Andrew D. Hershey

Background: Occipital neuralgia (ON) is well characterized in adults but remains poorly understood in children. Pediatric ON may present with overlapping headache features and variable treatment responses, creating diagnostic and management challenges. Objectives: We aimed to (1) characterize pediatric patients presenting to a tertiary outpatient neurology clinic with occipital headache symptoms consistent with ON, (2) describe their overlap with other headache symptom profiles, and (3) summarize documented diagnostic evaluation, treatment patterns, and clinical outcomes. Methods: We conducted a retrospective cohort study using prospectively collected, standardized headache intake questionnaire data from the Children's Hospital of Philadelphia (CHOP) headache registry, including pediatric patients evaluated in outpatient neurology from July 2016 through August 2024. Self‐reported headache characteristics were used to identify a cohort of patients with symptoms consistent with ON, defined as recurrent, short‐duration, stabbing or sharp, severe pain involving the occipital region. We excluded patients who also had frontotemporal or holocephalic pain. However, to avoid missing patients with overlapping headache phenotypes, we did not exclude patients whose headaches also met criteria for other diagnoses such as migraine. Results: We identified 89 of 14,876 (0.6%) patients within the registry with symptoms consistent with ON, predominantly male (54%) with a median age of 12.7 years (interquartile range, 9.3–15.5). Sixty of the 89 (67%) patients additionally met symptom‐based criteria for another headache disorder, mostly migraine. Forty‐five of 89 (51%) patients followed up over a median of 1.1 years (interquartile range, 0.6–4.2), with 35 of 45 attempting treatment. At the most recent follow‐up of those treated, 26% reported significant improvement (9 of 35; 95% confidence interval [CI], 12.5%–43.3%), 29% some improvement (10 of 35; 95% CI, 14.6%–46.3%), 26% no change (9 of 35; 95% CI, 12.5%–43.3%), and 20% worsened (7 of 35; 95% CI, 8.4%–36.9%). Conclusion: Symptoms consistent with ON are rare, even among children with occipital headaches, and frequently overlap with features of other primary headache disorders. These findings highlight the diagnostic complexity of pediatric occipital headache and the need for improved characterization and standardized evaluation to inform future treatment pathways for children with persistent ON‐like symptoms.

Background and ObjectivesThis systematic review (SR) provides updated evidence-based conclusions regarding the use of pharmacologic migraine prevention in adults to inform a new joint American Acad...

This practice guideline provides updated evidence-based recommendations regarding the use of pharmacologic migraine prevention in adults. A multidisciplinary panel conducted a systematic review and...

Migraine is one of the most common chronic health problems in children and adolescents, resulting in high levels of functional disability. Symptoms frequently persist into and impact the course of adulthood for affected individuals. Current practice recommendations include a combined therapy approach of preventive medication and cognitive behavioral therapy (CBT); however, no trials have systematically assessed whether a combined therapy approach is superior to a cognitive behavioral monotherapy intervention. The REACH (Responding With Evidence and Access for Childhood Headaches) trial will compare the impact of a CBT monotherapy to a combined treatment for prevention of migraine in youth, while addressing barriers to CBT access by utilizing a teletherapy approach. The study will include youth with migraine between the ages of 10 and 17 years from 15 sites across the United States, who will be randomly assigned to a CBT + pill (amitriptyline) group or CBT‐alone group. Both groups will complete six sessions of telehealth CBT, as well as three booster sessions, over the course of 6 months. Participants will report on headache and migraine frequency and related disability via a daily headache diary before (28‐day baseline), during, and after completion of the intervention (the last 28 days on the protocol). The CBT + pill group will also undergo a dose titration of clinically prescribed amitriptyline throughout the active treatment phase. Primary treatment outcomes are a ≥50% reduction in headache days and reduction in migraine‐related disability (i.e., Pediatric Migraine Disability Assessment score ≤20). Findings of the REACH study may confirm current practice guidelines or provide evidence of comparable effectiveness of combined therapy and CBT monotherapy for prevention of migraine. This trial is designed to reinforce current guidelines for preventive headache management strategies in youth with migraine. The study will also advance knowledge by determining whether CBT alone, without the potential side effects of medication, is sufficient.

Headache-associated symptoms (e.g., sensory sensitivity, nausea) are used to classify primary headache disorders and define treatment outcomes. We develope

Background: New daily persistent headache (NDPH) is a primary headache disorder that often presents in adolescence. Presently, there is no effective treatment for NDPH and a paucity of clinical trials exploring therapeutic options. In this study, we explored the relative benefit of currently used treatments to help inform future trials and clinical decision-making. Methods: In this retrospective chart review study, patients aged 5–17 years with abrupt onset continuous headache and headache duration of at least one month (constituting NDPH or probable NDPH) were identified based on responses to a Headache Questionnaire in child neurology clinic and confirmed with chart review. We included all treatments (transitional therapy, preventive supplement, preventive medication and preventive non-medication therapy) started during continuous headache until both break in continuous headache and sustained improvement in headache were achieved. For treatments tried by at least 10 patients and for the first treatment tried in each category, we calculated proportions of any documented benefit, including “Significant” (≥30% improvement lasting ≥4 weeks) and “Some improvement” (all other improvement) and proportions of negative outcome (those with worsened headaches or side effects warranting discontinuation), as well as median time to treatment. We used multivariable regression modeling to examine for factors associated with headache outcomes. Treatments may have overlapped. Results: Of the 165 patients, the largest proportion of patients experienced benefit with the first transitional therapy (62/108; 57%), which was usually intravenous medications ± oral corticosteroids. The first supplement tried, usually riboflavin ± magnesium, offered benefit in (36/118; 31%), with few negative outcomes (3/118; 3%). The first prescription preventive tried, usually amitriptyline or topiramate, offered similar benefit (37/106; 35%) as the first supplement, but with more negative outcomes (25/106; 24%). Despite being tried after oral preventives, onabotulinumtoxinA injections offered benefit to the largest proportion of patients (14/20; 70%) without negative outcomes (0%). Overall, the time to first therapy was weeks to months into continuous headache: shortest for transitional therapies (median = 49 days, interquartile range = 17–92 days), and longest for non-medication therapies (median = 144 days, interquartile range = 61–381 days). Increased time to any first treatment was associated with decreased odds of headache improvement at one-year follow-up (odds ratio = 0.823, 95% confidence interval = 0.715–0.946, p = 0.006). Conclusions: Children and adolescents with new onset continuous headache experience treatment delays which are associated with worse outcomes. Clinicians should consider use of transitional therapies in combination with preventive treatments as early as possible. Prospective natural history studies and trials are needed to improve treatment outcomes for pediatric patients with NDPH.

