MIGRAINE HEADACHE IN CHILDREN

1
MIGRAINE HEADACHE IN CHILDREN

• Suhair Shehadeh-Saieg M.D
• Pediatric Department
• Bnai-Zion Medical Center, Haifa

2
???? ????

• ?? 12 ???? ? 10 ??????
• ???? ????
• ?.?
• ??? 3 ?????? ???? ????? ??? ????????? ??????
  ??????? ??? ???? ??????? ????????? ?? ???? ?????
  ?????. ??? ????????? ?? ?????????. ????? ??????
  ?????? ?? ??? ?????.
• ?.?
• ??? ?? ????? ??? ??? ????.
• ????? ???? ?????? ?? ?????? ????? ?? ????? ???
  ???.

3

• ?????? ???????
• ???36.3 ????102 ??? ??104/87
• ????? ???????? ????? ???? ????? ????????
• ????? ?????????? ?????
• ?????
• (???? ????? ??, ???? ????, ??????????? ????
  ??????).
• ???? ??????? ??? ???? ?????? EEG
• ???? ???CT

4

• ???? ????? ????? ???? ????.
• ????? ??????? ??? ????? ????? ?????? ????? ??
  ?????
• Tension headache
• ????? ????72 ???? ???? ???? ?????? ??????
• ???? ??? ????????? ???????
• ?????? ???????? ????? ?????? ?????? ?????? ?????
  ?????????
• ?? ????? ????. US

5

• ???? ???? ??? ??????
• ???? ????? ????? ??? ???? ????? ?????.
• ??? ???? ????? ???? ??? ????? ???????? ??????
• ????? ????? ???? ?????????

6
Headache classification

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

7
Tension headache

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

8
Cluster headache

• More apparent between ages 10-20y
• MF 91 after age 20y.
• Always unilateral, mainly frontal-peri-orbital
• Severe nature, less than three hours
• Usually associated with ipsilateral autonomic
  findings
• ( lacrimation, rhinorrhea, ophthalmic
  injection, horner syndrome)

9
Migraine

• 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.
• Family history 70-90

10
Incidence of migraine

• In 50 of cases lt 20y
• The youngest age reported was 3y
• 7y 1-3
• 7-15 4-11
• lt 7y gtgtgt MgtF
• 7-11y MF
• gt11 FgtM

11
Signs and symptoms of intracranial pathology

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

12
pathophysiology

• Vascular theory
• Neuronal theory ( cortical spreading depression)

13
Precipitating factors

• Anxiety
• Fatigue
• Head trauma
• Stress
• Menses
• Illness
• diet

14
Dietary items and chemical migraine triggers

• Offending food items
• Cheese
• Chocolate
• Hot dogs,ham, cured meats
• Yugort, dairy products
• Asian frozen snack foods
• Wine, beer
• Fasting
• Coffee, tea,cola
• Food diyes, additives

• Chemical triggers
• Tyramin
• Nitric oxide, nitrites
• Allergenic proteins (casein )
• Monosodium glutamate
• Aspartame
• Histamine, tyramine sulfite

15
Pathophyiology schema

• Primary triger
• Locus ceruleus gtgt cortical deppretion
• Trigeminal nucleus vasoconstriction
• Neuronal inflammation aura
• Vasodilatation
• pain

16
Serotonin

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

17
Classification of migraine (revised
international headache society IHS 2004)

• Migraine without aura
• Migraine with aura
• Migraine with typical aura

18
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.

19
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.

20
Migraine with typical aura (IHS 2004)

• A. at least 2 attacks fulfilling criteria B or D.
• B. Aura consisting at least one of the following,
  but no motor weakness
• Fully reversible visual symptoms
• Fully reversible sensory symptoms
  (numbness, pins and needles)
• Fully reversible dysphasia
• C. at least two of the following
• Homonymous visual and/or unilateral
  sensory symptoms
• At least one aura symptom developes
  gradually over gt5minutes
• Each symptom lasts gt5 and lt60 minutes
• D. headache fulfilling criteria B through D for
  Migraine without aura
• begins during the aura or follows aura
  within 60 minutes
• E. not attributed to another disorder.

21
Familial Hemiplegic Migraine (IHS 2004)

• Migraine with aura
• At least one first or second degree relative who
  has migraine aura that includes motor weakness.
• AD inheritance

22
Sporadic hemiplegic migraine (IHS 2004)

• Migraine with an aura of motor weakness with no
  family history

23
Basilar type migraine

• 3-19 of children with migraine
• Average age 7y
• Occipital headache
• Any combination of vetigo, ataxia,diplopia,tinni
  tus,vomiting,visual symptoms,
• parasthesias and altered consciousness
• Absence of weakness.

24
Childhood periodic syndromes( precursors of
migraine according to revised IHS criteria)

• Cyclic vomiting syndrome.
• Abdominal migraine.
• Benign paroxismal vertigo of childhood.

25
Retinal migraine (ocular migraine)

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

26
Complications of migraine

• Chronic migraine
• Status migrainosus (gt 72 h)
• Persistent aura without infarction
• Migrainous infarction
• Migraine-triggered seizure.

27
Migraine variants

• Alice in wonderland syndrome
• Confusional migraine
• Hemisyndrome migraine
• Menstrual migraine
• Ophthalmoplegic migraine

28
Approach to the child with recurrent headache

• History
• Physical examination
• Laboratory or imaging studies

29
When to perform neuroimaging study ??

• Age lt 3 y
• Abnormal neurological exam
• Chronic progressive pattern
• Family reassurance

30
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.

31
EEG and migraine

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

32
Management of migraine

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

33
Pharmacologic Treatment

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

34
Triptans

• 5HT1 (hydroxytriptamin) receptor agonist
• Promote vasoconstriction
• Block pain pathway in the brain stem
• Overall efficacy 63-88
• Efficacy and safety were established in
  adolescents (gt12y)
• Approved for use in Israel from 18y
• Side effects feeling of warmth, burning,
  pressure in the head and neck, palpitations,
  arrythmias, hypotension lt1.
• C.I complicated migraine.

35
American academy of pediatricsoctober 9 2006

• Symptomatic treatment of migraine in children a
  systematic review of medication trials

36

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

37
Indications for migraine prophylaxis

• Attacks occur gt2-4 times per month
• Disability occurs gt 3 days per month
• Duration of attack gt 48 h
• Medications for acute attack are ineffective, C.I
  or overused
• Attacks produce prolonged aura or true migrainous
  infarction
• Patient preference

38
Duration of prophylactic therapy

• 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.
• Data are limited on the effectiveness of
  preventive agents in children

39
Preventive Therapy

• B blockers
• Antideppressants
• Anticonvulsants
• Ca channel blocker

40
B blocker

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