Migraine in Children and Adolescents
Introduction to Migraine in Children and Adolescents
Migraine is a common neurological disorder characterized by recurrent headaches, often accompanied by various sensory disturbances. In children and adolescents, migraine presents unique challenges in diagnosis and management due to age-specific variations in symptom presentation and the impact on developmental milestones.
Key points:
- Migraine is one of the most common causes of headaches in pediatric populations
- Symptoms and presentation can differ significantly from adult migraines
- Early diagnosis and management are crucial for minimizing the impact on quality of life and academic performance
- Treatment approaches must be tailored to the child's age, developmental stage, and individual needs
Epidemiology of Pediatric Migraine
Understanding the prevalence and distribution of migraine in children and adolescents is crucial for effective public health planning and clinical management.
- Prevalence:
- 3-10% in children (increasing with age)
- 8-23% in adolescents
- Higher prevalence in females, especially post-puberty
- Age of onset:
- Can occur as early as infancy
- Peak onset during adolescence
- Risk factors:
- Family history (70-80% of children with migraine have a first-degree relative with the condition)
- Hormonal changes (particularly in adolescent girls)
- Stress and academic pressures
- Sleep disturbances
- Dietary factors
Pathophysiology of Pediatric Migraine
The underlying mechanisms of migraine in children and adolescents are similar to those in adults, but with some age-specific considerations:
- Neurovascular theory:
- Activation of the trigeminovascular system
- Release of inflammatory neuropeptides (e.g., CGRP, substance P)
- Neurogenic inflammation and vasodilation
- Cortical spreading depression (CSD):
- Associated with aura symptoms
- May be more prevalent in pediatric migraines
- Neurotransmitter involvement:
- Serotonin dysregulation
- Dopamine system activation (may explain some pediatric-specific symptoms like vomiting)
- Genetic factors:
- Mutations in ion channel genes (e.g., CACNA1A, SCN1A)
- Mitochondrial DNA mutations
Clinical Presentation of Migraine in Children and Adolescents
The presentation of migraine in pediatric populations can differ significantly from adult manifestations:
- Headache characteristics:
- Often bilateral (unlike the typical unilateral pain in adults)
- Shorter duration (2-72 hours, compared to 4-72 hours in adults)
- May be frontal, temporal, or occipital
- Associated symptoms:
- Nausea and vomiting (more common than in adults)
- Photophobia and phonophobia
- Dizziness or vertigo
- Abdominal pain (abdominal migraine variant)
- Aura:
- Present in 15-30% of pediatric migraines
- Visual auras most common (scintillating scotomas, fortification spectra)
- Can include sensory or motor symptoms
- Behavioral changes:
- Irritability or mood changes preceding or during attacks
- Desire to sleep
- Food cravings or anorexia
- Migraine variants in children:
- Cyclic vomiting syndrome
- Benign paroxysmal vertigo
- Confusional migraine
Diagnosis of Migraine in Children and Adolescents
Diagnosing migraine in pediatric populations requires a careful history, physical examination, and consideration of age-specific diagnostic criteria:
- Diagnostic criteria (International Classification of Headache Disorders, 3rd edition):
- At least 5 attacks fulfilling the following criteria:
- Duration of 2-72 hours
- At least two of: bilateral/unilateral location, pulsating quality, moderate to severe intensity, aggravation by routine physical activity
- At least one of: nausea/vomiting, photophobia and phonophobia
- At least 5 attacks fulfilling the following criteria:
- Clinical history:
- Detailed description of headache characteristics
- Associated symptoms
- Frequency and duration of attacks
- Triggers and alleviating factors
- Family history
- Physical and neurological examination:
- To rule out secondary causes of headache
- Assessment of developmental milestones
- Diagnostic tools:
- Headache diaries (can be helpful in identifying patterns and triggers)
- Neuroimaging (MRI or CT) if atypical features or neurological deficits are present
- Differential diagnosis:
- Tension-type headache
- Cluster headache (rare in children)
