condition

Migraine without aura

Migraine without aura is the most common form of migraine in both children and adults. The ICHD-3 beta (seeTable 613.2) requires this to be recurrent (at least five headaches that meet the criteria, typically over the past year, but no firm time period is required). The recurrent episodic nature helps differentiate this from a secondary headache, as well as separates migraine from tension-type headache. Because headaches may first start in young childhood, this may limit the diagnosis in children as they are just be beginning to have headaches. The duration of the headache is defined as 4-72 hr for adults. It has been recognized that children may have shorter-duration headaches, so an allowance has been made to reduce this duration to 2-72 hr in children and adolescents under the age of 18 yr. Note that this duration is for the untreated or unsuccessfully treated headache. Furthermore, if the child falls asleep with the headache, the entire sleep period is considered part of the duration. These duration limits help differentiate migraine from both short-duration headaches, including the trigeminal autonomic cephalalgias, and prolonged headaches, such as those caused by idiopathic intracranial hypertension (pseudotumor cerebri). Some prolonged headaches may still be migraine, but a migraine that persists beyond 72 hr is classified as a variant termedstatus migrainosus. The quality of migraine pain is often, but not always, throbbing or pounding. This may be difficult to elicit in young children and drawings or demonstrations may help confirm the throbbing quality. The location of the pain has classically been described asunilateral (hemicrania); in young children it is more commonly bilateral. A more appropriate way to think of the location would therefore be focal, to differentiate it from the diffuse pain of tension-type headaches. Of particular concern is the exclusively occipital headache because although these can be migraines, they are more frequently secondary to another more proximate etiology such as posterior fossa abnormalities. Migraine, when allowed to fully develop, often worsens in the face of and secondarily results in altered activity level. For example, worsening of the pain occurs classically in adults when going up or down stairs. This history is often not elicited in children. A change in the child's activity pattern can be easily observed as a reduction in play or physical activity. Older children may limit or restrict their sports activity or exercise during a headache attack. Migraine may have a variety of associated symptoms. In younger children, nausea and vomiting may be the most obvious symptoms and often outweigh the headache itself. This often leads to the overlap with several of the gastrointestinal periodic diseases, including recurrent abdominal pain, recurrent vomiting, cyclic vomiting, and abdominal migraine. The common feature among all of these related conditions is an increased propensity among children with them for the later development of migraine. Oftentimes, early childhood recurrent vomiting may in fact be migraine, but the child is not asked about or is unable to describe headache pain. This may occur as early as infancy because babies with colic have a higher incidence of migraine once they are able to express their symptoms. Once a clear head pain becomes evident, the earlier diagnosis of a gastrointestinal disorder is no longer appropriate. When headache is present, vomiting raises the concern of a secondary headache, particularly related to increased intracranial pressure.One of the red flags for this is the daily or near daily early morning vomiting, or headaches waking the child up from sleep. When the headaches associated with vomiting episodes are sporadic and not worsening, it is more likely that the diagnosis is migraine. Vomiting and headache caused by increased intracranial pressure are frequently present on first awakening and remit with maintenance of upright posture. In contrast, if a migraine is present on first awakening(a relatively infrequent occurrence in children), getting up and going about normal, upright activities usually makes the headache and vomiting worse. As the child matures, light and sound sensitivity(photophobia andphonophobia) may become more apparent. This is either by direct report of the patient or the interpretation by the parents of the child's activity because the parent may become aware of this symptom before the child. These symptoms are likely a component of the hypersensitivity that develops during an acute migraine attack and may also include smell sensitivity(osmophobia) and touch sensitivity(cutaneous allodynia). Although only the photophobia and phonophobia are components of the ICHD-3 beta criteria, these other symptoms are helpful in confirming the diagnosis and may be helpful in understanding the underlying pathophysiology and determining the response to treatment. The final ICHD-3 beta requirement is the exclusion of causes of secondary headaches, and this should be an integral component of the headache history. Migraine typically runs in families with reports of up to 90% of children having a first- or second-degree relative with recurrent headaches. Given the underdiagnoses and misdiagnosis in adults, this is often not recognized by the family, and a headache family history is required. When a family history is not identified, this may be the result of either a lack of awareness of migraine within the family or an underlying secondary headache in the child. Any child whose family, upon close and both direct and indirect questioning, does not include individuals with migraine or related syndromes (e.g., motion sickness, cyclic vomiting, menstrual headache) should have an imaging procedure performed to look for anatomic etiologies for headache. In addition to the classifying features, there may be additional markers of a migraine disorder. These include such things as triggers (skipping meals, inadequate or irregular sleep, dehydration, and weather changes are the most common), pattern recognition (associated with menstrual periods in adolescents or Monday-morning headaches resulting from changes in sleep patterns over the weekend and nonphysiologic early waking on Monday mornings for school), and prodromal symptoms (a feeling of irritability, tiredness, and food cravings prior to the start of the headache) (Fig. 613.1). Although these additional features may not be consistent, they do raise the index of suspicion for migraine and provide a potential mechanism of intervention. In the past, food triggers were considered widely common, but the majority have either been discredited with scientific study or represent such a small number of patients that they only need to be addressed when consistently triggering the headache.

Ref:
Robert M. Kliegman MD, in Nelson Textbook of Pediatrics, 2020

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Added on Aug 29, 2022 by Barbara Van De Keer

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