MIGRAINE

By: Dr. Kaustubh Bahatkar

HEADACHE• Headache is common complaint in children.

• Headaches often cause significant impact on life of child.

– Decreases school performance

– affects family interactions

– Causes social withdrawal

Most common type of primary headaches of childhood are

– Migraine

– Tension type headache

EPIDEMIOLOGY

• Up to 75% of children report having a significant headache by the time they are 15 years of age

• 10.6% of children between 5 to 15 years diagnosed as migraine.

Analysis of pediatric MIGRAINE

• 3-7 Years : (1.2% to 3.2% ) Slightly male predominance

• 7-11 Yrs : 4–11% Equal male and female predominance.

• 11- 15 years of age: 18–23% Female predominance• 15 – 19 Yrs : 28% had migraine, Females, migraine

without aura common• 90% of adolescents with migraine had a positive

family history.

According to international classification of headache disorder 2ND edition migraine classified as:

Migraine without aura    Migraine with aura     Typical aura with migraine headache     Typical migraine with non migraine headache     Typical aura without headache     Familial hemiplegic migraine     Sporadic hemiplegic migraine     Basilar-type migraine   Childhood periodic syndromes that are commonly precursors of migraine      Cyclic vomiting     Abdominal migraine     Benign paroxysmal vertigo of childhood   Retinal migraine    Complications of migraine     Chronic migraine     Status migraine     Persistent aura without infarction     Migrainous infarction    

Migraine without Aura

• It is most common type of migraine.• Diagnostic criteria for migraine without aura by ICHD II A. At least 5 attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully

treated) C. Headache has at least two of the following characteristics:

– unilateral location– pulsating quality– moderate or severe pain intensity– aggravation by routine physical activity (eg, walking or climbing

stairs) D. During headache at least one of the following:

– nausea and/or vomiting– photophobia and phonophobia

E. Not attributed to another disorder

Migraine with aura

• Aura is neurological warning that precedes headaches.

• Typical aura can be visual, sensory or dysphasic lasting more than 5 min and less than 60 min with headache starting within 60 min.

• Visual aura like photopsia is most common type of aura in children and adolescents.

• Sensory aura occur unilaterally. children describe this sensation as insect or worms crawling from their hand up to face with numbness.

• Dysphasic auras it is least common type. It is an inability to respond verbally.

Pathophysiology of Aura• Cortical spreading depression is associated with migraine

aura• CSD is depolarization wave that moves across cortex at

rate of 3 to 5 mm/ min.• Alteration in neocortical function begins in occipital

region.• Activation of trigeminal afferents, trigeminovascular

neurogenic inflammation, neuronal excitation in trigeminal brainstem nuclear complex.

Continued…

• Sensory information is subsequently transmitted to thalamus, limbic and brainstem areas, nucleus raphe magnus and reticular formation.

• These areas are involved in regulation of autonomic, endocrine, affective and motor function.

• Their activation result in symptoms such as photophobia, nausea, vertigo, dysphoria and fatigue.

ICHD-II diagnostic criteria for migraine with typical aura

I. At least 2 Attacks fulfilling criteria II-IVII. Aura consists of at least 1 of following but no motor weakness. A. Fully reversible visual symptoms. B. Fully reversible sensory symptoms. C. Fully reversible dysphasic speech disturbance.III. At least 2 of the following. A. Homonymous visual symptoms and unilateral sensory

symptoms B. At least 1 aura symptom develop gradually over >5 min

different aura symptoms occur in succession over >5 min. C. each symptom lasts >5min and < 60 min.IV. Headache lasting 4-72 hrs.V. Not contributed to another disorder.

Familial hemiplegic migraine

• Autosomal dominant form of migraine with aura• It is characterized by prolonged hemiplegia

accompanied by numbness, aphasia, and confusion. Which precede, accompany, or follow the headache.

• Headache is usually contralateral to the hemiparesis

Typical migraine with non-migraine headache

• Typical aura consisting of visual or sensory or speech symptoms.

• At least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes

• each symptom lasts ≥5 and ≤60 minutes• This type of migraine Headache does not fulfil

criteria B-D for Migraine without aura. (B. Headache attacks lasting 4-72 hours, D. During headache at least one of the following: nausea and/or vomiting, photophobia phonophobia )

Typical aura without headache

• Typical aura consisting of visual or sensory symptoms with or without speech symptoms

• Each symptom lasts ≥5 and ≤60 minutes

• Headache does not occur during aura nor follow aura within 60 minutes

Basilar migraine

• It is migraine with aura symptoms clearly originating from the brainstem and/or from both hemispheres simultaneously affected, but no motor weakness.

