MIGRAINE HEADACHE IN MIGRAINE HEADACHE IN CHILDRENCHILDREN

Suhair Shehadeh-Saieg M.DSuhair Shehadeh-Saieg M.D

Pediatric DepartmentPediatric Department

Bnai-Zion Medical Center, Bnai-Zion Medical Center, HaifaHaifa

הצגת מקרההצגת מקרה

חודשים חודשים1010 שנים ו שנים ו 1212בן בן ברקע בריאברקע בריא

::ת.עת.ע שבועות סובל מכאבי ראש פרונטאלים לוחצים שבועות סובל מכאבי ראש פרונטאלים לוחצים 33מזה מזה

שנמשכים כמה שעות ועוברים ספונטאנית או אחרי שנמשכים כמה שעות ועוברים ספונטאנית או אחרי משכחי כאבים. ללא פוטופוביה או פונופוביה. לעתים משכחי כאבים. ללא פוטופוביה או פונופוביה. לעתים

..בליווי בחילות אך ללא הקאותבליווי בחילות אך ללא הקאות::ס.מס.מ

. .כאב גב תחתון מזה כמה ימיםכאב גב תחתון מזה כמה ימים..לציין ספור משפחתי של מיגרנה וכאבי גב תחתון אצל האבלציין ספור משפחתי של מיגרנה וכאבי גב תחתון אצל האב

::סימנים חיונייםסימנים חיוניים104/87104/87 לחץ דם= לחץ דם=102102 דופק= דופק=36.336.3חום=חום=

תקינה כולל בדיקת פונדוסים תקינה כולל בדיקת פונדוסיםבדיקה פיסיקלית:בדיקה פיסיקלית:בדיקה נוירולוגית תקינהבדיקה נוירולוגית תקינה

:: מעבדהמעבדהכולל ספירת דם, מדדי דלקת, אלקטרוליטים ושתן כולל ספירת דם, מדדי דלקת, אלקטרוליטים ושתן ))

.(.(לכלליתלכלליתEEG:EEG: האטה דיפוזית ללא מוקד פרכוסיהאטה דיפוזית ללא מוקד פרכוסי

CTCT:: מוח מוח תקיןתקין

. .בוצע ניקור מותני שהיה תקיןבוצע ניקור מותני שהיה תקיןבמהלך האישפוז היה שיפור קליני ושוחרר לביתו עם אבחנתבמהלך האישפוז היה שיפור קליני ושוחרר לביתו עם אבחנת

Tension headacheTension headache

:: שעות אחרי בצוע הניקור המותני שעות אחרי בצוע הניקור המותני7272אשפוז חוזראשפוז חוזרכאבי ראש פרונטאלים ובחילותכאבי ראש פרונטאלים ובחילות

בבדיקה פיסיקלית מתקשה בהליכה ועמידה וסימני גירוי בבדיקה פיסיקלית מתקשה בהליכה ועמידה וסימני גירוי מנינגיאלימנינגיאלי

US US . .גב מותני תקיןגב מותני תקין

מדדי דלקת היו תקיניםמדדי דלקת היו תקינים

..סוכם כסובל מכאבי ראש לאחר ניקור מותניסוכם כסובל מכאבי ראש לאחר ניקור מותני

היה שפור קליני ניכר תחת טיפול אנלגטיקה וקפאיןהיה שפור קליני ניכר תחת טיפול אנלגטיקה וקפאין

שוחרר להמשך מעקב נוירולוגישוחרר להמשך מעקב נוירולוגי

Headache classificationHeadache classification

• Primary headachePrimary headache

migraine, tension , clustermigraine, tension , cluster

• Secondary headacheSecondary headache

Infection, trauma, hemorrhage, tumor, Infection, trauma, hemorrhage, tumor, high intracranial pressure.high intracranial pressure.

Tension headacheTension headache

• Bilateral, pressing tightnessBilateral, pressing tightness

• Non-throbbing, mild to moderateNon-throbbing, mild to moderate

• Lasts from 30 minutes to several daysLasts from 30 minutes to several days

• May be associated with photophobia or May be associated with photophobia or phonophobiaphonophobia

• Is not accompanied by nausea or vomitingIs not accompanied by nausea or vomiting

Cluster headacheCluster headache

• More apparent between ages 10-20yMore apparent between ages 10-20y

• M:F = 9:1 after age 20y.M:F = 9:1 after age 20y.

