Migraine in children
Migraine is a common neurological condition in children, but it is often underdiagnosed due to its varied presentation and can be difficult to distinguish from tension-type headaches. It is a key cause of acute recurrent headaches in children.
Clinical Classification
Migraines are classified based on the presence and type of associated symptoms.
Migraine without Aura: This is the most common type, accounting for 80% of cases. The diagnosis requires at least 5 episodes of headache lasting 4 to 72 hours, with at least two of the following features: unilateral or pulsating pain, moderate to severe intensity, and aggravation by physical activity. The headache must also be accompanied by nausea, vomiting, or a sensitivity to light or sound.
Migraine with Aura: This type involves neurological symptoms that precede or accompany the headache. The aura is typically a fully reversible symptom, such as visual, sensory, or speech disturbances, that develops gradually over at least 5 minutes and lasts between 5 and 60 minutes.
Hemiplegic Migraine: A rare but severe form characterised by a fully reversible motor weakness that occurs during the aura phase.
Red Flags
It’s crucial to distinguish a benign migraine from a more serious, secondary cause of headache by looking for red flags.
Sudden onset: A sudden, severe “thunderclap” headache is a medical emergency.
Neurological signs: Any new neurological deficit, such as diplopia (double vision), ataxia, or weakness, warrants urgent investigation.
Nocturnal headache: Headaches that wake a child from sleep or are present on waking, especially with vomiting, are a red flag for raised intracranial pressure.
Age: A child under the age of 4 with a new headache should be thoroughly investigated.
Progression: A headache that is getting progressively worse over time is a red flag.
Management
Management is based on treating acute episodes and, in some cases, providing prophylactic treatment.
Acute Episode
Early Analgesics: Treatment is most effective if given early, at the first sign of a headache. Simple analgesics like paracetamol or ibuprofen are the first-line treatment.
Triptans: For moderate to severe attacks that do not respond to simple analgesics, a triptan (e.g., sumatriptan, rizatriptan) can be used.
Supportive Care: Encourage the child to rest in a dark, quiet room.
Triggers: Identify and avoid triggers, which can include stress, poor sleep, certain foods (e.g., cheese, chocolate, caffeine), and hunger.
Prophylaxis
Prophylactic treatment is considered when migraines are frequent and have a significant impact on the child’s daily life, such as causing school absences or affecting sports activities. According to UK guidelines, a prophylactic agent may be considered if a child is having a migraine attack more than once every two weeks.
First-line: Propranolol is often the first-line choice for prophylaxis.
Other options: Other options include pizotifen and topiramate.
Non-pharmacological: Prophylactic management should also include addressing lifestyle factors such as stress management, sleep hygiene, and a balanced diet.