Migraine and headache disorders are among the leading causes of disability and morbidity in the world. Migraine is the most frequent primary headache disorder in children and adolescents. Up to 18% of patients in the pediatric emergency room are found to be migraine-related. The diagnosis of migraine in children and adolescents remains a clinical diagnosis. The clinician must obtain a detailed and comprehensive headache history that focuses on location, quality, severity, and duration of the pain. Migraine in the pediatric population is slightly different than in the adult population, being mainly frontal rather than temporal/occipital and bilateral rather than unilateral. The successful treatment of pediatric migraine includes an individually tailored regimen of both non-pharmacologic and pharmacologic measures. Non-pharmacologic therapies, such as sleep hygiene patterns, diet, managing stress, exercise, and avoiding triggers. Many children with migraine disorder will need some form of prophylactic therapy. Successful migraine management in the pediatric population includes a very detailed and thorough history taking from the child and from the parents to understand the nature of triggers and how to avoid them. Pharmacologic therapies for migraine prophylaxis have been used successfully in the pediatric population and those including beta-blockers, calcium channel antagonists, serotonin antagonists, antidepressants, and antiepileptics. Only about 25% of patients suffer from only one or fewer migraine attacks per month; the majority of patients about 61% of patients had more than 4 major migraine attacks per month. This causes severe impairment in function and daily living during the attack. Similarly to adult migraine, once secondary headache causes are ruled, one can proceed with the diagnosis of migraine disorder.
Children with migraine have a genetic predisposition that is activated by a stimulus that could be environmental or physiological. Some of such stimulus is exposure to drugs, diet, stress, or puberty. Most children with a history of migraines seem to have a positive family history. Some studies have shown genetic contributions. However, it is not fully proven yet. For certain types of migraines such as hemiplegic migraine, genetic etiology is certain. Mutations have been reported in CACNA1A (calcium channel), ATP1A2 (Na/K-ATPase), and SCN1A (sodium channel) genes resulting in the development of hemiplegic migraine.
Migraine is one of the most burdensome of primary headache disorders in the pediatric population. Epidemiologic data help us to understand the scope and distribution of it. Knowing the sociodemographic, environmental risk factors usually help us to know which groups are at risk of migraine. Prevalence ranges from 5% to 40% in the pediatric population. The prevalence increases with age and reaches 80% at the time they transfer to adult neurologic care. Before puberty, no sex differences exist, but in later adolescence, females predominate. Another study showed that migraine prevalence estimates vary from 1% to 3% at seven years and 4% to 11% at 7 to 15 years. Before puberty, there is an equal prevalence in girls and boys, but after puberty, the prevalence is 2 to 3 times more common in girls.
Migraine is now considered a brain disease. In the past, it was thought of as a vascular disease. This new theory requires the brain to be genetically sensitive to migraine-inducing neurochemical changes that result in premonitory symptoms. These neurochemical changes lead to trigeminovascular activation and, eventually, neurogenic inflammation. This inflammation drops the threshold for trigeminal input entering the nucleus caudalis of the trigeminal nerve in the brain stem. These sensory changes from C1 and C2 dermatomes eventually synapse in the somatosensory and limbic cortices where conscious awareness of headache occur. The possible reason why children have more severe and cyclic vomiting compared to adults is related to their reduced cholinergic function. Centrally, area-postrema is considered the trigger zone and responds to neuronal and chemical emetic stimuli that are circulating. Peripherally, vagal pathways are involved in emetic stimulation. The act of emesis is coordinated via abdominal vagal nerve afferents that terminate in the tractus solitaries nucleus. Signals are mediated by multiple cholinergic and adrenergic neurotransmitters, mainly 5-HT, 5-hydroxytryptamine, which binds to the 5-HT3 receptor and substance P (SP), which binds to the neurokinin-1 receptor.
