1. Migraine is a common type of primary headache characterized by moderate to severe throbbing pain, nausea, photophobia, and phonophobia. 2. The classification and diagnostic criteria for migraine with and without aura according to the International Headache Society is described. 3. A thorough clinical evaluation including headache characteristics, triggers, family history, and examination for red flags is important to identify primary versus secondary headaches and guide further workup and treatment.

1. MIGRAINE - A HEADACHE FOR
PAEDIATRICIAN
Dr. Muzammil Koshish
MBBS DCH DNB(PAEDIATRICS)

2. z
Headache classification
• Primary headache
migraine, tension , cluster
• Secondary headache
Infection, trauma, hemorrhage, tumor, high
intracranial pressure.
• Cranial neuropathies

3. z
Migraine
• Episodic, periodic, paroxysmal attacks of modera
te to severe throbbing pain, separated by pain
free intervals,
• Associated with nausea, vomiting, photophobia,
abdominal pain and desire to sleep, motion sickn
ess.
• Family history 70-90%

4. z
Classification of migraine
(revised international headache society IHS 2004)
• Migraine without aura
• Migraine with aura

5. z
Migraine without aura (IHS 2004)
• A. at least 5 attacks fulfilling criteria B through D.
• B. Headache attacks lasting 4 to 72h
• C. headache has at least 2 of the following
-unilateral location
-pulsating quality
-moderate or severe pain intensity
-aggravation by or causing avoidence of
routine physical activity
• D. during headache at least one of the folowing:
nausea, vomiting, or both, photophobia, phonophobia
• E. not attributed to another disorder.

6. z
Migraine with aura (IHS 2004)
• A. at least 2 attacks fulfilling criteria B.
• B. migraine aura fulfilling criteria B or C for one of
the following subforms:
Typical aura with migraine headache
Typical aura with nonmigraine pain
Typical aura without headache
Familial hemiplegic migraine
Sporadic hemiplegic migraine
Basilar type migraine
• C. Not attributed to another disorder.

7. z
Childhood periodic syndromes
( precursors of migraine according to revised
HS criteria)
• Cyclic vomiting syndrome.
• Abdominal migraine.
• Benign paroxismal vertigo of childhood.

8. z
Clinical Evaluation
• Salient points in History
1. Headache characteristics
2. Trigger factors
3. Warning symptoms
4. Symptoms during attack
5. Relieving factors
6. Symptoms between attack
7. Family history

9. z
 Pattern of headache
1. Acute
2. Acute Recurrent
3. Chronic Progressive
4. Chronic Non-progressive

10. z
 Clues from clinical evaluation
1. Fever – URI and systemic infection
2. Weight loss – malignancy/tuberculosis
3. Neck rigidity – meningitis
4. Hypertension – renal/adrenal cause
5. Injuries – Trauma

11. z
Red Flag Signs
 Systemic signs and symptoms
 Neurologic signs and symptoms
 Sudden onset
 Occipital location
 Change in character of headache
 Age <6 years

12. z
When to perform neuroimaging
study ??
• Age < 6 years
• Abnormal neurological exam
• Chronic progressive pattern
• Family reassurance

13. z
MRI Vs CT
There was no sufficient data to make a
specific recommendation regarding
the relative sensitivity of MRI compar
ed with CT.
Most prefer MRI because of vascular
differential diagnosis.

14. z
EEG and migraine
• EEG is not indicated in the routine
evaluation of headache
• It is performed if seizures are
suspected.

15. z
Management of migraine
• Non-pharmacologic methods
1.Headache education
2.Lifestyle modification (Sleep,Meals,
Activity, Relaxation,Trigger avoidanc
e)
3.Biofeedback therapy (Relaxation
techniques, Hypnosis, Acupuncture,
Massage therapy)

16. z
Pharmacologic Treatment
• General pain medications
(acetaminophen, NSAIDS) alone or
in combination with antiemetic medi
cations
• Triptans-5HT1D agonists (Rizatriptan
, Almotriptan)

17. z
Indications for migraine
prophylaxis
• Attacks occur >2-4 times per month
• Disability occurs > 3 days per month
• Duration of attack > 48 h
• Medications for acute attack are ineff
ective, C.I or overused
• Attacks produce prolonged aura or
true migrainous infarction
• Patient preference

18. z
Duration of prophylactic
therapy
• The optimum duration of prophylact
ic therapy is uncertain
• The approach is to treat for 4-6 mo
nths and then taper over the course
of several weeks.

19. z
Preventive Therapy
• B blockers (Propranolol)
• Antihistaminic ( Cyproheptadine)
• Anticonvulsants (Topiramate, Valproi
c acid)
• Ca channel blocker (Flunarizine)

20. z
Key Messages
 History and detailed clinical examination
 Migraine is clinical diagnosis
 Identify Red Flags
 Neuroimaging only in suspected
secondary headache
 Lifestyle modification is an important part
of management

21. z
Thank you !