• Always unilateral, mainly frontal-peri-orbitalAlways unilateral, mainly frontal-peri-orbital

• Severe nature, less than three hoursSevere nature, less than three hours

• Usually associated with ipsilateral Usually associated with ipsilateral autonomic findings autonomic findings

( lacrimation, rhinorrhea, ophthalmic ( lacrimation, rhinorrhea, ophthalmic injection, horner syndrome)injection, horner syndrome)

MigraineMigraine

• Episodic, periodic, paroxysmal attacks of Episodic, periodic, paroxysmal attacks of moderate to severe throbbing pain, moderate to severe throbbing pain, separated by pain free intervals, separated by pain free intervals,

• Associated with nausea, vomiting, Associated with nausea, vomiting, photophobia, abdominal pain and desire to photophobia, abdominal pain and desire to sleep, motion sickness.sleep, motion sickness.

• Family history 70-90%Family history 70-90%

Incidence of migraineIncidence of migraine

• In 50% of cases : < 20yIn 50% of cases : < 20y

• The youngest age reported was 3yThe youngest age reported was 3y

• 7y : 1-3%7y : 1-3%

• 7-15 : 4-11%7-15 : 4-11%

• < 7y >>> M>F< 7y >>> M>F

• 7-11y M=F7-11y M=F

• >11 F>M>11 F>M

Signs and symptoms of intracranial Signs and symptoms of intracranial pathologypathology

• Sleep related headacheSleep related headache

• Absence of family history of migraineAbsence of family history of migraine

• Vomiting\absence of visual symptomsVomiting\absence of visual symptoms

• Headache of less than six month durationHeadache of less than six month duration

• ConfusionConfusion

• Abnormal neurologic examinationAbnormal neurologic examination

• Growth abnormality ,pulsatile tinitusGrowth abnormality ,pulsatile tinitus

• Lack of response to medical therapyLack of response to medical therapy

pathophysiologypathophysiology

• Vascular theory Vascular theory

• Neuronal theory ( cortical spreading Neuronal theory ( cortical spreading depression)depression)

Precipitating factorsPrecipitating factors

• AnxietyAnxiety

• FatigueFatigue

• Head traumaHead trauma

• StressStress

• MensesMenses

• IllnessIllness

• dietdiet

Dietary items and chemical Dietary items and chemical migraine triggersmigraine triggers• Offending food itemsOffending food items• CheeseCheese• ChocolateChocolate• Hot dogs,ham, cured Hot dogs,ham, cured

meatsmeats• Yugort, dairy productsYugort, dairy products• Asian frozen snack Asian frozen snack

foodsfoods• Wine, beerWine, beer• FastingFasting• Coffee, tea,colaCoffee, tea,cola• Food diyes, additivesFood diyes, additives

• Chemical triggersChemical triggers• TyraminTyramin• Nitric oxide, nitritesNitric oxide, nitrites• Allergenic proteins Allergenic proteins

(casein )(casein )• Monosodium Monosodium

glutamateglutamate• AspartameAspartame• Histamine, tyramine Histamine, tyramine

sulfitesulfite

Pathophyiology schemaPathophyiology schema

Primary trigerPrimary triger

Locus ceruleus >> cortical deppretionLocus ceruleus >> cortical deppretion

Trigeminal nucleus vasoconstrictionTrigeminal nucleus vasoconstriction

Neuronal inflammation auraNeuronal inflammation aura

Vasodilatation Vasodilatation

painpain

SerotoninSerotonin

• Released from brainstem serotonergic Released from brainstem serotonergic nuclei.nuclei.

• Plays an important role in the Plays an important role in the pathogenesis of migrainepathogenesis of migraine

• Direct action upon the cranial vasculatureDirect action upon the cranial vasculature

• Role in central pain control pathwaysRole in central pain control pathways

Classification of migraine Classification of migraine (revised international headache society IHS (revised international headache society IHS 2004)2004)

• Migraine without auraMigraine without aura

• Migraine with auraMigraine with aura

• Migraine with typical auraMigraine with typical aura

Migraine without aura (IHS 2004)Migraine without aura (IHS 2004)

• A. at least 5 attacks fulfilling criteria B through D.A. at least 5 attacks fulfilling criteria B through D.• B. Headache attacks lasting 4 to 72hB. Headache attacks lasting 4 to 72h• C. headache has at least 2 of the followingC. headache has at least 2 of the following -unilateral location-unilateral location -pulsating quality-pulsating quality -moderate or severe pain intensity-moderate or severe pain intensity -aggravation by or causing avoidence of-aggravation by or causing avoidence of routine physical activityroutine physical activity• D. during headache at least one of the folowing:D. during headache at least one of the folowing: nausea, vomiting, or both, photophobia, nausea, vomiting, or both, photophobia,

phonophobiaphonophobia• E. not attributed to another disorder.E. not attributed to another disorder.

