migraine in children

1. MIGRAINE
Presentation By: Dr. Rafi
Moderator: Dr. Vishnu Vandana

2. INTRODUCTION
• Headache is a common complaint in children and teenagers.
• It has both high incidence and prevalence , the burden of
this problem impacts not only the child but also the family
including school performance, social life , mental health and
quality of life.
• It is common during childhood and incidence increases with
age.
• Boys are involved more pre pubertally and girls are more
involved post pubertally.

3. MIGRAINE
• It is the most frequent type of recurrent headache that
is brought to the attention of parents & primary care
providers.
• It is characterized by episodic headaches that may be:
 Moderate to severe in intensity,
 Focal in location on the head,
 Have a throbbing quality, and
 May be associated with nausea, vomiting, light
sensitivity, and sound sensitivity.

4. • Up to 75% of children report having a significant headache
(migraine) by the time they are 15 year old.
• Recurrent headaches are less common, but remain highly
frequent.
• Migraine has been reported to occur in up to 10% of children
between the ages of 5 and 15 year, and up to 28% of older
adolescents.
• When the headaches become frequent, they convert into
chronic daily headaches in up to 1% of children.

5. PATHOPHYSIOLOGY
Vascular theory
Triggers
vasoconstriction
reduced blood
flow
aura
Vasodilation
distended
blood vessel
pain

7. PATHOPHYSIOLOGY
• Neurovascular theory:
• According to this migraine is primarily a
neurogenic process with secondary vascular
changes.
• A migraineur has a state of neuronal
hyperexcitability in the cerebral cortex.

8. Cortical spreading depression
• Is a wave of neuronal excitation in the cortical gray
matter that spreads slowly from origin site at the rate
of 3mm/min, followed by neuronal depression.
Trigeminovascular system activation
• CSD causes activation of TGVS
• results in release of vasoactive peptides including
calcitonin gene-related peptide, neurokinin A and
substance P
• It leads to vasodilatation of meningeal vessels, plasma
extravasation and degranulation of mast cells leads to
aseptic inflammation.

9. genetics
Hyperexcitability of cerebral
cartex
triggers
Cortical spreading depression
Activation of TGVS
Neurogenic Inflammation,
Meningeal Vasodilation
AURA
HEADACHE

10. Reactivation of trigeminal nerve
Pain carries to brainstem ,
thalmus
Central sensitization

12. CLINICAL PRESENTATION
Present with episodic headache with charecteristic features
• throbbing or pulsatile
• Moderate to severe in intensity
• Unilateral, bilateral
• localized in the frontotemporal
• Last for 4-72 hrs
• Nausea(80%), vomiting(50%), anorexia
• Sensitivity to light, sound
• Light headedness
• Hemiparesis, aphasia, parasthesia
• Approx 70% of patients have a first-degree relative with a
history of migraine

13. Aura
• It is a complex of neurologic symptoms that may precede or
accompany the headache phase or may occur in isolation.
• Usually develops over 5-20min and lasts less than 60 minutes.
• Can be visual, sensory, motor or combination of these
Visual:
• central scotoma, tunnel vision
• Scintillating scotoma-highly characteristic of migraine
• Negative visual phenomenon such as homonymous
hemianopia
• Photopsia or flashes of light
• Micropsia, macropsia.

15. Paresthesia
• Occurring in 40%of cases constitute the next most
common aura.
Sensory symptoms
• rarely occurs in isolation and usually follows visual
aura.
Motor symptoms may occur
Speech and language disturbances have been reported
in 17-20% of patients

16. PHYSICAL EXAMINATION
• Thorough neurologic examination is essential,
results will be normal in majority
• Possible findings may include
• Cranial/cervical muscle tenderness
• Horner syndrome
• Tachycardia/ bradycardia
• Conjunctival congetion
• Hypertension/hypotension
• Hemisensory/ hemiparetic neurological deficits(
complicated migraine)

17. Findings that suggest a headache diagnosis
other than migraine
• Dim scotoma lasting a few seconds to several
minutes, ie amaurosis
• Temporal artery tenderness
• Meningismus
• Mental status changes
• Focal neurologic deficit eg confusion, seizures

