Download MIGRAINE HEADACHE

MIGRAINE HEADACHE IN
CHILDREN
Suhair Shehadeh-Saieg M.D
Pediatric Department
Bnai-Zion Medical Center, Haifa
‫הצגת מקרה‬
‫בן ‪ 12‬שנים ו ‪ 10‬חודשים‬
‫ברקע בריא‬
‫ת‪ .‬ע ‪:‬‬
‫מזה ‪ 3‬שבועות סובל מכאבי ראש פרונטאלים לוחצים‬
‫שנמשכים כמה שעות ועוברים ספונטאנית או אחרי‬
‫משכחי כאבים‪ .‬ללא פוטופוביה או פונופוביה‪ .‬לעתים‬
‫בליווי בחילות אך ללא הקאות‪.‬‬
‫ס ‪.‬מ ‪:‬‬
‫כאב גב תחתון מזה כמה ימים‪.‬‬
‫לציין ספור משפחתי של מיגרנה וכאבי גב תחתון אצל האב‪.‬‬
‫סימנים חיוניים‪:‬‬
‫חום=‪ 36.3‬דופק=‪ 102‬לחץ דם=‪104/87‬‬
‫בדיקה פיסיקלית‪ :‬תקינה כולל בדיקת פונדוסים‬
‫בדיקה נוירולוגית תקינה‬
‫מעבדה ‪:‬‬
‫(כולל ספירת דם‪ ,‬מדדי דלקת‪ ,‬אלקטרוליטים ושתן לכללית)‪.‬‬
‫‪ :EEG‬האטה דיפוזית ללא מוקד פרכוסי‬
‫‪ CT‬מוח‪ :‬תקין‬
‫בוצע ניקור מותני שהיה תקין‪.‬‬
‫במהלך האישפוז היה שיפור קליני ושוחרר לביתו עם אבחנת‬
‫‪Tension headache‬‬
‫אשפוז חוזר‪ 72‬שעות אחרי בצוע הניקור המותני ‪:‬‬
‫כאבי ראש פרונטאלים ובחילות‬
‫בבדיקה פיסיקלית מתקשה בהליכה ועמידה וסימני גירוי מנינגיאלי‬
‫‪ US‬גב מותני תקין‪.‬‬
‫מדדי דלקת היו תקינים‬
‫סוכם כסובל מכאבי ראש לאחר ניקור מותני‪.‬‬
‫היה שפור קליני ניכר תחת טיפול אנלגטיקה וקפאין‬
‫שוחרר להמשך מעקב נוירולוגי‬
Headache classification
• Primary headache
migraine, tension , cluster
• Secondary headache
Infection, trauma, hemorrhage, tumor, high
intracranial pressure.
Tension headache
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Bilateral, pressing tightness
Non-throbbing, mild to moderate
Lasts from 30 minutes to several days
May be associated with photophobia or
phonophobia
Is not accompanied by nausea or vomiting
Cluster headache
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More apparent between ages 10-20y
M:F = 9:1 after age 20y.
Always unilateral, mainly frontal-peri-orbital
Severe nature, less than three hours
Usually associated with ipsilateral autonomic
findings
( lacrimation, rhinorrhea, ophthalmic injection,
horner syndrome)
Migraine
• Episodic, periodic, paroxysmal attacks of
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moderate to severe throbbing pain, separated by
pain free intervals,
Associated with nausea, vomiting, photophobia,
abdominal pain and desire to sleep, motion
sickness.
Family history 70-90%
Incidence of migraine
• In 50% of cases : < 20y
• The youngest age reported was 3y
• 7y : 1-3%
• 7-15 : 4-11%
• < 7y >>> M>F
• 7-11y M=F
• >11 F>M
Signs and symptoms of intracranial
pathology
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Sleep related headache
Absence of family history of migraine
Vomiting\absence of visual symptoms
Headache of less than six month duration
Confusion
Abnormal neurologic examination
Growth abnormality ,pulsatile tinitus
Lack of response to medical therapy
pathophysiology
• Vascular theory
• Neuronal theory ( cortical spreading depression)
Precipitating factors
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Anxiety
Fatigue
Head trauma
Stress
Menses
Illness
diet
Dietary items and chemical migraine
triggers
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Offending food items
Cheese
Chocolate
Hot dogs,ham, cured
meats
Yugort, dairy products
Asian frozen snack foods
Wine, beer
Fasting
Coffee, tea,cola
Food diyes, additives
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Chemical triggers
Tyramin
Nitric oxide, nitrites
Allergenic proteins
(casein )
• Monosodium glutamate
• Aspartame
• Histamine, tyramine
sulfite
Pathophyiology schema
Primary triger
Locus ceruleus
>> cortical deppretion
Trigeminal nucleus
Neuronal inflammation
Vasodilatation
pain
vasoconstriction
aura
Serotonin
• Released from brainstem serotonergic nuclei.
• Plays an important role in the pathogenesis of
migraine
• Direct action upon the cranial vasculature
• Role in central pain control pathways
Classification of migraine
(revised international headache society IHS 2004)
• Migraine without aura
• Migraine with aura
• Migraine with typical aura
Migraine without aura (IHS 2004)
• A. at least 5 attacks fulfilling criteria B through D.
