Pediatric migraine

Question 1

Epidemiology

Answer 1

worldwide prevalence 7.7%, school age prevalence 10%, increases w/ age, +c boys before puberty, +c girls during and after puberty

Question 2

Headache classification

Answer 2

According to ICDH-3 (international classification of HA disorders 3rd edition):
Primary
Secondary
Due to cranial neuropathies

Question 3

Primary HA

Answer 3

Migraine (with or without aura), tension type headache (TTH), trigeminal autonomic cephalalgias (TACs)

Question 4

Migraine pathophysiology

Answer 4

Ion channel dysfunction in brainstem that modulates sensory input and meningeal blood vessels
Cranial dilation of blood vessels causing further nerve activation and pain

Question 5

Pediatric migraine criteria

Answer 5

ICDH-3. 5-2-1
5 or more attacks not due to other medical diagnosis or medication overdose
2 or more: bilateral location, frontotemporal, pulsating quality, moderate to severe intensity, aggravated by regular physical activity
1 or more: nausea, vomiting, photophobia, phonophobia

Question 6

Tension type headache (TTH)

Answer 6

Bilateral 
Mild to moderate in intensity 
Tightening, pressing, squeezing quality 
Increased pericranial tenderness
Not aggravated by regular physical activity 
May or not be associated w nausea 
Photophobia or photophobia may occur

Question 7

Trigeminal autonomic cephalalgias

TACs

Answer 7

Unilateral
Moderate to severe to very severe
Stabbing quality
Parasympathetic autonomic features: conjunctival lacrimation/injection, nasal congestion, facial sweating. Ipsilateral

Question 8

Multitiered approach to migraines

Answer 8

4 tiers

1. Lifestyle modifications
2. Integrative approaches
3. Pharmacologic tx
4. Other tx

Question 9

What is key to Dx pediatric migraines?

Answer 9

Thorough medical history

Question 10

Questions to ask when taking the Hx? 1-4

Answer 10

1. Pattern of HA and what time do they occur? 2. How and when did the HA begin? 3. How often do they happen and how long do they last? 4. Where is the pain located?

Question 11

Questions to ask when taking the Hx? 5-8

Answer 11

5. What is the quality of the pain? 6. What other symptoms accompany the HA? 7. Anyone in the family has HA? 8. What do you think may be causing your HA?

Question 12

HA patterns?

Answer 12

1. Acute onset of 1st episode w/o prior Hx 2. Recurring HA with symptom free intervals 3. Chronic pattern of progressively increasing HA 4. Nonprogressive daily or near daily HA 5. Mixed pattern of daily HA with + intense attacks superimposed

Question 13

How and when did your HA begin? Rationale

Answer 13

Try to establish origin/history of attacks

Question 14

How often? How long? Rationale

Answer 14

ID characteristic patterns

Question 15

Pattern of Migraine or TTH (tension type HA)

Answer 15

Could be weekly 4 h attack

Question 16

Pattern of TACs (Trigeminal Autonomic Cephalalgias)

Answer 16

Brief attacks happening multiple times daily

Question 17

Pain locations for HAs?

Answer 17

Holocephalic, bifrontal, unilateral, posterior (occipital)

Question 18

Qualities of HAs

Answer 18

Throbbing/pounding, squeezing/pressure, stabbing, other

Question 19

Symptoms that could accompany HAs?

Answer 19

Nausea, vomiting, abdominal pain
Visual aura, diplopia
photophobia, photophobia
Vertigo, dizziness
Motion sickness, nocturnal leg cramps
Numbness, weakness

Question 20

What word should you use when taking family Hx?

Answer 20

Use the open ended term headache (no migraines) to see if there are other types of HA in the family

Question 21

What do you think maybe causing your HA?

Answer 21

Possibly the most important question, MC fear: Brain tumor, but w/ a normal physical and neurological exam you can reassure pt and family