Headache in Children
Pain-sensitive structures in the head
Intracranial Structures• Venous sinuses and afferent veins
• Arteries of the dura materand pia-arachnoid
• Arteries of the base of the brain and their major branches
• Parts of the dura matter near the large vessels
Pain-sensitive structures in the head
Extracranial Structures• Skin• Subcutaneous tissue• Muscles• Periosteum of the skull• Mucosa• Extracranial arteries• Delicate structures of
the eye, ear, nasal cavities and sinuses
Pain-sensitive structures in the head
Nerves• Trigeminal• Facial• Glossopharyngeal • Vagus• Upper three cervical roots
Pathophysiology of headache:Pain insensitive structures
SkullPia-arachnoid and dura over the
convexity of the brainBrain parenchymaEpendymaChoroid plexuses
Pain Mechanisms
TractionOn the Circle of Willis and dural structures
InflammationOf intra- and extracranial structures Of the meninges, and blood vessels
Vascular distention and spasmOf intra- and extracranial vessels
Pain Mechanisms
Muscle contractionOf neck and scalp muscles
Pressure- changes in ICP- Within nasal or paranasal cavities, orbits, ears and teeth, and on nerve-containing fibers
Temporal profile of headache
Acute Acute RecurrentChronicprogressive
Chronicnonprogressive
Time (days)0 30 60
Migraine
most important and frequent type of headache in the pediatric population
PrevalenceGirls - adolescents Boys - younger than 10 yr
50 % spontaneous prolonged remission after the 10th birthday
Adults, 5–10% of men and 15–20% of women have migraine headaches
Migraine without aura
the most prevalent type of migraine in children headache is throbbing or pounding and tends
to be unilateral at onset or throughout its duration but may also be located in the bifrontal or temporal regions
It may not be hemicranial in children and is less intense compared with the migraine in adults
Migraine without aura
headache usually persists for 1–3 hr although the pain may last for as long as 72 hr
pain may inhibit daily activity, because physical activity aggravates the pain
characteristic feature intense nausea and vomiting
Migraine without aura
Additional symptoms extreme paleness, photophobia, light-
headedness, phonophobia, osmophobia (aversion to odors), and paresthesias of the hands and feet
positive family history on the maternal side in ≈90% of children with migraine without aura
Migraine without aura
Additional features near synchrony with perimenstrual or periovulation
timing gradual appearance after sustained exercise relief with sleep stereotypical prodromes (hypersomnia, food
craving, irritability, moodiness) precipitation by food or odors onset after a letdown or high period of stress
Diagnostic Criteria Migraine without aura
A At least five attacks B Headache attack lasts 1–72 hr (untreated or unsuccessfully
treated) C Headache has at least two of the following characteristics:
Unilateral location, may be bilateral Pulsating quality Moderate or severe intensity Aggravation by or avoidance of routine physical activity
(i.e., walking or climbing stairs)D During headache at least one of the following:
Nausea, vomiting, or both Photophobia and Phonophobia
E Not attributed to another disorder
Migraine with aura
Aura precedes the headache Visual aura are uncommon in children but
when they occur they may be in the form of Binocular visual impairment with scotoma (77%) Distortion or hallucinations (16%) Monocular visual impairment or scotoma (7%)
[hachinshi et al., 1973]
Migraine with aura
Vertigo and light headedness Sensory symptoms
Perioral paresthesias Numbness of the hands and feet
Distortion of body image (alice in wonderland)
DIAGNOSTIC CRITERIAWITH AURA (CLASSIC MIGRAINE)
A At least two attacks B Migraine aura fulfills criteria for typical
aura, hemiplegic aura, or basilar-type aura C Not attributed to another disorder
DIAGNOSTIC CRITERIAWITH AURA (CLASSIC MIGRAINE)
TYPICAL AURA 1 Fully reversible visual, sensory, or speech
symptoms (or any combination) but no motor weakness
2 Homonymous or bilateral visual symptoms including positive features (e.g., flickering lights, spots, lines) or negative features (e.g., loss of vision), or unilateral sensory symptoms including positive features (e.g., visual loss, pins and needles) or negative features (i.e., numbness), or any combination
DIAGNOSTIC CRITERIAWITH AURA (CLASSIC MIGRAINE)
3 At least one of: a) At least one symptom develops gradually over a minimum of 5 min, or different symptoms occur in succession, or both b) Each symptom lasts for at least 5 min and for no longer than 60 min
4 Headache that meets criteria for migraine without aura begins during the aura or follows aura within 60 min
Hemiplegic Migraine
A migraine auraSudden onset of unilateral sensory or
motor signs during the migraine episodeCharacterized as numbness of the face ,
arm, leg, unilateral weakness and aphasiaMay be transient or may persist for days
Hemiplegic Migraine
Good prognosis(+) family history of hemiplegic migraine
Basilar-type migraine
Brainstem signs predominate because of the vasoconstrictor of the basilar and posterior cerebral arteries
Vertigo, tinnitus, diplopia,blurred vision, scotoma, ataxia and occipital headache
Pupils may be dilated, ptosisAlteration in consciousness followed by
seizures may occur
Basilar-type migraine
There is complete resolution of the neurologic signs and symptoms
Minor head injury can precipitate the headache
M = FGirls < 4 years old of higher risk
Childhood Periodic Syndromes—Migraine PrecursorCyclic vomiting
Periodic Syndromes—Migraine PrecursorCyclic vomiting
Diagnostic Criteria: A. At least five attacks fulfilling criteria B and C B. Episodic attacks, stereotypical in the individual
patient of intense nausea and vomiting lasting 1-5 days
C. Vomiting during attacks occurs at least 5 times/ hour for at least 1 hour
D. Symptom-free between attacks E. Not attributed to another disorder. History and
Physical Examination do not reveal signs of gastrointestinal disease.
