Diagnosis and Treatment of Pediatric Migraine

Diagnosis and Treatment of Pediatric Migraine

Jack Gladstein
Published: US Neurological Disease 2007 - Issue I
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The diagnosis of pediatric migraine is easily made on the basis of a good history and a benign physical examination. Severe pain, nausea or vomiting, and photophobia or phonophia may be quite alarming to a youngster and his or her family. Parents are convinced that their child has a tumor, so addressing those fears must become part of the visit. Ironically, this is usually good news, since most of the time the symptoms will end up being those of migraine. Once a diagnosis of migraine is made, the physician can focus on the impact of headache on home life, work environment, and social interactions. All headache fits into four distinctive patterns. Rothner s model divides headache into acute, acute recurrent, chronic progressive, and chronic non-progressive (see Figure 1).1 Time is measured in days on the X axis and severity of headache is measured on an arbitrary scale on the Y axis. Migraine is the main culprit of headaches that fit into the acute recurrent pattern.

Migraine Diagnosis
In a landmark study2 in adults, patients with a chief complaint of migraine had a final diagnosis of migraine. Patients with a chief complaint of sinus headache had a diagnosis of migraine, and patients with a chief complaint of tension headache left with a diagnosis of migraine. In fact, 94% of adults presenting with a headache as their chief complaint had migraine. What this shows is that migraine is prevalent and under-diagnosed. In the Lipton population study,3 migraine was under-diagnosed by about 50%, yet the diagnosis is very easy. Adults need to experience more than five episodes of headache lasting from four to 72 hours with nausea or vomiting, photophobia and phonophobia, and inability to perform strenuous exercise. Pain is unilateral, but does not necessarily need to be. Even easier is bad pain with autonomic symptoms, which is migraine. Positive family history and need to rest support this diagnosis. Note that location is not mentioned: although classic teaching classifies headache as a unilateral frontal phenomenon, most headaches can be bilateral, temporal, occipital, or holocranial. Childhood migraine differs from adult migraine in that headache is shorter (1 72 hours) and more often bilateral.4 Further, children do not describe their pain well, so using expressions such as knife-like, throbbing, and vise-like are irrelevant for most youngsters they just say it hurts.5 When obtaining family history, it is important to ask if the affected family members had headache, not migraine, since other family members may have been misdiagnosed as well. In order to establish degree of disability during an attack, ask the patient if he or she could run up and down the stairs a few times during an episode. Migraine is a disease of young people, with peak prevalence in the first few decades of life.6,7 Migraine can be with or without aura; most children, however, have migraine without aura. Migraine aura, when present, is usually stereotypical.

A migraine attack can begin with a warning: patients may feel sluggish or hungry or have some word-finding difficulties that they will report in retrospect. There is a feeling of doom similar to that seen in seizure patients. An aura, however, is a memorable phenomenon. Wavy lines, beginning peripherally, move across the visual field, usually sparing the midline. This has been coined fortification spectra, since forts were built with jagged outpouchings to protect a larger periphery. Headache usually begins approximately 30 minutes after the onset of the visual aura. Migraine with aura is an easy diagnosis, but most pediatric migraineurs do not present with aura.4 Migraine without aura is just as easy if you stick to the paradigm acute recurrent headache that stops what you are doing, and has autonomic symptoms. Other common autonomic symptoms include dizziness, lightheadedness, pallor, or purple bags around the eyes. Ask the parent if he or she can tell just by looking that the child has a headache.

A migraine attack can begin with a warning: patients may feel sluggish or hungry or have some word-finding difficulties that they will report in retrospect. There is a feeling of doom similar to that seen in seizure patients. An aura, however, is a memorable phenomenon. Wavy lines, beginning peripherally, move across the visual field, usually sparing the midline. This has been coined fortification spectra, since forts were built with jagged outpouchings to protect a larger periphery. Headache usually begins approximately 30 minutes after the onset of the visual aura. Migraine with aura is an easy diagnosis, but most pediatric migraineurs do not present with aura.4 Migraine without aura is just as easy if you stick to the paradigm acute recurrent headache that stops what you are doing, and has autonomic symptoms. Other common autonomic symptoms include dizziness, lightheadedness, pallor, or purple bags around the eyes. Ask the parent if he or she can tell just by looking that the child has a headache.

In all forms of childhood migraine, time of day is not that helpful. Some patients routinely awaken in the middle of the night, some get worse as the day goes on, and some have no particular predictable pattern. Triggers vary from person to person and a long list of triggers has been implicated.9 One can tell patients that as a migraineurs, they are more susceptible to triggers in effect, they have a sensitive autonomic system that responds to triggers with migraine. Headache sufferers need to eat, exercise, and sleep regularly. School is a tremendous trigger. School stressors include waking up too early, worrying about grades, bullying, undiagnosed learning disabilities, and pressure from parents, to name but a few.10,11 Some foods to avoid include caffeine, monosodium glutamate (MSG), chocolate, cheese, and sulfites. However, adhering to this diet is onerous. An elimination trial is a better option for most, where one type of food is eliminated and then a judgment is made about whether this caused a difference. If not, the potentially migrainogenic food can be reintroduced in moderation.12 Migraineurs have a heightened sensitivity to flickering lights in the room, startle more easily, and have more sensitive skin interictally.13 They also have more gastroparesis even when not having a headache.14

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