The aim of our observational study was to highlight some clinical observations on chronic daily headache (CDH) in children and adolescents. Data on patients ≤18 years aged presenting with CDH to the Pediatric Headache Clinic at the Royal University Hospital, Saskatoon, Canada, were collected prospectively and sequentially from February 2004 to July 2006. Standardized data sheets and definitions were used. Follow‐up information on the 70 participants (22 males, 48 females) was current to February 2007. Fifty‐four participants (77%) had had recurrent headaches before transformation to CDH. Comorbid chronic migraine and chronic tension‐type headache was the most frequent subtype of CDH (37 participants; 53%). Anxiety and mood disorders were diagnosed in 17 and 15 children respectively. Stressors that precipitated or contributed to the maintenance of CDH were judged important in 44 (63%). The possibility of a somatoform disorder was considered in five children, a factitious disorder in one, and malingering in another. We suggest that CDH be viewed from a biopsychosocial rather than a narrow biomedical perspective and the classification improved to enhance clinical utility.

'Cognitive biases plus' are hard wired, primarily at the unconscious level, and the resulting behaviours are not easily corrected. Social behavioural researchers advocate multi-pronged measures in similar situations: (i) abolish incentives that spawn self-serving bias; (ii) enforce severe deterrents for breaches of conduct; (iii) value integrity; (iv) strengthen self-awareness; and (v) design curricula especially at the trainee level to promote awareness of consequences to society. Virtuous professionals and organizations are essential to fulfil the vision for high-quality individualized health care globally.

Mathew et al 1 first characterized chronic daily headache (CDH) in adults. The International Headache Society (IHS) Classification, 2,3 does not incorporate CDH as a separate entity. Silberstein et al 4 proposed a classification for CDH; they recognized that further modifications to their proposal would occur. Gladstein et al 5 highlighted the need to study CDH in ABSTRACT: Objective: Characterize chronic daily headache in those less than 20 years of age. Material and methods: Study design: Prospective, observational, and sequential. Setting: Private practice Pediatric Neurology Clinic in a Canadian city (Winnipeg). Patients and data collection: Data on those referred with headache between September 1998 and December 2001 were entered on data sheets. Patients were followed up for one month to four years. Results: One hundred and forty-three (31%) of 463 referred with headache had chronic daily headache with duration of one month to five years (median: eight months). The age range was 5.5 years to 20 years (median: 13 years). There were significantly more females (N=93) than males (N=50). The main groups were: (1) transformed migraine: 6 (4%), (2) transformed tension-type headache: 80 (56%) and (3) transformed comorbid migraine and tension-type headache: 39 (27%). Tension-type features dominated in 94%. Analgesia overuse occurred in two. Stressors were recognized in 60 (42%); anxiety disorder was diagnosed in 8 (6%), and depression in 13 (9%). Computed tomography scans were done in 31 (22%), and MRI/MR angiography in 8 (6%) and were normal or showed nonspecific incidental findings. Twenty-two (15%) were lost to follow-up; 115 of the remaining 121 (95%) were headache free or greatly improved, 63 (55%) without specific treatment. Conclusions: Chronic daily headache is a common headache disorder in children and adolescents, especially in teenage girls. A prospective neuropsychiatric approach is necessary for evidenced-based management, since the condition has mental health, social and economic ramifications. CTT, 39 (27%). Les caractéristiques la céphalée de tension dominaient chez 94% et l'abus de médicaments analgésiques était présent chez 2. Des facteurs de stress ont été identifiés chez 60 (42%); un trouble anxieux a été diagnostiqué chez 8 (6%) et une dépression chez 13 (9%). Trente et un patients (22%) ont subi une tomodensitométrie et 8 (6%) ont subi une angiographie par résonance magnétique qui se sont avérées normales ou qui montraient des anomalies non spécifiques dont la découverte était fortuite. Vingtdeux patients (15%) ne se sont pas présentés pour un suivi; 115 des 121 patients restants (95%) ne présentaient plus de céphalée ou étaient très améliorés lors du suivi, dont 63 (55%) sans traitement spécifique. Conclusions: La céphalée quotidienne chronique est un type de céphalée qui est fréquent chez les enfants et les adolescents, surtout parmi les filles. Il faut avoir recours à une approche neuropsychiatrique tel que recommandé pour la prise en charge basée sur les données actuelles de la science par...

The evidence-based medicine (EBM) paradigm has been associated with many benefits, but there have also been 'some negative consequences'. In part, the consequences may be attributable to: (1) limitations in some of the tenets of EBM, and (2) flawed or unethical decisions in healthcare related organisations. We hypothesise that at the core of both is a cascade of predominantly unconscious cognitive processes we have syndromically termed 'cognitive biases plus', with conflicts of interest (CoIs) as crucial elements. CoIs (financial, and non-financial including intellectual) catalyse self-serving bias and a cascade of other 'cognitive biases plus' with several reinforcing loops. Authority bias, herd effect, scientific inbreeding, replication publication biases, and ethical violations (especially subtle statistical), are key contributors to the cascade; automation biases through uncritical use of statistical software and applications (apps) of preappraised sources of evidence at point of care, may be other increasingly important factors. The 'cognitive biases plus' cascade which involves several intricately connected healthcare-related organisations has the potential to facilitate, compound and entrench flaws in the paradigm, evidence and decisions that converge to inform person-centered healthcare. Our reasoning is based on observational data and opinion. However, the susceptibility of all humans to 'cognitive biases plus' makes our hypothesis plausible. Individual and collective fallibility may be minimised and the quality of healthcare decisions (including those related to improving EBM) enhanced by being conscious of our vulnerability and open-minded to the 'outside view'.Sir Francis Bacon (1620): "The human understanding when it has once adopted an opinion (either as being the received opinion or as being agreeable to itself ) draws all things else to support and agree with it…" (Novum Organum: XLVI)