- Intracranial pathologies (tumors, infections)
- Idiopathic intracranial hypertension
- Medication overuse headache
Treatment of Migraine in Children and Adolescents
Management of pediatric migraine involves a multifaceted approach, including acute treatment, preventive strategies, and lifestyle modifications:
- Acute treatment:
- Non-pharmacological:
- Rest in a quiet, dark room
- Cold compresses
- Relaxation techniques
- Pharmacological:
- NSAIDs (ibuprofen, naproxen)
- Acetaminophen
- Triptans (approved for adolescents, off-label use in younger children)
- Antiemetics for associated nausea
- Non-pharmacological:
- Preventive treatment (for frequent or disabling migraines):
- First-line options:
- Topiramate
- Propranolol
- Amitriptyline
- Second-line options:
- Valproic acid (not for females of childbearing potential)
- Cyproheptadine (for younger children)
- CGRP monoclonal antibodies (emerging evidence in adolescents)
- Non-pharmacological prevention:
- Cognitive behavioral therapy
- Biofeedback
- Acupuncture
- First-line options:
- Lifestyle modifications:
- Regular sleep schedule
- Balanced diet and regular meals
- Hydration
- Stress management techniques
- Regular exercise
- Education and support:
- Patient and family education about migraine
- School accommodations if needed
- Psychological support for coping with chronic pain
Prognosis of Migraine in Children and Adolescents
Understanding the long-term outlook for children and adolescents with migraine is crucial for patient counseling and management planning:
- Natural history:
- 50-60% of children with migraine continue to experience attacks into adulthood
- Some experience a reduction in frequency or intensity over time
- Puberty can lead to changes in migraine patterns, especially in females
- Factors influencing prognosis:
- Age of onset (earlier onset may predict longer duration)
- Family history
- Presence of comorbidities (e.g., anxiety, depression)
- Adherence to preventive strategies and lifestyle modifications
- Impact on quality of life:
- Academic performance may be affected
- Social and extracurricular activities can be limited
- Potential for development of anxiety or depression
- Long-term considerations:
- Risk of medication overuse headache with frequent use of acute medications
- Potential for chronic migraine development (15 or more headache days per month)
- Importance of ongoing follow-up and treatment adjustments
Overview of Migraine Treatment in Children
The treatment of migraine in children requires a comprehensive, multidisciplinary approach tailored to the individual patient's needs, age, and migraine characteristics. The primary goals of treatment are to:
- Reduce the frequency, severity, and duration of migraine attacks
- Improve the child's quality of life and minimize disability
- Prevent progression to chronic migraine
- Avoid medication overuse
Treatment strategies can be broadly categorized into:
- Acute (abortive) treatment
- Preventive (prophylactic) treatment
- Non-pharmacological approaches
The choice of treatment depends on various factors, including the frequency and severity of attacks, the presence of comorbidities, and the impact on daily activities. A stepwise approach is often recommended, starting with lifestyle modifications and non-pharmacological interventions before progressing to medications.
Acute Treatment of Migraine in Children
Acute treatment aims to abort an ongoing migraine attack or reduce its severity. Key principles include:
- Early intervention: Treating at the first sign of migraine
- Appropriate dosing: Using weight-based dosing for optimal efficacy
- Route of administration: Considering alternatives to oral medication if nausea is prominent
Pharmacological options:
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs):
- Ibuprofen: 10 mg/kg/dose (max 600 mg/dose)
- Naproxen: 5-7 mg/kg/dose (max 500 mg/dose)
- Acetaminophen: 15 mg/kg/dose (max 1000 mg/dose)
- Triptans:
- Sumatriptan: Nasal spray (5-20 mg) or subcutaneous injection (0.06 mg/kg)
- Rizatriptan: 5 mg for 20-39 kg, 10 mg for ≥40 kg
- Zolmitriptan: Nasal spray (2.5-5 mg)
- Antiemetics:
- Ondansetron: 0.15 mg/kg/dose (max 8 mg)
- Promethazine: 0.25-1 mg/kg/dose (max 25 mg)
Note: The use of triptans in children under 12 years is often off-label and should be considered carefully.
