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Background: New daily persistent headache (NDPH) is a challenging and understudied primary headache disorder with no known effective treatment. Although the International Classification of Headache Disorders criteria require that the new onset continuous headache be present for at least three months before diagnosing NDPH, the biologic basis for when a new, continuous headache starts to behave as NDPH is unknown, and some pediatric headache experts consider that the minimum duration criterion could be shorter., Methods: In this retrospective study, we reviewed the intake questionnaires and medical records of 5-17 year-olds seen in neurology clinic for headache at the Children's Hospital of Philadelphia. Those with a new onset continuous headache of at least one month in duration were eligible. The patient's self-report and clinician's description both had to indicate that the headache was new, of abrupt onset, and continuous to be included, although patients were allowed to have a prior history of infrequent headaches. We compared headache outcomes at last follow-up and at one year after continuous headache onset between those who had a continuous headache duration of 1 to <3 months ("new onset headache", or NOH) at first visit vs. those with ≥3 months (NDPH). We used multivariate regression modeling to examine for predictors of headache outcomes., Results: Of 472 patient records reviewed, 172 met the inclusion criteria for analysis. Of these, 84 had a headache duration of 1 to <3 months in duration and 88 had a duration of ≥3 months. Those with shorter duration continuous headache were younger (median (interquartile range) 13.5 (11.1-15.7) vs. 15.1 (12.3-16.5) years, and less likely to have previously received a prescription preventive for the continuous headache (n = 14 (17%) vs. 26 (30%), p = 0.046), but were otherwise similar to those with NDPH in terms of baseline clinical and demographic variables. Sixty-five (74%) of those with NDPH and 60 (71%) with NOH had follow-up data. At last clinic follow-up, 41/65 (63%) with NDPH and 43/60 (72%) with NOH had experienced any headache benefit ( p  = 0.307), although 39/65 (60%) with NDPH and 29/60 (48%) with NOH still had continuous headache ( p  = 0.191). Headache duration was not associated with outcomes in multivariate regression modeling., Conclusions: Headache outcomes of children and adolescents with new onset continuous headache, whether of 1 to <3 months (NOH) or ≥3 months in duration (NDPH) are suboptimal. More research is needed to improve treatment outcomes for this patient population., Competing Interests: Declaration of conflicting interestsCS: Dr Szperka or her institution have received compensation for serving as a consultant for AbbVie and Teva. She has received personal compensation for serving on a data safety monitoring board for Eli Lilly and Upsher-Smith. She has also received research support from the NIH NINDS (K23NS102521), PCORI and the CHOP CARES/ Doris Duke COVID-19 Fund to Retain Clinical Scientists. ME: None. CPG: Dr Patterson Gentile has received salary support from grants from the American Academy of Neurology Clinical Research Training Scholarship in the past 24 months, and is currently funded by the National Institutes of Health/National Institute of Neurological Disorders and Stroke (K23 NS124986). PP: None. NR: None. BMP: None. ADH: Dr Hershey or his institution have received compensation for serving as a consultant for AbbVie, Amgen, Biohaven, Eli Lilly, Lundbeck, Supernus, Teva, Theranica and Upsher-Smith. His institution has also received research support from Amgen, Biohaven, Eli Lilly, Theranica, Upsher-Smith, and the NIH NINDS/NICHDS. AAG: In the last 24 months, Dr Gelfand has received honoraria from UpToDate (for authorship) and from the Headache Cooperative of the Pacific and the Taiwan Headache Society for speaking. She receives payment to her institution from the American Headache Society for her role as Editor of Headache. She receives grant support from PCORI as a member of the Steering Committee for the REACH study.

