Beyond ICHD-3 criteria: Diagnostic challenges in headache in pediatric age

BackgroundDiagnosing headache in children and adolescents is challenging because clinical features vary with age, primary and secondary forms may overlap and the use of investigations is often inconsistent.MethodsWe conducted a scoping review following PRISMA guidelines. PubMed, Ovid MEDLINE, Scopus and the Cochrane Library were searched for studies on headache diagnosis in individuals aged 1-18 years (2018-2025). Of 126 records identified, 36 met eligibility criteria and were included.ResultsSeveral studies indicate that ICHD-3 criteria, developed mainly in adults, may not fully reflect paediatric presentations, contributing to diagnostic uncertainty. Evidence clarifies the value of some red flags while challenging others. Neuroimaging demonstrates low diagnostic yield except in selected cases. Common pitfalls include overdiagnosis of sinusitis, inappropriate EEG use and unnecessary ophthalmologic or allergologic testing.ConclusionsAccurate diagnosis relies on careful history taking, recognition of age-specific patterns and judicious use of investigations. Paediatric-focused diagnostic pathways are needed. Emerging digital tools and biomarkers may support earlier and more precise diagnosis.