A cerebrospinal fluid (CSF) leak developed in a 14-year-old girl and a 12-year-old boy following a diagnostic lumbar puncture. Two days and sixteen years later, respectively, paraplegia developed due to a functional disorder. Imaging revealed an extensive extradural CSF collection in both patients and digital subtraction myelography was required to pinpoint the exact site of a ventral dural puncture hole where the lumbar spinal needle had gone \"through and through\" the dural sac. The CSF leak was complicated by cortical vein thrombosis in one patient. Both patients underwent uneventful surgical repair of the ventral dural puncture hole with prompt resolution of the paraplegia. Iatrogenic ventral CSF leaks may become exceptionally long standing and may be complicated by paraplegia on a functional basis both in the acute and chronic phases.

OBJECTIVE: Socio-culturally defined identity factors present significant and often understudied influences on the experience, management, and treatment of chronic pain. For instance, there exist societal narratives about how males and females are expected to experience and express pain. Such gender roles may impact youth and caregiver openness to individual multidisciplinary treatments for pediatric headache.
METHODS: In this cross-sectional study, participants (N = 1087 youth/caregiver dyads, Mage = 14.5 years, 71% female, 97% cisgender, 77% White) completed a series of questionnaires, including Openness to Headache Treatment (OHT), upon presenting for initial multidisciplinary evaluation of chronic headache. Pearson correlations, independent samples t-tests and hierarchical regressions were used to analyze potential gender differences in youth and caregiver openness, as well as its relationships with pain-related and psychological factors.
RESULTS: Overall, female youth and their caregivers were more open to headache treatment, broadly and for individual interventions, when compared to male counterparts. Caregiver distress related to their child\'s headaches (i.e., fear and avoidance) was significantly correlated with openness in female youth and their caregivers, but not males.
CONCLUSIONS: Gendered patterns in healthcare decision-making in youth and caregivers provide insight on individual, societal, and systemic gender bias.

BACKGROUND: Currently no guidelines for repeating a lumbar puncture to guide management in primary intracranial hypertension (PIH) exist.
METHODS: An institutional database of patients 18 years and younger followed in the institution\'s pediatric intracranial hypertension clinic was examined for opening pressure changes in PIH at diagnosis, before medication wean, and following medication wean, as well as to examine whether measurements at the time of diagnosis differed between those with and without disease recurrence.
RESULTS: Forty-two patients were included in this study; 36% were male and the mean age at diagnosis was 11.01 years. Treatment duration averaged 9.68 months in those without recurrence and 8.5 months in those with recurrence. Average body mass index percentile of patients with disease recurrence was 83.7 and 72.1 in those without recurrence (P = 0.16). Average opening pressure values of all patients at diagnosis, prewean, and postwean was 36.53 cm H2O, 30.7 cm H2O, and 31.1 cm H2O, respectively. There was no statistically significant difference in opening pressures across these time points (P = 0.14). The change in opening pressure from diagnosis to postwean was statistically significant with a reduction of 5.18 cm H2O (P = 0.04). There was no statistical difference between change in opening pressure at diagnosis versus postwean between those with and without recurrence (P = 0.17).
CONCLUSIONS: This clinical observational study suggests that mean opening pressure measurements in patients with PIH remain elevated both before and after medication wean despite papilledema resolution and patient-reported PIH symptoms. Clinically, this suggests that other features such as signs of optic disc edema and symptoms should be used to inform a clinical determination of disease recurrence and treatment course.

OBJECTIVE: The aim of this study was to summarize the evidence regarding screen use as a contributing factor in pediatric headache and migraine.
BACKGROUND: Screen exposure is often reported as a headache trigger, though there is no current consensus in terms of how screen type, duration, or frequency influences pediatric headache and the associated burden of disease.
METHODS: A systematic search in PubMed, Scopus, Cochrane Library, ProQuest Health and Medical Database, and Google Scholar was performed through November 2022 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All English-language articles of pediatric patients aged ≤18 years evaluating screen use in relation to headache were included.
RESULTS: A total of 48 studies were included. Nearly all studies were cross-sectional and represented international samples. The strongest association between screen use and headache found was for duration of use, and computer use emerged as the most common device type related to headache. While there were mixed findings related to screen use and specific headache diagnosis, migraine appeared to confer a higher risk. Across studies, there were insufficient data to assess the impact of screen use on headache frequency or headache-related disability. Several studies demonstrated changes in screen use and headache patterns related to the COVID-19 pandemic and computer vision syndrome was commonly reported.
CONCLUSIONS: While there is preliminary evidence supporting possible associations between screen use and pediatric headache, there are several limitations in the present review including a lack of prospective and randomized controlled trials to better demonstrate causal relationships as well as methodological limitations with significant variability in how both headache and screen use are defined and measured. Future studies including real-time screen use and device monitoring are needed to better understand the influence of screen use behaviors on pediatric headache and to help further define best-use guidelines around these technologies.