Objective: To conduct a retrospective cross‐sectional multicenter study to validate the relationships between migraine‐associated symptoms. Background: Symptoms associated with headache—photophobia and phonophobia, nausea, and/or vomiting—are required criteria for migraine diagnosis based on the International Classification of Headache Disorders‐Third Edition (ICHD‐3). However, individuals with migraine report high rates of other symptoms (e.g., lightheadedness, difficulty thinking). We recently completed a single‐center study assessing the relationships between an expanded set of migraine‐associated symptoms. Methods: A pre‐registered cross‐sectional multicenter retrospective analysis was conducted on standardized questionnaire data of youth ages 6–17 years from two headache registries at pediatric tertiary care centers. Cluster Analysis of Migraine‐associated Symptoms (CAMS) was implemented to assess associations between 11 migraine‐associated symptoms. We explored differences between the two centers, and how CAMS was associated with demographics, including sex and age, and headache burden. Results: There were 10,721 participants who were 66.5% female and had a median (interquartile range) age of 13 (10–15) years. The first three CAMS dimensions accounted for 46.5% of the variance and were consistent across sites. The first dimension indicated those reporting any migraine‐associated symptoms were likely to report multiple. The second dimension separated symptoms into those included in ICHD‐3 migraine diagnostic criteria and non‐ICHD symptoms (e.g., lightheadedness, difficulty thinking). The third dimension separated sensory hypersensitivity and vestibular symptoms. An abundance of migraine‐associated symptoms correlated with greater headache severity (Spearman's ρ = 0.18, 95% confidence interval [CI] 0.17–0.20; small effect size) and disability (ρ = 0.26, 95% CI 0.25–0.28; small effect size). We also observed differences in associated symptoms across age and sex. Discussion: Associations between an expanded set of migraine‐associated symptoms are informative for headache burden and reveal intriguing changes across child development and sex. We were able to replicate findings across two centers, indicating that these symptom clusters are inherent to migraine. Plain Language Summary: The presence of symptoms such as light or sound sensitivity, nausea, and vomiting can help clinicians differentiate between migraine and other headache disorders, such as tension‐type headache. However, people with migraine commonly experience symptoms that are not part of migraine diagnostic criteria per the International Classification for Headache Disorders‐Third Edition criteria, including lightheadedness, vision changes, and vertigo. In this study, we found that by considering these other associated symptoms, we were able to better understand the burden of headache in children and adolescents; e.g., we found that having more associated symptoms was associated with more headache severity and greater headache impact in children and teenagers. [ABSTRACT FROM AUTHOR]

Objective: To provide healthcare professionals guidance on youth at risk for prolonged recovery and post‐traumatic headache (PTH), and on pharmacologic and non‐pharmacologic management of PTH due to concussion and mild traumatic brain injury. Background: Headache is the most common persistent post‐concussive symptom affecting 8% of youth for >3 months after concussion. Over the past decade, many studies have explored the treatment of PTH in youth, but there are no established guidelines. Methods: This white paper is based on a synthesis of an updated systematic review of the literature on treatment of PTH and a narrative review of the literature on risk factors for prolonged recovery and health disparities. Results were interpreted by a group of expert providers in PTH in children and adolescents through collaboration of the PTH and pediatric special interest groups of the American Headache Society. Results: Factors that consistently were associated with prolonged recovery from concussion and persistent PTH included female sex, a high number of acute symptoms, and adolescent age. Social determinants of health also likely play an important role in PTH and deserve consideration in the clinical and research settings. A total of 33 studies met the criteria for inclusion in the systematic review of PTH treatment in youth, although most were retrospective and of fair‐to‐poor quality. Treatment strategies included acute and preventive pharmacologic management, procedures, neuro‐modulatory devices, physical therapy, physical activity, and behavioral health support. A collaborative care approach that includes a thoughtful combination of these management strategies is likely most effective. Conclusions: This white paper provides a roadmap for tailoring the treatment of PTH based on factors influencing prolonged headache, the timing of therapies, and therapies with the most evidence for treating PTH in youth. We also highlight research needed for developing more definitive guidelines on PTH management in youth. Plain Language Summary: Post‐traumatic headache (PTH) following concussion is a common and potentially disabling condition impacting youth, yet there are no standards for treatment. This article reviews current evidence and identifies knowledge gaps to guide future research. Based on the limited available evidence and expert opinion, we offer a roadmap for the treatment of PTH in children. [ABSTRACT FROM AUTHOR]

