Headache and migraine in children: Case

This girl has chronic migraine complicated by medication-overuse headache. Her headache pattern meets the ICHD-3 definition of chronic migraine, which is 15 or more headache days a month for over three months with at least eight migrainous days, and her attacks are bilateral, throbbing, and accompanied by nausea and photophobia, with a family history of migraine in her mother. Her daily use of ibuprofen and a combination paracetamol and codeine tablet over the last two months meets the threshold for medication-overuse headache, which is acute medication on 15 or more days a month for simple analgesics, or 10 or more days a month for combination analgesics, sustained for over three months. Her normal fundi, blood pressure, and neurological examination, and the absence of any red flag, confirm that this is a primary headache disorder rather than a secondary cause, so imaging is not indicated. ^[1]

Confirming the diagnosis and excluding a secondary cause

The first task is to confirm that this is a primary headache and to exclude a secondary cause. The history meets the ICHD-3 criteria for chronic migraine, and the deliberate red-flag screen is negative: there is no thunderclap onset, no occipital location, no focal deficit, no papilloedema, no early-morning vomiting, no progressive or under-five pattern, and no systemic features. Her blood pressure is normal, her fundi show no papilloedema, and her full neurological examination including gait and coordination is normal. On these grounds I would not arrange neuroimaging, because a primary headache that meets the criteria, with a negative red-flag screen and a normal examination, does not need a scan. The disability is substantial: she has missed three weeks of school, withdrawn from sport, and describes low mood, which I would quantify with the PedMIDAS to guide the intensity of the preventive plan. ^[1]