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

Migraines are severe, throbbing headaches frequently located in the temples or frontal head regions. In children, the headaches are often bilateral, and aura is infrequent prior to age 8 years. During the migraine episode, the child often looks ill and pale. Nausea and vomiting are frequent, particularly in young children. Patients avoid light (photophobia), noise (phonophobia), and strong odors. Relief typically follows sleep. Initial evaluation focuses on excluding other conditions. Treatment consists of identifying triggering factors, providing pain relief, and considering prophylaxis.

Migraine is a common disorder among the young. Estimates indicate that 3.5-5% of all children will experience recurrent headaches consistent with migraine. As in adults, most children (approximately 64%) have migraine without aura. Approximately 18% have only migraine with aura, 13% have both, and 5% experience only aura. Headaches are chronic, typically severe, and often associated with autonomic dysfunction. The pain is throbbing, located in the trigeminal nerve distribution, aggravated by movement, frequently accompanied by GI symptoms, may be hemicranial, often associated with photophobia and phonophobia, and is relieved by sleep.

Several conditions relatively common among the pediatric population thought to be variations and/or precursors of migraine include (1) benign paroxysmal vertigo, (2) cyclic vomiting, (3) paroxysmal torticollis, and (4) transient global amnesia (rare in children) or acute confusional migraine.

Migraine Types

Migraine with aura (classic migraine)

Migraine with aura is a severe, often throbbing, generalized or hemicranial headache that is preceded by an aura that is typically visual. Approximately one third of children have migraine with aura. The visual disturbance may consist of seeing sparkling lights or colored lines, visual hallucinations, blindness, hemianopia, blurred vision, or micropsia. The aura usually precedes the headache by less than 30 minutes and lasts 5-20 minutes. Other less common auras consist of sensory symptoms or focal motor deficits (hemiplegia). Approximately 5% of affected children have aura without headache.

Migraine without aura (common migraine)

Approximately 60% of children with migraine do not experience an aura. These headaches are usually associated with nausea, vomiting, or both. They may be unilateral but are usually poorly localized and frequently accompanied by sensitivity to light, sound, and movement. If untreated, these headaches can last up to 72 hours. In children, duration of head pain is typically less than in adults and lasts less than 4 hours.

Complicated migraine

A complicated migraine is an attack associated with neurologic signs or symptoms that persist beyond the head pain. Examples include hemiplegic migraine and ophthalmoplegic migraine (OP). OP is an uncommon disorder characterized by a severe unilateral headache associated with prolonged ocular nerve palsies. OP typically involves the oculomotor nerve, and recurrent attacks may cause permanent deficit.

Basilar migraine (Bickerstaff migraine)

This disorder is usually seen in adolescent females. Head pain is occipital and associated with an aura consistent with brainstem, occipital, and/or cerebellar dysfunction, such as ataxia, hearing disturbance, altered consciousness, diplopia, dizziness, dysarthria, tinnitus, visual disturbance, drop attacks, paresthesias, and weakness. The neurologic symptoms are usually brief.

Confusional migraine

This type of migraine is uncommon and usually occurs early in the second decade of life. Attacks are sometimes precipitated by minor head trauma and are characterized by the rapid development of confusion and agitation. Affected children are delirious, restless, combative, and appear in pain but do not complain of headache. Episodes typically last less than 6 hours and are followed by deep sleep. Upon awakening, the child is normal and is amnestic for the attack. These confusional attacks tend to recur but are eventually replaced by typical migraine.

Pathophysiology

For years physicians accepted the vascular theory as proposed by Graham and Wollf as a plausible explanation of the pathophysiology of migraine. This theory held that the prodromal phase and/or aura resulted from vasospasm, which caused focal cerebral ischemia and transient neurologic symptoms. The vasospasm would then cause compensatory vasodilation and the second phase of the migraine—a pulsating headache in the distribution of the trigeminal nerve and upper cervical roots. The vascular theory was later replaced by the neuronal theory, which proposed that migraine resulted from a paroxysmal depolarization of cortical neurons. However, neither theory adequately explained the pathophysiology of migraine, which remains incompletely understood.

Most investigators have now combined aspects of the vascular and neuronal theories into what is called the trigemino-vascular theory, which proposes that migraine results from depolarization of cortical neurons followed by a reduction in posterior cerebral blood flow. 

Substances that may precipitate migraine include prostaglandin E and the vasoactive amines tyramine and phenylethylamine. Foods such as chocolate, cheese, and red wine are known to contain these compounds and often initiate migraine in adults. Diet and foods containing vasoactive amines appear to be much less important in children.

Hormonal changes and fluctuations also appear to play a role. Prior to puberty, migraine occurs equally among boys and girls. With the onset of puberty, migraine becomes significantly more prevalent among females (approximately 3 times as common).

The familial occurrence of migraine has been recognized for many years. The significantly higher concordance rate among monozygotic twins compared with dizygotic twins supports a strong genetic basis for this condition. Studies also suggest that migraine with aura is genetically distinct from migraine without aura; however, neither migraine type appears to have a distinctive pattern of mendelian inheritance.

Vascular theory

Models that explain the characteristic sensory and motor disturbances in migraine with aura include the vascular theory and neuronal theories. It has been suggested that migraine results from a reactive defect in the CNS vasculature. The vascular theory views migraine as having two phases. The first (the prodromal phase) is characterized by vasospasm, which causes cerebral ischemia and transient focal deficits. The second phase results from compensatory vasodilatation of the intracranial and extracranial vasculature. Brain acidosis and stretching of pain fibers in arterial walls would then cause a pulsating headache.

