Prevalence of headache and migraine in schoolchildren. BMJ. 1995;309:765-769.
  6. Martin VT, Behbehani M. Ovarian hormones and migraine headache: Understanding mechanisms and pathogenesis—Part 1. Headache. 2006;46:3-23.
  7. Kröner-Herwig B, Vath N. Menarche in girls and headache—A longitudinal analysis. Headache. 2009;49:860-867.
  8. Martin VT, Behbehani M. Ovarian hormones and migraine headache: Understanding mechanisms and pathogenesis—Part 2. Headache. 2006;46:365-386.
  9. Finkelstein JW. Endocrine Physiology at Puberty in Comprehensive Adolescent Health Care. Mosby Year Book, St. Louis, MO (1998).
  10. Crawford MJ, Lehman L, Slater S, et al. Menstrual migraine in adolescents. Headache. 2008;49:341-347.
  11. Schwedt TJ, Guo Y, Rothner AD. ‘Benign’ imaging abnormalities in children and adolescents with headaches. Headache. 2006;46:387-398.
  12. Winner P, Gladstein J. Chronic daily headache in pediatric practice. Curr Opin Neurol. 2002;15:297-301.
  13. Rabner J, Kaczynski K, Lazdowsky L, et al. (June, 2016). Pediatric headache and sleep disturbance: A comparison of diagnostic groups. Presented as part of the American Headache Society annual meeting, San Diego, California.
Next summary: Depression and Disability, Problems for Children with Migraine
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