• B. Headache attacks lasting 4 to 72h
• C. headache has at least 2 of the following
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-unilateral location
-pulsating quality
-moderate or severe pain intensity
-aggravation by or causing avoidence of
routine physical activity
D. during headache at least one of the folowing:
nausea, vomiting, or both, photophobia, phonophobia
E. not attributed to another disorder.
Migraine with aura (IHS 2004)
• A. at least 2 attacks fulfilling criteria B.
• B. migraine aura fulfilling criteria B or C for one of the
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following subforms:
Typical aura with migraine headache
Typical aura with nonmigraine pain
Typical aura without headache
Familial hemiplegic migraine
Sporadic hemiplegic migraine
Basilar type migraine
C. Not attributed to another disorder.
Migraine with typical aura (IHS 2004)
• A. at least 2 attacks fulfilling criteria B or D.
• B. Aura consisting at least one of the following, but no motor weakness:
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Fully reversible visual symptoms
Fully reversible sensory symptoms (numbness, pins and needles)
Fully reversible dysphasia
C. at least two of the following:
Homonymous visual and/or unilateral sensory symptoms
At least one aura symptom developes gradually over >5minutes
Each symptom lasts >5 and <60 minutes
D. headache fulfilling criteria B through D for Migraine without aura
begins during the aura or follows aura within 60 minutes
E. not attributed to another disorder.
Familial Hemiplegic Migraine (IHS
2004)
• Migraine with aura
• At least one first or second degree relative who
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has migraine aura that includes motor
weakness.
AD inheritance
Sporadic hemiplegic migraine (IHS
2004)
• Migraine with an aura of motor weakness with
no family history
Basilar type migraine
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3-19% of children with migraine
Average age 7y
Occipital headache
Any combination of : vetigo,
ataxia,diplopia,tinnitus,vomiting,visual
symptoms,
parasthesias and altered consciousness
Absence of weakness.
Childhood periodic syndromes
( precursors of migraine according to revised
IHS criteria)
• Cyclic vomiting syndrome.
• Abdominal migraine.
• Benign paroxismal vertigo of childhood.
Retinal migraine (ocular migraine)
• Sudden loss of vision, perception of bright light
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followed within one hour by a migrainous
headache.
Reversible neurologic symptoms.
Permanent visual loss may occur.
Visual symptoms may occur without headache.
Complications of migraine
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Chronic migraine
Status migrainosus (> 72 h)
Persistent aura without infarction
Migrainous infarction
Migraine-triggered seizure.
Migraine variants
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Alice in wonderland syndrome
Confusional migraine
Hemisyndrome migraine
Menstrual migraine
Ophthalmoplegic migraine
Approach to the child with recurrent
headache
• History
• Physical examination
• Laboratory or imaging studies
When to perform neuroimaging study
??
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Age < 3 y
Abnormal neurological exam
Chronic progressive pattern
Family reassurance
MRI Vs CT
There was no sufficient data to make a specific
recommendation regarding the relative
sensitivity of MRI compared with CT.
Most prefer MRI because of vascular differential
diagnosis.
EEG and migraine
• EEG is not indicated in the routine evaluation of
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headache
It is performed if seizures are suspected.
EEG findings in children with migraine:
-Rolandic spike and wave
-Benign focal epileptiform discharges
Management of migraine
• Non-pharmacologic methods (biofeedback,
relaxation,exercise)
• Pharmacologic therapy for acute attack
• Preventive therapy
Pharmacologic Treatment
• General pain medications
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(acetaminophen, NSAIDS) alone or in
combination with antiemetic medications
(migraleve)
Vasoconstrictors ergot alkaloids/xanthine
(cafergot, tamigran)
Triptans-5HT1D agonists (imitrex, zomig)
Migraine status (> 72 h in adults) - steroids,
DHE
dihydroergotamin
Triptans
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5HT1 (hydroxytriptamin) receptor agonist
Promote vasoconstriction
Block pain pathway in the brain stem
Overall efficacy 63-88%
Efficacy and safety were established in adolescents
(>12y)
• Approved for use in Israel from 18y
• Side effects: feeling of warmth, burning, pressure in the
head and neck, palpitations, arrythmias, hypotension
<1%.
• C.I: complicated migraine.
American academy of pediatrics
october 9 2006
Symptomatic treatment of migraine in
children: a systematic review of
medication trials
Conclusion:
Acetaminophen, ibuprofen, and nasal,
spray sumatryptan are all effective
symptomatic pharmacologic treatments for
episodes of migraine in children.
Indications for migraine prophylaxis
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Attacks occur >2-4 times per month
Disability occurs > 3 days per month
Duration of attack > 48 h
Medications for acute attack are ineffective, C.I
or overused
Attacks produce prolonged aura or true
migrainous infarction
Patient preference
Duration of prophylactic therapy
• The optimum duration of prophylactic therapy is
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uncertain
The approach is to treat for 6-12 months and
then taper over the course of several weeks.
Data are limited on the effectiveness of
preventive agents in children
Preventive Therapy
• B blockers
• Antideppressants
• Anticonvulsants
• Ca channel blocker
B blocker
• Propranolol was the prophylactic treatment most
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commonly used in children, primarily based
upon evidence in adults.
C.I: asthma
Caution: depression, diabetes, orthostatic
hypotension, impotense