Although the vascular theory influenced medical literature for many decades, the involvement of the cranial vessels in the initiation and pathogenesis of migraine is now under considerable debate.

Cortical-spreading depression

The vascular theory was replaced by the neuronal theory, which suggested that migraine with aura is related to the paroxysmal depolarization of cortical neurons. These ideas are now combined into what is called the trigemino-vascular theory. 

According to this theory, the initial phase is the result of a wave of spreading cortical depression, which is associated with depression of spontaneous EEG activity. The cortical depression begins in the occipital head region, moves anteriorly during the course of an attack, and is thought to be responsible for the patient's aura, focal neurologic symptoms, or both. This wave of cortical depression is preceded by brief ionic changes in neurons and glia causing prolonged depolarization and depression of EEG activity. These ionic changes move across the cortical gyri at 2-3 mm/min, resulting in decreased neuronal activity.

The cortical depression stops at the central sulcus and then spreads ventrally to the meningeal trigeminal fibers causing headache. Brain ion homeostasis falters, allowing an efflux of excitatory amino acids from nerve cells and enhanced energy metabolism. Activation of N-methyl-D-aspartate receptors may be involved. Decreased blood flow to the occipital cortex follows in response to the decreased neuronal activity. A reactive hyperemic phase follows. This increased blood flow does not precisely follow the timing of the head pain.

Involvement of serotonin

Serotonin (5-hydroxytryptamine) also seems to play a role in the pathogenesis of migraine. Intermittent neuronal discharges from serotonergic neurons in the pons may cause an initial discharge in the ipsilateral occipital cortex. This discharge could then cause a wave of spreading excitation followed by depression of neuronal activity.

During an attack, urine levels of the serotonin metabolite hydroxyindoleacetic acid are increased significantly in migraineurs. At the onset and for the duration of the headache, intraplatelet serotonin levels decrease. Serotonin is released from platelets at the onset of an attack. During a migraine attack, serotonin turnover is also reduced. Migraineurs, however, have increased synthesis of serotonin between attacks.

In addition, several serotonin receptors appear to be important in the pathophysiology of migraine. The 3 most important receptors are 5-HT1, 5-HT2, and 5-HT3. The 5-HT1 receptors are inhibitory, and the 5-HT2 receptors are excitatory. All triptans are 5-HT1 agonists, while many prophylactic agents (eg, beta-blockers) are 5-HT2 antagonists. An injection of serotonin during an attack decreases migraine symptoms but is associated with many unpleasant adverse effects.

Sterile inflammation process

Investigators also have proposed that a sterile inflammation process causes the release of vasoactive neuropeptides, such as substance P and neurokinin A, from the trigeminal nerve. This causes vasodilatation of the arterioles and arteries, which activates endothelial cells, mast cells, and platelets. In turn, these release vasoactive substances such as histamine, serotonin, peptikinins, prostaglandins, catecholamines, and slow-reacting substances of anaphylaxis. These substances cause contraction and relaxation of smooth muscle and the symptoms of migraine. The sterile inflammation process is proposed to increase the pain and lengthen the duration of a migraine attack. It is also known that obesity causes the release of tumor necrosis factor-alpha and other cytokines from adipocytes, which results in a low-grade systemic inflammatory state. Obesity may therefore play a role in headache progression. 

Nitric oxide

NO recently was found to cause cerebral arterial dilation and a delayed headache in migraineurs; however, it does not cause an aura.

NO regulates blood pressure, inhibits platelet function, and acts as a neurotransmitter. It is involved in the central processing of pain and the regulation of vasodilatation in the CNS and is produced by NO synthase in neurons. NO donator agents (eg, nitroglycerin, glyceryl trinitrate, isosorbide) cause migrainelike pain after 3-10 hours. Monomethyl-L-arginine, a specific inhibitor of NO synthase, is an effective treatment for migraine pain.

Calcium channelopathy

Ion channels control and maintain electrical potentials across cell membranes. Mutations in ion channel genes cause numerous neurologic disorders. Brain-specific P/Q-type voltage-gated calcium channel alpha-1A subunit gene mutations are responsible for such diverse phenotypic symptoms as typical migraine with or without aura, familial hemiplegic migraine (FHM), episodic ataxia type 2, and spinocerebellar ataxia type 6. Half the known FHMs studied have linkage to 19p13. Different missense mutations (R192Q, T666M, V714A, I1811L, G4644T) cause FHM with different phenotypic accompaniments. Linkage to a separate gene on chromosome 1 has also been reported. An estimated 5% of migraineurs may carry a mutation in the calcium channel gene.

Mitochondrial dysfunction

Many migraine families demonstrate a predominant maternal inheritance pattern that may be caused by mitochondrial dysfunction. Both migraine with aura and migraine without aura are associated with abnormalities in brain energy metabolism; thus, mitochondrial dysfunction may be involved in a subset of patients. In 1998, Schoenen et al found that a high dose of riboflavin (400 mg/d) was an effective migraine prophylaxis, reducing attack frequency by 56%. The full benefit is obtained after 3 months. Riboflavin was postulated to improve the altered mitochondrial energy metabolism.¹

Frequency

United States

The 1-year prevalence rate among males is 6% and is 14-18% among females. The median frequency of attacks is 1.5 events per month. The median duration is 24 hours, with 20% lasting 2-4 days. Approximately 5% of the US population experiences 18 or more days of migraine per year. Estimates indicate that at least 2.5 million individuals in the United States have at least 1 day of migraine per week. Among the young, studies suggest that up to 5% of the pediatric population experience juvenile migraine. Approximately one third of children will have an aura. Approximately 20% of children with migraines develop attacks when younger than 5 years.

