MIGRAINE HEADACHE IN CHILDREN

1. MIGRAINE HEADACHE IN CHILDREN Suhair Shehadeh-Saieg M.D Pediatric Department Bnai-Zion Medical Center, Haifa

2. הצגת מקרה בן 12 שנים ו 10 חודשים ברקע בריא ת.ע: מזה 3 שבועות סובל מכאבי ראש פרונטאלים לוחצים שנמשכים כמה שעות ועוברים ספונטאנית או אחרי משכחי כאבים. ללא פוטופוביה או פונופוביה. לעתים בליווי בחילות אך ללא הקאות. ס.מ: כאב גב תחתון מזה כמה ימים. לציין ספור משפחתי של מיגרנה וכאבי גב תחתון אצל האב.

3. סימנים חיוניים: חום=36.3 דופק=102 לחץ דם=104/87 בדיקה פיסיקלית: תקינה כולל בדיקת פונדוסים בדיקה נוירולוגית תקינה מעבדה : (כולל ספירת דם, מדדי דלקת, אלקטרוליטים ושתן לכללית). האטה דיפוזית ללא מוקד פרכוסי :EEG תקין מוח:CT

4. בוצע ניקור מותני שהיה תקין. במהלך האישפוז היה שיפור קליני ושוחרר לביתו עם אבחנת Tension headache אשפוז חוזר72 שעות אחרי בצוע הניקור המותני : כאבי ראש פרונטאלים ובחילות בבדיקה פיסיקלית מתקשה בהליכה ועמידה וסימני גירוי מנינגיאלי גב מותני תקין. US

5. מדדי דלקת היו תקינים סוכם כסובל מכאבי ראש לאחר ניקור מותני. היה שפור קליני ניכר תחת טיפול אנלגטיקה וקפאין שוחרר להמשך מעקב נוירולוגי

6. Headache classification • Primary headache migraine, tension , cluster • Secondary headache Infection, trauma, hemorrhage, tumor, high intracranial pressure.

7. Tension headache • Bilateral, pressing tightness • Non-throbbing, mild to moderate • Lasts from 30 minutes to several days • May be associated with photophobia or phonophobia • Is not accompanied by nausea or vomiting

8. Cluster headache • More apparent between ages 10-20y • M:F = 9:1 after age 20y. • Always unilateral, mainly frontal-peri-orbital • Severe nature, less than three hours • Usually associated with ipsilateral autonomic findings ( lacrimation, rhinorrhea, ophthalmic injection, horner syndrome)

9. Migraine • Episodic, periodic, paroxysmal attacks of moderate to severe throbbing pain, separated by pain free intervals, • Associated with nausea, vomiting, photophobia, abdominal pain and desire to sleep, motion sickness. • Family history 70-90%

10. Incidence of migraine • In 50% of cases : < 20y • The youngest age reported was 3y • 7y : 1-3% • 7-15 : 4-11% • < 7y >>> M>F • 7-11y M=F • >11 F>M

11. Signs and symptoms of intracranial pathology • Sleep related headache • Absence of family history of migraine • Vomiting\absence of visual symptoms • Headache of less than six month duration • Confusion • Abnormal neurologic examination • Growth abnormality ,pulsatile tinitus • Lack of response to medical therapy

12. pathophysiology • Vascular theory • Neuronal theory ( cortical spreading depression)

13. Precipitating factors • Anxiety • Fatigue • Head trauma • Stress • Menses • Illness • diet

14. Offending food items Cheese Chocolate Hot dogs,ham, cured meats Yugort, dairy products Asian frozen snack foods Wine, beer Fasting Coffee, tea,cola Food diyes, additives Chemical triggers Tyramin Nitric oxide, nitrites Allergenic proteins (casein ) Monosodium glutamate Aspartame Histamine, tyramine sulfite Dietary items and chemical migraine triggers

15. Pathophyiology schema Primary triger Locus ceruleus >> cortical deppretion Trigeminal nucleus vasoconstriction Neuronal inflammation aura Vasodilatation pain

16. Serotonin • Released from brainstem serotonergic nuclei. • Plays an important role in the pathogenesis of migraine • Direct action upon the cranial vasculature • Role in central pain control pathways

17. Classification of migraine (revised international headache society IHS 2004) • Migraine without aura • Migraine with aura • Migraine with typical aura

18. Migraine without aura (IHS 2004) • A. at least 5 attacks fulfilling criteria B through D. • B. Headache attacks lasting 4 to 72h • C. headache has at least 2 of the following -unilateral location -pulsating quality -moderate or severe pain intensity -aggravation by or causing avoidence of routine physical activity • D. during headache at least one of the folowing: nausea, vomiting, or both, photophobia, phonophobia • E. not attributed to another disorder.

