 duration or rapid in onset, a paroxysmal event may be the cause.
Migrainous have been reported to have nonspecific EEG abnormalities. Some of them are now believed to be normal variants such as 14 and 6 phantom spike, others are felt to be a benign rolandic pattern which often does not require treatment. Migraine presentations that a practitioner may encounter includes: hemiplegic migraine, basilar migraine, ophthalmoplegic migraine, benign paroxysmal vertigo, cyclical vomiting, and benign torticollis.
Hemiplegic migraine often begins in young children, the familial form requires a first degree relative that suffers identical attacks. This disorder has been linked to Chromosome 19 in 50 to 60% of individuals. Hemiplegic migraine is sometimes referred to as "football headache' because attacks may be triggered by a mild head injury. The headaches usually follows the hemiparesis with the hemiparesis lasting from hours to days. Attacks occur infrequently and may be associated with dysarthria, aphasia, altered levels of consciousness that are frequently associated with visual symptomatology.
Basilar migraine most often occurs in adolescent females with a positive family history of migraine. Brainstem symptomatology: bilateral visual symptomas, tinnitus (ringing of the ears), vertigo and ataxia are common. In half the patients, bilateral weakness and parasthesias which may be very frightening to both the parents and the patients are noted.
Ophtalmoplegic migraine with ptosis and 3rd nerve palsy although more common in young children, can occur for the first time prior to one year of age. The 3rd nerve is invloved in 80% of these cases, attacks last anywhere from 30 minutes to a month. Ophthalmoplegic migraine is a diagnosis of exclusion. Organic disorders may provoke similar symptoms with differential including sphenoid sinus tumor, orbital and sphenoid sinus granuloma, Tolosa Runt, internal carotid artery aneurysm and chronic sinusitis.
Benign paroxysmal vertigo, a child will suddenlly turn pale, seem frightened, grab somthing for stability often have nausea and vomiting. a quick glance may note nystagmus, attacks are very short, usually 1-2 minutes. They usually occur monthly and resolve as the child bnecomes older. If the attacks do not improve with time, are atypical or have residual deficits, a complete workup is recomended. There should be no loss of consciousness, and a positive family history of migraine.
Cylical vomiting usually starts between the ages of 4 and 8 and occurs at regular intervals approximately monthly although it can vary from 15 to 60 days. Vomiting may occur with or without a headache. This condition is not progressive although if there is worsening a thorough examination including a complete GI workup, an MRI scan of the brain is suggestive.
Bening torticollis is a condition of recurring attacks of head tilt in infants for no apparent cause. Extremely frightening to parents when withnessed for the first time. Attacks usually begin before 12 months of age and the infant may or may not appear sick. Often the condition is short-lived and will resolve spontaneously. A good prognostic sign for benign disease is the ability to move the head to mid-position. However, if the head tilt is always one-sided or the position is fixed, there may be an organic underlying cause and a complete workup is suggested.
Tension-type headache may be hard to differentiate from migraine in children, as some of the symptoms will overlap. A characteristic tension-type headache is identified by a bilateral (2-sided) pressing tightness ocurring anywhere on the cranium or suboccipital region. The headache is non-throbbing sensation of pain and mild to moderate in intensity, and lasts from 30 minutes to several days. It is not accompanied by nausea or vomitting and it is not aggravated by routine physical activity. Although it can be associated with either photophobia (sensitivity to light) or phonophobia (sensitivity to sound). Rather than using traditional terms such as muscle contraction headache, tension headache or stress headache, a new IHS classification employs the term "tension-type" and gives it a rather complex definition for more accurate descriptions.
While cluster headache is very rare under the age of 10, it has been reported in children as young as 3. Therefore it should be included among the differential diagnoses of primary headaches,although not at the top of the list. Cluster headache becomes more apparent between the ages of 10 to 30, and from 20 we see the usual rate of 9 males to 1 female.
