MIGRAINE HEADACHE IN CHILDREN Suhair Shehadeh-Saieg M.D Pediatric Department Bnai-Zion Medical Center, Haifa

הצגת מקרה בן 12 שנים ו 10 חודשים ברקע בריא ת. ע : מזה 3 שבועות סובל מכאבי ראש פרונטאלים לוחצים שנמשכים כמה שעות ועוברים ספונטאנית או אחרי משכחי כאבים. ללא פוטופוביה או פונופוביה. לעתים בליווי בחילות אך ללא הקאות. ס. מ : כאב גב תחתון מזה כמה ימים. לציין ספור משפחתי של מיגרנה וכאבי גב תחתון אצל האב.

סימנים חיוניים : חום =36.3 דופק =102 לחץ דם =104/87 בדיקה פיסיקלית : תקינה כולל בדיקת פונדוסים בדיקה נוירולוגית תקינה מעבדה : ( כולל ספירת דם, מדדי דלקת, אלקטרוליטים ושתן לכללית ). האטה דיפוזית ללא מוקד פרכוסי :EEG האטה דיפוזית ללא מוקד פרכוסי :EEG תקין מוח :CT

בוצע ניקור מותני שהיה תקין. במהלך האישפוז היה שיפור קליני ושוחרר לביתו עם אבחנת Tension headache אשפוז חוזר 72 שעות אחרי בצוע הניקור המותני : כאבי ראש פרונטאלים ובחילות בבדיקה פיסיקלית מתקשה בהליכה ועמידה וסימני גירוי מנינגיאלי גב מותני תקין. US גב מותני תקין. US

מדדי דלקת היו תקינים סוכם כסובל מכאבי ראש לאחר ניקור מותני. היה שפור קליני ניכר תחת טיפול אנלגטיקה וקפאין שוחרר להמשך מעקב נוירולוגי

Headache classification Primary headache Primary headache migraine, tension, cluster migraine, tension, cluster Secondary headache Secondary headache Infection, trauma, hemorrhage, tumor, high intracranial pressure. Infection, trauma, hemorrhage, tumor, high intracranial pressure.

Tension headache Bilateral, pressing tightness Bilateral, pressing tightness Non-throbbing, mild to moderate Non-throbbing, mild to moderate Lasts from 30 minutes to several days Lasts from 30 minutes to several days May be associated with photophobia or phonophobia May be associated with photophobia or phonophobia Is not accompanied by nausea or vomiting Is not accompanied by nausea or vomiting

Cluster headache More apparent between ages 10-20y More apparent between ages 10-20y M:F = 9:1 after age 20y. M:F = 9:1 after age 20y. Always unilateral, mainly frontal-peri-orbital Always unilateral, mainly frontal-peri-orbital Severe nature, less than three hours Severe nature, less than three hours Usually associated with ipsilateral autonomic findings Usually associated with ipsilateral autonomic findings ( lacrimation, rhinorrhea, ophthalmic injection, horner syndrome) ( lacrimation, rhinorrhea, ophthalmic injection, horner syndrome)

Migraine Episodic, periodic, paroxysmal attacks of moderate to severe throbbing pain, separated by pain free intervals, Episodic, periodic, paroxysmal attacks of moderate to severe throbbing pain, separated by pain free intervals, Associated with nausea, vomiting, photophobia, abdominal pain and desire to sleep, motion sickness. Associated with nausea, vomiting, photophobia, abdominal pain and desire to sleep, motion sickness. Family history 70-90% Family history 70-90%

Incidence of migraine In 50% of cases : < 20y In 50% of cases : < 20y The youngest age reported was 3y The youngest age reported was 3y 7y : 1-3% 7y : 1-3% 7-15 : 4-11% 7-15 : 4-11% >> M>F >> M>F 7-11y M=F 7-11y M=F >11 F>M >11 F>M

Signs and symptoms of intracranial pathology Sleep related headache Sleep related headache Absence of family history of migraine Absence of family history of migraine Vomiting\absence of visual symptoms Vomiting\absence of visual symptoms Headache of less than six month duration Headache of less than six month duration Confusion Confusion Abnormal neurologic examination Abnormal neurologic examination Growth abnormality,pulsatile tinitus Growth abnormality,pulsatile tinitus Lack of response to medical therapy Lack of response to medical therapy

pathophysiology Vascular theory Vascular theory Neuronal theory ( cortical spreading depression) Neuronal theory ( cortical spreading depression)