International

In one of the few longitudinal studies of migraine patients, Bille observed 73 children with migraine for 40 years. The average age of onset was 6 years. During puberty or young adulthood, 62% of the children were migraine free for at least 2 years; approximately 33% of these children regained regular attacks after an average of 6 migraine-free years, and a surprising 60% of the original 73 children still had migraine attacks after 30 years. In 30 years, 22% of the children never had a migraine-free year.²

Mortality/Morbidity

Although migraine has long been considered a benign and self-limited condition, it can significantly impact the patient's life. The pain is intense, and often the patient cannot concentrate or function effectively during or immediately after episodes. An estimated 65-80% of children with migraine attacks interrupt their normal activities because of the symptoms. Among 970,000 self-reported migraineurs aged 6-18 years, 329,000 school days were lost per month. The burden of migraine may cause emotional changes such as anxiety or sadness. The course and severity of migraine may be influenced by a variety of factors including stress, depression, sleep deprivation, overuse of analgesics, and hormonal fluctuation. Appropriate diagnosis and treatment of migraine can significantly improve quality of life.

Sex

• Migraine begins earlier in boys than girls. From infancy to 7 years, boys are affected equally or slightly more than girls.
• The prevalence of migraine increases during the adolescent and young-adult years, during which 20-30% of young women and 10-20% of young men experience migraine attacks.
• After menarche, a female predominance occurs and continues to increase until middle age. Migraine declines in both sexes by age 50 years.

Age

• Migraine headaches are a common problem in children and are found in 5-10% of school-aged children. Most migraineurs begin to experience their attacks when younger than 20 years. Approximately 20% of migraine patients experience their first attack when younger than 5 years. In preschool children, migraine often consists of episodes involving an ill appearance, abdominal pain, vomiting, and the need to go to sleep. They may exhibit pain by irritability, crying, rocking, or seeking a dark room in which to sleep.
• Young patients with migraine (5-10 y) experience bifrontal, bitemporal, or retro-orbital headache; nausea; abdominal cramping; vomiting; photophobia; phonophobia; and a need to sleep. They usually are asleep within 1 hour of attack onset. The most common accompanying symptoms include pallor with dark circles under the eyes, tearing, swollen nasal passages, thirst, swelling, excessive sweating, increased urination, and diarrhea. Older children may present with a unilateral, temporal headache. Many "sinus headaches" are actually of migrainous origin. The headache location and intensity often change within or between attacks.
• As children mature, headache intensity and duration increase. They begin to describe a pulsating or throbbing character to the headache. Headache presentation may shift to the unilateral, temporal location characteristic of most adult migraines. Childhood migraine attacks often stop for a few years after puberty.
• Nonheadache symptoms may be more distressful to young children than the headache. Younger children may experience photophobia and phonophobia without GI or headache accompaniments. Some children have recurrent bouts of nonlateralized abdominal pain without accompanying headache (abdominal migraine). Patients who eventually develop migraine with aura present earlier than patients who experience migraine without aura.

CLINICAL

Section 3 of 10  

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

History

Headache may be a presenting symptom of a benign or a life-threatening condition. The patient's medical history and physical examination findings often are enough to identify or exclude serious underlying processes. Because no specific diagnostic test is available for migraine, the diagnosis is made by history and examination. Elicit reasons for the current presentation, including past history, previous test results, allergies, and current and previous medication usage. The patient should describe the headache quality (eg, throbbing, pounding, squeezing, pressing, pulsating, aching, burning, lancinating, dull), location, timing, severity, precipitating events, duration, and heredity.

Disorders that cause acute headache in children include both primary and secondary disorders. Primary headaches are conditions in which the headache is the medical condition and no underlying structural or metabolic cause is present. Treatment is aimed at the specific headache disorder. Primary headache types include migraine, tension, chronic daily, and cluster headaches. Differentiate these headache categories because optimal treatment regimens vary. Recurrent headaches usually represent primary disorders.

Secondary headaches represent a manifestation of some underlying pathologic process that alleviates the headache when treated. Secondary headaches can herald a wide range of diagnostic possibilities from benign to life threatening, including intracranial and extracranial infections, intracranial mass lesions, head or neck trauma, febrile illness (eg, influenza), meningitis, encephalitis, sinusitis, dental abscess, subarachnoid hemorrhage, and hypertension. A patient with a primary headache disorder also may present with a secondary headache disorder at subsequent visits.

Migraine is a relatively common condition among the young, affecting up to 5% of the pediatric population. Approximately 20% of patients have attacks before age 5 years. Headaches may occur in the early morning and often awaken the child. The occurrence of these early morning headaches should not cause one to assume that the child has increased intracranial pressure.

The headache is often poorly described but is usually frontotemporal in location. Hemicranial headaches are less common in the pediatric population, particularly in younger patients. Affected children may also experience recurrent abdominal pain without nausea, vomiting, headache, or visual symptoms. Migraine should be considered in pediatric patients with unexplained paroxysmal abdominal pain. Infants may present with only episodic "head banging." Young children with migraine or who may be predisposed to developing migraine may have a history of motion sickness.

During an attack, children appear ill and often are pale. The headache is aggravated by movement and may be associated with nausea, vomiting, photophobia, and/or phonophobia. Between attacks, children may have a dark discoloration beneath their eyes (ie, so-called migraine facies). This facial appearance is similar to that of children with an allergic diathesis (ie, so-called allergic facies).