Migraine with aura (IHS 2004Migraine with aura (IHS 2004))

• A. at least 2 attacks fulfilling criteria B.A. at least 2 attacks fulfilling criteria B.• B. migraine aura fulfilling criteria B or C for one of B. migraine aura fulfilling criteria B or C for one of

the following subforms:the following subforms: Typical aura with migraine headacheTypical aura with migraine headache Typical aura with nonmigraine painTypical aura with nonmigraine pain Typical aura without headacheTypical aura without headache Familial hemiplegic migraineFamilial hemiplegic migraine Sporadic hemiplegic migraineSporadic hemiplegic migraine Basilar type migraineBasilar type migraine• C. Not attributed to another disorder.C. Not attributed to another disorder.

Migraine with typical aura (IHS Migraine with typical aura (IHS 2004)2004)

• A.A. at least 2 attacks fulfilling criteria B or D.at least 2 attacks fulfilling criteria B or D.• B. Aura consisting at least one of the following, but no motor B. Aura consisting at least one of the following, but no motor

weakness:weakness: Fully reversible visual symptomsFully reversible visual symptoms Fully reversible sensory symptoms (numbness, pins and needles)Fully reversible sensory symptoms (numbness, pins and needles) Fully reversible dysphasiaFully reversible dysphasia• C. at least two of the following:C. at least two of the following: Homonymous visual and/or unilateral sensory symptomsHomonymous visual and/or unilateral sensory symptoms At least one aura symptom developes gradually over >5minutesAt least one aura symptom developes gradually over >5minutes Each symptom lasts >5 and <60 minutesEach symptom lasts >5 and <60 minutes• D. headache fulfilling criteria B through D for Migraine without auraD. headache fulfilling criteria B through D for Migraine without aura begins during the aura or follows aura within 60 minutesbegins during the aura or follows aura within 60 minutes• E. not attributed to another disorder.E. not attributed to another disorder.

Familial Hemiplegic Migraine (IHS Familial Hemiplegic Migraine (IHS 2004)2004)

• Migraine with auraMigraine with aura

• At least one first or second degree relative At least one first or second degree relative who has migraine aura that includes motor who has migraine aura that includes motor weakness.weakness.

• AD inheritanceAD inheritance

Sporadic hemiplegic migraine (IHS Sporadic hemiplegic migraine (IHS 2004)2004)

• Migraine with an aura of motor weakness Migraine with an aura of motor weakness with no family historywith no family history

Basilar type migraineBasilar type migraine

• 3-19% of children with migraine3-19% of children with migraine

• Average age 7yAverage age 7y

• Occipital headacheOccipital headache

• Any combination of : vetigo, Any combination of : vetigo, ataxia,diplopia,tinnitus,vomiting,visual ataxia,diplopia,tinnitus,vomiting,visual symptoms,symptoms,

parasthesias and altered consciousnessparasthesias and altered consciousness

• Absence of weakness.Absence of weakness.

Childhood periodic syndromesChildhood periodic syndromes( precursors of migraine according to ( precursors of migraine according to revised IHS criteriarevised IHS criteria))

• Cyclic vomiting syndrome.Cyclic vomiting syndrome.

• Abdominal migraine.Abdominal migraine.

• Benign paroxismal vertigo of childhood.Benign paroxismal vertigo of childhood.

Retinal migraine (ocular migraineRetinal migraine (ocular migraine))

• Sudden loss of vision, perception of bright Sudden loss of vision, perception of bright lightlight

followed within one hour by a migrainous followed within one hour by a migrainous headache.headache.

• Reversible neurologic symptoms.Reversible neurologic symptoms.

• Permanent visual loss may occur.Permanent visual loss may occur.

• Visual symptoms may occur without Visual symptoms may occur without headache.headache.

Complications of migraineComplications of migraine

• Chronic migraineChronic migraine

• Status migrainosus (> 72 h)Status migrainosus (> 72 h)

• Persistent aura without infarctionPersistent aura without infarction

• Migrainous infarctionMigrainous infarction

• Migraine-triggered seizure.Migraine-triggered seizure.

Migraine variantsMigraine variants

• Alice in wonderland syndromeAlice in wonderland syndrome

• Confusional migraineConfusional migraine

• Hemisyndrome migraineHemisyndrome migraine

• Menstrual migraineMenstrual migraine

• Ophthalmoplegic migraineOphthalmoplegic migraine

Approach to the child with Approach to the child with recurrent headacherecurrent headache

• HistoryHistory

• Physical examinationPhysical examination

• Laboratory or imaging studiesLaboratory or imaging studies

When to perform neuroimaging When to perform neuroimaging study ??study ??