Precipitating factors Anxiety Anxiety Fatigue Fatigue Head trauma Head trauma Stress Stress Menses Menses Illness Illness diet diet

Dietary items and chemical migraine triggers Offending food items Offending food items Cheese Cheese Chocolate Chocolate Hot dogs,ham, cured meats Hot dogs,ham, cured meats Yugort, dairy products Yugort, dairy products Asian frozen snack foods Asian frozen snack foods Wine, beer Wine, beer Fasting Fasting Coffee, tea,cola Coffee, tea,cola Food diyes, additives Food diyes, additives Chemical triggers Chemical triggers Tyramin Tyramin Nitric oxide, nitrites Nitric oxide, nitrites Allergenic proteins (casein ) Allergenic proteins (casein ) Monosodium glutamate Monosodium glutamate Aspartame Aspartame Histamine, tyramine sulfite Histamine, tyramine sulfite

Pathophyiology schema Primary triger Locus ceruleus >> cortical deppretion Trigeminal nucleus vasoconstriction Neuronal inflammation aura Vasodilatation pain pain

Serotonin Released from brainstem serotonergic nuclei. Released from brainstem serotonergic nuclei. Plays an important role in the pathogenesis of migraine Plays an important role in the pathogenesis of migraine Direct action upon the cranial vasculature Direct action upon the cranial vasculature Role in central pain control pathways Role in central pain control pathways

Classification of migraine (revised international headache society IHS 2004) Migraine without aura Migraine without aura Migraine with aura Migraine with aura Migraine with typical aura Migraine with typical aura

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

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

Migraine with typical aura (IHS 2004) A. at least 2 attacks fulfilling criteria B or D. A. at least 2 attacks fulfilling criteria B or D. B. Aura consisting at least one of the following, but no motor weakness: B. Aura consisting at least one of the following, but no motor weakness: Fully reversible visual symptoms Fully reversible visual symptoms Fully reversible sensory symptoms (numbness, pins and needles) Fully reversible sensory symptoms (numbness, pins and needles) Fully reversible dysphasia Fully reversible dysphasia C. at least two of the following: C. at least two of the following: Homonymous visual and/or unilateral sensory symptoms Homonymous visual and/or unilateral sensory symptoms At least one aura symptom developes gradually over >5minutes At least one aura symptom developes gradually over >5minutes Each symptom lasts >5 and 5 and <60 minutes D. headache fulfilling criteria B through D for Migraine without aura D. headache fulfilling criteria B through D for Migraine without aura begins during the aura or follows aura within 60 minutes begins during the aura or follows aura within 60 minutes E. not attributed to another disorder. E. not attributed to another disorder.

Familial Hemiplegic Migraine (IHS 2004) Migraine with aura Migraine with aura At least one first or second degree relative who has migraine aura that includes motor weakness. At least one first or second degree relative who has migraine aura that includes motor weakness. AD inheritance AD inheritance

Sporadic hemiplegic migraine (IHS 2004) Migraine with an aura of motor weakness with no family history Migraine with an aura of motor weakness with no family history

Basilar type migraine 3-19% of children with migraine 3-19% of children with migraine Average age 7y Average age 7y Occipital headache Occipital headache Any combination of : vetigo, ataxia,diplopia,tinnitus,vomiting,visual symptoms, Any combination of : vetigo, ataxia,diplopia,tinnitus,vomiting,visual symptoms, parasthesias and altered consciousness parasthesias and altered consciousness Absence of weakness. Absence of weakness.

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

Retinal migraine (ocular migraine ) Sudden loss of vision, perception of bright light Sudden loss of vision, perception of bright light followed within one hour by a migrainous headache. followed within one hour by a migrainous headache. Reversible neurologic symptoms. Reversible neurologic symptoms. Permanent visual loss may occur. Permanent visual loss may occur. Visual symptoms may occur without headache. Visual symptoms may occur without headache.

