Migraine headache in children

The diagnosis is clinical.

Clinical history

Migraine with or without aura

• Food triggers (e.g., cheese, chocolate, citrus fruits) and stress may be triggers in predisposed children.[17]Rothner AD. Childhood migraine: clinical features, classifications and diagnostic criteria. In: Abu-Arefeh I, ed. Childhood headache. London: MacKeith Press; 2002:54-65.[18]Hamalainen ML. Medical and dietary management of headache and migraine. In: Abu-Arefeh I, ed. Childhood headache. London: MacKeith Press; 2002:136-48.[19]Passchier J, Orlebeke JF. Headaches and stress in schoolchildren: an epidemiological study. Cephalalgia. 1985 Sep;5(3):167-76. http://www.ncbi.nlm.nih.gov/pubmed/4042154?tool=bestpractice.com

• Patients >2 years of age commonly present with gradual onset of unilateral or bilateral headache with or without aura, and are completely well in between attacks.

• Associated symptoms include nausea, vomiting, diplopia, photophobia, phonophobia, and blurred vision.

• There may be a link between childhood migraine and periodic syndromes that include cyclical vomiting, benign paroxysmal torticollis, benign paroxysmal vertigo of childhood, and abdominal migraine. These conditions may be precursors to or associated with migraine.

Migraine with brainstem aura

• Brainstem signs predominate, and the major symptoms include occipital headache, ataxia, diplopia, blurred vision, vertigo, and tinnitus.

• Ptosis may be evident, with dilated pupils; altered consciousness level and a generalised seizure may develop. Post-attack there is a complete return to normality.

• Many develop migraine with or without aura later in life, and most have a strong family history of migraine.

Hemiplegic migraine

• Manifests as unilateral motor or sensory signs during an episode of migraine.

• Attacks may persist for days. More than one attack is unusual in childhood, although a positive family history is common.

Migraine may also present as an acute confusional state, preceded by some of the symptoms typical of migraine with or without aura. Great care must be taken to exclude more serious alternative diagnoses before this diagnosis is reached.

Physical examination

For the diagnosis to be secure, physical examination should be normal. The presence of any of the following together with headache suggests an alternative diagnosis, and should be specifically looked for and excluded:

• Altered consciousness

• Seizure

• Inappropriate behaviour (especially if recent onset)

• Increasing head circumference, 'sun-setting eyes', and prominent scalp veins

• Papilloedema

• New or worsening squint

• Hypertension with or without bradycardia

• Cranial nerve palsies or motor deficits

• Cerebellar signs

• Hepatosplenomegaly.

Clinical investigations

For a child with a classic clinical presentation and a normal physical examination, no investigation is required. Routine laboratory studies, lumbar puncture, and electroencephalogram are not recommended.

Brain computed tomography or magnetic resonance imaging are not typically indicated; however, realistically there are individual cases where it is essential to allay extreme levels of anxiety. Such imaging may prove 'therapeutic', although there remains a risk of detecting an incidental anxiety-enhancing (and asymptomatic) abnormality: for example, an Arnold-Chiari malformation.[3]Goadsby PJ. To scan or not to scan in headache. BMJ. 2004 Aug 28;329(7464):469-70. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15331454 http://www.ncbi.nlm.nih.gov/pubmed/15331454?tool=bestpractice.com The presence of hypertension, bradycardia, altered consciousness level, or any focal neurological deficit suggests a more serious injury or alternative diagnosis and is an indication for urgent central nervous system imaging. In very rare cases, scan may demonstrate focal ischaemia in patients with hemiplegic migraine.

Neuroimaging and infection screening is mandatory for suspected migraine with brainstem aura, to exclude alternative diagnoses.