The patient must have at least 5 attacks that fulfill the criteria of migraine, which include the duration of at least an hour to 72 hours, unilateral location, and pulsating quality, moderate to severe in intensity, aggravated by activity. At least one of the following: nausea and/or vomiting or photophobia and photophobia. A thorough physical examination is needed, including blood pressure measurement, palpation of the head in search of sinus tenderness, nuchal rigidity. Must perform a funduscopic examination looking for papilledema, hemorrhage, or any pathology. Visual field examination should be done. Head circumference also is a must despite the age of the child. Examine the skin for any neurocutaneous finding that could indicate possible neurofibromatosis and tuberous sclerosis, which are highly associated with intracranial neoplasms and headaches as a result. Vomiting is more prominent in the pediatric migraine population. A study by Barlow showed that recurrent vomiting during their first 2 years in toddlers before migraine headaches start and other associated symptoms of migraine. It is important to administer the standard International Headache Society (IHS) questionnaire routinely for the child and the parents to complete.
While the diagnosis of pediatric migraine is mostly clinical, lab testing and neuroimaging may be needed in certain circumstances.
Indications for Lab Testing
Neuroimaging for patients with migraine may be indicated in the following scenarios.
Treatment for migraine is warranted in children if the headaches prevent the child from going through daily activities like going to school, playing, etc.
Strategies for Migraine Management
Recommended Abortive Treatment
For mild headaches - acetaminophen with a dosage of 15 mg/kg every 4 to 6 hours; ibuprofen 10 mg/kg every 6 to 8 hours; naproxen 15 mg/kg every 4 to 6 hours.
For moderate to severe headaches - the addition of a triptan may be necessary. Rizatriptan and sumatriptan, along with combination with analgesics, have been FDA approved to be used in children.
Recommended Preventive Treatment
If preventive medications are chosen, propranolol or nadolol (beta-blockers) can be given daily. Caution is advised in patients where beta-blockers are contraindicated, such as asthmatics, etc. Other medications that have proven useful include amitriptyline or nortriptyline, verapamil, antiepileptic agents (divalproex, topiramate, levetiracetam, and as used more in the past, phenobarbital and phenytoin), trazodone, and naproxen sodium.
Natural remedies such as ginkgolide B butterbur, riboflavin, magnesium, CoQ-10, polyunsaturated fatty acids, and oral melatonin have also proven efficient and have a lower side effect profile.
For status migrainosus, consider intravenous or intramuscular administration of a drug like valproate sodium (10 to 15 mg/kg), metoclopramide (5 to 10 mg), or prochlorperazine (2.5 to 5 mg).
Counseling- Additional aspects of counseling include the following: (1) reassurance to the parents about the prognosis; (2) avoidance of triggers (3) the importance of lifestyle adjustments such as proper sleep and water intake and (4) the importance of using analgesics early in the headache.
Addressing these issues may reduce the frequency and severity of headaches. Inadequate sleep might be due to obstructive sleep apnea, among other possibilities.
There are several other health conditions that may present like a pediatric migraine.
In one of the published studies, 25% of patients stopped having migraines by the age of 25 years. Another study reported about 80% improvement in migraine by the age of 10 years. Lidegaard et al. reported a significant association between migraine and stroke in women aged 15 to 45 years who smoked or were on oral contraceptives.
Migraine complicated by prolonged neurologic signs has rarely been associated with a permanent neurologic deficit, and some of these cases may have been due to unrecognized metabolic diseases.
It is crucial to seek clinical help with symptoms to rule out any other secondary causes of headaches. Studies have reported improvement in migraines with weight loss in obese children. Prenatal diagnosis may be available for hemiplegic migraine, for which genetic counseling is, thus, advised.
The management of migraine in the pediatric population is interprofessional. There are several types of treatments, and healthcare workers, including nurse practitioners, need to be aware of them. The nonpharmacological approach is considered the first line of treatment. If avoiding triggers and nonpharmacological approach is not helping with the headaches, then we start medications. There has not been enough evidence in the literature on interventional procedures such as botulinum toxin or nerve blocks in the pediatric migraine population. There has been enough evidence [Level 1] combination of pharmacological and nonpharmacological approaches is the best one. It is also imperative to do a thorough neurological and physical examination to rule out secondary headaches.
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