Headache and Migraine

Headache and Migraine: Excerpt from The 5-Minute Pediatric Consult

Brad C. Klein, MD, MBA

Headache and Migraine - BASICS

Headache and Migraine - description

• Primary headache: No underlying condition (migraine, tension headache, cluster headache)
• Secondary headache: Symptomatic of a specific cranial, oral, dental, or cervical pathologic process (e.g., trauma or tumor)

Headache and Migraine - epidemiology

Headache and Migraine - prevalence

Headache prevalence increases toward 80% by age 15. Migraines may start by age 6–7. Between 3% and 5% of prepubertal children are affected; 2–3-year-olds may also have headache or “migraine equivalent” symptoms: Episodic vomiting, episodic ataxia that improves after sleep. Many youngsters may also suffer from chronic daily headache (a primary headache).

Headache and Migraine - DIAGNOSIS

Migraine in children can be divided into 3 groups:

• Migraine without aura: Most cases. Mood changes or withdrawal from activity, sensitivity to light and sound
• Migraine with aura: Migraine with visual spots, colors, image distortions, visual scotoma, vertigo, blurry vision, paresthesias
  • Basilar-type migraine (now classified as a migraine with aura): Vertigo, diplopia, ataxia, visual field deficits
• Migraine variants:
  • Vertigo, hemiplegic migraine
  • Alice in Wonderland syndrome: Distortions of vision, space, and/or time (e.g., micropsia, metamorphopsia, sensory hallucinations)
  • Confusional migraine: Impaired sensorium, agitation, and lethargy; may progress to stupor
  • Benign paroxysmal vertigo, cyclic vomiting, and abdominal migraine may also be pediatric migraine variants.

Headache and Migraine - signs & symptoms

Migraine without aura criteria:

• In children, 5 or more headache attacks that:
  • Last 1–72 hours
  • Have at least 2 of the following:
    • Bilateral (more common in children) or unilateral, frontal/temporal location
    • Pulsating quality
    • Moderate to severe intensity
    • Aggravated by routine physical activities
  • At least 1 of the following accompanies headache:
    • Nausea and/or vomiting
    • Photophobia and/or phonophobia (may be inferred from behavior)
  • 70% of those affected have a family history of migraine, especially those with migraine with aura

Headache and Migraine - history

• Clarify temporal pattern, location, duration, and intensity. Also, time of onset, associated symptoms, precipitating and ameliorating factors, response to therapy, and family history.
• The following questions should be considered:
  • Is there more than 1 type of headache? How are they different from each other?
  • Since they started, have headaches gotten worse or stayed the same?
  • How is the pain described? (e.g., pounding, squeezing, stabbing, or some other description)
  • Do the headaches occur at any special time of day?
  • Do they wake the sufferer up?
  • What does the patient do during the headaches?
  • Does the patient have ideas about what is causing the headaches?
• Migraine typically fits the acute-recurrent headache pattern (pattern 3, see below for pattern types). Nausea, vomiting, photophobia, phonophobia, and transitory neurological disturbances are more suggestive of migraine.
• Agitation, pacing, and loud crying are atypical for migraine.
• Tension headache usually presents as the chronic or episodic nonprogressive headache pattern (pattern 4). Pain is often bilateral, band-like, diffuse, dull, and of mild to moderate intensity
• Mixed headache pattern (pattern 5) refers to migraine superimposed on tension headache.

Headache and Migraine - physical exam

• Obesity: Consider pseudotumor or sleep apnea syndrome.
• Skin changes consistent with neurocutaneous syndrome: Patients with neurofibromatosis commonly experience headache
• Auscultation for bruits over the supraclavicular areas, neck, temporal and occipital areas: Arteritis, vascular malformation
• Examination for sinus tenderness, limitation of jaw excursion, or occipital trigger points
• Funduscopic exam: The presence of venous pulsations, best seen at the origin of branch points of the veins, definitively excludes intracranial hypertension (except in patients with glaucoma).
• Visual acuity examination may reveal eye strain–related headache.
• Neurological examination should be normal in primary headache syndromes (migraine, tension), except perhaps during a migraine with prolonged aura or migraine variant. Stiff neck, head tilt, decreased alertness, abnormal eye movements, asymmetric deep tendon reflexes, asymmetric motor weakness or sensory deficit, ataxia, and gait disturbance may signal infection, stroke, hemorrhage, tumor, or demyelination.