19. Migraine with aura (IHS 2004) • A. at least 2 attacks fulfilling criteria B. • B. migraine aura fulfilling criteria B or C for one of the following subforms: Typical aura with migraine headache Typical aura with nonmigraine pain Typical aura without headache Familial hemiplegic migraine Sporadic hemiplegic migraine Basilar type migraine • C. Not attributed to another disorder.

20. Migraine with typical aura (IHS 2004) • A.at least 2 attacks fulfilling criteria B or D. • B. Aura consisting at least one of the following, but no motor weakness: Fully reversible visual symptoms Fully reversible sensory symptoms (numbness, pins and needles) Fully reversible dysphasia • C. at least two of the following: Homonymous visual and/or unilateral sensory symptoms At least one aura symptom developes gradually over >5minutes Each symptom lasts >5 and <60 minutes • D. headache fulfilling criteria B through D for Migraine without aura begins during the aura or follows aura within 60 minutes • E. not attributed to another disorder.

21. Familial Hemiplegic Migraine (IHS 2004) • Migraine with aura • At least one first or second degree relative who has migraine aura that includes motor weakness. • AD inheritance

22. Sporadic hemiplegic migraine (IHS 2004) • Migraine with an aura of motor weakness with no family history

23. Basilar type migraine • 3-19% of children with migraine • Average age 7y • Occipital headache • Any combination of : vetigo, ataxia,diplopia,tinnitus,vomiting,visual symptoms, parasthesias and altered consciousness • Absence of weakness.

24. Childhood periodic syndromes( precursors of migraine according to revised IHS criteria) • Cyclic vomiting syndrome. • Abdominal migraine. • Benign paroxismal vertigo of childhood.

25. Retinal migraine (ocular migraine) • Sudden loss of vision, perception of bright light followed within one hour by a migrainous headache. • Reversible neurologic symptoms. • Permanent visual loss may occur. • Visual symptoms may occur without headache.

26. Complications of migraine • Chronic migraine • Status migrainosus (> 72 h) • Persistent aura without infarction • Migrainous infarction • Migraine-triggered seizure.

27. Migraine variants • Alice in wonderland syndrome • Confusional migraine • Hemisyndrome migraine • Menstrual migraine • Ophthalmoplegic migraine

28. Approach to the child with recurrent headache • History • Physical examination • Laboratory or imaging studies

29. When to perform neuroimaging study ?? • Age < 3 y • Abnormal neurological exam • Chronic progressive pattern • Family reassurance

30. MRI Vs CT There was no sufficient data to make a specific recommendation regarding the relative sensitivity of MRI compared with CT. Most prefer MRI because of vascular differential diagnosis.

31. EEG and migraine • EEG is not indicated in the routine evaluation of headache • It is performed if seizures are suspected. • EEG findings in children with migraine: -Rolandic spike and wave -Benign focal epileptiform discharges

32. Management of migraine • Non-pharmacologic methods (biofeedback, relaxation,exercise) • Pharmacologic therapy for acute attack • Preventive therapy

33. Pharmacologic Treatment • General pain medications (acetaminophen, NSAIDS) alone or in combination with antiemetic medications (migraleve) • Vasoconstrictors ergot alkaloids/xanthine (cafergot, tamigran) • Triptans-5HT1D agonists (imitrex, zomig) • Migraine status (> 72 h in adults) - steroids, DHE dihydroergotamin

34. Triptans • 5HT1 (hydroxytriptamin) receptor agonist • Promote vasoconstriction • Block pain pathway in the brain stem • Overall efficacy 63-88% • Efficacy and safety were established in adolescents (>12y) • Approved for use in Israel from 18y • Side effects: feeling of warmth, burning, pressure in the head and neck, palpitations, arrythmias, hypotension <1%. • C.I: complicated migraine.

35. American academy of pediatricsoctober 9 2006 Symptomatic treatment of migraine in children: a systematic review of medication trials

36. Conclusion: Acetaminophen, ibuprofen, and nasal, spray sumatryptan are all effective symptomatic pharmacologic treatments for episodes of migraine in children.

37. Indications for migraine prophylaxis • Attacks occur >2-4 times per month • Disability occurs > 3 days per month • Duration of attack > 48 h • Medications for acute attack are ineffective, C.I or overused • Attacks produce prolonged aura or true migrainous infarction • Patient preference

38. Duration of prophylactic therapy • The optimum duration of prophylactic therapy is uncertain • The approach is to treat for 6-12 months and then taper over the course of several weeks. • Data are limited on the effectiveness of preventive agents in children

39. Preventive Therapy • B blockers • Antideppressants • Anticonvulsants • Ca channel blocker

40. B blocker • Propranolol was the prophylactic treatment most commonly used in children, primarily based upon evidence in adults. • C.I: asthma • Caution: depression, diabetes, orthostatic hypotension, impotense