• Phases of a migraine attack: A migraine attack has 4 potential phases that are important to recognize and describe.
• • Premonitory phase or prodrome: Both migraine with aura and migraine without aura have a premonitory phase that may precede the headache phase by up to 24 hours. During this phase, irritability, elation or sadness, talkativeness or social withdrawal, an increase or decrease in appetite, food craving or anorexia, water retention, and/or sleep disturbances may occur. These premonitions are often more pronounced in migraine without aura than in migraine with aura. Children with frequent migraine headaches or migraine variants often have a vague feeling that something is different in their world. They often learn to recognize these premonitions, which are difficult to explain to their parents or physicians.
  • Aura: An aura is a focal cerebral dysfunction that immediately precedes or coincides with the headache onset. The aura may manifest without headache or may be more severe than the subsequent headache. Only 10-20% of children with migraine experience an aura. The aura usually precedes the headache by less than 30 minutes and lasts for 5-20 minutes. Motor auras tend to last longer than other forms of aura.

    Children are often unaware or unable to describe their aura; pictorial cards that illustrate typical visual aura may aid in obtaining an accurate history. The visual aura is the most common form in children, consisting of blurred vision, fortification spectra (zigzag lines), scotomata (field defects), scintillations, black dots, kaleidoscopic patterns of various colors, micropsia, macropsia (distortion of size), and metamorphopsia ("Alice in Wonderland" syndrome). Visual auras are often reported as moving or changing shapes; other auras include attention loss, confusion, amnesia, agitation, aphasia, ataxia, dizziness, vertigo, paraesthesia, or hemiparesis. Aura symptoms vary widely within and between attacks.

  • Headache: The actual headache phase of the migraine attack is usually shorter in the pediatric population compared with adults; pediatric headaches can last 30 minutes to 48 hours but are usually less than 4 hours. Some young patients report short headaches lasting 10-20 minutes. Coughing, sneezing, climbing stairs, or bending over increases headache pain by increasing intracranial pressure. Childhood migraine headaches are often less severe than adult migraine headaches. The headache phase is often associated with cold extremities, nausea, anorexia, vomiting, diarrhea, increased urination, constipation, dizziness, chills, excessive sweating, ataxia, numbness, photophobia, phonophobia, memory loss, or confusion.
  • Postdrome: After the headache phase, the patient may feel either elated and energized or, more typically, exhausted and lethargic. This stage of migraine may last from hours to days.
• Types of migraines: A patient may experience varying types of headaches, including different forms of migraine. The 2 most frequent forms are common migraine and classic migraine. Complicated migraines, migraine equivalents, and migraine variants also occur and are differentiated by patient history.
• • Migraine with aura: Classic migraine (migraine with aura) is characterized by a visual aura followed by a unilateral throbbing headache, which may later generalize to both sides. It lasts between 30 minutes and 48 hours. Headaches usually occur 1-2 times per month but the frequency may vary considerably among individuals.
  • Common migraines: Common migraines lack an aura. Migraine without aura in children is traditionally described as a recurring bilateral headache disorder with a throbbing and/or pulsating pain quality, moderate-to-severe intensity, and severe GI symptoms. It is aggravated by physical activity and relieved by sleep. Common accompanying symptoms in children are irritability and pallor with dark circles under the eyes. The presentation in young children is more often bilateral, orbital, or frontotemporal, and the pain may radiate to the face, occiput, or neck. Migraine without aura occurs in 60-85% of migrainous children.
  • Status migrainosus: Status migrainosus is a severe form of migraine in which the headache attack is continuous for over 72 hours. Patients usually have a preexisting migraine history. In those who vomit, rehydration is often the necessary first step. An effective treatment is intravenous dihydroergotamine (DHE) with an antiemetic. Intravenous valproic acid (VPA) is also often effective.
  • Complicated and variant migraines: These are classified as migraines because they often have the same triggers. They are brief, recurrent, episodic disorders that are intensified by movement and are relieved by deep sleep or typical migraine medications.

    Complicated and variant migraines have some of the same symptoms as typical migraines, including pain, GI syndromes, autonomic symptoms, neurologic symptoms, and changes in mood or emotion. Debate exists regarding whether these disorders are migrainous or nonmigrainous. These usually benign disorders are frightening because they mimic life-threatening emergency situations.

    Migraine equivalents are underrecognized and underreported manifestations of childhood migraine. They are often forerunners of the typical migraine, and complicated and variant migraines occasionally alternate with typical migraine symptoms. Complicated migraine has dramatic focal features and a persistent neurologic deficit that remains for at least 24 hours after the headache.

  • Familial hemiplegic migraine: FHM is an autosomal dominant form of migraine with aura. Patients have a prolonged hemiplegia accompanied by numbness, aphasia, and confusion. The hemiplegia may precede, accompany, or follow the headache, and symptoms may last for hours or as long as a week.

    The headache is usually contralateral to the hemiparesis. Some FHM attacks are associated with cerebellar ataxia. Other types of severe FHM may manifest with coma, fever, and meningismus. A third type of FHM involves progressive ataxia, nystagmus, gait unsteadiness, limb incoordination, and dysarthria. Some forms of FHM respond to acetazolamide. Consider structural lesions, vasculitis, cerebral hemorrhage, brain tumor, mitochondrial myopathy, encephalopathy, and lactic acidosis in the differential diagnosis. If hemiparesis is always on the same side, consider a vascular abnormality.