BACKGROUND: Pediatric headache is a common cause of pediatric emergency department (ED) visits, and 8.8% of cases require imaging. Alarmingly, 12.5% of imaged cases have a pathologic cause. A pediatric patient with a complicated medical history presented to the pediatric ED with multiple cerebral abscesses. The possible causes and contributors to this rare cause of pediatric headache and a review of pediatric headache emergency management are presented.Case Presentation: A 12-year-old male patient with a complex medical and surgical history, including post-repair pulmonary valve stenosis, visited the pediatric ED for intractable and worsening left frontoparietal headache, refractory to ibuprofen, for 6 days. A physical examination revealed severe photophobia and restlessness secondary to severe head pain. Non-contrast brain computed tomography demonstrated two round, bilateral, parietal hypodense lesions with surrounding vasogenic edema. The lesions were consistent with abscesses on magnetic resonance imaging. Eventually, the patient underwent successful surgical abscess drainage and made a full recovery. The patient was lost to follow-up; therefore, no causative bacterial species was determined.
CONCLUSIONS: Managing pediatric headache in emergency settings requires a robust history and physical examination. Cerebral abscesses are an infrequent but fatal cause of pediatric headache and therefore should be considered among the differential diagnoses.

BACKGROUND: Girls and women are more frequently affected by headache than boys and men. The influence of gender on the effectiveness of headache therapies has so far been hardly investigated. We examined gender differences in the outpatient multimodal Dresden Child and Adolescent Headache Program DreKiP.
METHODS: We treated 140 patients with primary headache in a 15-hour structured group program. At baseline (T0) and six (T1) and twelve months (T2) after the end of the program, data on headache-related limitation of daily activities (PedMIDAS) as well as headache frequency, intensity, and pain-related disability (P-PDI) were collected. Retrospectively, these data were analyzed separately for girls and boys.
RESULTS: For 91 patients (9-19 years, median = 15; 71.4 % female) data were available for at least two measurement time points. Girls showed significantly higher headache frequency than boys at all time points (median headache days/last three months at T0: ♀ 43, ♂ 20; T1: ♀ 32, ♂ 12; T2: ♀ 28, ♂ 9) as well as numerically higher headache-related limitation of daily life. There were significant effects over time with a decrease in headache frequency (F (2.88) = 5.862; p = 0.004) and improvement in daily functioning (F (2.92) = 5.340; p = 0.006). There was no gender-specific treatment response.
CONCLUSIONS: The DreKiP therapy shows effects in girls and boys with primary headache. Higher headache frequencies and everyday life restrictions in girls may have hormonal but also psychosocial causes and should be addressed in educational measures.
UNASSIGNED: HINTERGRUND: Mädchen und Frauen sind häufiger von Kopfschmerzen betroffen als Jungen und Männer. Der Einfluss des Geschlechts auf die Wirksamkeit von Kopfschmerztherapien ist bisher kaum untersucht. Wir prüften geschlechterspezifische Unterschiede im ambulanten multimodalen Dresdner Kinder- und Jugendkopfschmerzprogramm DreKiP.
METHODS: 140 Patienten mit primären Kopfschmerzen wurden in einem 15-stündigen strukturiertem Gruppenprogramm behandelt. Zu Beginn des Programms (T0) sowie 6 (T1) und 12 Monate (T2) nach dem Ende wurden Daten zu kopfschmerzbedingter Einschränkung der Alltagsfähigkeit (PedMIDAS), Kopfschmerzfrequenz, -intensität und schmerzbedingter Alltagseinschränkung (P-PDI) erhoben. Retrospektiv wurden diese Daten für Mädchen und Jungen getrennt analysiert.
UNASSIGNED: Von 91 Patienten (9–19 Jahre, Median = 15; 71,4 % weiblich) lagen Daten für mindestens zwei Messzeitpunkte vor. Mädchen zeigten zu allen Zeitpunkten eine signifikant höhere Kopfschmerzfrequenz als Jungen (Mediane Kopfschmerztage/letzte 3 Monate zu T0: ♀ 43, ♂ 20; T1: ♀ 32, ♂ 12; T2: ♀ 28, ♂ 9) sowie eine numerisch höhere kopfschmerzbedingte Alltagseinschränkung. Es zeigten sich signifikante Effekte über die Zeit mit Abnahme der Kopfschmerzfrequenz (F (2,88) = 5,862; p = 0,004) und Verbesserung der Alltagsfunktion (F (2,92) = 5,340; p = 0,006). Eine geschlechtsspezifische Therapieantwort zeigte sich nicht.
CONCLUSIONS: Therapieinhalte des DreKiP zeigten bei Mädchen und Jungen mit primären Kopfschmerzen Effekte. Höhere Kopfschmerzfrequenzen und Alltagseinschränkung bei Mädchen können vor allem hormonelle, aber auch psychosoziale Ursachen haben und sollten in Edukationsmaßnahmen aufgegriffen werden.

