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Patient Story

A 15-year-old girl presented to the office with her mother to discuss her migraines. She has episodic unilateral throbbing headaches accompanied by nausea, photophobia, and phonophobia. She also reports a visual prodrome, characterized by a jagged line pattern (Figure 201-1). She used to have a migraine about every 3 months, but is now having one almost every week. She misses a day of school with each migraine. She is not under any unusual stressors. Her mother has migraines and benefitted greatly from taking a prophylactic medication.

FIGURE 201-1

Jagged line pattern prodrome often described in patients with migraine headaches. This is called teichopsia and may resemble the fortification pattern of a medieval town. (Used with permission from Richard P. Usatine, MD.)


More than 50 percent of children report a headache in the past year. Headaches are either primary or secondary and the presence or absence of red flags is useful to distinguish dangerous causes of secondary headaches. The most common primary headaches are tension and migraine headaches. Medication overuse can complicate headache therapy. Treatment and prognosis is dependent on type of headache.


  • Prevalence of headache in children increases during childhood, peaking between ages 11 and 13.

  • Fifty-three percent of children have had a headache in the past year.1

  • Episodic tension-type headache (TTH) prevalence is 15.9 percent in children.1

  • Chronic (>15 days per month) TTH has a prevalence of 0.9 percent in children.1

  • Migraine has a prevalence of 9.2 percent in children.1

  • Chronic daily headache has lifetime prevalence of 4 to 5 percent.2

  • Cluster headache has a lifetime prevalence of 0.2 to 0.3 percent.1

Etiology and Pathophysiology

  • The most common causes of headaches in children and adolescents are migraine and TTH.3

  • TTH etiology is uncertain, but likely caused by activation of peripheral afferent neurons in head and neck muscles.4

  • Migraine headache is thought to be caused by central sensory processing dysfunction, which is genetically influenced.5 Nociceptive input from the meningeal vessels is abnormally modulated in the dorsal raphe nucleus, locus coeruleus, and nucleus raphe magnus. This activation can be seen on positron emission tomography (PET) scan during an acute attack.

  • Cluster headache is caused by trigeminal activation with hypothalamic involvement, but the inciting mechanism is unknown.6

Risk Factors

  • For migraines—Family history reported in over 60 percent.


A headache diary is helpful for diagnosis and follow-up.

Clinical Features

  • Red flags for dangerous secondary cause:3

    • Worst headache of life.

    • Recent onset of headache.

    • Increase in severity or frequency of headache.

    • Headache occurring only in ...

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