  • Basilar migraine (basilar artery migraine or Bickerstaff syndrome): Basilar migraine is a subtype of migraine with aura. It most commonly is observed in adolescent and young adult females. Headache pain is located in the occipital area. Basilar migraine is characterized by disturbances in function originating from the brain stem, occipital cortex, and cerebellum. The occipital headache must have at least 2 of the aura symptoms listed below, which are associated with dysfunction originating from the occipital and/or brainstem area.
    • Ataxia
    • Bilateral paresthesias
    • Deafness
    • Decreased level of consciousness
    • Diplopia
    • Dizziness
    • Drop attacks
    • Dysarthria
    • Fluctuating low-tone hearing loss
    • Tinnitus
    • Unilateral or bilateral vision loss
    • Vertigo
    • Weakness

    A history of typical migraine exists in 86% of families studied. Many patients experience basilar migraine attacks intermingled with typical migraine attacks.

  • Ophthalmoplegic migraine: This form of migraine is rare. It is characterized by a severe unilateral headache with prolonged oculomotor nerve palsies involving the third, fourth, or sixth cranial nerves. Ophthalmoplegia may precede, accompany, or follow the headache; recurrent episodes may cause permanent oculomotor deficit.
  • Ophthalmic (retinal) migraines: These migraines involve repeated attacks of monocular scotoma or blindness usually followed by headache. The patient must have normal ophthalmologic examination findings between attacks. Exclude a retinal embolism or abnormality.
  • Benign paroxysmal vertigo of childhood: This condition is characterized by brief episodes of vertigo, disequilibrium, and nausea. It is usually found in children aged 2-6 years. The patient may have nystagmus within, but not between, the attacks. The child does not have hearing loss, tinnitus, or loss of consciousness. Symptoms usually last only a few minutes. These children often develop a more common form of migraine as they mature. Brain MRI can be performed to exclude posterior fossa abnormalities, especially if abnormalities in the neurologic examination are found between episodes.
  • Acute confusional migraine: This type of migraine is characterized by transient episodes of amnesia, acute confusion, agitation, lethargy, and dysphasia precipitated by minor head trauma. The child may have a receptive or expressive aphasia, and the confusional state may either precede or follow the headache. Some children also experience recurrent episodes of transient amnesia and confusion. The patient usually recovers within 6 hours. The child may not have a history of headache, but he or she usually develops typical migraine attacks in the future. Exclude drug abuse; brain MRI results should be normal.
  • Migraine-associated cyclic vomiting syndrome (periodic syndrome): This syndrome is characterized by recurrent periods of intense vomiting separated by symptom-free intervals. Many patients with cyclic vomiting have regular or cyclic patterns of illness. Symptoms usually have a rapid onset at night or in the early morning and last 6-48 hours. Associated symptoms include abdominal pain (80%), nausea (72%), retching (76%), anorexia (74%), pallor (87%), lethargy (91%), photophobia (32%), phonophobia (28%), and headache (40%).

    Headache often does not appear until the child is older. Migraine-associated cyclic vomiting syndrome usually begins when the patient is a toddler and resolves in adolescence or early adulthood; it rarely begins in adulthood. More females than males are affected by cyclic vomiting. Infections, psychological stress, physical stress, and dietary triggers are often clearly identified in the patient's history. Examples of triggers include cheese, chocolate, monosodium glutamate (MSG), emotional stress, excitement, or infections. Usually, the parents or siblings have a family history of migraine. Some children with cyclic vomiting respond to antimigraine drugs (eg, propranolol, amitriptyline, cyproheptadine, sumatriptan). These children often experience severe fluid and electrolyte disturbances that require intravenous fluid therapy. Cyclic vomiting syndrome is a diagnosis of exclusion.

    Differentiate cyclic vomiting related to migraine from nonmigraine cyclic vomiting conditions. Other causes of cyclic vomiting include GI disorders (malrotation), neoplasms, urinary tract disorders, metabolic and endocrine disorders, and mitochondrial DNA deletions. Children with cyclic vomiting associated with migraine tend to experience fewer severe vomiting episodes per hour and fewer attacks per month than those with cyclic vomiting associated with other GI disorders. These children exhibit a higher incidence of pallor, abdominal pain, headache, social withdrawal, motion sickness, photophobia, and physical exhaustion. Cyclic vomiting associated with developmental delay, poor growth, seizures, and strong maternal history is associated with mutations of the mitochondrial DNA. When mitochondrial mutations are suggested, obtain plasma lactate and urine organic acid levels during an attack.

  • Abdominal migraine: The patient may have recurrent bouts of generalized abdominal pain with nausea and vomiting; no headache is present. After several hours, the child can sleep and later awakens feeling better. Abdominal migraine may alternate with typical migraine and usually leads to typical migraine as the child matures. These children respond to typical migraine prophylactic medication.
  • Paroxysmal torticollis of infancy: This rare disorder is characterized by repeated episodes of head tilting and is associated with nausea, vomiting, and headache. Attacks usually occur in infants and may last from hours to days. Consider posterior fossa abnormalities in the differential diagnosis.
  • Acephalic migraine of childhood (migraine sine hemicrania): This is characterized by a migraine aura without headache, usually visual auras, and a female predominance. A positive family history of migraine is essential. Ophthalmic migraine is a variant of acephalic migraine.
• Associated diseases and conditions
• • Psychiatric diseases: These can include depression, hypomania, panic attacks, anxiety disorders, or phobia.
  • Asthma, allergies, and seizure disorders: These are more common in childhood migraine patients.
  • Preeclampsia, stroke, and hypertension: These are observed more commonly in adult migraine patients.
  • Epilepsy: Migraine and epilepsy often occur in the same individual and may be related. Approximately 70% of patients with partial complex seizures have migraines. Most patients with migraines do not have seizures.
• Unusual symptoms
• • Motion sickness: Migraineurs are more prone to motion sickness than patients without migraine.
  • Intermittent vertigo: This is found in 63% of patients with classic migraine and in 21% of patients with common migraine.
  • Cardiovascular reactivity to postural changes: In 1999, Rashed et al demonstrated a higher cardiovascular reactivity to postural changes in patients with cyclic vomiting and migraine.³
  • Diarrhea: This is common in migraine patients and sometimes is severe enough to result in excessive fluid loss and dehydration.
  • Sleep disturbances: Migraines are associated with sleep disturbances, and somnambulism is found in 20-30% of migraine patients.
  • Stripped-pattern aversion: This symptom is found in 82% of tested migraine patients.
  • Ice cream ingestion: In 1976, Raskin and Knittle found that ingestion of ice cream caused headache in 93% of migraine subjects.⁴ The headache is typically located at the usual site of migraine pain.