Complications of migraine Chronic migraine Chronic migraine Status migrainosus (> 72 h) Status migrainosus (> 72 h) Persistent aura without infarction Persistent aura without infarction Migrainous infarction Migrainous infarction Migraine-triggered seizure. Migraine-triggered seizure.

Migraine variants Alice in wonderland syndrome Alice in wonderland syndrome Confusional migraine Confusional migraine Hemisyndrome migraine Hemisyndrome migraine Menstrual migraine Menstrual migraine Ophthalmoplegic migraine Ophthalmoplegic migraine

Approach to the child with recurrent headache History History Physical examination Physical examination Laboratory or imaging studies Laboratory or imaging studies

When to perform neuroimaging study ?? Age < 3 y Age < 3 y Abnormal neurological exam Abnormal neurological exam Chronic progressive pattern Chronic progressive pattern Family reassurance Family reassurance

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

EEG and migraine EEG is not indicated in the routine evaluation of headache EEG is not indicated in the routine evaluation of headache It is performed if seizures are suspected. It is performed if seizures are suspected. EEG findings in children with migraine: EEG findings in children with migraine: -Rolandic spike and wave -Rolandic spike and wave -Benign focal epileptiform discharges -Benign focal epileptiform discharges

Management of migraine Non-pharmacologic methods (biofeedback, relaxation,exercise) Non-pharmacologic methods (biofeedback, relaxation,exercise) Pharmacologic therapy for acute attack Pharmacologic therapy for acute attack Preventive therapy Preventive therapy

Pharmacologic Treatment General pain medications General pain medications (acetaminophen, NSAIDS) alone or in combination with antiemetic medications (migraleve) (acetaminophen, NSAIDS) alone or in combination with antiemetic medications (migraleve) Vasoconstrictors ergot alkaloids/xanthine (cafergot, tamigran) Vasoconstrictors ergot alkaloids/xanthine (cafergot, tamigran) Triptans-5HT1D agonists (imitrex, zomig) Triptans-5HT1D agonists (imitrex, zomig) Migraine status (> 72 h in adults) - steroids, DHE Migraine status (> 72 h in adults) - steroids, DHE dihydroergotamin dihydroergotamin

Triptans 5HT1 (hydroxytriptamin) receptor agonist 5HT1 (hydroxytriptamin) receptor agonist Promote vasoconstriction Promote vasoconstriction Block pain pathway in the brain stem Block pain pathway in the brain stem Overall efficacy 63-88% Overall efficacy 63-88% Efficacy and safety were established in adolescents (>12y) Efficacy and safety were established in adolescents (>12y) Approved for use in Israel from 18y Approved for use in Israel from 18y Side effects: feeling of warmth, burning, pressure in the head and neck, palpitations, arrythmias, hypotension <1%. Side effects: feeling of warmth, burning, pressure in the head and neck, palpitations, arrythmias, hypotension <1%. C.I: complicated migraine. C.I: complicated migraine.

American academy of pediatrics october Symptomatic treatment of migraine in children: a systematic review of medication trials

Conclusion: Acetaminophen, ibuprofen, and nasal, spray sumatryptan are all effective symptomatic pharmacologic treatments for episodes of migraine in children. Acetaminophen, ibuprofen, and nasal, spray sumatryptan are all effective symptomatic pharmacologic treatments for episodes of migraine in children.

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

Duration of prophylactic therapy The optimum duration of prophylactic therapy is uncertain The optimum duration of prophylactic therapy is uncertain The approach is to treat for 6-12 months and then taper over the course of several weeks. The approach is to treat for 6-12 months and then taper over the course of several weeks. Data are limited on the effectiveness of preventive agents in children Data are limited on the effectiveness of preventive agents in children

Preventive Therapy B blockers B blockers Antideppressants Antideppressants Anticonvulsants Anticonvulsants Ca channel blocker Ca channel blocker

B blocker Propranolol was the prophylactic treatment most commonly used in children, primarily based upon evidence in adults. Propranolol was the prophylactic treatment most commonly used in children, primarily based upon evidence in adults. C.I: asthma C.I: asthma Caution: depression, diabetes, orthostatic hypotension, impotense Caution: depression, diabetes, orthostatic hypotension, impotense