AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Migraine in children may be similar to adult presentations and include headache, with or without aura, accompanied by nausea, vomiting, photophobia, and relief with sleep. However, several variations of migraine are unique to children and rarely if ever occur in adults. Migraine may present with prominent nonheadache symptoms in young children (migraine without headache), or neurologic symptoms (aura) may be much more prominent than the headache.

Various recognized childhood syndromes assumed to be pathophysiologically related to migraine include benign paroxysmal vertigo of childhood, abdominal migraine, cyclic vomiting of childhood, and acute confusional migraine (acute confusional state). Basilar migraine (particularly in adolescent girls) may present with prominent dizziness and near-syncope and/or syncope with or without a subsequent headache. Hemiplegic migraine (usually an autosomal dominant disorder) may present in early childhood and occasionally may continue into adulthood. Ophthalmoplegic migraine also may occur in childhood.

Pathophysiology

Although migraine and variants of migraine have long been assumed to have a vascular etiology, increasing evidence points to underlying primary neurologic causes. Some forms of migraine are genetic. Specific markers on chromosome 19 were found in some families with hemiplegic migraine.

Mitochondrial abnormalities, either from autosomal or mitochondrial DNA, may contribute particularly to the cyclic vomiting syndrome.

Sex

• In contrast to female predominance in adults, the overall frequency of migraine headaches in childhood is slightly higher in boys than in girls.
• Frequency of migraine variants is not known to vary between the sexes.

Age

Benign paroxysmal vertigo of childhood, sometimes considered a migraine variant, generally presents in toddlers.

Acute confusional migraine generally presents in the elementary school years. Less commonly, children can present either in the preschool years or in early adolescence. First attacks during the postpubertal teenage years are rare, although episodes may continue beyond puberty.

Hemiplegic migraine may present in early childhood. Basilar migraine, particularly with syncope, often presents in the early teenage years.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Variant migraine episodes may be independent of actual head pain. Other symptoms may predominate and be significantly more troublesome.

• Hemiplegic migraine
• • Hemiplegic migraine presents with hemiplegia or hemiparesis, with or without a speech and/or language disturbance, which clears in minutes to hours.
  • Headache may be less dramatic than the hemiplegia. Other migrainous symptoms such as nausea, vomiting, and photophobia are present variably. Hemiplegia may precede or accompany the headache.
  • This variant is often familial, dominantly inherited, and linked to chromosome 19 in some studies. An alternative locus has been described on chromosome 1. A defect in the gene for the calcium channel is documented in some families (affecting the voltage-dependent P/Q-type calcium channel alpha-1A [CACNA1A] subunit). An increased risk of stroke exists in families with this disorder. Cerebral autosomal dominant arteriopathy and subcortical infarcts and leukoencephalopathy (CADASIL), an autosomal dominant disorder in which multiple subcortical strokes may lead to dementia in early adulthood, sometimes presents in adolescence as atypical hemiplegic migraine. The CADASIL mutation also localizes to chromosome 19.
  • Diagnosis cannot be made during the first episode, although it may be suspected in the presence of a positive family history. Exclude more serious causes of headache with hemiplegia and/or hemiparesis including intracranial hemorrhage, mass, infection, or stroke. With repeated stereotyped episodes and complete clearing between episodes, the diagnosis can be made with more confidence, particularly in the presence of a positive family history.
  • Differential diagnosis of repeated episodes includes alternating hemiplegia of childhood, unobserved partial seizures with postictal paralysis, and mitochondrial cytopathies, particularly the mitochondrial encephalomyopathy, lactic acidosis, and stroke syndrome.
• Confusional migraine
• • This variant is more common in younger children and almost never is seen in postpubertal adolescents or adults. Occasionally, a child whose episodes began in the prepubertal years continues to have episodes into adolescence. The child has a period of confusion and disorientation, with or without agitation, followed by vomiting, which is relieved by sleep. Headache may not be prominent or may be elicited only retrospectively.
  • Making the diagnosis during the first episode is difficult, and it can be made only after the episode has resolved fully.
  • Acute differential diagnosis of a single episode includes all types of encephalopathy and/or encephalitis, toxic ingestion, intoxication, and/or an unobserved seizure with postictal agitation.
• Abdominal migraine
• • The child may complain of episodic pain, nausea, and vomiting. The headache may be minimal or absent. An aura may precede the pain but is not frequent. Symptoms are relieved by sleep and antiemetic and/or antimigraine therapies.
  • Cyclic vomiting of childhood, which can be associated with a mitochondrial cytopathy, may be a severe variant of abdominal migraine.
  • Diagnosis is difficult to make during the first episode.
• Basilar migraine
• • The patient may have an aura followed by dizziness, vertigo, syncope, and dysarthria. Headache may be minimal or absent.
  • It is observed most frequently in adolescent girls.
  • Differential diagnosis includes cardiogenic or vasovagal syncope, inner ear disease, and posterior fossa tumors.
• Migraine aura without headache
  • Migraineurs of any age may experience an aura with or without the typical headache. In some, the headache may be minimal while neurologic symptoms predominate.
  • Visual symptoms without subsequent headache are fairly frequent. These include scintillating scotomata, formed visual hallucinations (usually stereotyped, in a single visual field), micropsia, and tunnel vision.
  • Differential diagnosis includes occipital epilepsy, with or without an identifiable lesion. If episodes never are accompanied by headache, the diagnosis is speculative.
  • Auditory hallucinations as migraine auras are infrequent but can occur.
  • Sensory dysesthesias (usually hemisensory numbness and/or tingling) similar to more typical migraine aura may occur without subsequent head pain.
• Benign paroxysmal vertigo of childhood
• • Based on a high proportion of children with a family history of migraine, it is sometimes considered a migraine variant. This syndrome is not uncommon and frequently is followed by the development of more typical migraine headaches later in childhood.
  • This syndrome presents with brief episodes of vertigo.
  • Toddlers may be unable to verbalize the symptoms but typically cling to the parent and look frightened.
  • Older children often verbalize that they are "moving."
  • Headache does not follow the attack.
• Ophthalmoplegic migraine
  • This migraine variant may begin in childhood.
  • Acute disorders of eye movement, unilateral abnormal pupillary response, or Horner syndrome may precede or accompany the headache.

