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Migraine in children
Recurrent headaches fuel parental
concern
BY Jean K. Mah, MD
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Sophie, a 7-year-old girl, is brought to the
office by her mother because of "sick headaches." Over the last
year, Sophie has had "pounding" frontal headaches every 2-4 weeks
that disrupt her usual activities. She typically feels nauseous
during the attacks and has to lie down in a dark quiet room for
several hours before the pain settles. She vomits on occasion, but
the headaches never wake her from sleep. Between episodes, she's
feeling fine, and the rest of the history is unremarkable.
Sophie is doing well in Grade 2. She
gets along with her peers and family, sleeps 8 hours per night,
skips lunch on occasion, and drinks 1-2 glasses of water a day.
Since early childhood, she has motion sickness and asthma. Her father
suffers from recurrent "sinus headaches" with weather change. The
mother is concerned that Sophie might have "a brain tumour."
Presentation
Physical examination
- alert, oriented, not in distress
- height, weight and head circumference
at 50th percentile for age
- blood pressure 90/50 mmHg, heart
rate 80 beats/min
- general exam normal: no bruit, neck
stiffness, sinus tenderness, or temporomandibular joint
pain
- visual acuity 20/20 in both eyes;
extraocular movements, visual fields and fundi normal; other
cranial nerves intact
- motor exam: normal muscle bulk, strength,
and tone; deep tendon reflexes 2+ throughout; plantar responses
down-going
- gait, coordination and sensation
all normal
Investigations
Diagnosis
and treatment
Sophie has migraine headaches. Her mother is reassured by
the normal general and neurologic exam. I suggest that Sophie
should get more sleep, drink more water and keep a headache
diary to identify migraine triggers. Her headaches have since
decreased to once every 3 months. She responds to ibuprofen
at the onset of the migraine.
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Making the case
Migraine headaches are common in children, with an estimated prevalence
of 5-10%. Diagnostic criteria for pediatric migraine include recurrent,
i.e. five or more, attacks of pulsatile headaches associated with
nausea, vomiting, photophobia, or phonophobia lasting at least an
hour -- in the absence of symptoms and signs suggestive of secondary
headaches (see below).
In this case, the history points to a non-progressive, paroxysmal
kind of migraine, where the child is completely well in between
attacks. Similarly to adults, children may experience aura with
reversible visual, sensory, motor, or complex symptoms preceding
the onset of migraine headaches. Motion sickness, cyclical vomiting,
abdominal pain and paroxysmal vertigo as precursors are also common
in the younger age bracket. A family history of migraine is helpful
for the diagnosis, but isn't required except in familial hemiplegic
migraine.1
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