Objective: The presence of cranial autonomic symptoms often leads to a misdiagnosis of "sinus headache" in adult migraineurs, leading to unnecessary treatments and delaying appropriate migraine therapy. In this study, we examined the frequency of cranial autonomic symptoms in pediatric/adolescent patients with migraine.Methods: This cross-sectional study included all pediatric and adolescent patients with migraine evaluated by a single investigator at 4 different sites over the course of the study period.Results: Of 125 pediatric migraineurs, 62% had at least one cranial autonomic symptom based on current International Classification of Headache Disorders, second edition (ICHD-II) criteria, and 70% based on proposed ICHD-III criteria. The majority had more than one cranial autonomic symptom and the symptoms tended to be bilateral. Age, sex, laterality of headache, presence of aura, and whether migraine was episodic vs chronic did not influence the likelihood of having cranial autonomic symptoms. Conclusions:In pediatric/adolescent migraine, the presence of cranial autonomic symptoms appears to be the rule rather than the exception. Clinicians should be careful to consider migraine when evaluating a child with headache and associated ocular or nasal symptoms so as to avoid giving a misdiagnosis of sinus headache. Cranial autonomic symptoms are typically associated with the trigeminal autonomic cephalalgias, such as cluster headache.1 The anatomy and physiology of these symptoms, consisting of the trigeminal-autonomic reflex, have been described and are well understood.2 However, it is only recently that the implications of the data have been more broadly realized with the relatively high frequency, between 27% and 73%, of cranial autonomic symptoms in adult migraineurs. [3][4][5][6] Recognizing that cranial autonomic symptoms are a common component of migraine is important diagnostically and thus therapeutically. Sinusitis, which also may present with head pain, is one of the most common misdiagnoses given to migraineurs.7-10 In a pediatric study, nearly 40% of pediatric migraineurs were initially mislabeled as having "sinus headache." 11 Misdiagnosis puts these patients at risk of inappropriate treatments and procedures, and delays appropriate treatment of their migraine. In this study, we examined the frequency of cranial autonomic symptoms in pediatric patients with migraine presenting for care.The International Classification of Headache Disorders, second edition (ICHD-II) 12 includes the following cranial autonomic symptoms: 1) conjunctival injection, lacrimation, or both; 2) nasal congestion, rhinorrhea, or both; 3) eyelid edema; 4) forehead and facial sweating; 5) forehead/facial flushing; and 6) miosis, ptosis, or both. In ICHD-III, a sense of aural fullness 13 will be added as a cranial autonomic symptom. 14 METHODS Standard protocol approvals, registrations, and patient consents. This study was approved by the University of California, San Francisco (UCSF) Committee for Human Research (protocol ...

Background Chronic migraine is common in pediatrics and generally disabling. In adults, infiltration of the area around the greater occipital nerve can provide short to medium term benefit in some patients. This study reports the efficacy of greater occipital nerve infiltrations in pediatric patients with chronic primary headache disorders. Methods Retrospective chart review of patients <18 years with a chronic primary headache disorder undergoing a first-time injection. Infiltrations were unilateral and consisted of a mixture of methylprednisolone acetate, adjusted for weight, and lidocaine 2%. Results Forty-six patients were treated. Thirty-five (76%) had chronic migraine, nine (20%) New Daily Persistent Headache (NDPH), and two (4%) a chronic trigeminal autonomic cephalalgia. Medication overuse was present in 26%. Ages ranged from 7–17 years. Follow-up data were available for 40 (87%). Overall, 53% (21/40) benefitted, 52% (11/21) significantly. Benefit onset ranged from 0–14 days, mean 4.7(SD 4.3), with mean benefit duration of 5.4(SD 4.9) weeks. In chronic migraine, 62% (18/29) benefitted, 56% (10/18) significantly. In NDPH, 33% (3/9) benefitted; 33% (n=1) significantly. Neither child with a chronic trigeminal autonomic cephalalgia benefitted. In logistic regression modeling, medication overuse, age, sex, and sensory change in the distribution of the infiltrated nerve did not predict outcome. There were no serious side effects. Conclusions Greater occipital nerve injections benefitted 53% of pediatric patients with chronic primary headache disorders. Efficacy appeared higher in chronic migraine than NDPH. Given the benign side effect profile, a greater occipital nerve infiltration prior to more aggressive approaches seems appropriate.