Physical

• Typically, as with all vascular headache syndromes, the neurologic examination between episodes is completely normal.
• If persistent neurologic signs (eg, hemiparesis, visual changes, sensory loss) are evident between episodes, strongly consider and investigate alternative diagnoses.

Causes

• Migraine, in general, may have a genetic predisposition with environmental and systemic triggers.
• Hemiplegic migraine may be autosomal dominant.
• Mitochondrial abnormalities (maternally inherited via mitochondrial DNA, recessively inherited via chromosomal DNA, sporadic) may account for some cases of abdominal migraine or cyclic vomiting of childhood.
• In subjects with mitochondrial disorders, fasting or systemic stress such as fever or illness may precipitate episodes.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Alternating hemiplegia of childhood
Benign occipital epilepsy of childhood
CADASIL, for alternating hemiplegias presenting in adolescents
Complex partial status epilepticus
Epilepsy: pediatric overview
Ingestions
Intoxications
Organic acidurias

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• During the first or worst episode, perform appropriate laboratory and neuroradiologic studies to exclude other causes of the symptoms.
• Laboratory studies generally are not helpful between episodes when a history of multiple, recurrent episodes and complete clearing between episodes exists.
• Evaluate a child with cyclic vomiting with or without head pain for metabolic disease, particularly mitochondrial cytopathy.
• • Studies performed during attacks have higher yield than those performed while the child is feeling well.
  • During the attack, perform the following investigations: serum lactate, serum pyruvate, urine organic acids, and serum ammonia samples. Samples must be collected carefully and handled appropriately by the laboratory. If suspicion of mitochondrial cytopathy is high, blood may be collected any time to examine the DNA for mitochondrial point mutations and deletions.
• For aura without headache, the differential diagnosis often includes simple partial (focal) seizures. Therefore, electroencephalography (EEG [sleep-deprived is possible] or video EEG [if episodes are frequent]) may help in the diagnosis.
• For other migraine variants, EEG generally does not confirm or exclude migraine or other alternatives, since epileptiform EEG changes can be observed in migraineurs.

Imaging Studies

• Neuroimaging (CT, MRI) is indicated during the first or worst attack that presents with simultaneous focal neurologic deficits or altered mental status and/or if any focal findings persist between attacks. Perform these studies to exclude other acute causes of the symptoms. Neuroimaging is less important if the patient presents during a symptom-free interlude, with a history of multiple attacks with complete recovery. In these patients, the clinician can usually rule out acute, life-threatening conditions and more reasonably make a diagnosis of migraine based on history.
• During or immediately after an attack, functional neuroimaging may help with diagnosis.
• • Single photon emission computed tomography may show hypoperfusion during an aura or episode.
  • Functional MRI (fMRI), a research technique, also may demonstrate abnormalities of perfusion.
  • Gadolinium-enhanced MRI may show focal enhancement during or immediately after the attack. This can cause confusion with ischemic stroke, inflammatory conditions, or infection.

