Framework for headache management in pediatric patients with stroke and cerebrovascular lesions: A narrative review.

OBJECTIVE: To present a practical, evidence-based framework for the management of headache disorders in pediatric patients with prior stroke or underlying cerebral vascular lesions, with particular attention to safety and efficacy of pharmacologic and non-pharmacologic therapies. BACKGROUND: Chronic headache is frequent after ischemic or hemorrhagic stroke (reported in 12-57% of patients) and is also common in cerebrovascular disorders. Pediatric patients with these conditions face unique therapeutic challenges because many typical headache medications have vasoactive or blood pressure-modulating effects that may increase cerebrovascular risk. METHODS: We performed a comprehensive MEDLINE literature review (July 2024) searching combinations of headache medication classes paired with specific neurovascular conditions. INCLUSION CRITERIA: English or translated articles since 1990, comprising human and animal in vitro/in vivo studies, narrative reviews, case series/reports. Extracted data were organized by vascular condition, with summary tables of preventive and acute interventions categorized by evidence of efficacy, safety, and theoretical risk. RESULTS: Across conditions, vasoconstrictive agents (triptans, ergots) remain generally contraindicated or used with extreme caution in patients with vascular lesions due to risk of ischemia or hemorrhage. Anti-hypertensive agents (β-blockers, calcium channel blockers [CCBs], angiotensin II receptor blockers [ARBs]) are generally safe and may confer additional vascular benefit in post-stroke headache. Calcitonin gene-related peptide (CGRP) -targeting therapies are not formally contraindicated but may impair compensatory vasodilation in flow-dependent vascular lesions. Anti-seizure medications, antidepressants, melatonin, and non-pharmacologic therapies appear to have favorable risk-benefit profiles, although direct data in these populations are limited. Interventions addressing underlying vascular lesions (e.g., arteriovenous fistulas [AVF] embolization, arteriovenous malformations [AVM] or cavernoma resection, pial synangiosis) often lead to headache improvement. CONCLUSION: In pediatric patients with cerebrovascular disease who have headaches, individualized management is essential. Drug selection must incorporate vascular pathophysiology, hemodynamic stability, and collateral flow considerations. More prospective, pediatric-specific and lesion-specific studies are needed to guide optimal headache therapies in this complex population.