5. Johnson S, Gilmore C, Gallimore I, Jaekel J, Wolke D. The long-term consequences of preterm birth:
what do teachers know? Dev Med Child Neurol 2015; 57: 571–77.
6. Odd D, Evans D, Emond A. Preterm birth, age at school entry and educational performance. PLoS ONE 2013; 8: e76615.
Migraine in young children AMY A GELFAND Division of Child Neurology, UCSF Department of Neurology, San Francisco, CA, USA. doi: 10.1111/dmcn.12697 This commentary is on the original article by Raieli et al. on pages 585– 588 in this issue.
Migraine is a common neurological disorder affecting children and adolescents. By age 10 the prevalence of migraine is 5%, and this increases in adolescence.1 Children with migraine miss more school and have a poorer academic performance than children without migraine.2 Despite all this, children with migraine often go undiagnosed. Their headaches may be misdiagnosed as ‘sinus headaches’ or as an attempt to get out of going to school. In young children, recurrent headaches can be misinterpreted as a symptom of a brain tumor, frequently leading to unnecessary testing. There has been surprisingly little research focused on migraine in young children in either epidemiological studies or migraine treatment trials. This is what makes the study by Raieli et al.3 so interesting and important. It is a testament to how a thorough clinical history can lead to a diagnosis of migraine, even in preschool-aged children. In this study, 82% percent of all of the 456 children evaluated in neurology clinic for a primary headache disorder were found to have migraine. This point should be emphasized – the vast majority of children presenting to neurological care for recurrent headaches have migraine. In adults, 94% of patients coming to the primary care doctor for recurrent headaches have migraine or probable migraine.4 The proportion is likely similar in children. Pediatric providers ought to keep migraine high on the differential when evaluating children for recurrent headaches. In the Raieli et al. study, children under age 7 had a remarkably similar migraine phenotype compared to older children. There is good reason to focus on the effect of age on migraine phenotype as the International Headache Society criteria recognize that migraine in children differs from adults. Children have shorter attacks, typically bilateral rather than unilateral headache, and clinicians often need to infer sensitivity symptoms like photophobia and
phonophobia from behavior, as a young child may not be able to articulate sensitivity to light and sound.5 In fact, the main difference found in the current study was that children under age 7 had shorter migraine attacks than older children (2.6h vs. 3.8h on average), validating the use of a 2-hour minimum attack duration for children in the International Classification of Headache Disorder, 3rd Edition (beta version)5 compared to the 4-hour minimum attack duration (untreated) in adults. The reason for the shorter migraine attack duration in young children is unknown. The authors suggest an interesting and testable hypothesis: as sleep can terminate a migraine attack, could it be that young children are better able to terminate migraine via their capacity for daytime naps? If initiating sleep is indeed how young children’s brains are actively turning off a migraine attack, wouldn’t it be interesting to bring this knowledge to the treatment of migraine in adults? What if taking a dose of melatonin and nodding off for an hour nap could be a quick and well-tolerated way for an adolescent or an adult to actively treat a migraine attack? Moving forward, there is much still to be learned about migraine in young children and about migraine from young children. Migraine is a highly genetic disorder, yet only in the rare form of familial hemiplegic migraine have the genes been well worked out. Children who manifest migraine at a young age may have a stronger genetic load, or a more homogenous genetic make-up, compared to the population of migraineurs as a whole – features that could be advantageous in the search for underlying genes. The potential to identify migraine genes could be even greater among children who express a specific age-sensitive phenotype of migraine such as abdominal migraine or infant colic.6 Finally, how best to treat migraine in very young children is an area urgently in need of medical research. Most of the acute and preventive treatment trials in pediatric migraine have focused on older children and adolescents. Studies of safe and age-appropriate pharmacological and non-pharmacological treatments for migraine in young children should be pursued. Effective migraine treatment, given early, has the potential to change the arc of a child’s life.
REFERENCES 1. Victor TW, Hu X, Campbell JC, Buse DC, Lipton RB.
3. Raieli V, Pitino R, Giordano G, et al. Migraine in a
Migraine prevalence by age and sex in the United States:
pediatric population: a clinical study in children youn-
a life-span study. Cephalalgia 2010; 30: 1065–72.
ger than 7 years of age. Dev Med Child Neurol 2015;
2. Arruda MA, Bigal ME. Migraine and migraine subtypes in preadolescent children: association with school performance. Neurology 2012; 79: 1881–8.
57: 585–88. 4. Tepper SJ, Dahl€ of CG, Dowson A, et al. Prevalence and diagnosis of migraine in patients consulting their
physician with a complaint of headache: data from the Landmark Study. Headache 2004; 44: 856–64. 5. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33: 629–808. 6. Gelfand AA. Migraine and childhood periodic syndromes in children and adolescents. Curr Opin Neurol 2013; 26: 262–8.