Other Tests

• EEG may be abnormal during or immediately after an episode, with slowing in focal or generalized patterns. In general, nonspecific interictal EEG abnormalities, including epileptiform activity, are reported in higher frequencies in migraineurs.
• Continuous ambulatory or video EEG may be useful in the rare patient with episodic confusion, hallucinations, or focal neurologic deficits; partial seizures or nonconvulsive status epilepticus are included in the differential diagnosis for the attack.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

The first step in treatment is to establish the diagnosis. When attacks have occurred on multiple occasions, with complete resolution between attacks, particularly in the presence of a positive family history of migraine, extensive laboratory evaluations and imaging can be avoided. When the child is observed acutely, particularly during the first episode, more extensive evaluation may be necessary to exclude alternative diagnoses. Treatment can be divided into the short-term care of the specific attack and long-term medication to reduce severity or frequency of episodes.

• Hemiplegic migraine
• • Acute treatment: Antiemetics and nonnarcotic pain relievers are generally safe. However, vasoconstrictors, triptans, and ergotamine preparations are contraindicated.
  • Chronic prevention: Beta-blockers, low-dose tricyclics, low-dose daily aspirin, low-dose anticonvulsants, and calcium channel blockers can be administered. Flunarizine, a calcium channel blocker not available in the US, is probably the most effective agent.
• Cyclic vomiting of childhood
• • Acute treatment: If mitochondrial cytopathy or organic aciduria is suggested or diagnosed, tailor treatment to the underlying disorder. In general, early use of IV fluids containing adequate glucose (to prevent a catabolic state), IV or rectal antiemetics, and analgesics may abort the attack. Some patients respond to the triptans or ergotamine classes of medication.
  • Chronic prevention: Low-dose amitriptyline can be effective. Other antimigraine agents (eg, beta-blockers, anticonvulsants, calcium channel blockers) occasionally are useful. If serum carnitine is low, consider a trial of supplementation with l-carnitine.

Consultations

• If an underlying metabolic disease, mitochondrial cytopathy, or inborn error of metabolism is suggested clinically, consult with a medical geneticist with expertise in metabolic disease.

Diet

• As for all migraineurs, diet, particularly certain chemicals in food, may precipitate attacks in some patients.
• Patients should keep a detailed diary of food, activities, and episodes in an attempt to identify precipitant(s).
• Rather than embarking on elimination diets, which are unlikely to be helpful, a trial of elimination may be useful if a particular food or additive is suspected as a trigger for the attacks.

Activity

• Some migraineurs experience attacks related to specific activities or exposures.
• The most common identifiable and avoidable precipitant is glare and/or flashing lights. Encourage children who are sensitive to glare to wear sunglasses when outdoors and to avoid strobes and strobelike conditions.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Acute treatment (symptomatic therapy) terminates the particular episode. Prophylactic treatment prevents episodes or reduces the number of attacks and/or severity of episodes. Medications used to treat or abort attacks include antiemetics, ergot alkaloids, serotonin agonists, and NSAIDs. Minor analgesics, with or without antiemetics or caffeine, are useful in most children. Avoid narcotics and sedatives in most patients. Some of the prophylactic medications that are effective in some patients with migraine variants include low-dose aspirin, beta-blockers, low-dose tricyclic antidepressants, cyproheptadine, calcium channel blockers, and low-dose anticonvulsants, including valproic acid or topiramate.

Drug Category: Antiemetics

May be used (oral, rectal, IV) if nausea and/or vomiting are prominent.

Drug Category: Ergot alkaloids

Ergotamine preparations (alone or combined with caffeine) are direct vasoconstrictors of smooth muscle in cranial blood vessels. Their activity depends on the CNS vascular tone at administration. They also help establish the diagnosis. Ergot alkaloids should never be used to treat hemiplegic migraine.

Drug Category: Serotonin agonists

Sumatriptan or newer varieties stimulate 5-HT1 receptors, producing a direct vasoconstrictive effect. Serotonin agonists help establish the diagnosis, but they never should be used for hemiplegic migraine. Some triptans have slightly different pharmacokinetics or adverse effect profiles, but all have substantially the same mechanism as sumatriptan. None has been adequately evaluated in children.

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs)

Most commonly used to relieve mild to moderate pain. Although effects of NSAIDs in treatment of pain tend to be patient specific, ibuprofen is usually DOC for initial therapy. In randomized trials, ibuprofen is one of the only agents with proven efficacy in pediatric migraine. Ibuprofen, sodium naproxen, or other NSAIDs, particularly if combined with or preceded by an antiemetic, may abort acute episodes.