Childhood Periodic Syndromes—Migraine PrecursorCyclic vomiting
Treatment rectally administered or injected
antiemetics such as dimenhydrinate or ondansetron
careful attention to fluid replacement if the vomiting is excessive
Precursors of migraineAbdominal migraine
Description:An idiopathic recurrent disorder seem
mainly in children & characterized by episodic midline abdominal pain manifesting in attacks lasting 1-72 hours with normality between episodes. The pain is of moderate-to-severe intensity & associated with vasomotor symptoms, nausea and vomiting.
Precursors of migraineAbdominal migraine
Diagnostic Criteria: A. At least 5 attacks fulfilling criteria B through DB. Attacks of abdominal pain lasting 1-72 hoursC. Abdominal pain has all of the ff. characteristics
A. Midline location, periumbilical or poorly localizedB. Dull or “just sore” qualityC. Moderate or severe intensity
D. During abdominal pain, at least two of the ff:A. AnorexiaB. Nausea C. VomitingD. Pallor
Management of Pediatric MigraineGoals of Treatment
1. Reduction of headache frequency, severity, duration, and disability
2. Reduction of reliance on poorly tolerated, ineffective, or unwanted acute pharmacotherapies
3. Improvement in quality of life 4. Avoidance of acute headache medication escalation 5. Education and enabling of patients to manage their
disease to enhance personal control of their migraine
6. Reduction of headache-related distress and psychological symptoms
Treatment of Pediatric MigraineAcute attack
Analgesic1. acetaminophen (15 mg/kg)2. ibuprofen (7.5–10 mg/kg)
Antiemetic1. dimenhydrinate by rectal suppository
5 mg/kg/24 hr in four divided doses2. Parenteral metoclopramide
Treatment of Pediatric MigraineAcute attack
Triptans (e.g., Sumatriptan) are specific and selective 5-hydroxytryptamine
receptor agonists that are effective abortive drugs Sumatriptan may be administered
subcutaneously, nasally, or orally suggested dose is 5 mg in children <25 kg, 10 mg (two sprays) in those weighing 25–50 kg,
and 20 mg sumatriptan in children ≥50 kg
TreatmentAcute attack
Triptans (e.g., Sumatriptan) dose may be repeated 2 or more hours
after the initial dose, limited to two doses per 24 hr
adverse effects are usually minor and transient, and include hot flushes, nausea and vomiting, fatigue, and drowsiness
Children may develop severe intractable migraine attacks or status migrainosus (persistent headache lasting longer than 3 days) that are unresponsive to conventional drug regimens Intravenous prochlorperazine, 0.15 mg/kg
(max 10 mg)
continuous daily medication (prophylactic therapy)
severity and frequency of the headaches on the impact of the migraine on the
child's daily activities, including school attendance and performance as well as participation in recreation
if a child experiences more than two to four severe episodes monthly or is unable to attend school regularly
continuous daily medication (prophylactic therapy)
Ppropranolol 10–20 mg tid (beginning with 10 mg/24 hr
and gradually increasing the drug to the maximum dose or until the desired therapeutic effect is achieved) in children 7–8 yr and older.
A common mistake is to discontinue the drug prematurely, because it often takes several weeks to a month until the drug is effective.
continuous daily medication (prophylactic therapy)
Flunarizine initial dose is 5 mg at bedtime and
increased if necessary to 10 mg most frequent side effect is drowsiness
Behavioral Management
effective method for the treatment of migraine in some children and adolescents
Biofeedback can be mastered by most children older than 8 yr and has been effective in many clinical trials
Indications for Neuroimaging in a Child with Headaches
Abnormal neurologic signRecent school failure, behavioral
change, fall-off in linear growth rateHeadache awakens child during sleep;
early morning headache, with increase in frequency and severity
Periodic headaches and seizures coincide, especially if seizure has a focal onset
Indications for Neuroimaging in a Child with Headaches
Migraine and seizure occur in the same episode, and vascular symptoms precede the seizure (20–50% risk of tumor or arteriovenous malformation)
Cluster headaches in child; any child <5–6 yr whose principal complaint is a headache
Focal neurologic symptoms or signs developing during a headache (i.e., complicated migraine)
Indications for Neuroimaging in a Child with Headaches
Focal neurologic symptoms or signs (except classic visual symptoms of migraine) develop during the aura, with fixed laterality; focal signs of the aura persisting or recurring in the headache phase
Visual graying-out occurring at the peak of a headache instead of the aura
Brief cough headache in a child or adolescent