HEADACHES AND MIGRAINE

1. MIGRAINE
By: Dr. Kaustubh Bahatkar

2. 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

3. 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.

4. Analysis of pediatric MIGRAINE
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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.

5. 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

6. Migraine without Aura
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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

7. 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.

8. 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.

9. Continued…
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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.

10. ICHD-II diagnostic criteria for migraine with typical
aura
I. At least 2 Attacks fulfilling criteria II-IV
II. 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.

11. 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

12. Typical migraine with non-migraine
headache
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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 )

13. Typical aura without headache
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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

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

15. Childhood Periodic Syndromes
• These are common precursors of migraine
1. Cyclic vomiting
2. Abdominal migraine
3. Benign paroxysmal vertigo of childhood.

16. 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.

17. 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.

18. 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.

19. 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

20. Complications of migraine
1. Chronic migraine
2. Status migraine
3. Persistent aura without infarction
4. Migrainous infarction

21. 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.

22. 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
.

23. 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

24. 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

25. 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.

26. Detailed Headache History
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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

27. 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;

28. History contd
• Medical History : trauma, infection, allergies,
ventriculo-peritoneal (VP) shunt placement , epilepsy.
• Family History : headaches in first- and seconddegree relatives
• Social History : Changes or stressors in the home,
school, or outside should be obtained

29. 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.
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Increased intracranial pressure
Sinusitis
Dental disease
Abnormalities of the cervical spine
Tempo-mandibular joint disorders

30. 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

31. 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.

32. Three components are incorporated in treatment
plan
• Acute treatment strategy – for stopping headache
attacks
• Preventive treatment strategy – for frequent and
disabling headaches
• Biobehavioral therapy

33. 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.

34. 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

35. • 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

36. 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.

37. • References:
Nelson Textbook of Pediatrics
Rudolph`s pediatrics
IHS classification ICHD II
IAP Text book pediatrics

38. THANK YOU