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INTRODUCTION

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Children may experience a variety of recurrent chronic pain, such as headache or abdominal pain. Chronic pain is more common in children than persistent pain and is less likely to be associated with underlying organic disease. Some common conditions that may turn chronic pain into persistent pain include rheumatoid arthritis, malignancies, sickle-cell disease (SCD), and neuropathic pain syndromes.

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The management of chronic pain is an important part of pediatric practice. It requires an understanding of pediatric illnesses as well as the psychosocial aspects of chronic pain conditions experienced by children. Most of the pediatric pain and related problems are undertreated. Because of the complex nature of chronic pain, treatment is often approached from a broad-based, comprehensive medical model that utilizes the expertise of psychologists, neurologists, anesthesiologists, nurses, and other health care providers (HCPs). This chapter evaluates some common types of recurrent and persistent pain in infants and children and summarizes treatment strategies, including pharmacologic and nonpharmacologic therapies.

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HEADACHES

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Recurrent headaches are an exceedingly common form of recurrent pain in pediatric patients. The most common types of headaches children experience include migraine, tension headache, and combined migraine-tension headache. Up to 10% of all children experience recurrent headaches.1 The prevalence of nonmigrainous headache in childhood and adolescence is 10% to 25%.2 Migraine headaches are more commonly experienced by boys than girls in early childhood but become more common in girls upon reaching puberty. There is usually a strong family history of migraine headaches. Children typically report an abrupt onset of unilateral or bilateral severe, throbbing headache pain, which is often associated with nausea and vomiting. Although some children experience classic visual or auditory auras of migraine, many experience more subtle premonitory signs such as pallor, irritability, and fatigue.3 Patients typically experience relief after sleep. Tension headaches are most common among adolescents. Typically, there is no associated aura, nausea, or vomiting. These headaches are usually described as a squeezing pain located circumferentially around the head. It is not uncommon for patients with tension headaches to experience them daily. Children with combined headaches experience both chronic tension headache and episodic acute migraine headache and their associated abdominal pain, nausea, and vomiting. The diagnosis of chronic daily headache is made when headache has been present for more than 15 days per month, with a duration of 3 months or longer.

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Chronic progressive headache is most likely the result of a secondary etiology, such as changes in intracranial pressure, infection, or neoplasm.4

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Most headaches in children are not associated with serious underlying intracranial pathology or organic disease. A thorough history and physical examination are essential and should include a careful neurologic with funduscopic examination. A psychosocial history is also beneficial in helping to determine whether family stressors or maladaptive behaviors might play a causative role in reinforcing pain behaviors. A history of personality changes, visual disturbances, fever, and ...

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