Physical

• When evaluating a patient presenting with headache, perform a thorough general physical examination and a detailed neurologic examination. All examination findings should be overwhelmingly normal.
• Abnormal vital signs, nuchal rigidity, cranial nerve abnormalities, macrocephaly, bruits, papilledema, cutaneous lesions, cognitive changes, or asymmetric signs require appropriate follow-up evaluations.

Causes

The exact cause of migraine is unknown. Migraine is most likely a heterogeneous disorder and has trigger factors and multiple physiologic causes (see Pathophysiology and History). Although many of these diseases do not develop until middle age, early recognition of migraine risk factors may help the child to adopt a healthy lifestyle.

The cause of pain in persons with migraine is poorly understood. Migraine pain does involve cranial blood vessels, trigeminal innervation of these vessels, and reflex connections of the trigeminal system with cranial parasympathetic outflow. Most patients experience pain in the distribution of the ophthalmic division of the fifth cranial nerve and/or in the distribution of C2.

Migraine pain may in part be related to the ventral propagation of cortical spreading depression to meningeal trigeminal nerve fibers. This appears to cause the release of a number of vasoactive substances, including neurokinin A, substance P, and calcitonin.

DIFFERENTIALS

Section 4 of 10  

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

Other Problems to be Considered

Analgesic rebound headache
Benign exertional headache
Caffeine headache
Chronic daily headache
Inflammatory sinus disease
Posttraumatic headache
Tension headache

WORKUP

Section 5 of 10  

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

Lab Studies

• Only the small percentage of headache patients in whom a nonmigrainous cause is suspected requires further laboratory and radiologic studies.

Imaging Studies

• A neuroimaging study typically is not necessary in adults with a chronic (>6 mo) history of headaches, normal neurologic examination findings, and no seizures. Although similar data on children are not available, headache alone is not a sufficient reason to order a neuroimaging study.
• Studies have shown that children with a history consistent with migraine and normal neurologic examination findings will not have abnormalities on head CT scans or cranial MRIs. A small percentage of migrainous children may have incidental and unrelated findings, but routine neuroimaging is not necessary in juvenile migraine patients. However, children with chronic progressive headaches or those younger than 4 years probably should have a cranial MRI.
• Consider an imaging study in patients with a history of seizures, recent head trauma, significant change in the headache, or evidence of focal neurologic deficits or papilledema upon physical examination. No absolute rules exist in the evaluation of the headache patient; the need for a neuroimaging study ultimately is based on clinical judgment.
• Electroencephalography is not useful in the routine evaluation of headache patients. Reserve it for patients with an atypical migraine aura, episodic loss of consciousness, or symptoms suggestive of a seizure disorder. Focal or diffuse background slowing can be seen during a migraine headache, particularly hemiplegic or confusional migraine; however, electroencephalography results are often normal.

Procedures

• Lumbar puncture is indicated if meningitis, encephalitis, subarachnoid hemorrhage, or high-low pressure syndromes are considered. Cerebrospinal fluid examination and pressure measurements are not indicated unless the history or examination findings are not consistent with juvenile migraine.
• Patients in whom elevated intracranial pressure is suggested or those with focal neurologic deficits should undergo a neuroimaging study prior to a lumbar puncture.

TREATMENT

Section 6 of 10  

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

Medical Care

First, educate patients and parents concerning migraine triggers. Second, formulate a plan of treatment for the acute attacks. Third, consider prophylaxis for patients with frequent migraines. The treatment of children with mild, infrequent attacks consists primarily of rest, trigger avoidance, and stress reduction.

