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According to the 1988 classification of the International Headache Society (IHS) there are 13 different types of headache, the main ones being migraine with aura, migraine without aura, and tension headache. The suitability of this classification for paediatrics and the nosological integrity of the various types have been much debated. Workers in Milan (Livia N Rossi and colleagues. Developmental Medicine and Child Neurology 2001;43:45–51) have tried to distinguish between migraine without aura and tension headache in children, without much success. To reach a diagnosis of migraine using the IHS criteria there must be: at least five attacks, attacks lasting for two hours or more, nausea or vomiting and/or photophobia plus phonophobia, and at least two of four other criteria (unilateral headache, pulsating character, moderate or severe intensity, aggravation by walking upstairs). They compared this system with one introduced for use in children by Seshia et al in 1995. (The changes from the IHS system were: duration of attacks one hour or more, nausea, vomiting, photophobia, or sonophobia should be severe, and moderate to severe abdominal pain might replace nausea or vomiting, and the four other criteria might include bilateral headache, first degree family history of migraine, and aggravation by other forms of exercise.) Three hundred and twenty children aged 3–14 years (mean 10 years) with recurrent or chronic headache (or both) had their headaches classified by both systems. With either system 291 children (91%) had either migraine without aura or tension headache or both. Thirteen had migraine with aura and 16 were unclassifiable. The Seshia system classified more as migraine without aura (186v 129) and fewer as tension headache (52v 75) or both (53v 87). Duration of attacks and aggravation by exertion were not found to be helpful criteria and it is suggested that they should be dropped. Pulsating quality was not a helpful criterion in younger children. Rossi and colleagues question whether it is appropriate to distinguish between migraine without aura and tension headache in children. They support the theory that migraine with aura, migraine without aura, and tension headache are one end, the middle, and the other end of a spectrum of disorders and that individual children may have symptoms suggestive of each of the three at various times. On the whole, children with less severe headaches tend to be classified in the tension headache group. Where all this gets us as regards treatment options seems unclear.
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