18. • Focal neurologic findings that occur with
headache and persist temporarily after the
pain resolves suggests a migraine variant
• U/L paralysis or weakness-hemiplegic
migraine
• Aphasia, dysarthria, vertigo, tinnitus, syncope,
balance problems-basilar migraine
• Third nerve palsy with sparing of pupillary
response -ophthalmoplegic migraine

19. Peadiatric Migraine Disabilit assessment(pedMIDA)
• Simple questionnaires like MIDAS migraine
disability assessment can be used to quantify the
disability and for follow up

20. Migraine triggers
• Stress
• Excessive or insufficient sleep
• Strong odors eg. perfumes
• Head trauma
• Weather changes
• Metabolic or infectious disease
• Physical exertion
• Cold stimulus eg. ice cream
• Hormonal changes such as menstruation
• Medications (OCP, vasodilators)
• Foods containing tyramine-Vinegar,Beans,Peanuts

21. International Classification Of Headache-3Beta Code
• Migraine
• Migraine without aura
• Migraine with aura
• Migraine with typical aura
– With headache
– Without headache
• Migraine with brainstem aura
• Hemiplegic migraine
– Familial Hemiplegic migraine
– Sporadic Hemiplegic migraine
• Retinal migraine
• Chronic migraine

22. • Episodic Syndromes That May Be Associated
with Migraine
– Recurrent gastrointestinal disturbance
• Cyclical vomiting syndrome
• Abdominal migraine
– Benign paroxysmal vertigo
– Benign paroxysmal torticollis

23. Diagnostic criteria

24. Migraine without aura
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours
C. Headache with at least 2 of the following :
1. unilateral location
2. pulsating quality
3. moderate or severe pain
4. aggravation by routine physical activity
D. At least one of the following during headache:
1. nausea or vomiting
2. photophobia or phonophobia
E. Not better accounted for any another ICHD-3 diagnosis

25. Migraine with Typical Aura
A. At least 2 attacks fulfilling criteria B and C
B. Reversible Aura symptoms: visual, sensory,
language symptoms, but no motor, brainstem or
retinal symptoms
C. At least 2 of the following 4 characteristics:
1. At least 1 aura symptom spreads gradually over 5 or more
minutes, or 2 or more symptoms occur in succession
2. Each individual aura symptom lasts 5-60 minutes
3. At least 1 aura symptom is unilateral
4. The aura is accompanied or followed by headache within
1hour
D. Not better accounted for by another ICHD-3
diagnosis

26. Migraine with Brainstem Aura
A. At least 2 attacks fulfilling criteria B to D
B. Aura : visual, sensory, language symptoms, each
fully reversible.
C. At least 2 of the following brainstem symptoms:
– 1. Dysarthria
– 2. Vertigo
– 3. Tinnitus
– 4. Hyperacusis
– 5. Diplopia
– 6. Ataxia
– 7. Decreased level of consciousness

27. Migraine with Brainstem Aura
D. At least 2 of the following 4 characteristics:
1. At least 1 aura symptom spreads gradually over 5 or
more minutes, and/or 2 or more symptoms occur in
succession
2. Each individual aura symptom lasts 5-60 minutes
3. At least 1 aura symptom is unilateral
4. The aura is accompanied, or followed by headache
within 1 hour
E. Not better accounted for by another ICHD-3
diagnosis.

28. Familial Hemiplegic Migraine
• Migraine with aura including motor weakness,
and at least one first- or second-degree relative
has migraine aura including motor weakness
• hemiplegia that typically resolves
• FHM type 1 - Linked to mutations in the calcium
channel gene – chromosome 19. May be
associated with cerebellar ataxia
• FHM type 2 - mutation in the sodium channel
gene ATP1A2 on chromosome 3
• FHM type 3- mutation in a sodium channel alpha
subunit coding gene

29. • Sporadic hemiplegic migraine
Migraine with aura including motor weakness,
and no first- or second-degree relative has
migraine aura including motor weakness.