• Explanation and education
• • The first step in migraine treatment is to explain the disease to the child and the parents. The patient and parents benefit from a simple explanation of the headache pain and reassurance that it is not caused by a brain tumor or other life-threatening condition. A regular bedtime, strict meal schedules, and avoidance of overloading the child's schedule with activities are important. Helping the child recognize migraine triggers is helpful but often difficult. Eliminating precipitating triggers reduces the frequency of headaches in some patients. Importantly, the patient must have realistic expectations; identifying and avoiding triggers reduces the frequency of migraine headaches but does not eliminate headaches.
  • A headache diary can be used to record unique triggers and features of the attack. However, unfortunately, even the most obsessive patients and parents cannot always identify specific triggers of migraine. Advise the patient to list precipitating factors that occurred 12 hours before the attack. Other important factors include the following:
  • • Date and time of attack onset
    • Type and location of headache pain
    • Symptoms before headache
    • All food and drink consumed
    • Bedtime, wake time, and quality of sleep
    • Menstrual periods or female hormones
    • Activities before headache
    • Medications taken and their effects
• Acute attacks
• • During the attack, advise the child to lie down in a cool, dark, quiet room and fall asleep at the time of the attack. Sleep is the most potent antimigraine treatment. During a migrainous attack, a child commonly can be found resting in the fetal position with the affected side of the head down.
  • They should be given simple analgesics such as acetaminophen or ibuprofen. They should be taught to "give in" to their headache because activity will probably aggravate their pain. Stronger analgesic medication such as butalbital may be necessary. Promethazine diminishes nausea, causes drowsiness, and seems to decrease pain; therefore, it frequently is used as a rescue medication.
  • Some patients find that ice or pressure on the affected artery can temporarily alleviate pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective if taken at a high but appropriate dosage during the aura or early headache phase. Gastric stasis occurs in most migraine patients and causes delay in absorption of oral medications. Occasionally, carbonated beverages may improve absorption. Nonpharmacologic treatment modalities such as self-relaxation, biofeedback, and self-hypnosis may be reasonable alternatives to pharmacologic treatment in managing childhood migraine, particularly in adolescents. Response rates in children tend to be higher than in adults and show continued effectiveness over time.
  • Specific drugs for acute attacks include ergot preparations and triptans. Older vasoconstrictive medications (ergot preparations) such as Cafergot (1 mg ergotamine tartrate with 100 mg caffeine) are rarely used today as rescue medications in the pediatric population. Intravenous DHE is an effective abortive agent when used early in an attack and is an option for the older child. Triptans are basically serotonin antagonists and appear to work primarily by stimulating an inhibitory receptor. These 5-HT1 agonists are being successfully used with increasing frequency as rescue medications in young migraineurs.
• Prophylaxis
• • The primary goals of prophylactic drugs are to prevent migraine attacks and to reduce the frequency and severity of attacks. Half of all patients experience at most a 50% reduction in migraines. Most prophylactic migraine medications have potential adverse effects; therefore, consider only patients with 1-2 attacks per week (>4 headache days per mo) for prophylaxis. Possible medications include amitriptyline, propanolol, selective serotonin reuptake inhibitors (SSRIs), gabapentin, valproate, and riboflavin.
  • Anticonvulsants (eg, divalproex, topiramate) are often effective prophylactic agents.
  • Tricyclic antidepressants (TCAs) have been shown to be safe and effective.
  • Calcium channel blockers had been used in children, but results have been inconsistent.
  • The 5-HT2 antagonists block the excitatory serotonin receptor (5-HT2). These agents seem to be the most effective prophylactic medication in children. These medications include beta-blockers, cyproheptadine, and methysergide (Sansert). Beta-blockers and cyproheptadine appear to be effective and well tolerated.

Consultations

If headaches cannot be reasonably controlled within 6 months, consider consulting a pediatric neurologist. In addition, refer children with a new onset of neurologic deficits to a pediatric neurologist.

Diet

An estimated 20-50% of migraineurs are sensitive to certain foods; common examples are listed below. These dietary triggers are believed to cause a change that provokes a migraine attack. Helping the child learn to recognize and avoid these triggers is helpful but often difficult.

• Tyramine: Patients with low levels of phenolsulfotransferase P are believed to be sensitive to dietary monoamines such as tyramine and phenylethylamine. Cultured dairy products (eg, aged cheese, sour cream, buttermilk), chocolate, and citrus fruits are believed to cause vasodilation in predisposed individuals. Some migraine headaches may be triggered by artificial sweeteners such as aspartame.
• Beverages: Alcoholic beverages, especially red wine, and excess or withdrawal of caffeinated drinks such as coffee, tea, cocoa, or colas may trigger a migraine headache. The patient should limit caffeinated sources to no more than 2 cups per day to prevent caffeine-withdrawal headaches.
• Nitrates and nitrites: These vasodilating agents are found in preserved meats. Examples of foods containing these chemicals are lunch meats, processed meats, smoked fish, sausage, pork and beans with bacon, sausage, salami, pastrami, liverwurst, hot dogs, ham, corned beef, corn dogs, beef jerky, bratwurst, and bacon.
• Monosodium glutamate: MSG is a flavor enhancer and vasodilator found in many processed foods. Food labels should be carefully checked. MSG sources include prepackaged seasonings (eg, Accent), bacon bits, baking mixtures, basted turkey, bouillon cubes, chips (eg, potato, corn), croutons, dry roasted peanuts, breaded foods, frozen dinners, gelatins, oriental foods and soy sauce, pot pies, relishes, salad dressing, soups, and yeast extract.
• Medications: Cimetidine, estrogen, histamine, hydralazine, nifedipine, nitroglycerin, ranitidine, and reserpine can increase migraine frequency. Both over-the-counter (OTC) and prescription medications can trigger or exacerbate migraines. Excessive use of OTC pain medications and analgesics can cause occasional migraine attacks to convert to analgesic-abuse headaches or drug-induced refractory headaches. Advise patients to avoid frequent or long-term use of NSAIDs, acetaminophen, triptans, or ergotamines. Naproxen sodium can be a particularly useful medication if acute therapy is needed frequently, as risk of rebound headache is lower with this agent. Advise migraine patients who have undergone prolonged treatment with amphetamines, phenothiazine, or propranolol to avoid sudden withdrawal from these medications because migraine headaches may result.
• Citrus fruits, avocados, bananas, raisins, and plums may be triggers. Although occasional individuals are sensitive to fruit, the authors encourage children with migraines to eat a well-rounded, natural (ie, avoid processed foods) diet that includes fruits and vegetables. A headache diary (see Medical Care) may be helpful; a pattern often emerges after 6-8 weeks. Nitrates and MSG are often mentioned as childhood migraine dietary triggers. Note that some patients inappropriately use the diary to create elaborate restrictive diets that could harm normal growth and development.

