History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include positive FHx of migraine; chocolate, cheese, citrus fruits; stress; menses; and use of oral contraceptives.
age >2 years
Migraine is rarely diagnosed in children <2 years of age because of the symptom-based definition, but diagnosis increases steadily with age thereafter.[1][4][20]
The mean age at onset is 7.2 years for boys and 10.9 years for girls, with 20% of children experiencing their first attack before the age of 5 years.
The symptom-based definition precludes diagnosis in very young children.[5][6] Incidence increases steadily with age.
gradual onset of headache
Onset is usually gradual over approximately 15 minutes.
A sudden, abrupt onset of a severe headache, particularly if occipital, is not typical of migraine.
normal physical examination
For the diagnosis to be confirmed, physical examination should be normal.
Other diagnostic factors
common
aura
May be associated with migraine.
May include change to visual perception (wavy lines), flashing lights, or deja vu.
nausea and/or vomiting
May be associated with migraine.
visual disturbance
Diplopia, blurred vision, and photophobia may be associated symptoms.
phonophobia
May be associated with migraine.
uncommon
occipital headache, ataxia, diplopia, blurred vision, vertigo, and tinnitus
Associated with basilar migraine.
unilateral motor or sensory signs and headache
Associated with hemiplegic migraine.
More than one attack is unusual in childhood, although a positive family history is common.
ptosis
Ptosis may be evident, with dilated pupils, in patients with basilar migraine.
generalised seizure
Altered consciousness level and a generalised seizure may develop in patients with basilar migraine.
Risk factors
strong
positive family history of migraine
Migraine is approximately 50% more likely in relatives of people with the condition than in those whose relatives do not have it.[16]
chocolate, cheese, and citrus fruits
Food triggers for migraine are relatively infrequent and occur in <10% of patients.[17][18] Cheese and chocolate are classic precipitants in predisposed children, and a trial of empirically removing them from the diet is a reasonable initial approach.
Much of the evidence for risk factors in paediatric migraine has been extrapolated from data from adult studies.
stress
Stress may be contributory in as many as 25% of children; school and interpersonal relationships are the most common source of difficulty.[19]
Much of the evidence for risk factors in paediatric migraine has been extrapolated from data from adult studies.
hormonal changes
In affected children and adolescents it is likely that gonadal hormone fluctuation (e.g., with menses and oral contraceptive use) accounts for the pattern of symptoms.
It affects only a minority, although in those affected the strength of association is strong.
Much of the evidence for risk factors in paediatric migraine has been extrapolated from data from adult studies.
weak
alcohol and caffeine
A trigger in a small minority.[18]
Much of the evidence for risk factors in paediatric migraine has been extrapolated from data from adult studies.
volume depletion
A trigger in a small minority.[18]
Much of the evidence for risk factors in paediatric migraine has been extrapolated from data from adult studies.
overuse of analgesics
A trigger in a small minority.[18]
Much of the evidence for risk factors in paediatric migraine has been extrapolated from data from adult studies.
sleep disturbance
Lack of sleep can be a significant trigger for many children.
Much of the evidence for risk factors in paediatric migraine has been extrapolated from data from adult studies.
bright or flickering lights
A trigger in a small minority.[18]
Much of the evidence for risk factors in paediatric migraine has been extrapolated from data from adult studies.
periodic syndromes
There may be a link between childhood migraine and periodic syndromes: for example, cyclical vomiting, benign paroxysmal torticollis, benign paroxysmal vertigo of childhood, and abdominal migraine.
These conditions may be precursors to or associated with migraine.
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