Investigators at the University of California, San Francisco, examined the frequency of cranial autonomic symptoms in all pediatric and adolescent patients with migraine seen in 4 different clinical settings during July 2010 to June 2012. Of 125 patients, mean age 13.1 yrs (range 4-17), 60% were female, 46% had chronic migraine and 54% episodic migraine. Headache was unilateral in 16%, bilateral in 52% and variable in 26%. The majority (49%) was seen in a pediatric headache subspecialty clinic, and 22% in a general child neurology clinic. At least one cranial autonomic symptom was experienced by each of 91 (73%) patients. In order of decreasing frequency, aural fullness was experienced by 30%, facial flushing/sweating 25%, lacrimation 25%, conjunctival injection 23%, ptosis 20%, grittiness in eye in 20%, nasal congestion in 15%, rhinorrhea in 10%, and periorbital edema in 8%. The majority had more than one cranial autonomic symptom, usually bilateral. The likelihood of autonomic symptoms was not related to age, sex, headache laterality, aura, or episodic vs chronic headache. Autonomic symptoms are the rule rather than the exception in pediatric/adolescent migraineurs, and headache with autonomic symptoms involving eye and nose should not be misdiagnosed as sinus headache. [1]

COMMENT. Cluster headache or trigeminal autonomic cephalalgia is typically suspected when headache is complicated by cranial autonomic symptoms. This study shows that pediatric/adolescent migraine is also frequently associated with autonomic symptoms. A sense of aural fullness, the most common autonomic symptom in the San Francisco cohort, will be added to the list of cranial autonomic symptoms in the International Classification of Headache Disorders. [2, 1]