Commentaries
503
Copyright of Developmental Medicine & Child Neurology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
what do teachers know? Dev Med Child Neurol 2015; 57: 571–77.
6. Odd D, Evans D, Emond A. Preterm birth, age at school entry and educational performance. PLoS ONE 2013; 8: e76615.
Migraine in young children AMY A GELFAND Division of Child Neurology, UCSF Department of Neurology, San Francisco, CA, USA. doi: 10.1111/dmcn.12697 This commentary is on the original article by Raieli et al. on pages 585– 588 in this issue.
Migraine is a common neurological disorder affecting children and adolescents. By age 10 the prevalence of migraine is 5%, and this increases in adolescence.1 Children with migraine miss more school and have a poorer academic performance than children without migraine.2 Despite all this, children with migraine often go undiagnosed. Their headaches may be misdiagnosed as ‘sinus headaches’ or as an attempt to get out of going to school. In young children, recurrent headaches can be misinterpreted as a symptom of a brain tumor, frequently leading to unnecessary testing. There has been surprisingly little research focused on migraine in young children in either epidemiological studies or migraine treatment trials. This is what makes the study by Raieli et al.3 so interesting and important. It is a testament to how a thorough clinical history can lead to a diagnosis of migraine, even in preschool-aged children. In this study, 82% percent of all of the 456 children evaluated in neurology clinic for a primary headache disorder were found to have migraine. This point should be emphasized – the vast majority of children presenting to neurological care for recurrent headaches have migraine. In adults, 94% of patients coming to the primary care doctor for recurrent headaches have migraine or probable migraine.4 The proportion is likely similar in children. Pediatric providers ought to keep migraine high on the differential when evaluating children for recurrent headaches. In the Raieli et al. study, children under age 7 had a remarkably similar migraine phenotype compared to older children. There is good reason to focus on the effect of age on migraine phenotype as the International Headache Society criteria recognize that migraine in children differs from adults. Children have shorter attacks, typically bilateral rather than unilateral headache, and clinicians often need to infer sensitivity symptoms like photophobia and
phonophobia from behavior, as a young child may not be able to articulate sensitivity to light and sound.5 In fact, the main difference found in the current study was that children under age 7 had shorter migraine attacks than older children (2.6h vs. 3.8h on average), validating the use of a 2-hour minimum attack duration for children in the International Classification of Headache Disorder, 3rd Edition (beta version)5 compared to the 4-hour minimum attack duration (untreated) in adults. The reason for the shorter migraine attack duration in young children is unknown. The authors suggest an interesting and testable hypothesis: as sleep can terminate a migraine attack, could it be that young children are better able to terminate migraine via their capacity for daytime naps? If initiating sleep is indeed how young children’s brains are actively turning off a migraine attack, wouldn’t it be interesting to bring this knowledge to the treatment of migraine in adults? What if taking a dose of melatonin and nodding off for an hour nap could be a quick and well-tolerated way for an adolescent or an adult to actively treat a migraine attack? Moving forward, there is much still to be learned about migraine in young children and about migraine from young children. Migraine is a highly genetic disorder, yet only in the rare form of familial hemiplegic migraine have the genes been well worked out. Children who manifest migraine at a young age may have a stronger genetic load, or a more homogenous genetic make-up, compared to the population of migraineurs as a whole – features that could be advantageous in the search for underlying genes. The potential to identify migraine genes could be even greater among children who express a specific age-sensitive phenotype of migraine such as abdominal migraine or infant colic.6 Finally, how best to treat migraine in very young children is an area urgently in need of medical research. Most of the acute and preventive treatment trials in pediatric migraine have focused on older children and adolescents. Studies of safe and age-appropriate pharmacological and non-pharmacological treatments for migraine in young children should be pursued. Effective migraine treatment, given early, has the potential to change the arc of a child’s life.
REFERENCES 1. Victor TW, Hu X, Campbell JC, Buse DC, Lipton RB.
3. Raieli V, Pitino R, Giordano G, et al. Migraine in a
Migraine prevalence by age and sex in the United States:
pediatric population: a clinical study in children youn-
a life-span study. Cephalalgia 2010; 30: 1065–72.
ger than 7 years of age. Dev Med Child Neurol 2015;
2. Arruda MA, Bigal ME. Migraine and migraine subtypes in preadolescent children: association with school performance. Neurology 2012; 79: 1881–8.
57: 585–88. 4. Tepper SJ, Dahl€ of CG, Dowson A, et al. Prevalence and diagnosis of migraine in patients consulting their
physician with a complaint of headache: data from the Landmark Study. Headache 2004; 44: 856–64. 5. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33: 629–808. 6. Gelfand AA. Migraine and childhood periodic syndromes in children and adolescents. Curr Opin Neurol 2013; 26: 262–8.
Commentaries
503
Copyright of Developmental Medicine & Child Neurology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