To examine the association between genetic risk of migraine and post-traumatic headache (PTH) in children. This is a secondary analysis of a cohort study that recruited children aged 8–17 years within 48 hours of concussion or orthopedic injury (OI) from 5 pediatric emergency departments and followed them for 6 months. Genetic risk of migraine was estimated through (1) family history of migraine, (2) polygenic risk scores (PRSs), and (3) forty individual single-nucleotide polymorphisms (SNPs). PTH was categorized as: no PTH (no PTH), PTH nonmigraine phenotype (PTH-NM), or PTH migraine phenotype. Ordinal regression models with cluster-adjusted standard errors and restricted cubic splines were used to estimate associations between genetic risk of migraine and increasing severity of PTH (no PTH vs PTH-NM vs PTH migraine phenotype), adjusting for injury type (concussion vs OI), age, sex, time since injury, first principal component, deprivation indices, concussion history, and preinjury headache history. The sample included 646 children (median [interquartile range] age = 12.38 [10.52–14.41] years, including 436 (67.5%) with concussion. Family history of migraine was associated with increasing severity of PTH in 2/5 models (rs7684253 model: χ² = 3.99, df = 1, p = 0.046; rs75002882 model: χ² = 4.02, df = 1, p = 0.045), while migraine PRS was not (χ² = 12.95, df = 12, p = 0.373). Four SNPs were associated with increasing severity of PTH (rs13078967: χ² = 103.87, df = 6, p < 0.001; rs7684253: χ² = 12.90, df = 6, p = 0.045; rs2160875: χ² = 17.35, df = 6, p = 0.008; and rs75002882: χ² = 291.79, df = 6, p < 0.001) and 2 remained significant after Bonferroni correction (rs13078967 and rs75002882). Four migraine susceptibility genetic variants were associated with PTH, as was family history of migraine in some models, but a migraine PRS was not.

Plain Language Summary: It remains unclear whether avoiding uncomfortable light is the best strategy to manage light sensitivity associated with migraine, or if restricting light exposure increases intolerance over time. We found that youth with migraine were more likely to report light sensitivity in the winter when light exposure tends to be lower. This finding suggests that light sensitivity is worse when light exposure is lower, but further research is needed to confirm this relationship.

Objectives: The aim of this work was to develop an American Headache Society position statement addressing diagnostic screening for migraine among girls and women. Background: Despite its high prevalence and substantial negative impacts, migraine is underdiagnosed and undertreated. Diagnostic screening for migraine enables more patients to receive timely, appropriate, and effective management. Methods: Development of this position statement followed the rules established by the American Headache Society Guidelines Committee. The published literature was reviewed to determine if migraine meets criteria for when disease screening is justified, to guide recommendations for screening tools, and to determine subpopulation(s) for which migraine screening is indicated. After author consensus was reached, the position statement was reviewed and approved by the American Headache Society Board of Directors. Results: Migraine fulfills established criteria for conditions in which screening is appropriate since it is highly prevalent, results in significant morbidity, and exerts substantial economic and social costs. Migraine incidence and prevalence are exceptionally high among girls and women during adolescence and through menopause. Furthermore, there are valid and reliable diagnostic screening methods (e.g., ID Migraine) and effective treatments that reduce migraine symptoms and disease impact. Conclusion: Yearly diagnostic screening for migraine should be included as part of women's preventive healthcare services, particularly from adolescence to menopause.

Aim: Sensitivity to light and noise is commonly associated with headache. It is unclear if exposure to more intense sensory environments, or exposure to more restricted sensory environments leading to intolerance, worsens sensory sensitivity more over time. We aimed to determine if photophobia is more common during the winter months when daily light exposure is reduced. Methods: We conducted a single-center cross-sectional study from a pediatric headache clinic in the Philadelphia area assessing patient-reported headache-related photophobia and phonophobia from an outpatient headache intake questionnaire. Rates were compared in the 3 months surrounding the winter and summer solstice, which has an average daylight difference of 5 hours between these time windows. Monthly symptom rates were fitted to a sinusoid across the 12-month calendar to characterize seasonal variation. Results: A total of 2,040 headache intake questionnaires were included in the analysis. Headache-associated photophobia was significantly more common in the winter compared to summer (OR 1.38, p = 0.018), but this seasonal variation was not observed for phonophobia (p = 0.698). Conclusion: Headache-related photophobia is more prevalent near the winter, compared to the summer, solstice.