OBJECTIVE: Headaches are common in children and adolescents. Treatments for debilitating migraine are often not FDA approved or lack evidence of efficacy for children. This narrative review looks at the evidence for acute and preventative pharmacologic and non-pharmacologic treatment of pediatric migraine, as well as reviewing any recent or ongoing clinical trials.
RESULTS: Studies have been published on pharmacological treatments for headache, as well as non-pharmacological treatments. Recent findings in pediatric migraine using onabotulinumtoxinA, calcitonin gene related peptide antagonists, interventional procedures, and devices are reviewed. Pharmacologic as well as non-pharmacologic approaches for the prevention and treatment of migraine show safety and efficacy data that is promising. These treatments should be incorporated in a multi-modal approach to the management of pediatric migraine. Continued studies, prospective and randomized, are needed to further assess these newer treatments for migraine in the pediatric setting.

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Juvenile Fibromyalgia (JFM) is poorly known, leading to delay in the identification of the syndrome. On the other hand, early diagnosis in children is important to prevent the worsening of the disease. This study aims to estimate the prevalence of JFM in an Italian population-based convenience sample, using different criteria (2010 and 2016 ACR, Yunus and Masi), by involving family pediatricians. It also aims to assess the relationships between JFM and contextual factors of the children and their parents, as well as to raise awareness of JFM among pediatricians. Children\'s data were collected using an ad hoc electronic questionnaire. Overall, 7275 questionnaires were collected (48.5% females; mean age: 8.2 ± 3.6 years). Thirty-eight children (0.5%) met the 2010 ACR criteria, and 4 (0.1%) met the 2016 ACR criteria. The likelihood of meeting the 2010 ACR criteria was significantly higher for children older than 8 years (OR: 2.42), those who had injuries during the leisure time that caused persistent pain (OR: 6.49), whose parents (at least one) had a diagnosis of fibromyalgia (OR: 2.54) or diffuse pain (OR: 9.09). In conclusion, 2010 ACR criteria are confirmed as the more appropriate for children and adolescents and the analysis of contextual factors suggests the need for family pediatricians to pay particular attention to the most important predictors of JFM.

This prospective, longitudinal cohort study examined the trajectory, classification, and features of posttraumatic headache after pediatric mild traumatic brain injury.
Children (N = 213; ages 8.00 to 16.99 years) were recruited from two pediatric emergency departments <24 hours of sustaining a mild traumatic brain injury or mild orthopedic injury. At 10 days, three months, and six months postinjury, parents completed a standardized questionnaire that was used to classify premorbid and posttraumatic headache as migraine, tension-type headache, or not otherwise classified. Multilevel mixed effects models were used to examine posttraumatic headache rate, severity, frequency, and duration in relation to group, time postinjury, and premorbid headache, controlling for age, sex, and site.
PTH risk was greater after mild traumatic brain injury than mild orthopedic injury at 10 days (odds ratio = 197.41, p < .001) and three months postinjury (odds ratio = 3.50, p = .030), especially in children without premorbid headache. Posttraumatic headache was more frequent after mild traumatic brain injury than mild orthopedic injury, β (95% confidence interval) = 0.80 (0.05, 1.55). Groups did not differ in other examined headache features and classification any time postinjury.
Posttraumatic headache risk increases after mild traumatic brain injury relative to mild orthopedic injury for approximately three months postinjury, but is not clearly associated with a distinct phenotype.