Objective: To determine the underlying relationships between a broad range of headache-associated symptoms and how they relate to headache burden. Background: Symptoms associated with head pain inform classification of headache disorders. However, many headache-associated symptoms are not included in the diagnostic criteria, which is largely based on expert opinion. Large symptom databases can assess headache-associated symptoms irrespective of pre-existing diagnostic categories. Methods: We conducted a large single-center cross-sectional study on youth (6–17 years old) assessing patient-reported outpatient headache questionnaires between June 2017 and February 2022. Multiple correspondence analysis, an exploratory factor analysis, was applied to 13 headache-associated symptoms. Results: 6662 participants (64% female; median age 13.6 years) were included. Multiple correspondence analysis dimension 1 (25.4% of the variance) captured the absence or abundance of headache-associated symptoms. A greater number of headache-associated symptoms correlated with greater headache burden. Dimension 2 (11.0% of the variance) revealed three symptom clusters: (1) cardinal features of migraine (light, sound, and smell sensitivity, nausea, and vomiting), (2) nonspecific global neurologic dysfunction symptoms (lightheadedness, trouble thinking, blurry vision), (3) vestibular and brainstem dysfunction symptoms (vertigo, balance problems, ear ringing, double vision). Conclusion: Assessing a broader range of headache-associated symptoms reveals clustering of symptomatology and a strong relationship with headache burden. [ABSTRACT FROM AUTHOR]

Objective: To compare clinical features in youth with continuous headache from migraine, persistent post-traumatic headache, and new daily persistent headache to determine if they are similar, contrary to their distinction in the International Classification of Headache Disorders. Methods: We pursued a single center age- and sex-matched observational study comparing the clinical characteristics of 150 youth (11 – 17 years old) with continuous headache from migraine, persistent post-traumatic headache, and new daily persistent headache. A diagnostic algorithm based on international classification of headache disorders criteria was used to identify those with migraine (headache features of migraine with gradual onset), and persistent post-traumatic headache and new daily persistent headache (based on the circumstances of headache onset regardless of headache features). Fifty participants each with migraine, persistent post-traumatic headache, and new daily persistent headache were matched by age and sex. Participant survey responses on headache characteristics were compared. Results: Median usual headache severity was 6.0 [95%CI 6.0, 6.0] and was not different across diagnostic groups (H statistic = 1.2, p = 0.55). Headache exacerbation frequency, disability, associated symptoms, and most triggers were not significantly different across groups. The majority of persistent post-traumatic headache and new daily persistent headache had headache features consistent with a diagnose of migraine (72% and 62%, respectively). Conclusion: Our findings suggest that most persistent post-traumatic headache and new daily persistent headache may represent abrupt onset of migraine. [ABSTRACT FROM AUTHOR]

Objective: To equip clinicians with recommendations specific to concerns related to the novel coronavirus disease 2019 (COVID‐19), which impact the physical, emotional, and social health of youth with headache disorders. Background: COVID‐19 has affected societies on a global scale including children and youth with chronic headache disorders. Many concerns are predicted to arise in the 2020–2021 school year, whether classes are conducted in‐person or virtually. Methods: Clinical impressions were combined with a review of the literature, although limited due to the recent nature of this issue. Results: We describe recommendations to support caregivers and youth as they face changes expected with the return to school in the fall of 2020. Conclusion: Although there are significant concerns for caregivers and youth with migraine given the context of changes related to the pandemic, there are many recommendations that can help minimize exacerbations of the physical, emotional, and social health of youth with chronic migraine. [ABSTRACT FROM AUTHOR]