• Age < 3 yAge < 3 y

• Abnormal neurological examAbnormal neurological exam

• Chronic progressive patternChronic progressive pattern

• Family reassuranceFamily reassurance

MRI Vs CTMRI Vs CT

There was no sufficient data to make a There was no sufficient data to make a specific recommendation regarding the specific recommendation regarding the relative sensitivity of MRI compared with relative sensitivity of MRI compared with CT. CT.

Most prefer MRI because of vascular Most prefer MRI because of vascular differential diagnosis.differential diagnosis.

EEG and migraineEEG and migraine

• EEG is not indicated in the routine EEG is not indicated in the routine evaluation of headacheevaluation of headache

• It is performed if seizures are suspected.It is performed if seizures are suspected.

• EEG findings in children with migraine:EEG findings in children with migraine:

-Rolandic spike and wave-Rolandic spike and wave

-Benign focal epileptiform discharges-Benign focal epileptiform discharges

Management of migraineManagement of migraine

• Non-pharmacologic methods (biofeedback, Non-pharmacologic methods (biofeedback, relaxation,exercise)relaxation,exercise)

• Pharmacologic therapy for acute attackPharmacologic therapy for acute attack

• Preventive therapyPreventive therapy

Pharmacologic TreatmentPharmacologic Treatment

• General pain medicationsGeneral pain medications

(acetaminophen, NSAIDS) alone or in (acetaminophen, NSAIDS) alone or in combination with antiemetic medications combination with antiemetic medications (migraleve)(migraleve)

• Vasoconstrictors ergot alkaloids/xanthine Vasoconstrictors ergot alkaloids/xanthine (cafergot, tamigran)(cafergot, tamigran)

• Triptans-5HT1D agonists (imitrex, zomig)Triptans-5HT1D agonists (imitrex, zomig)

• Migraine status (> 72 h in adults) - steroids, Migraine status (> 72 h in adults) - steroids, DHEDHE

dihydroergotamindihydroergotamin

TriptansTriptans

• 5HT1 (hydroxytriptamin) receptor agonist5HT1 (hydroxytriptamin) receptor agonist

• Promote vasoconstrictionPromote vasoconstriction

• Block pain pathway in the brain stemBlock pain pathway in the brain stem

• Overall efficacy 63-88%Overall efficacy 63-88%

• Efficacy and safety were established in adolescents Efficacy and safety were established in adolescents (>12y)(>12y)

• Approved for use in Israel from 18yApproved for use in Israel from 18y

• Side effectsSide effects: feeling of warmth, burning, pressure in : feeling of warmth, burning, pressure in the head and neck, palpitations, arrythmias, the head and neck, palpitations, arrythmias, hypotension <1%.hypotension <1%.

• C.IC.I: complicated migraine.: complicated migraine.

American academy of pediatricsAmerican academy of pediatricsoctober 9 2006october 9 2006

Symptomatic treatment of migraine in Symptomatic treatment of migraine in children: a systematic review of children: a systematic review of

medication trialsmedication trials

Conclusion:Conclusion:

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

Indications for migraine prophylaxisIndications for migraine prophylaxis

• Attacks occur >2-4 times per monthAttacks occur >2-4 times per month

• Disability occurs > 3 days per monthDisability occurs > 3 days per month

• Duration of attack > 48 hDuration of attack > 48 h

• Medications for acute attack are Medications for acute attack are ineffective, C.I or overusedineffective, C.I or overused

• Attacks produce prolonged aura or true Attacks produce prolonged aura or true migrainous infarctionmigrainous infarction

• Patient preferencePatient preference

Duration of prophylactic therapyDuration of prophylactic therapy

• The optimum duration of prophylactic The optimum duration of prophylactic therapy is uncertaintherapy is uncertain

• The approach is to treat for 6-12 months The approach is to treat for 6-12 months and then taper over the course of several and then taper over the course of several weeks.weeks.

• Data are limited on the effectiveness of Data are limited on the effectiveness of preventive agents in childrenpreventive agents in children

Preventive TherapyPreventive Therapy

• B blockersB blockers

• AntideppressantsAntideppressants

• AnticonvulsantsAnticonvulsants

• Ca channel blockerCa channel blocker

B blockerB blocker

• Propranolol was the prophylactic Propranolol was the prophylactic treatment most commonly used in treatment most commonly used in children, primarily based upon evidence in children, primarily based upon evidence in adults.adults.

• C.I: asthmaC.I: asthma

• Caution: depression, diabetes, orthostatic Caution: depression, diabetes, orthostatic hypotension, impotensehypotension, impotense