• Aura consisting of at least two of the following fully reversible symptoms, but no motor weakness:

– Dysarthria

– Vertigo

– Tinnitus

– Diplopia

– Occipital headache

– visual symptoms simultaneously in both temporal and nasal fields of both eyes

– ataxia

– simultaneously bilateral paraesthesias

Childhood Periodic Syndromes

• These are common precursors of migraine

1. Cyclic vomiting

2. Abdominal migraine

3. Benign paroxysmal vertigo of childhood.

Cyclic vomiting• It is characterized by recurrent, sometimes monthly bouts of

severe vomiting that may be so intense that dehydration and electrolyte abnormalities occur, particularly in infants.

• The vomiting may be projectile and persist for 1–5 days.• After a period of deep sleep, the child awakens and resumes

normal play and eating habits as if the vomiting had not occurred.

• Vomiting during attacks occurs at least 5 times/hr for at least 1 hr.

• Cyclic vomiting is treated with rectally administered or injected antiemetics such as ondansetron and careful attention to fluid replacement if the vomiting is excessive.

Abdominal migraine

• It is characterized by Recurrent mid-abdominal pain. The pain may persist from 1 to 72 hr.

• To meet the criteria of abdominal migraine, the child must complain at the time of the abdominal pain of at least two of the following: anorexia, nausea, vomiting.

• Mid-abdominal pain with pain-free periods between each attack.

Benign paroxysmal vertigo of childhood

• The onset is usually between 2 and 8 years of age.• symptoms are -Repeated episodes of positional vertigo. -Short duration (paroxysmal): Lasts only seconds to

minutes -Positional in onset: Can only be induced by a change in

position. -Nausea is often associated -Associated with nystagmus• Some children complain of vertigo or dizziness as an

initial feature of later migraine attacks. • The vertigo becomes progressively less severe and may

disappear altogether.

Retinal migraine• International Headache Society defines RM as “at least two

attacks of fully reversible monocular visual disturbance (positive or negative), associated with migraine headache within sixty minutes of the visual event”.

• The neuro-ophthalmic examination must be normal between attacks and the visual events must not be attributable to another disorder.

• visual disturbance like:

-flashing lights

-blind spots in your field of vision

-blindness in the eye

Complications of migraine

    

1. Chronic migraine    

2. Status migraine    

3. Persistent aura without infarction    

4. Migrainous infarction

Chronic migraines• The name "transformed migraine" is also used, since

chronic migraines can evolve (or transform) from episodic to almost daily headaches.

• The symptoms of a chronic migraine are the same as a "usual" migraine including unilateral headache that is usually described as "throbbing," pain. 

• Headache present more than 15 days out of the month for at least 3 months.

Status migraine

• It is a severe form of migraine.• Continuous headache for over 72 hours. • In addition, patients must have at least one of the

following:

-Nausea and/or vomiting

-Photophobia and phonophobia

.

Persistent Aura without Infarction

• one or more of the aura symptoms last for longer than a week, rather than disappearing after the migraine starts. 

• Most commonly visual aura are involved

-Zigzag lines

-Flashing lights

-Visual hallucinations

-Temporary blind spots

-Light sensitivity

Migrainous infarction• According to the International Headache Society, it

consists of "one or more migrainous aura symptoms associated with an ischemic brain lesion in appropriate territory demonstrated by neuroimaging.“

• Migraine to fit the criteria for Migrainous Infarction, it must include the following:

-The migraine must be associated with aura -The migraine attack must be similar in intensity to

previous migraines -The aura symptoms must last longer than 60 minutes -The stroke must occur in the area of the brain that can

explain the aura symptoms -The stroke cannot be caused by another medical

condition

Approach to case of headache

• A detailed history and medical examination is most sensitive indicator of underlying etiology.

• The first step in evaluating a child with headache is to rule out secondary causes

• Neuroimaging is done when neurological examination is abnormal.

Detailed Headache History

• Length of time the child has had headaches • Severity • Quality :Throbbing, pulsating, tightness. • Location :frontal, temporal, occipital, unilateral,

bilateral • Duration : number of minutes, hours, or days• Frequency : number per month, time interval

between headaches • The effect on the child’s quality of life and disability • Any aura before headaches • Presence of Nausea/ vomitting

History contd

• Time of onset: specific time of day, night-time waking, relationship to particular activity.

