Migraine

Question 1

Define

Answer 1

Infection => don’t forget sinusitis

CVS - do BP measurement

Allergies like rhinitis, hayfever

Stress/ screen time etc can all cause headache

Dehydration/ missing meals

Hypothyroidism, diabetes

XS use of analgesia

Question 2

Classification of headaches

Answer 2

Primary headaches
* Migraine -MOST COMMON in children
* Tension-type headache
* Cluster
* Other primary headaches e.g. primary stabbing headache

These are thought to be due to a primary malfunction of neurons and their networks

Secondary headaches
* Symptomatic of some underlying pathology e.g. raised ICP or SOL

Trigeminal and other cranial neuralgias
* Includes root pain from herpes zoster

NOTE: a medication overuse headache is a secondary headache

Abscess formation due to infection can also head to a secondary headache

Episodic < 15 dys/month
Chronic ≥ 15 dys/ month

Question 3

Tension headaches

Answer 3

Tension-type

• Lasts 30 minutes to 7 days
• Pressing/ tightening
• Bilateral
• Gradual onset
• Described as ‘tightness’, ‘band’ or ‘pressure’ – NON-pulsating
• Mild or moderate intensity
• No aggravation by routine physical activity
• Usually NO other symptoms

Question 4

Migraine

Answer 4

Migraine WITHOUT aura
* MOST COMMON type of primary headache in children
* 90% of migraines
* Episodes last 4-72 hours
* Commonly bilateral but can be unilateral
* Pulsatile over the temporal or frontal area
* Often accompanied by GI disturbance (e.g. nausea, vomiting, abdominal pain)
* Photophobia and phonophobia
* Aggravated by physical activity or routine physical activity and relieved by sleep

Migraine WITH aura
* 10% of migraines
* Headache is preceded with an aura (visual, sensory or motor)
* Aura can occur without headache
* Features: ABSENCE of problems between episodes and frequent presence of premonitory symptoms (tiredness, difficulty concentrating, autonomic features etc.)
* Common auras include visual disturbances:
* Negative phenomena- hemianopia scotoma (small areas of visual loss)
* Positive phenomena- fortification of spectra (zigzag lines)
* Rarely, it may cause unilateral sensory or motor symptoms e.g. hemiplegic migraine
* Attacks usually last a few hours
* Children will prefer to lie down in a quiet, dark room
* Symptoms of tension-type headaches or a migraine overlap
* Both result from primary neuronal dysfunction, including channelopathies, with vascular phenomena as secondary events
* Bouts can be triggered by disturbances of inherent biorhythms e.g. late nights, early rises, stress, foods (e.g. cheese, chocolate, caffeine)
* In girls, headaches can be related to menstruation and the OCP

Question 5

Management of migraine

Answer 5

Good history and examination (imaging not needed unless red flag symptoms; i.e. early morning headache)

Medical education:

• Headaches are common
• No long-term harm

Medications:
Analgesia -> ibuprofen > paracetamol

Anti-emetics:
· 6+ cyclizine
· 12+ prochlorperazine, metoclopramide (2nd line: codeine phosphate)

Serotonin 5HT1 agonists:
· 12+ triptans (sumatriptan)

Consider using a headache diary for a minimum of 8 weeks to identify triggers

Acute Management (for 12-17 years old)

1st Line: **simple analgesia- paracetamol < ibuprofen **

If ineffective- offer nasal triptan

NOTE: oral triptans are NOT licensed in people < 18 years

If ineffective- combination therapy with nasal triptan and NSAID/ paracetamol

Add anti-emetics e.g. metoclopramide or prochlorperazine

• IMPORTANT: do NOT offer aspirin to children < 16 years because of risk of Reye’s syndrome

Follow up within 1 month, and return sooner if symptoms worsen

Have a LOW threshold for referral- treatment options limited in children

Question 6

Complications

Answer 6

Complications

• Reduced functional ability and QoL
• Medication overuse headache
• Progression to chronic migraine
• Status migrainosus (debilitating attack lasting > 72 hours)

Prognosis
* Varies but generally improves with increasing age

Question 7

6 flags

Answer 7

• Features indicating strong suspicion of a significant intracranial pathology:
• Walking from sleep with pain
• Fine motor skills deteriorating (e.g., handwriting getting worse)
• Cerebellar signs such as ataxia
• Early morning vomiting and headache may indicate raised intracranial pressure
• Weight loss
• Cranial N palsy e.g., new onset strabismus (squint)

Question 8

Idiopathic Intracranial Hypertension

Answer 8

Raised intracranial pressure in the absence of a mass lesion or hydrocephalus

Aetiology
* Unknown cause
* Thought to be due to impaired CSF absorption from the subarachnoid space across the arachnoid villi into the dural sinuses
* Common in obese female teenagers of childbearing age and can lead to significant visual impairment
* Obesity is the leading cause

Presentation
* Severe throbbing headaches
* Often constant, worse in the morning, aggravated by straining or coughing
* Associated with N+V
* Double vision and other vision changes (i.e. papilloedema)
* Tinnitus
* Tiredness
* Neck pain
* Mood and behaviour changes
* Difficulty sleeping

Investigations
* Bloods- FBC, ESR, iron studies, ANA, coagulation studies
* Visual field testing
* Optic disc photographs
* CT/ MRI – need to rule out SOL
* LP with manometry

Management
* Referred to Ophthalmologist if suspected, or possibly Neurologist
* Eliminate causal factors
* Lose weight- Referred to dietician, obesity clinics
* Medication
* Combination of acetazolamide or topiramate and/or furosemide
* Prednisolone
* Analgesia

May consider CSF shunting

Other specialist treatment

Complications

Permanent loss of vision

Prognosis

Weight loss helps improve symptoms

Can be self-limited or lifelong chronic course