Four children (two girls) with cluster headache-like disorder beginning between 6 and 15 years of age are reported from Birmingham Children’s Hospital, UK. Bizarre behaviorisms, including screaming and thrashing around, during attacks contributed to a delay in diagnosis from a few weeks to 6 years before referral to the pediatric neurology clinic. Attacks were characterized by severe, episodic headache and autonomic symptoms (eyes and nose watering, sweating, flushing) occurring several times a day in clusters. Pain was bilateral in 3 cases, mainly frontal, and unilateral occipital in one, and not located in the unilateral orbital, supraorbital, or temporal regions typical of pure cluster headache. EEG and cerebral imaging were normal. Treatment consisted of home oxygen, successful during acute attacks in 2 patients, whereas subcutaneous sumatriptan was of limited value. Pizotifen had some prophylactic effect. 
COMMENT. A variant of cluster headache or paroxysmal hemicrania may occur during childhood and is termed cluster headache-like disorder. Abnormal and bizarre behavior characterized by motor restlessness during episodes of headache, sometimes mistaken for pseudo seizures, should suggest the diagnosis.