Type of headache

Migraine

• episodic attacks
• focal
• associated with nausea and vomiting
• bilateral and bifrontal

Diagnosis of migraines

• can occur in 10.6% of 5-15 yr old children

migraine without aura

• recurrent and episodic

• usual duration 4-72 hrs

• young children can have much shorter duration (2-72 hrs)

• if child falls sleeps with headache - sleep period is considered duration of headache

• beyond 72 hours - status migrainosus

• worsening while doing daily activities like walking upstairs or downstairs

• overlap of abdominal symptoms

  • recurrent vomiting
  • recurrent abdominal pain
  • early morning vomiting

• babies with high colicky pain can often end up in migraine

• vomiting + ----> think of raised intracranial pressures

  • vomiting improves after starting daily activities - intracranial pressure
  • vomiting worsens after starting routine activities - migraine

• 90% have familial preponderance

• additional triggers

  • skipping meals
  • inadequate sleep
  • dehydration
  • weather changes
  • pattern association (Monday mornings, before schools, menses)

migraine with aura

• most common aura - photopsia
  • flashes of light
  • multicolored
  • fortification spectra (brilliant white zig-zag lines)
  • shimmering scotoma (shinning spot that grows or a sequined curtain closing)
• sensory auras (less common)
  • insects crawling from hand, arm to face
  • associated with numbness
• dysphasic auras
  • inability or difficulty to respond verbally

hemiplegic migraine

• transient unilateral weakness lasting for hours to days
• familial and sporadic forms
• mutations in CACNA1A, ATP1A2, SCN1A
• triggered by head trauma, exertion and emotional stress
• motor weakness is associated with other aura symptom that slowly progress over 20-30 mins
• headache has no relation to motor weakness
• rarely can cause
  • coma with encephalopathy
  • CSF pleocytosis
  • cerebral edema

migraine with brainstem aura (basilar type migraine)

disorder of basilar artery
can cause symptoms as described above
pupils dialated and ptosis evident

syndrome of transient headache and neurological deficit with CSF pleocytosis

• migraine like headaches with neurological deficits
• not reported in pediatric population

childhood periodic syndromes

• group of recurrent episodic events that frequently occur with migraine
• events include
  • GI related symptoms
    • colic
    • motion sickness
    • recurrent abdominal pain
    • recurrent vomiting
    • abdominal migraine
  • sleep disorders
    • sleep walking
    • sleep talking
    • night terrors
    • unexplained recurrent fevers
• most have family history
• cyclic vomiting can sometimes cause dehydration
• must be differentiated from other causes
• diagnosis of exclusion

abdominal migraine

• migraine without headache
• mid-abdominal pain with free pian between attacks
• 1-72 hrs
• must be associated with anorexia, nausea, vomiting, pallor

diagnosis

• Detailed history including
  • frequency
  • duration
  • severity
  • use of medicines
  • disability
• Family history is very important almost all cases of migraine has family history
• History of potential comorbid conditions
• drug use
• some patient with chronic migraine might have increased cranial pressure without papilledema in which CSF drain can relieve pain
• CADASIL (cerebral autosomal dominant arteriopathy with subcortical infracts and leukopathy), moya moya disease, SMART (stoke like migraine attacks after radiation therapy) can initially present with migraine
• indications for neuroimaging
  • neurological imaging abnormal
  • migraine on awakening
  • migraine causing waking from sleep
  • negative family history
• imaging indication of choice - MRI
• in case of acute headache - Do CR to look for blood ---> if negative do CSF to rule out xanthochromia

Treatment

Acute management

1. NSAIDs
2. Triptans

NSAIDS

• Ibuprofen at 7.5 to 10 mg/kg/day
• Acetaminophen at 15 mg/kg/day
• Aspirin can be tried in older children
• Naproxen sodium
• Can use a maximum of 2-3 times per week to prevent transformation into medication overuse headache

Triptans

• if migraine is severe then use triptans
• 3 triptans approved by the FDA
  • Almotriptan for children aged 12 to 17 yrs
  • Rizatriptan for children as young as 6 yrs
  • zolmitriptan for children 12 and over
• intranasal sumatriptan with naproxen sodium is effective in children 8 yrs and older
• can be used for upto 4-6 headaches per weeks
• Adverse effects - tightening of jaws, chest and fingers; feeling of grogginess; and fatigue from central serotonin effect

if more than 6 episodes per weeks then hydration can be tried as a abortive therapy

Antiemetics can be tried as with acute therapy
Antiemetics with dopaminergic activity can have the best efficacy. (prochlorperazine, metoclopramide)

in case of status migrainosus, ergots can be tried

emergency room management of migraine

Antidopaminergic drugs (prochlorperazine, metoclopramide)