Preventive Treatment of Migraine in Children
Preventive treatment is considered when:
- Migraines occur more than 4 times per month
- Attacks significantly impact daily activities or school performance
- Acute treatments are ineffective or poorly tolerated
Pharmacological options:
- First-line options:
- Topiramate: 2-3 mg/kg/day (max 200 mg/day), divided doses
- Propranolol: 1-4 mg/kg/day (max 160 mg/day), divided doses
- Amitriptyline: 0.5-1 mg/kg/day (max 50 mg/day), at bedtime
- Second-line options:
- Valproic acid: 15-30 mg/kg/day (avoid in females of childbearing potential)
- Cyproheptadine: 0.2-0.4 mg/kg/day (commonly used in younger children)
- Emerging therapies:
- CGRP monoclonal antibodies: Currently under investigation for pediatric use
- Erenumab, Fremanezumab, Galcanezumab: Dosing to be established for pediatric populations
Preventive medications should be started at a low dose and titrated slowly. A trial of 2-3 months at the target dose is recommended before assessing efficacy.
Non-Pharmacological Approaches
Non-pharmacological interventions play a crucial role in pediatric migraine management and should be implemented alongside pharmacological treatments:
- Lifestyle modifications:
- Regular sleep schedule: Consistent bedtime and wake time
- Balanced diet: Regular meals, adequate hydration
- Exercise: Regular physical activity appropriate for age
- Stress management: Age-appropriate relaxation techniques
- Trigger identification and avoidance:
- Maintain a headache diary to identify patterns and triggers
- Common triggers: Stress, certain foods, dehydration, irregular sleep
- Cognitive Behavioral Therapy (CBT):
- Teaching coping strategies and pain management techniques
- Addressing any comorbid anxiety or depression
- Biofeedback:
- Training to control physiological processes (e.g., muscle tension, heart rate)
- Particularly effective in combination with relaxation techniques
- Acupuncture:
- May be considered in older children and adolescents
- Evidence is limited but promising for migraine prevention
- Nutraceuticals:
- Magnesium: 9 mg/kg/day (max 600 mg/day)
- Riboflavin (Vitamin B2): 200-400 mg/day
- Coenzyme Q10: 1-3 mg/kg/day
Emergency Management of Pediatric Migraine
In cases of severe, prolonged, or treatment-resistant migraine attacks, emergency management may be necessary:
- Intravenous hydration:
- Normal saline bolus followed by maintenance fluids
- Parenteral medications:
- Ketorolac: 0.5 mg/kg IV (max 30 mg)
- Prochlorperazine: 0.15 mg/kg IV (max 10 mg)
- Metoclopramide: 0.1 mg/kg IV (max 10 mg)
- Dihydroergotamine (DHE): 0.1-0.3 mg IV, may repeat (max 1 mg/dose, 3 mg/day)
- Magnesium sulfate: 25-50 mg/kg IV (max 2000 mg)
- Dexamethasone: 0.25 mg/kg IV (max 10 mg) for status migrainosus
In the emergency setting, combination therapy (e.g., NSAID + antiemetic) is often more effective than monotherapy.