• reliving factors: sleep, exercise, quiet, dark room • Associated factors: photophobia, phonophobia • Lifestyle factors: sleep pattern, exercise; diet.• Prior treatment: response to past treatment, frequency of

use of medications.• Activities; changes in school attendance or performance;

History contd

• Medical History : trauma, infection, allergies, ventriculo-peritoneal (VP) shunt placement , epilepsy.

• Family History : headaches in first- and second-degree relatives

• Social History : Changes or stressors in the home, school, or outside should be obtained

Physical Exam

• Conducting a physical examination is important, with an emphasis on the neurological examination.– Include a thorough search for potential sources of

secondary headache. • Increased intracranial pressure

• Sinusitis

• Dental disease

• Abnormalities of the cervical spine

• Tempo-mandibular joint disorders

Indications for Neuroimaging in a Child with Headaches

 

• Abnormal neurological signs  • Recent school failure, behavioral change, fall-off in linear growth rate  • Headache awakens child during sleep; early morning headache, with

increase in frequency and severity  • Periodic headaches and seizures coincide, especially if seizure has a focal

onset  • Migraine and seizure occur in the same episode, and vascular symptoms

precede the seizure (20–50% risk of tumor or arteriovenous malformation)  • Headaches in child; <6 yr whose principal complaint is a headache. child

can not describe headache.  • Focal neurological symptoms or signs developing during a headache (i.e.,

complicated migraine)  • Focal neurological symptoms or signs develop during the aura, with fixed

laterality; • Brief cough headache in a child or adolescent

MANAGEMENT

The American Academy of Neurology established useful practice guidelines for the management of migraine as follows:

1. Reduction of headache frequency, severity, duration, and disability  

2. Reduction of reliance on poorly tolerated, ineffective, or unwanted acute pharmacotherapy's  

3. Improvement in quality of life  

4. Avoidance of acute headache medication escalation  

5. Education and enabling of patients to manage their disease to enhance personal control of their migraine.  

6. Reduction of headache-related distress and psychological

symptoms.

Three components are incorporated in treatment plan

• Acute treatment strategy – for stopping headache attacks

• Preventive treatment strategy – for frequent and disabling headaches

• Biobehavioral therapy

Acute treatment strategy

• This mainly include 2 groups of medicines: 1. NSAIDS Ibuprofen at dose of 7.5-10 mg/kg over use needs to be avoided not more than 2-3 times a

week 2. Triptans Almotriptan used for treatment of acute migraine. Used for moderate to sever attacks, restricting use to 4-6 times per

month.

PREVENTIVE THERAPY• IF HEADACHES ARE FREQUENT >1/WK AND

DISABLING.• Prophylactic agent should be given for atleast 4-6

months and then weaned.• Multiple preventive medications are used like:

-Calcium channel blockers like Flunarizine

-Antiepileptic drugs

-Antidepressants like amitriptyline most commonly

used

-Antihistamines like cyproheptadine

• PROPHYLAXIS• Calcium channel blockers Flunarizine[*]5 mg at hs. Calcium channel blocking agent. • Antihypertensive: Propranolol (contraindicated in

asthma)10–20 mg tid. Nonselective β-adrenergic blocking agent.

• Anticonvulsants: Sodium valproate5–20 mg/kg/day (begin 5 mg/kg/24 hr)

↑ 5 mg/kg/wk Topiramate 100-200mg/day two divided. Gabapentin 900–1200 mg/day in two divided doses.• Antihistamines Cyproheptadine 0.2–0.4 mg/kg/BD

H1-receptor & serotonin agonist.• Antidepressants Amitriptyline Children: 1 mg/kg/day

Biobehavioral therapy

• The patient and parents must understand that these objectives are lifetime goals that can control the effect of migraines and minimize the use of medication

• Essential for children to maintain a lifetime response to the treatment and management of their headaches.

• Adequate fluid hydration, with limited use of caffeine • Regular exercise • Adequate nutrition through regular meals and a balanced diet • Adequate sleep • Lifestyle changes may result in an overall long-term

improvement in quality of life and may reverse any progressive nature of the disease.

• References:

Nelson Textbook of Pediatrics

Rudolph`s pediatrics

IHS classification ICHD II

IAP Text book pediatrics

THANK YOU