Drug Category: Beta-blockers

Effective in migraine prophylactic therapy, possibly by blocking vasodilators, decreasing platelet adhesiveness and aggregation, stabilizing membranes, and/or increasing the release of oxygen to tissues.

Drug Category: Tricyclic antidepressants

Low-dose tricyclic antidepressants (eg, amitriptyline, imipramine, nortriptyline) are useful in preventing migraines, particularly in cyclic vomiting syndrome.

Drug Category: Anticonvulsants

Valproic acid, topiramate, phenobarbital, and phenytoin usually have antimigraine activity in doses lower than those generally used for preventing seizures. Only divalproex sodium (Depakote) is approved specifically for migraine prophylaxis. Topiramate has been reported to reduce migraine attacks in adults but is not yet approved for migraine prophylaxis in children.

Drug Category: Calcium channel blockers

Migraine prophylaxis has been reported with various calcium channel blockers, including verapamil, nifedipine, and others. The calcium channel blocker with the highest evidence of efficacy is flunarizine, which is not available in the US. Results are not entirely predictable, and dosage must be individualized. Some patients experience exacerbation of migraine with these agents.

Drug Category: Metabolic support

Metabolic support to prevent catabolic state is indicated in migrainelike episodes caused by suspected mitochondrial cytopathies. IV glucose and occasionally carnitine supplementation may be useful.

Drug Category: Antihistamines

Cyproheptadine occasionally is useful for migraine prophylaxis, probably because of its serotonergic, rather than antihistaminic, effects. Other antihistamines generally are not useful for migraine prophylaxis.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Encourage patients and families to keep diaries of episodes, foods consumed, activities, illness, and medications. They should bring this list to follow-up visits to assist in identification of precipitants and to assess the efficacy of treatment.

In/Out Patient Meds

• Acute abortive treatment
• • Antiemetic and/or sedatives
  • Minor analgesics
  • Ergotamines
  • Triptans
  • Fluid replacement, if vomiting is severe
• Chronic prophylactic treatment is indicated if episodes are frequent, disruptive, and/or the patient and/or family desire treatment and are ready to comply with daily medication.
• • Beta-blockers
  • Tricyclic antidepressants
  • Aspirin (minidose)
  • Anticonvulsants
  • Cyproheptadine

Complications

• Risk of stroke is higher in migraineurs, and patients with hemiplegic migraine may be at even higher risk.
• Abdominal migraine (cyclic vomiting syndrome) may cause significant dehydration.

Prognosis

• Migraine variants may cause significant disability from loss of school time for the child, loss of work time for parents, and general disruption of family function.

Patient Education

• As with all migraine patients, education is an important part of care. Teach patients and families appropriate means to avoid and manage attacks.
• Instruct patient and parents to keep a detailed diary of episodes, food consumed, activities, and medications. The goal is to identify avoidable precipitants, assess attack patterns, and determine response to treatment.
• Making a specific diagnosis that episodes are migrainous in origin may be quite helpful. Often families are sufficiently relieved to know that the child does not have a more serious condition (eg, brain tumor) and that further medical intervention may not be necessary.
• For excellent patient education resources, see eMedicine's Headache Center. Also, visit eMedicine's patient education articles Causes and Treatments of Migraine and Related Headaches, Alternative and Complementary Approaches to Migraine and Cluster Headaches, Migraine Headache in Children, and Understanding Migraine and Cluster Headache Medications.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• The diagnosis of migraine and migraine variants is a clinical, based largely on a history of repeated episodes, with complete normalization between attacks. Imaging is useful only to rule out other causes, particularly in the acute setting, not to diagnose migraine or migraine variant. In an acute setting, particularly with a first attack, failure to find a serious alternative cause (eg, tumor, hemorrhage, hydrocephalus) would likely be viewed as a breach in standard of care.
• • When the patient is symptomatic and has an abnormal neurological examination, migraine variant can almost never be diagnosed unless a consistent pattern exists of similar previous events and the child has had a well-documented normal examination between events. First episodes should never be diagnosed as variant migraine without carefully ruling out other serious pathology.
  • Although alternative causes of symptoms are rare, most patients are not satisfied with a simple explanation and neuroimaging is often performed to rule out serious alternative pathology (eg, intracranial hemorrhage, tumor, hydrocephalus). If the physician decides that imaging is not indicated (eg, it has been repeatedly performed for similar attacks), the reasoning should be well documented in the medical record and a clear explanation should be given to the patient and family.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Dec 7, 2006