The treatment of headaches in children requires both pharmacological and non-pharmacological modalities to be utilized in together. Prevention of incapacitating acute migraine attacks is helped by a comprehensive approach of elimination of known triggers, appropriate use of non-pharmacologic modalities such as biofeedback or relaxation training, appropriate pharmacologic acute migraine treatment and when necessary instituting prophylactic (preventative) therapy.
Acute migraine therapy for children over the age of 12 is compatible to adult therapy. In most cases, an adjustment of the dosage is all that is necessary. However, in children under 12, interventions must be substantially modified.
In children under 6, a limited amount of Tylenol works well with few problems. The headaches are usually short-lived and generally resolve with sleep. In older children, oral therapy such as acetaminophen, nonsteroidals such as ibuprofen, and combination analgesics butalbital containing compounds may be useful provided there is no significant nausea present. It is important to avoid aspirin because of its correlation to Reye's syndrome in children under the age of 15.
In acute, incapacitating migraines, it has been known that dihydroergotamine mesylate and Sumatriptan injectibles (Imitrex) have been effective in children. A recent study has demonstrated the efficiency of Sumatriptan oral tablets in the adolescent patient poplulation (12 and under) to be 73% effective in the relief of headache pain in four hours with 80% relief in disability.
Note: the injectible forms of both DHE and Sumatriptan are adjusted for weight depending on age.
Antimetics are often useful in this population either oral or suppository forms. Phenergan suppository is often effective while in older children, treatments may be necessary. Compazine is used with caution in this age group due to the higher incidence of extra pyramindal side effects. Opiods can be utilized in this patient population with caution and supervision.
If a child is absent from school excessively, cannot use abortive medicines, or the abortive medicines are ineffective, you will have to consider prophylactic pharmacologic therapy. As with the acute therapy, age plays a role in the selection of these medications. The treatment must be individualized with attention to dosages. At our facility we have had excellent results with beta blockers, specifically propranolol (Inderal). Beta blockers have been approved for migraine prophylactics and double blind studies in adults have demonstrated their efficacy. There have been 3 double blind, crossover studies of propranolol in children. In one study the medication found to be effective although in the other two it was no more effective than controlled. We start the initial dose quite small, then increase gradulally until we get a therapeautic response or side effects prohibit increasing the dosage. There is often a delay in the patient's clinical response of several weeks and this must be discussed with both the patient and the parents. Periactin is often used as a preventative in young children with its most common side effects being drowsiness and weight gain.
The antimigraine effects of tricyclic antidepressants seem to be independence of antidepressant effects. The side effect profile, especially cardiac, limits its usefulness as a first line medication in children. The trcyclics amitriptyline and nortriptyline in our facility have proven to be effective. No controlled studies in children have been reported.
Double-blind placebo controlled trials using calcium channel blocker nimodipine and migraine prophylactics in children ages 7-18 years note significantly reduction of both frequency and duration of migraine attacks as compared to placebo.
There have been recent double-blind control studies on the effectiveness of sodium valproate as a prophylactic treatment for migraine. These studies have been conducted in adults, however, we must be cautious with the use of this medication, especially in children under the age of 10. The side effects of hepatic toxicity and pancreatitus need to be addressed with the family. The effectiveness of Phenobarbital, phenytoin and carbamazepine have been documented in older literature. It is not known if seizure patients were included in the study populations. However, anticonvulsants can be used effectively in children who are refractory to the above prophylactic therapies.
Several studies evaluating biofeedback and relaxation training have demonstrated a beneficial effect in the management of pediatric headache. The frequency of attacks were consistently modified, as high as twice that scene in adults. These therapies are proven to be effective and work well on mature children, usually over the age of 9.
Discuss appropriate therapeutic goals with both the patient and the parents. While medications may be limited for younger children, there are more options for the adolescent such as the newer SRTI agonist medications., those available today and also those that are under study. Parents and patients need to know other options so that if the headaches recur in 2 or 3 years they will be able to return to appropriate therapy rather than continuing to suffer.
*Note: Dr. Winner is one of North America's top pediatric headache neurologists. Treatments may vary in your country. Please consult a pediatric headache neurologist. See our "Find-a-Headache-Doctor" link.Problem: Write a positive (OPTIONS:
