Migraine in Children and Adolescents

Background

• Migraine is a common primary headache disorder characterized by recurrent attacks, typically consisting of moderate-to-severe head pain with associated nausea, vomiting, photophobia, and/or phonophobia.
  • The pain is usually frontotemporal (often bilateral in children and unilateral in older adolescents) and has a pulsating quality.
  • The headaches last 2-72 hours and may be preceded or accompanied by an aura that consists of sensory, motor, or language symptoms that last 5-60 minutes.
• Migraine attacks may include a headache without an aura, a headache with an aura, or an aura without a headache.
• Although the cause of migraine is often not known, it may involve a genetic susceptibility to environmental triggers (for example, hormone fluctuation or stress), and some forms have a clear genetic etiology (as in familial hemiplegic migraine).

Evaluation

• Suspect migraine in children with recurrent headaches that are unassociated with trauma, fever, or other clear causes.
  • Consider using a headache diary to help diagnose migraine by tracking attack frequency, duration, possible triggers, and other attack characteristics.
  • Testing is not necessary in most children.
    • Routine laboratory studies, lumbar puncture, and electroencephalogram (EEG) are generally not indicated (Weak recommendation).
    • Neuroimaging is not recommended in children with a normal neurologic exam, but should be considered in those with (Weak recommendation):
      • abnormal neurologic exam or coexisting seizures
      • recent onset of severe headache, change in type of headache, or associated features suggestive of neurologic dysfunction
• Diagnose migraine based on clinical features.
  • Migraine without an aura - diagnose in children with ≥ 5 headache attacks, each lasting 2-72 hours and involving typical migraine features, such as:
    • moderate-to-severe unilateral or bilateral head pain
    • a pulsating quality
    • aggravation by routine physical activity
    • associated nausea, vomiting, photophobia, and/or phonophobia
  • Migraine with an aura:
    • Diagnose in children with ≥ 2 attacks (with or without a headache) of visual, sensory, speech or language, motor, brainstem, or retinal symptoms that are fully reversible and include ≥ 2 of the following features:
      • At least 1 symptom spreads gradually over ≥ 5 minutes, or at least 2 symptoms occur in succession.
      • Each symptom lasts 5-60 minutes (motor symptoms may last 72 hours).
      • At least 1 symptom is unilateral.
      • A headache occurs within 60 minutes of or during aura.
    • Subtypes include:
      • migraine with typical aura - visual and/or sensory and/or speech/language symptoms, but no motor weakness
      • migraine with brainstem aura - at least 2 brainstem symptoms (dysarthria, vertigo, tinnitus, hypacusis, diplopia, ataxia, or decreased level of consciousness)
      • hemiplegic migraine - motor weakness, as well as visual, sensory, and/or speech and language symptoms
      • retinal migraine - monocular visual disturbance

Management

• Management of acute attack
  • Start abortive medication as soon as possible after the onset of the headache or aura (whichever comes first).
    • Consider ibuprofen as an initial treatment option (Weak recommendation).
    • Consider triptans in adolescents (Weak recommendation).
    • Use dopamine antagonists (such as, prochlorperazine and metoclopramide) as an antiemetic or if analgesics and/or triptans are not tolerated or are ineffective.
    • Valproate and magnesium sulfate are less commonly used abortive therapies that may also be considered.
  • For intractable headache, provide IV hydration in addition to medication.
• Management of status migrainosus
  • Dihydroergotamine (DHE) is the first-line treatment for status migrainosus refractory to standard abortive therapy (premedicate with an antiemetic 30 minutes before each dose).
  • If DHE is contraindicated or ineffective:
    • valproate (alone or in combination with DHE) is the second-line treatment
    • magnesium sulfate may also be considered
• Migraine prophylaxis
  • Consider medication if the migraine frequency or severity is sufficient to justify daily medication, or if acute treatments are ineffective, contraindicated, or not tolerated.
    • Topiramate is FDA-approved for migraine prophylaxis in children ≥ 12 years old.
    • Off-label use of other antiseizure medications, as well as antidepressants, antihypertensives, and antihistamines, may also be considered.
  • Consider nonpharmacologic measures, such as, relaxation, behavioral therapy, oligoantigenic diet, sleep hygiene, and acupuncture.