COMMENTARY—Valuable Information About a Common Disorder

Dr. Tunc's literature review and retrospective review of headache clinic data provide food for thought with regard to chronic daily headache (CDH) in younger children. The rate of CDH in the papers reviewed ranged from 8% to 30%. I think this range represents the differences in nature between the pediatric headache clinics included in the sample. In some areas, the local primary care providers refer all children with headache to headache clinics. In other areas, the primary care providers hold on to "easy" headache patients and refer only the "tough cases." For that reason, it is hard to generalize from Dr. Tunc's finding. Suffice it to say that tertiary pediatric headache clinics do see some younger children with CDH. The Cleveland Clinic experience showed a prevalence of 58%, so that clinic sees the harder cases.

Dr. Tunc did not find MRI to be useful in children with CDH. I just want to caution readers to order MRIs when patients have systemic signs (eg, growth failure or secondary amenorrhea), neurologic signs (eg, ataxia, slurred speech, one-sided weakness, or facial asymmetry), abrupt onset of headache (think of ruptured aneurysm), or a new change in headache pattern. We must be careful with conclusions drawn from retrospective studies because we can't control for any factors. Although no MRIs were positive, we don't know about patients who came to the neurosurgeon through other pathways besides the headache clinic.

Dr. Tunc mentioned that younger patients had a longer duration of illness before seeking tertiary care, and she speculated as to why. Further clarification is needed to develop a plausible explanation. How was the time measured? Was it measured from the first headache until the tertiary care visit, or from onset of CDH until the tertiary care visit? If the former is true, then I might reach a different conclusion. Perhaps it takes longer for younger children to chronify than older children. If, on the other hand, time was measured from the onset of CDH until presentation, then the authors' explanations may indeed be sound.

In summary, this is a great study that shows that small children presenting to a tertiary care center do get CDH at a higher rate than we thought. It would be terrific to poll other pediatric headache programs to compare and contrast with the findings of this study.

—Jack Gladstein, MD
Professor of Pediatrics and Neurology
Director of the Pediatric Headache Clinic
University of Maryland School of Medicine
Baltimore