Special Considerations in Pediatric Migraine Treatment
Several factors require special attention when treating migraine in children:
- Age-specific approaches:
- Younger children may require liquid formulations or alternative routes of administration
- Dosing should be weight-based and adjusted as the child grows
- Menstrual migraine in adolescent girls:
- Consider hormonal interventions in consultation with a gynecologist
- Short-term prophylaxis around menstruation may be beneficial
- Comorbidities:
- Address sleep disorders, anxiety, or depression concurrently
- Choose medications that may treat multiple conditions (e.g., amitriptyline for migraine and depression)
- School considerations:
- Develop a school action plan for managing migraines
- Educate teachers and school nurses about the child's condition
- Consider 504 plan or IEP if migraines significantly impact academic performance
- Medication overuse:
- Educate patients and families about the risk of medication overuse headache
- Limit use of acute medications to 2-3 days per week
- Transition of care:
- Prepare adolescents for transition to adult care
- Encourage self-management skills and medication adherence
Migraine in Children and Adolescents
- Question: What is the estimated prevalence of migraine in children and adolescents? Answer: Approximately 7-10% of children and adolescents
- Question: At what age do migraines typically begin in children? Answer: Average age of onset is around 7 years old
- Question: What is the most common type of migraine in children? Answer: Migraine without aura
- Question: What is the typical duration of a migraine attack in children compared to adults? Answer: Shorter, often lasting 2-72 hours
- Question: What is a common location of pain in pediatric migraines? Answer: Bilateral (both sides of the head) rather than unilateral
- Question: What additional symptoms often accompany migraine headaches in children? Answer: Nausea, vomiting, photophobia, and phonophobia
- Question: What is the term for recurrent abdominal pain associated with migraines in children? Answer: Abdominal migraine
- Question: What is the most common aura symptom in children with migraine with aura? Answer: Visual disturbances
- Question: What is the term for the temporary neurological deficit that can occur with some migraines? Answer: Hemiplegic migraine
- Question: What is the recommended first-line treatment for acute migraine attacks in children? Answer: Ibuprofen or acetaminophen
- Question: At what frequency of headaches should preventive therapy be considered in children with migraines? Answer: More than 3-4 headaches per month
- Question: What class of medications is commonly used for migraine prevention in children and adolescents? Answer: Anticonvulsants (e.g., topiramate)
- Question: What non-pharmacological approach is often recommended as part of migraine management in children? Answer: Lifestyle modifications (regular sleep, meals, hydration, and exercise)
- Question: What is the term for the overuse of acute migraine medications leading to more frequent headaches? Answer: Medication overuse headache
- Question: What imaging study is recommended for children with atypical headache patterns or neurological signs? Answer: MRI of the brain
- Question: What is a common trigger for migraines in children and adolescents? Answer: Stress
- Question: What is the recommended tool for tracking migraine frequency and severity in children? Answer: Headache diary
- Question: What is the term for the premonitory symptoms that can occur before a migraine attack? Answer: Prodrome
- Question: What is a common prodromal symptom in children with migraines? Answer: Mood changes
- Question: What is the recommended duration of preventive therapy in children before assessing its effectiveness? Answer: At least 2-3 months
- Question: What is the term for the temporary visual disturbance that can precede or accompany a migraine? Answer: Scintillating scotoma
- Question: What is the recommended management for mild to moderate migraine attacks in children? Answer: Rest in a quiet, dark room and use of simple analgesics
- Question: What class of medications is sometimes used for acute treatment of severe migraines in adolescents? Answer: Triptans
- Question: What is the term for the phase after the headache when some children may experience fatigue or mood changes? Answer: Postdrome
- Question: What is a common comorbid condition in children with migraines? Answer: Anxiety or depression
- Question: What is the recommended approach for managing migraines in children and adolescents? Answer: Multimodal approach combining pharmacological and non-pharmacological strategies
- Question: What percentage of children with migraines also have a family history of migraines? Answer: Approximately 70-80%
- Question: What is the term for the sensation of spinning or dizziness that can accompany migraines in some children? Answer: Vestibular migraine
- Question: What is the recommended frequency of follow-up visits for children with well-controlled migraines? Answer: Every 3-6 months
- Question: What is the prognosis for children with migraines as they enter adulthood? Answer: About 50% may experience improvement or resolution of symptoms