Activity

In predisposed individuals, migraine attacks can occur as a result of psychological, physiological, or environmental triggers; however, encourage the patient to maintain a relatively normal lifestyle by optimizing trigger factors and using prophylactic medications.

• Psychological triggers include stress, anxiety, worry, depression, and bereavement. Emphasizing to the patient and family that migraine is not an imagined or psychological illness is important. Stress is not the sole cause, although it makes an underlying migraine predisposition more difficult to manage. The frequency of migraines can be reduced by maintaining a healthy lifestyle, but it cannot be eliminated.
• Physiological triggers include fever or illness, fasting, missing a meal, fatigue, and sleep deprivation. Encourage children with migraine attacks to maintain a routine with regular meal times and adequate sleep. Ice cream or cold is an interesting physiological stimulus. Raskin and Knittle found that ingestion of ice cream caused headaches in 93% of their migraine patients. The headache typically was located at the usual site of migraine pain.
• Environmental triggers of migraine include fluorescent light, bright light, flickering light, fatigue, barometric pressure changes, high altitude, strong odors, computer screens, or rapid temperature changes. Some report that complex visual patterns such as stripes, checks, or zigzag lines may trigger migraine attacks.
• Physical exertion can trigger childhood migraine. Some migraineurs report that they are more likely to develop a headache after participating in sports or being extremely active. Minor head trauma (eg, being hit in the head with a ball, falling on one's head) also may result in a migraine attack.
• Travel or motion may cause migraine, particularly in young children.

MEDICATION

Section 7 of 10  

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

The pharmacologic treatment of migraine headache and associated symptoms can be divided into analgesic, abortive, and prophylactic therapy. Analgesic and abortive therapies are for the treatment of occasional acute headache attacks and associated symptoms. Analgesic and abortive medications should not be used frequently because this may result in rebound headaches. In general, the earlier in an attack the pain is treated, the less severe the pain becomes. The longer the wait prior to starting therapy, the more difficult the pain is to control. Established migraines are notoriously difficult to treat successfully.

Gastric stasis occurs with migraine attacks and may prevent absorption of oral antimigraine agents. In addition to pharmacologic approaches, other approaches to reducing the severity of many childhood migraines include avoiding sensory stimulation (eg, bright lights, intense odors), applying ice packs, and resting in a quiet, dark room.

Prophylactic medications are taken daily over a prolonged period to reduce the frequency or severity of headaches and associated symptoms. None of the preventative medications is 100% effective in preventing all attacks; a good response to prophylactic medications is a 50% reduction in the frequency or severity of attacks. Reserve consideration of prophylactic drugs for children with frequent (>2/wk), prolonged, and disabling migraine attacks that do not respond to other treatments. Often, several weeks are necessary before therapeutic gains are observed with prophylactic medications.

Initially administer drugs at very low dosages and slowly titrate to therapeutic efficacy. This approach lessens adverse effects and results in better long-term patient compliance. No consensus exists on the duration of prophylactic medication usage, although most neurologists aim for 3-6 months of good symptom control.

Some patients must be maintained on long-term prophylactic therapy, and others tolerate drug holidays, particularly during summer when migraine attacks are less frequent for many children. Occasionally, prophylactic drugs are effective initially but they become ineffective with long-term prophylaxis. Subsequent prophylaxis with the same agent often is not as effective. Withdraw drugs slowly to prevent relapse and withdrawal symptoms.

For more information, see New Developments in Headache Diagnosis and Management. 

Drug Category: Analgesics

Initial therapy for patients with infrequent migraines.

Drug Category: Nonsteroidal anti-inflammatory agents

Used in acute attacks because of effects on prostaglandins, low cost, OTC availability, and uncommon association with rebound headaches.

Drug Category: Antimigraine agents

Abortive medications. Used to stop (abort) a migraine attack in progress. Although ergot derivatives were used frequently a decade ago, currently triptans provide a safer alternative. Occasionally, intravenous DHE may help in status migrainosus. Sumatriptan is good for shorter-duration headaches (0.5-2 h), but naratriptan (because of its longer half-life) may help more in longer (4-8 h) migraines.

Drug Category: Ergots

Abortive medications. Intravenous DHE is still used in relieving status migrainosus. Often, pretreatment with a benzodiazepine (eg, lorazepam 0.01 mg/kg IV), followed in 15-30 min by an antiemetic (eg, 0.1 mg/kg metoclopramide), followed in 15-30 min by 0.1-0.5 mg DHE is effective in treating status migrainosus. Intravenous fluids such as D5 NS or NS are administered simultaneously to improve hydration.

Drug Category: Tricyclic antidepressants

Prophylactic medications. Most published data discuss use of amitriptyline in migraine prevention. Some newer SSRIs may be involved in migraine prophylaxis; however, only limited studies are available. SSRIs likely are effective in some migraineurs.

Drug Category: Beta-blockers

Prophylactic medications. May decrease frequency and severity of migraine headaches by affecting central catecholaminergic system and brain serotonin receptors; 5-HT2 antagonist. Beta-blockers reduce headache frequency in approximately 70% of migraineurs. In addition to regular propanolol, long-acting forms of beta-blockers such as Inderal LA and atenolol are available.

Drug Category: Anticonvulsants

Prophylactic medication. Anticonvulsants, particularly those that interact with the GABAergic system, seem to have a positive effect in reducing migraine attacks. Valproate and gabapentin are used most commonly in this manner.