In children the distinction between tension type (ordinary) headache and migraine is less easy to make. Younger children in particular may present with “periodic syndrome” which can have many and varied symptoms. The common factor is that the child will be completely well in between attacks. Symptoms typically include intermittent abdominal pain, however recurrent vomiting, cyclical torticollis, attacks of vertigo and vomiting characterised by a high intensity of symptoms can all be seen.
The prevalence of migraine in children is reported as high as 10% and can result in significant morbidity with school days lost and significant distress for both the child and parents. The presentation of migraine (with the exception of periodic syndrome) is similar in young children to adolescents.
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A child presenting with migraine may also have another headache type present. (e.g. pattern 4 as previously shown) The importance of a good history and perhaps the use of the headache diary can be helpful in the assessment of headache type.
- Is there one or more than one type of headache?
- When did they start?
- How frequent?
- How long does it last?
- Site of headache? – Is there more than one site?
- Intensity of pain?
- Precipitating factors?
- What makes the pain worse?
- What makes the pain better?
- Medicine use/overuse?
- Associated symptoms
Visual disturbance (when?)
Nausea or vomiting
Dizziness or lightheaded
- Well between attacks?
Children with migraine will typically experience recurrent episodic headaches of moderate or severe intensity. They may be described as unilateral and pulsing although in children there is a higher frequency of bilateral pain. Adult migraine normally lasts between 4 and 72 hours although in children the duration may be shorter. Children are more likely to have gastrointestinal disturbance as a prominent symptom. Typically the child will limit physical activity during the attack and prefer darkened conditions and quiet.
Children may experience aura (about 30% of sufferers) with progressive visual disturbance 5-60 minutes before the headache. Aura may progress to further neurological symptoms and signs, with unilateral paraesthesia of the upper limb and or face. Occasionally there is dysphasia – a child with a good history of focal aura should be evaluated by a paediatrician with an interest in headache.
Migraine without aura may be a little more tricky to diagnose. The International Headache Society diagnostic criteria for migraine without aura are:-
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:
1. unilateral location*
2. pulsating quality (ie, varying with the heartbeat)
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
D. During headache at least one of the following:
1. nausea and/or vomiting*
2. photophobia and phonophobia
E. Not attributed to another disorder (history and examination do not suggest a secondary headache disorder or, if they do, it is ruled out by appropriate investigations or headache attacks do not occur for the first time in close temporal relation to the other disorder)
*In children, attacks may be shorter-lasting, headache is more commonly bilateral, and gastrointestinal disturbance is more prominent.
Treatment in children
The BASH guidelines are very specific about the Primary Care management of migraine headache. They state that many children respond to simple measures, and initial management should be conservative. Reassurance of the parents is an important factor. They further note that most children can be managed in the same way as adults, allowing for the different symptom complex and dose adjustments to medication and age related contraindications.
Children with troublesome migraine not responding to simple analgesia should be referred to a paediatrician with an interest in headache.