• not only control nausea vomiting associated with migraine, but can abort migraine itself
• metoclopramide (0.13-0.15 mg/kg/day) max dose of 10mg given IV over 15 mins
• extrapyramidal side-effects can be treated with diphenhydramine

NSAIDS - ketorolac

• prevent aseptic inflammation associated with migraine when used alone of with prochlorperazine

Antiepileptics - valporate

• mechanism is not understood
• 15-20 mg/kg IV bolus followed by 15-20 mg/kg/day oral can abort migraine

triptans

• sublingual sumatriptan can be given
• contraindicated if the child is treated with ergots in the last 24 hours or MAO inhibitors in the last week
• DHE should not be given within 24 hr of sumatriptan use
• can lead to serotonin syndrome

Ergots - Dihydroergotamine (DHE)

• used in the management of intractable and status migrainosus

status migrainosus

6-7% of patients can fail emergency room treatment
those patients can need prolonged admission in hospitals for 3-5 days
they can be treated with DHE, valproate, antiemetics etc

DHE to be premedicated with prochlorperazine. 0.5 to 1 mg of DHE can be given, effect is seen within the fifth dose.
Valproate 15mg/kg bolus followed by 7.5mg/kg every eight hourly upto 10 doses can be tried

preventive therapy

used in children who suffer from frequent ( more than 1 headaches per week) or disabling headaches (pedMIDAS score >20). To be given for at least 4-6 months for the improvement in the life.

Flunarizine

• calcium channel blocking agent
• start with 5mg orally increased to 10mg after months
• off period of 1 month for every 4-6 months

amitriptyline

• 1 mg/kg is effective
• this does need to be gradually raised over 2 weeks
• adverse effect - weight gain, QT prolongation

antiepileptics

• topiramate, valproate, levetiracetam
• topiramate 50 mg/day. adverse effects include weight loss, paresthesia, kidney stones, low bicarbonate levels, rarely glaucoma
• valproate 10mg/kg twice a day,

β blockers

• propranolol
• CI in asthma or allergic reaction
• most effective in basilar type of migraine

cyproheptadine 0.1-0.2 mg/kg orally twice a day. riboflavin 25-400 mg, CoQ 1-2 mg/kg/day, butterbur are other modalities that can be tried

Onabotulinismtoxin A is first FDA approved drug for chronic migraine in adults.

Eptinezumab, erunumab, galcanezumab, fremanezumab are some monoclonal antibiotics against the calcitonin gene related peptide.

behavioral therapy

• identification of behavioral barriers to treatment
• adherence to treatment is important
• discussion of healthy habits (avoidance of skipping of meals, hydration, avoidance of caffeine, exercise etc..)
• sleep for 8-9 hours
• biofeedback associated relaxation and cognitive behavioral therapy are effective

transition from pediatric to adult health care provider

OCPs can prevent menstural migraine. but OCPs is not approved for treatment of menstrual migraine.

Secondary headaches

• can occur after head trauma
• chronic headache if occurs 3 months after head trauma
• pervious h/o headache, family history are at higher risk of conversion into chronic migraine
• can sometimes present with features of primary headaches like tension type, migraine or cervicogenic headaches
• may require frequent analgesics - can sometime lead to medication overuse headache
• can be complicated by headache relapses

sinus headache

• over-diagnosed
• headaches are recurrent and respond to analgesics then migraines should be suspected
• in the absence of chronic cough, nasal discharge, fever - sinus headache should not be made

medication overuse headache

• headache more than 15days / month for 3 months with h/o taking analgesics 15 days / month or prescription medication including triptans more than 10 days / month
• if the patient is complaining of decreased effectiveness following medication, medication overuse headache should be suspected

raised intracranial pressure

• can be caused by mass, or intrinsic increase in pressure
• headache is caused by increased pressure on dura
• idiopathic intracranial hypertension can be caused by increased ingestion of fat soluble vitamins like vitamin A, minocycline, hormonal changes, or blocked venous drainage due to causes like mastoiditis
• MRA or MRV should be performed
• if headache persist or visual changes present - carbonic anhydrase inhibitors, optic nerve fenestration or shunt need to be considered

other causes

• arteriovenous malformation, berry aneurysms, collagen vascular diseases, hypertensive encephalopathy, infective etiology, subarachnoid hemorrhage

Tension type headache

ICHD-3 classification

• mild to moderate
• generalized
• not affected by physical activity
• non throbbing
• not commonly associated with photophobia or increased sensitivity
• never associated with more than 1 time vomiting

• same general principles in medicines in migraines in children can be applied to TTH
• simple analgesics like ibuprofen can be effective in treatment
• Flupirtine approved in EU for children more than 6 yrs
• amitriptyline has most evidence of effective prevention of TTH
• biofeedback associated relaxation and cognitive behavioral therapy are effective