Headache and Migraine - tests

Headache and Migraine - imaging

• Neuroimaging studies (CT or MRI): Emergency evaluation should focus on identifying acute processes that require urgent intervention. These include subarachnoid hemorrhage, meningitis, and mass lesions causing elevated intracranial pressure that may lead to herniation.
  • CT should be used if there is any suspicion for subarachnoid hemorrhage, but otherwise MRI is generally preferred.
• Neuroimaging is not necessarily warranted in patients with acute-recurrent or chronic nonprogressive headache (patterns 3 and 4) who have normal findings on neurological exam.
• Neuroimaging should be performed for:
  • Acute 1st episode of severe headache (“worst headache of my life”)
  • Headaches or vomiting in the morning
  • Headache worse in supine position
  • Seizures
  • Cognitive decline
  • New, focal neurological symptoms or abnormal neurological exam findings (e.g., papilledema, hemiparesis, ataxia, asymmetric reflexes, abnormal eye movements, alteration of consciousness, nuchal rigidity)
  • Presence of ventriculoperitoneal shunt

Headache and Migraine - diag proced-surgery

• EEG: Although 10% of children with migraine may show nonspecific abnormalities, there is no role for EEG in routine testing of patients with headache.
• Other modalities:
  • Sinus films or CT if concern for sinusitis
  • Sphenoid sinusitis may produce unremitting chronic frontal headache.
  • Migraine may mimic sinusitis and vice versa.
• Lumbar puncture (LP):
  • In addition to meningitis, diagnostic considerations include subarachnoid hemorrhage, sinus thrombosis, pseudotumor cerebri, and low pressure headache.
  • CT (prior to LP): Considered in chronic progressive headache (pattern 2) in a nonfebrile patient, even when chronic migraine or tension headache is (statistically) more likely.
  • Measure opening pressure with patient recumbent to rule out pseudotumor cerebri (where result of cerebrospinal fluid analysis otherwise is normal).
  • Check urine drug screen in suspect cases.

Headache and Migraine - differencial diagnosis

A temporal pattern of headache can help clarify the differential. They can roughly be divided into 5 patterns:

• Pattern 1: Acute, 1st severe headache:
  • Meningitis, encephalitis, cocaine or other substance abuse, medication (methylphenidate, steroids, psychotropic drugs, analgesics, cardiovascular agents), hypertension (usually secondary); hydrocephalus, pseudotumor cerebri (idiopathic intracranial hypertension), post-LP, subarachnoid hemorrhage, intracerebral hemorrhage, ventriculoperitoneal shunt malfunction, sinus thrombosis, migraine, upper respiratory tract infection, somatization
• Pattern 2: Chronic progressive headache:
  • Brain tumor, abscess, hydrocephalus, vascular malformation, hematoma, chronic meningitis (e.g., Lyme disease), sinus thrombosis, idiopathic intracranial hypertension, drug induced, depression, anemia, rheumatologic diseases
• Pattern 3: Acute-recurrent headache
  • Migraine and variants, cluster, tension
• Pattern 4: Chronic nonprogressive or daily headache
  • Medication overuse, substance abuse, (rebound headache), caffeine, sinusitis, occipital neuralgia, temporomandibular joint syndrome, orthostatic headache, post-LP, other systemic disease, posttraumatic, sleep disorder, depression, anxiety, other psychiatric illness, tension headache, fibromyalgia
• Pattern 5: Mixed headache
  • Migraine-superimposed tension headache

Headache and Migraine - TREATMENT

Headache and Migraine - general measures

The management of migraine should include:

• Education and reassurance to both the patient and parents, emphasizing the absence of life-threatening disease; the episodic nature of migraine; genetic, lifestyle, and environmental factors
• Review expectations of therapy: Medicines help 60–70% of the time.
• Patient should keep a headache journal to identify possible triggers.
• Address comorbid depression, anxiety, substance abuse, and other medical conditions that may influence migraines: Orthostatic intolerance, nocturnal hypoventilation, asthma, diabetes, gut, or rheumatologic conditions.
• Nonpharmacologic approaches include avoiding triggers (e.g., caffeine, disrupted sleep, skipped meals, volatile chemicals, analgesic overuse, and dietary precipitants). Resolution of analgesic-induced rebound headache, if present, may require a few weeks.

