Symposium on Pediatric Neurology

Migraine and Migrainous Variants in Pediatric Patients Arthur L. Prensky, M.D. *

INCIDENCE Migraine is a venerable disease and a very common one. Waters and O'Connor" suggested that such headaches occur in 23 to 29 per cent of women and 15 to 20 per cent of men on the basis of several population studies done in the British Isles. Their figures are somewhat higher than the frequently quoted prevalence of approximately 10 per cent of the general population. Population studies also suggest there are no significant differences in the prevalence of migraine based upon social class or intelligence. 54 The most thorough study of migraine in children of school age is that of Bille7 who found that there was approximately a 4 per cent incidence in school children ages 7 to 15 in Uppsala, Sweden, though the incidence was somewhat lower in the 7 to 9 year old group (2.5 per cent) than at older ages. Approximately 20 per cent of adults who suffer from migraine indicate that their headaches began prior to the age of 10. 40 ,46 In several studies involving children, 70 to 80 per cent of the headaches appeared when the patients were under 10 years of age,B, 29. 38 and 35 per cent of the patients of Krupp and Friedman32 and 18 per cent of those of Holguin and FenicheP9 were under the age of five when their symptoms began.

CLASSIFICATION AND DIAGNOSTIC CRITERIA The generally accepted classification of migraine headaches is that of the ad hoc committee on Classification of Headache published in 1962.10 This report described headaches of the migraine type as "recurrent attacks of headache, widely varied in intensity, frequency and duration." Associated findings were unilateral cephalgia often only at the outset of the attack, anorexia, and occasionally nausea and vomiting, as"The Allen P. and Josephine B. Green Professor of Pediatric Neurology, Washington University School of Medicine, St. Louis, Missouri Supported in part by the Allen P. and Josephine B. Green Foundation, Mexico, Missouri, NINDS Grant 5T01NS05633 and NINDS Grant IT32NS07027.

Pediatric Clinics of North America- Vol. 23, No.3, August 1976

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sociated sensory and motor disturbances, and a history of similar disturbances in the immediate family. Migraine was subdivided into the "classic" form in which the headache is sharply defined and associated with transient visual or other sensory or motor prodromes; "common" migraine in which the headaches do not have a striking prodrome and are less likely to be unilateral; "cluster" headaches which occur in closely packed groups, are unilateral, and are usually associated with ipsilateral or bilateral autonomic changes such as profuse tearing or nasal discharge; and "hemiplegic and ophthalmoplegic" migraine in which the headache is accompanied by sensory or motor phenomenon which "persists during and after the headache." This classification can be applied to children, though as we shall see, children sometimes present special problems. Our criteria for the diagnosis of migraine vary slightly from those of Vahlquist and Hackzell published in 1949. 51 The headache must be recurrent and separated by symptom-free intervals and be accompanied by at least three of the following six symptoms: abdominal pain, nausea or vomiting; localized unilateral headaches or hemicrania; a throbbing, pulsatile quality to the pain; complete relief after a brief period of sleep; an aura which may be visual, sensory, or motor; and a family history of migraine. The headache may be abrupt at onset and reach maximal intensity rapidly or it may worsen slowly. These headaches vary greatly in severity and not all need interrupt activity. The pain may occur at any time during the day, but in most patients some attacks occur in the early morning and can awaken the child from sleep. Many children also complain of periods of abdominal pain with nausea and often with vomiting unassociated with cephalgia. Although observations of patients with migraine headaches at St. Louis Children's Hospital suggest that visual auras are rare under the age of seven, the problem of diagnosing migraine in children does not appear to be the result of insufficient criteria, but one of difficulty eliciting a consistent history. This may account for the enormous variation in incidence of associated symptoms in published studies of the problem. Children are highly suggestible and often respond affirmatively to direct questions; thus we tend to rely upon the parents' description of complaints at the time of the headache if the child is under the age of 10. Direct questions are always avoided. It is always much better to ask "where is the headache" than "is the headache on one side." This approach does present problems since children under the age of five often have great difficulty in describing such symptoms as transient auras, throbbing, and the exact location of the pain. The data obtained in Table 1 are derived from a comparison of eight series in the literature describing aspects of migrainous attacks in children3 • 7. 8. 27. 29, :12. 34, 38, 51 with four series in adults. '7 , 40, 4(;. 59 It can be seen there are significant differences. Over one-half of children with migraine are male. Fewer complain of unilateral headache or visual aura and more have seizures in headache-free intervals. In both populations a very high percentage of patients have at least one member of the immediate family who has migraine. Hemiplegic migraine is also considerably more common in children 7 • 29 and may occur in several

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MIGRAINE AND MIGRAINOUS VARIANTS IN PEDIATRIC PATIENTS

Table 1. A Comparison of Migraine in Children and Adults':'

Sex Unilateral headache Nausea and/or vomiting Visual aura History of seizures Family history of migraine

CHILDREN

ADULTS

-60% male 25-66% 70-100% 10-50% 5.4-12.3% 72% (44-87%)

-33% male 75-91% 60-90% 60-75%

Migraine and migrainous variants in pediatric patients.

Symposium on Pediatric Neurology Migraine and Migrainous Variants in Pediatric Patients Arthur L. Prensky, M.D. * INCIDENCE Migraine is a venerable...
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