Headache - case report

Abstract

Introduction: Headaches in childhood are a common reason for seeking medical care. Headaches are classified as primary or secondary. Primary headaches, most commonly migraine and tension-type headache, are not associated with underlying organic disease, whereas secondary headaches result from other pathological conditions such as infections, trauma, or intracranial processes. Proper recognition and assessment of the type of headache enables a rational diagnostic and therapeutic approach to the patient.

In this paper, we present two patients with different types of headaches to illustrate the clinical characteristics and diagnostic approach to various headache disorders.

Case report: The first patient is a 13.5-year-old boy who has been under long-term follow-up by a pediatric gastroenterologist and neurologist due to episodic gastrointestinal and neurological symptoms. Symptoms began at the age of four with recurrent episodes of nausea, vomiting, pronounced fatigue, and pallor, which over time became associated with headache.

An extensive diagnostic workup was performed (brain MRI, EEG, transcranial color-coded Doppler, metabolic and endocrinological evaluation, and ophthalmologic examination). All findings were normal, and secondary causes of headache were excluded. According to the Rome IV criteria, a diagnosis of cyclic vomiting syndrome was established, which belongs to the spectrum of pediatric episodic syndromes associated with migraine. Prophylactic therapy with cyproheptadine was initiated, resulting in remission of gastrointestinal symptoms.

During further follow-up, the patient developed typical and frequent migraine attacks accompanied by autonomic symptoms, predominantly fatigue, exhaustion, loss of appetite, nausea, and occasional vomiting. Prophylactic therapy with topiramate and amitriptyline was introduced but proved ineffective, whereas treatment with sumatriptan showed a good clinical response.

The described clinical course corresponds to the progression of cyclic vomiting syndrome into migraine during adolescence.

The second patient is an 11-year-old girl who has complained of headaches intermittently since the age of four, with a gradual increase in frequency and duration. The headaches are predominantly frontal, of strong intensity, and of a pressing quality, sometimes lasting several days. They occur without associated nausea, vomiting, photophobia, or phonophobia.

A comprehensive diagnostic evaluation was performed. EEG revealed dysrhythmic changes. A brain MRI showed a polycystic pineal gland and an arachnoid cyst in the region of the left lateral cerebellomedullary cistern, without signs of mass effect or hydrocephalus; neurosurgical evaluation did not indicate the need for surgical treatment. Ophthalmologic examination was normal. Laboratory testing revealed subclinical hypothyroidism with autoimmune thyroiditis, which did not require substitution therapy.

The clinical picture, characterized by long-lasting headaches without autonomic symptoms and without a clear organic substrate, is consistent with the diagnosis of chronic tension-type headache. In our patient, analgesic therapy did not result in clinical improvement, nor did alternative therapeutic approaches such as laser acupuncture. Currently, prophylactic therapy combined with a psychotherapeutic approach and riboflavin supplementation has been recommended. Such therapeutic response and the need for a multimodal treatment approach are consistent with the known characteristics of chronic tension-type headache, in which analgesics often have limited efficacy, while non-pharmacological and prophylactic measures play a key role in symptom control.

Conclusion: The two pediatric patients presented illustrate different phenotypes of primary headaches in childhood. The first case demonstrates migraine in adolescence, while the second case represents chronic tension-type headache, both without an underlying organic substrate and with a limited response to analgesic therapy. These cases highlight the importance of accurate differential diagnosis and an individualized diagnostic and therapeutic approach in the management of different headache entities.