Headache and Migraine - special therapy

Headache and Migraine - comp alt-medicine

• Relaxation techniques
• Stress management
• Biofeedback
• Vitamins and supplements such as riboflavin, magnesium, coenzyme q10, and feverfew

Headache and Migraine - medication

• Acute treatment:
  • Abortives are generally most effective if given early in the acute migraine attack.
  • 1st line is ibuprofen (10 mg/kg).
  • Acetaminophen (15 mg/kg) is probably effective and may have a quicker onset than ibuprofen.
• Additional acute treatments for refractory patients:
  • Antiemetics such as prochlorperazine and metoclopramide for nausea and vomiting also enhance the effectiveness of other analgesics and may abort migraines as adjunctive or monotherapy. Ondansetron may also be effective.
  • If unresponsive to conventional analgesics or antiemetics: Sumatriptan (Imitrex), nasal in 5, 10, or 20 mg was shown to be effective in Class 1 trials of 12–17 year olds.
  • Sumatriptan, 25-mg oral tablets; rizatriptan (Maxalt, Maxalt-MLT) 5–10-mg tablets or oral dissolving wafers; and zolmitriptan (Zomig) 2 mg tablets or oral dissolving wafers may provide relief, although not proven statistically. A SC injection of sumatriptan may be necessary. SC dose is 0.06 mg/kg; 3 mg for children >6 years and weighing <30 kg; 6 mg for those >30 kg.
  • Although trials in children demonstrate overall excellent safety profiles, triptans are not currently FDA approved for use in children or adolescents. Neither triptans nor ergotamines are recommended in patients with a basilar-type migraine, hemiplegic migraine, migraine with prolonged aura, or vascular risk factors.
  • Drugs containing isometheptene (Midrin) or butalbital (Fiorinal) may aggravate headaches.
• Status migrainosus:
  • Migraine lasting >72 hours
  • Hydrate patient with IV fluids: D5 1/2 NS or NS. Dehydration will exacerbate symptoms.
  • Raskin protocol: Dihydroergotamine
  • Linder modification: May be initiated in the emergency department or inpatient setting
    • Premedicate with metoclopramide 0.2 mg/kg PO 30 minutes before dose of IV dihydroergotamine (DHE-45): 6–9 years old: 0.1 mg; 9–12 years old: 0.15 mg; 12–16 years old: 0.2 mg.
    • This sequence is repeated q6h for up to 12 doses or until the pain abates or patient develops adverse effects.
  • IV valproate has similar effectiveness to DHE-45 and metoclopramide for status migrainosus. Typical administration: 15 mg/kg at 3 mg/kg/min up to 1 g
  • Corticosteroids and IV ketorolac may be effective, but they remain controversial.
  • Narcotics often lose efficacy, requiring dosages that soon cause greater levels of sedation than pain relief. Addiction and rebound potential is also of concern.
• Prophylaxis:
  • >10 headache days/month or 3–4 severe attacks per month (i.e., leading to missed school or social activities, etc.) constitutes a relative indication for prophylaxis.
  • Start medication at a low dose, and then increase weekly or biweekly toward a target maximum until headaches relent or adverse effects supervene. Choose a drug that may address other comorbidities.
    • Calcium channel blockers (e.g., verapamil)
    • Beta-blockers (e.g., propranolol, nadolol) are discouraged in patients with asthma, depression, or diabetes.
    • Tricyclic agents (e.g., amitriptyline, nortriptyline) may provide relief from insomnia or depression.
    • Anticonvulsants (e.g., topiramate, valproic acid) may have dual efficacy in patients with epilepsy.
    • Cyproheptadine, an antihistamine/antiserotonin agent, is often used in younger children (i.e., 5–12 years old).

Headache and Migraine - bibliography

1. Annequin D, Tourniaire B, Massiou H. Migraine and headache in childhood and adolescence. Pediatr Clin North Am. 2000;47:617–631.
2. Holden EW, Levy JD, Lewis DW, et al. Practice parameter: Evaluation of children and adolescents with recurrent headaches. Neurology. 2002;59:490–498.
3. Lewis D, Ashwal S, Hershey A, et al. Practice parameter: Pharmacological treatment of migraine headache in children and adolescents. Neurology. 2004;63:2215–2224.
4. Rothner AD, Linder SL, Wasiewski WW, et al. Chronic nonprogressive headaches in children and adolescents. Semin Pediatr Neurol. 2001;8:34–39.
5. Wang S, Fuh J, Lu S, et al. Chronic daily headache in adolescents: Prevalence, impact, and medication overuse. Neurology. 2006;66:193–197.

Headache and Migraine - CODES

Headache and Migraine - icd9

346.9 Migraine

Headache and Migraine - FAQ

• Q: What about allergy and headache?
• A: Many believe that headache may represent a symptom of hypersensitivity. Headache in the setting of allergic rhinitis/asthma may be owing to associated sinusitis/sinus congestion, side effect of treatment (especially theophylline), or muscle tension.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Migraine

• Back to disease: Migraine: Introduction
• Next Book Extract About Migraine: Surveys relating to Migraine
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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