Al-Beltagi M, Nazeer JA, Elbeltagi RM. Contrasting diagnostic challenges of headache before and after acute disseminated encephalomyelitis in children: Two case reports and review of literature. World J Clin Cases 2026; 14(26): 126833 [DOI: 10.12998/wjcc.126833]
Corresponding Author of This Article
Mohammed Al-Beltagi, MD, PhD, Professor, Consultant, Department of Pediatrics, Faculty of Medicine, Tanta University, Bld 1039, Road 2626, Block 226, Tanta 31511, Algharbia, Egypt. mbelrem@hotmail.com
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Pediatrics
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case-report
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Al-Beltagi M, Nazeer JA, Elbeltagi RM. Contrasting diagnostic challenges of headache before and after acute disseminated encephalomyelitis in children: Two case reports and review of literature. World J Clin Cases 2026; 14(26): 126833 [DOI: 10.12998/wjcc.126833]
World J Clin Cases. Sep 16, 2026; 14(26): 126833 Published online Sep 16, 2026. doi: 10.12998/wjcc.126833
Contrasting diagnostic challenges of headache before and after acute disseminated encephalomyelitis in children: Two case reports and review of literature
Mohammed Al-Beltagi, Jameel Ahmed Nazeer, Reem M Elbeltagi
Mohammed Al-Beltagi, Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Algharbia, Egypt
Mohammed Al-Beltagi, Department of Pediatrics, University Hospital, Arabian Gulf University, Manama 26671, Manama, Bahrain
Jameel Ahmed Nazeer, Department of Radiology, University Hospital, Arabian Gulf University, Manama 26671, Manama, Bahrain
Reem M Elbeltagi, Department of Medicine, Royal College of Surgeons in Ireland, Medical University of Bahrain, Busaiteen 15503, Muharraq, Bahrain
Author contributions: Al-Beltagi M contributed to the conception and design of the report, clinical management and interpretation of the clinical findings; Nazeer JA and Elbeltagi RM contributed to the clinical data collection and radiological interpretation; Al-Beltagi M and Elbeltagi RM contributed to the laboratory interpretation and manuscript writing; Elbeltagi RM contributed to the manuscript review. All authors reviewed and approved the final manuscript.
AI contribution statement: Portions of this manuscript were edited using Grammarly solely for language refinement, grammar correction, and improvement of readability. Google Gemini was used as an assistive tool to develop the visual timelines for cases 1 and 2. AI tools were not used to generate original clinical data, perform independent scientific analyses, interpret clinical findings, or draw scientific conclusions. All AI-assisted outputs were carefully reviewed, verified, and approved by the authors. The authors take full responsibility and accountability for the accuracy, integrity, originality, and scientific validity of the manuscript and all submitted materials.
Informed consent statement: Written informed consent was obtained from the parents/legal guardians of both patients for the publication of their clinical details and accompanying neuroimaging figures.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: Mohammed Al-Beltagi, MD, PhD, Professor, Consultant, Department of Pediatrics, Faculty of Medicine, Tanta University, Bld 1039, Road 2626, Block 226, Tanta 31511, Algharbia, Egypt. mbelrem@hotmail.com
Received: August 14, 2026 Revised: August 25, 2026 Accepted: September 16, 2026 Published online: September 16, 2026 Processing time: 35 Days and 15.2 Hours
Abstract
BACKGROUND
Acute disseminated encephalomyelitis (ADEM) is an acute inflammatory demyelinating disorder of the central nervous system (CNS) where headache can occur at different clinical stages, creating diagnostic challenges when it precedes the neurological syndrome or persists during recovery.
CASE SUMMARY
We report two children with contrasting headache presentations in ADEM. Case 1 involved a 6-year-old boy who presented with isolated severe headache that evolved into encephalopathy and ataxia; brain magnetic resonance imaging (MRI) demonstrated multifocal bilateral cerebral lesions consistent with ADEM. After corticosteroid and intravenous immunoglobulin (IVIG) therapy, he fully recovered. Case 2 involved a 10-year-old girl presenting with acute ADEM (headache, confusion, ataxia) who initially received high-dose intravenous corticosteroids followed by IVIG with partial neurological recovery. She subsequently developed a persistent, unremitting daily frontal headache for approximately 3 months, unresponsive to lifestyle modifications and preventive agents (amitriptyline, propranolol, topiramate). Pre-retreatment MRI at 3 months and cerebrospinal fluid examination showed no new demyelinating lesions or abnormalities. Despite a second course of intravenous methylprednisolone and an oral taper, and near-complete radiological resolution of prior lesions, the clinical course did not establish an inflammatory cause for the persistent headache.
CONCLUSION
Headache significance in pediatric ADEM depends on its temporal relationship to neurological disease. Evolving encephalopathy or multifocal signs accompanying headache warrant evaluation for secondary CNS pathology. Conversely, persistent headache following ADEM-absent new encephalopathy, polyfocal events, or new MRI lesions-should not be interpreted as recurrent or multiphasic ADEM. Persistent headache resolved after corticosteroid retreatment, independent of new demyelinating lesions, and this temporal sequence does not establish a causal therapeutic or inflammatory mechanism.
Core Tip: Headache may occur at different stages of pediatric acute disseminated encephalomyelitis (ADEM) and can create distinct diagnostic challenges. In the first case, severe headaches preceded the development of encephalopathy and multifocal neurological abnormalities. In the second, persistent headache continued after neurological recovery and prompted reassessment for ongoing inflammatory disease. Importantly, persistent headache alone does not establish recurrent or multiphasic ADEM. These cases emphasize the importance of interpreting headache based on its temporal relationship to neurological findings and using repeat neuroimaging and cerebrospinal fluid evaluation selectively when clinically indicated.
