Neurological disease in a child: Migraine Flashcards
Define migraine.
Migraine is defined by the International Headache Society (IHS) as a recurrent headache that occurs with or without aura and lasts for 2 to 48 hours.
It is usually unilateral in nature, of gradual onset (15 to 30 minutes), pulsating in quality, of moderate or severe intensity, and is aggravated by routine physical activity. Nausea, vomiting, photophobia, and phonophobia are common accompanying symptoms.
What is migraine without aura?
Accounts for 90% of migraine. In children, episodes may last 1-72 hours; the headache is common bilateral but may be unilateral.
Characteristically pulsatile, over temporal or frontal area, it is often accompanied by unpleasant GI disturbance such as nausea, vomiting, and abdominal pain and photophobia or phonophobia. Aggravated by physical activity.
What is migraine with aura?
Accounts for 10% of migraine. The headache is preceded by an aura (visual, sensory or motor), although the aura may occur without a headache. Features are the absence of problems between episodes and the frequent presence of premonitory symptoms (tiredness, difficulty concentrating, autonomic features, etc).
Most common aura is visual disturbance, which may include:
- Negative phenomena, such as hemianopia (loss of half the visual field) or scotoma (small areas of visual loss)
- Positive phenomena such as fortification spectra (seeing zigzag lines)
What are uncommon forms of migraine?
Familial - Linked to a calcium channel defect, dominantly inherited.
Sporadic hemiplegic migraine
Basilar-type migraine - Vomiting with nystagmus and/or cerebellar signs
Periodic syndromes - Often precursors of migraine and include:
- Cyclical vomiting: Recurrent stereotyped episodes of comiting and intense nausea associated with pallor and lethargy. The child is well in between.
- Abdominal migraine: An idiopathic recurrent disorder chaarcterised by episodic midline abdominal pain in bouts lasting 1-72 hours. Pain is moderate to severe in intensity and associated with vasmotor symptoms, nausea and vomiting. The child is well in between episdoes.
- Benign paroxysmal vertigo of childhood: A heterogenous disorder characterised by recurrent brief episodes of vertigo occuring without warning and resolving spontaneously in otherwise healthy children. Between episodes, neurological examination is normal.- Linked to a calcium channel defect, dominantly inherited.
Explain the aetiology of migraines.
Central neuronal hyperexcitability underlies susceptibility to and development of migraine episodes. The broad evidence base for this suggest a multi-factorial causation, with amino acids, magnesium depletion, calcium channels, and controlling genes all being implicated.
What are risk factors for migraines?
- Positive family history of migraine
- Chocolate
- Cheese
- Citrus fruits
- Stress
- Menses
- Use of oral contraceptives
Summarise the epidemiology of migraine.
Rarely diagnosed in children under 2 years of age because of the symptom-based definition, but increases steadily with age thereafter. Mean age of onset is 7 years for boys and 11 years for girls. 20% of children experience their first attack before the age of 5 years.
Currently affects an estimated 50 per 1000 school-age children in the UK and an estimated 7.8 million children in the EU.
What are the signs and symptoms of migraine?
Onset is usually gradual over approximately 15 minutes. Be be associated with aura. May have nausea and vomiting.
Visual disturbance include: Diplopia, blurred vision. For the diagnosis to be confirmed, physical examination should be normal.
NB: A sudden, abrupt onset of a severe headache, particularly if occipital, is not typical of migraine.
What are appropriate investigations for migraine?
No initial test, but may consider CT/MRI
What is the management for migraine?
The emphasis in a treatment plan should be on reducing headache frequency, duration, severity, and associated disability, and treatment should be tailored to each individual.
What is the management for acute migraine?
- Analgesic e.g. Paracetamol, Ibuprofen, codeine phosphate
+ Anti-emetic, e.g. cyclizine - 5-HT1 agonist, e.g. sumatriptan nasal, rizatriptan
+ Ibuprofen
What is the management for ongoing migraines?
- Prophylaxis with propranolol or pizotifen
- Prophylaxis with topiramate
- Prophylaxis with other anticonvulsants or amitriptyline
- Prophylaxis with verapamil or indomethacin
What are complications associated with migraines?
Negative effect on schooling
What is the prognosis of migraines?
Spontaneous remission after puberty may occur, and migraine headaches may cease before the age of 25 years in 23% of people, although by the age of 50 years >50% of people remain affected.