30. Vestibular Migraine with Vertigo
A. At least 5 episodes fulfilling criteria C and D
B. A current or past history of Migraine without
aura or Migraine with aura
C. Vestibular symptoms of moderate or severe
intensity, lasting between 5 min and 72 hr

31. D. At least 50% of episodes are associated with at
least 1 of the following 3 migrainous features:
1. Headache with at least 2 of the following 4
characteristics:
1. a. Unilateral location
2. b. Pulsating quality
3. c. Moderate or severe intensity
4. d. Aggravation by routine physical activity
2. Photophobia and phonophobia
3. Visual aura
E. Not better accounted for by another ICHD-3
diagnosis or by another vestibular disorder

32. Chronic Migraine
• A. Headache (tension-type-like and/or
migraine-like) on 15 or more days per month
for more than 3 mo and fulfilling criteria B and
C
• B. at least 5 attacks fulfilling
– criteria B to D for Migraine without aura
– criteria B and C for Migraine with aura

33. C. On 8 or more days per month for more than 3
mo, fulfilling any of the following:
• 1. Criteria C and D for Migraine without aura
• 2. Criteria B and C for Migraine with aura
• 3. Believed by the patient to be migraine at
onset and relieved by a triptan or ergot
derivative
D. Not better accounted for by another ICHD-3
diagnosis

34. Cyclical vomiting syndrome
• A. At least 5 attacks of intense nausea and
vomiting fulfilling criteria B and C
• B. Stereotypical and predictable periodicity
• C. Any of the following :
1. nausea and vomiting occur at least 4 times
per hour
2. Attacks last > 1 hour and up to 10 days
3. Attacks occur > 1 week apart

35. Abdominal migraine
• A. At least 5 attacks of abdominal pain, fulfilling criteria
B-D
• B. Pain has at least 2 of the following 3 characteristics :
1. midline location, periumblical or poorly localized
2. dull or just sore quality
3. moderate or severe intensity
• C. During attacks, at least two of the following :
anorexia, vomiting, pallor
• D. Attacks last 2-72 hours
• E. complete freedom from symptoms between attacks

36. Benign paroxysmal vertigo
• A. At least 5 attacks fulfilling criteria B and C
• B. Vertigo without warning, maximal at onset
and resolving spontaneously after minutes to
hours without loss of consciousness
• C. At least one of the following :
1. nystagmus, 2. ataxia, 3. vomiting, 4. pallor,
5. fearfulness

37. Benign paroxysmal torticollis
• A. Recurrent attacks in a young child, fulfilling
criteria B and C
• B. Tilt of the head to either side, with or
without slight rotation, remitting
spontaneously after minutes to days
• C. At least one of the following signs : 1. pallor,
2. irritability, 3. malaise, 4. vomiting, 5. ataxia
• D. Normal CNS examination
• E. Not attributed to another disorder

38. COMPLICATIONS OF MIGRAINE
• Chronic migraine
– Migraine headache that occurs more than 15 days a month
for greater than 3 months
• Status migrainosus
– Migraine attacks persists for >72 hours.
• Persistent aura ( 30-60 min ) without infarction
– Aura symptoms persisting for one week or more without
evidence of infarction on neuroimaging
• Migrainous infarction
– One or more aura symptoms associated with an ischaemic
brain lesion on neuroimaging
• Migraine triggered seizures
– seizure triggered by an attack of migraine with aura

39. • Migraine is a clinical diagnosis.
• Diagnostic investigations are performed due to
following reasons
– Exclude structural, metabolic and causes of heada
– Rule out comorbid disease that could complicate
headache and its treatment
• Role of neuroimaging
• Not recommended in typical migraine with
normal CNS examination with recurrent
headaches
INVESTIGATIONS

40. Indications for Neuroimaging in a Child
with Headaches
• Abnormal neurologic examination
• Abnormal or focal neurologic signs or symptoms
• Seizures
• Headache in children younger than 6 yr old or
any child who cannot adequately describe his
headache
• Headache worst on first awakening or that
awakens the child from sleep
• Migrainous headache in the child with no family
history of migraine or its equivalent

41. EEG
• In migraine occasional spikes in the occipital
region is seen in EEG
• Needed in :
• In migraine with syncope and epilepsy
• Migraine with sensory or motor aura or
transient neuro deficits
• Abdominal migraine Vs Abdominal epilepsy

