Headache Far More Common Stroke Symptom in Kids

Megan Brooks

February 23, 2017

HOUSTON, Texas — Children are much more likely than adults to have a headache at onset of arterial ischemic stroke (AIS), new research shows.

Stroke in children is rare but should be considered as a possible diagnosis in any child with a headache and new-onset focal neurologic symptoms or signs, said lead investigator, Lori L. Billinghurst, MD, clinical assistant professor of neurology at the University of Pennsylvania, Philadelphia.

Stroke diagnosis in children is confounded by stroke "mimics," most commonly migraine with aura, followed by Bell's palsy and conversion disorder, she explained. "Urgent brain imaging may be required to distinguish a migraine with aura from a stroke," Dr Billinghurst noted.

Dr Lori L. Billinghurst

She reported the study results here at the International Stroke Conference (ISC) 2017.

VIPS Study

Among 355 children (age 29 days to 18 years) with AIS enrolled in the multicenter Vascular Effects of Infection in Pediatric Stroke (VIPS) study, headache was uncommon in children younger than 3 years (5 of 90 [6%]) but was present in nearly half of those aged 3 years and older (108 of 265 [46%]).

Dr Billinghurst noted that children younger than 3 years may not be able to communicate about whether they are having a headache. She also noted that the percentage of older children reporting headache at ischemic stroke onset is much higher than that in adults with ischemic stroke (46% vs 25%).

In children aged 3 years and older, infarcts occurred most often in the posterior cerebral artery (23%) and superior cerebellar artery (13%). Nearly half of infarcts occurred on the right side (48%).

After exclusion of 31 children with an unclear headache presentation, there was no significant difference in headache prevalence at AIS in children age 3 years and older with definite (46 of 92 [50%]), possible (15 of 24 [63%]), or absent (60 of 118 [51%]) arteriopathy (P = .53).

However, in patients with definite arteriopathy, headache was most commonly associated with arterial dissection and transient cerebral arteriopathy of childhood (70% each; P > .001). Acute headache was uncommon in children with moyamoya (12%).

"It is possible that younger brains have blood vessels that are more easily distended and more likely to activate pain sensors that trigger headache," said Dr Billinghurst in a conference statement.

"It is also possible that inflammation — a powerful activator of pain sensors — may be more important in the processes underlying stroke in children than in adults," she added. "The VIPS study has already shown that inflammation plays a key role in the vascular injury pathway in children with stroke.

"We will be doing further work to see if there are differences in blood markers of inflammation in those with and without headache at time of stroke," she added.

Headache Under-recognized Stroke Symptom

Reached for comment, Sami Saba, MD, neurologist at Lenox Hill Hospital in New York City, noted that headache is an often "under-recognized" symptom of stroke, "even by neurologists and emergency room physicians, who are most likely to be those first evaluating patients with potential stroke.

"This study shows that headache at the time of stroke onset is more common in children than adults — in about 50% of cases," Dr Saba told Medscape Medical News. "Stroke is much less common in children but still does occur; when it does occur, it is more likely to be attributed to an abnormality of the blood vessels."

He said more research is needed "in order to develop guidelines that could help predict the presence of stroke in a child with a headache, based on the characteristics of the headache as well as other associated symptoms. Earlier detection would hopefully lead to earlier treatment and better outcomes/less stroke-related disability."

The VIPS study is funded by the National Institute of Neurological Disorders and Stroke. Dr Billinghurst has disclosed no relevant financial relationships.

International Stroke Conference (ISC) 2017. Abstract 174. Presented February 22, 2017.

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