Migraine is a common disorder in children. Estimates indicate that 3.5-5% of all children will experience recurrent headaches consistent with migraine. Management consists of identifying triggering factors, providing pain relief, and considering prophylaxis.

Signs and symptoms

No specific diagnostic test is available; the diagnosis is made by history and examination. The history should address the following:

• Possible reasons for the current presentation, including past history, previous test results, allergies, and current and previous medication usage
• Family history of headache
• Quality of the headache (eg, throbbing, pounding, squeezing, pressing, pulsating, aching, burning, lancinating, dull)
• Other aspects of the headache (eg, location, timing, severity, precipitating events, and duration)

Manifestations of migraine may vary according to patient age, as follows:

• Infants may present with only episodic “head banging”
• Preschool children often have episodes involving an ill appearance, abdominal pain, vomiting, and the need to go to sleep; they may exhibit pain by irritability, crying, rocking, or seeking a dark room in which to sleep
• Children aged 5-10 years typically have bifrontal, bitemporal, or retro-orbital headache; nausea; abdominal cramping; vomiting; photophobia; phonophobia; a need to sleep; migraine facies; tearing, swollen nasal passages; thirst; edema; excessive sweating; increased urination; or diarrhea
• Older children may experience increasing headache intensity and duration; a pulsating or throbbing character to the headache; and a shift to a unilateral, temporal location

A thorough general physical examination and a detailed neurologic examination are indicated. All examination findings should be completely normal. Follow-up evaluations are necessary for patients with any of the following:

• Abnormal vital signs
• Nuchal rigidity
• Cranial nerve abnormalities
• Macrocephaly
• Bruits
• Papilledema
• Cutaneous lesions
• Cognitive changes
• Asymmetrical signs

Diagnosis

Laboratory and imaging studies are unnecessary for the diagnosis of migraine but may be indicated for the exclusion of other disorders. Investigative studies that may be considered include the following:

• Neuroimaging studies – Such studies may be worthwhile for children with chronic, progressive headaches; those younger than 4 years; those with a history of seizures, recent head trauma, or significant change in the headache; and those with physical findings suggestive of focal neurologic deficits or papilledema
• Electroencephalography – This should be reserved for patients with an atypical migraine aura, episodic loss of consciousness, or symptoms suggestive of a seizure disorder
• Lumbar puncture – This is indicated if meningitis, encephalitis, subarachnoid hemorrhage, or high-low pressure syndromes are considered

Management

Management of pediatric migraine has the following 3 facets:

• Educate patients and parents concerning migraine triggers
• Formulate a plan of treatment for the acute attacks
• Consider prophylaxis for patients with frequent migraines

Treatment of mild, infrequent attacks consists primarily of rest, trigger avoidance, and stress reduction.

Education regarding migraine triggers includes the following:

• Explaining the disease to the child and the parents
• Encouraging parents to maintain a regular bedtime and strict meal schedules for the child and to avoid overloading the child’s schedule with activities
• Helping the child recognize and avoid precipitating triggers to the extent possible, while maintaining realistic expectations (ie, migraine frequency may be reduced, but headaches will not be entirely eliminated)
• Helping the child keep a headache diary to record unique triggers and features of attacks

Measures that may be helpful for managing acute attacks include the following:

• Advising the child to lie down in a cool, dark, quiet room during the attack and go to sleep
• Providing simple analgesics (eg, acetaminophen or ibuprofen); in some cases, stronger agents (eg, butalbital) may be necessary
• Applying ice or pressure to the affected artery
• Using nonpharmacologic treatment modalities such as self-relaxation, biofeedback, and self-hypnosis
• Employing specific pharmacologic abortive therapies for acute attacks (ie, ergot preparations or triptans)

Analgesic and abortive therapies are for occasional acute attacks and should not be used frequently (frequent use may result in rebound headaches).

Possible medications for migraine prophylaxis include the following:

• Amitriptyline
• Propranolol
• Selective serotonin reuptake inhibitors
• Anticonvulsants (eg, gabapentin, valproate, and topiramate)
• Riboflavin
• Tricyclic antidepressants

The agents that seem to be the most effective for prophylaxis in children are those that block the serotonin 5-HT2 receptor, such as the following:

• Beta blockers
• Cyproheptadine
• Methysergide

In cases of status migrainosus, aggressive therapy is warranted, including the following 5 components:

• Rehydration
• Analgesics (eg, ketorolac, naproxen, or indomethacin; ideally, narcotics should be avoided)
• Specific antimigraine medications (eg, triptans, valproate, or dihydroergotamine)
• Antiemetics (eg, prochlorperazine or metoclopramide)
• Sedatives (eg, diphenhydramine or a benzodiazepine)