42. Treatment
• General principles :
• Asses the headache burden or disability
• Decide on the need for prophylaxis
• Counsel the child and family about the
treatment
• Encourage the child to identify the triggers
and avoid them
• Treat the comorbid conditions

43. Acute treatment
goal is headache relief with in 1 hr with normal
return to normal function
• 2 groups of medications :
– NSAIDS
– TRIPTANS

44. • NSAIDs
• Are the first line of treatment
• Ibuprofen  7.5 – 10 mg/kg
• Acetamenofen 15 mg/kg
• Naproxen
• Aspirin – reserved for older children > 15 yrs

45. Triptans
• In Severe migraine NSAIDs alone may not be
sufficient. In this case triptans may be considered
• Amlotriptan : in adolescents (12-17 yrs),12.5 mg
tab
• Rizatriptan : in 6- 17 yrs
– 5mg for < 40 kg child & 10 mg for > 40
• Sumatriptan, zolmitriptan, naratriptan

46. In severe intractable migraine:
• Antidopaminergic medications:
– Procholperazine : 0.15 mg/kg/iv (max 10mg)
– Metaclopramide : 0.2 mg/kg/iv (max 10mg)
• But extrapyramidal reactions are more
common in peadiatric age, controlled by IV
diphenhydramine 25-50 mg

47. In severe intractable migraine:
• NSAIDs:
Keterolac
– 0.5 mg/kg IV , (15mg max)
– Used in combined with prochlorperazine
– monotherapy – 55 %
– In combination – 93 %

48. In severe intractable migraine:
• Dihydroergotamine :
• 5HT receptor agonist + central vasoconstrictor
• Premedication with prochlorperazine 0.15 mg/kg
• After 30 min IV DHE
– 0.5mg/kg in <40 kg
– 1 mg/kg in >40 kg @ 8th hrly untill headache subsides
• One extra dose- to prevent recurrence
• 97 % improvement
• 77% free from headache

49. In severe intractable migraine:
• Sodium valproate :
• Also used in prophylaxis of migraine
• Used when DHE is contraindicated or
ineffective In intractable headache:
• 15 mg / kg loading followed by 5 mg/kg @ 8th
hrly until headache subsides or up to
maximum 10 doses
• 80 % improvement

50. Preventive therapy
• Frequent attacks
– > 1attack/week
– >3 attacks /month or 1 disabling headache in a
month
– pedMIDAS score > 20
• Goal:
– Reduce frequency (1-2 attacks/month) and
disability (pedMIDAS score > 10)

51. PROPHYLAXIS
• Calcium channel blockers :
Flunarzine : age 5-11 years
– 5mg daily orally before bed
– Increase the dose to 10 mg 1 month after
– A month off of the drug @ every 4-6 months
• Antidepressants :
– Amitriptyline : 1mg/kg/day HS
• Prolonged QT syndrome

52. PROPHYLAXIS
• Antiepileptics :
• Valproic acid:
– begin 5 mg/ kg/24 hrs
– Increase 5mg/kg every 2 wks to 20 mg /kg/24 hrs
• Topiramate : 1- 10mg/kg/day in BD
• Levetiracetam: 20-60mg/kg/ in BD
• Gabapentin : 300-1200mg in TID

53. PROPHYLAXIS
• Antihistamines :
– Cyprohepatidine : 0.2-0.4mg/kg/day in BD
• Antihypertensives :
– Propranolol : 2-4 mg/kg/day in BD
• Onabotulinum A-
– inhibits Ach release from nerve endings
– FDA approved for chronic migraine

54. Protocol
• Migraine child with asthma :
- 1st choice : Flunarzine
- 2nd choice : Amitriptyline
• Migraine child with somatization complaints :
Amitriptyline
• Occipital migraine : Amitriptyline
• Posttraumatic migraine : Amitriptyline

55. • Behavioral therapy
• Identifying triggers
• Diet modification
• Lifestyle modification
– Adequate sleep, hydration, well balanced diet,
meditation

56. References
• Nelson text book of pediatrics
• Swaimon’s pediatric neurology
• IJPP : April – June 2016
• IAP textbook of pediatric neurology 1st edition

57. Thank you..!!!