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Headache in Children
Pain-sensitive structures in the head
Intracranial Structures
• Venous sinuses and
afferent veins
• Arteries of the dura mater
and pia-arachnoid
• Arteries of the base of the
brain and their major
branches
• Parts of the dura matter
near the large vessels
Pain-sensitive structures in the head
Extracranial Structures
• Skin
• Subcutaneous tissue
• Muscles
• Periosteum of the skull
• Mucosa
• Extracranial arteries
• Delicate structures of
the eye, ear, nasal
cavities and sinuses
Pain-sensitive structures in the head
Nerves
•
•
•
•
•
Trigeminal
Facial
Glossopharyngeal
Vagus
Upper three cervical
roots
Pathophysiology of headache:
Pain insensitive structures
Skull
 Pia-arachnoid and dura over the
convexity of the brain
 Brain parenchyma
 Ependyma
 Choroid plexuses

Pain Mechanisms

Traction


On the Circle of Willis and dural structures
Inflammation
Of intra- and extracranial structures
 Of the meninges, and blood vessels


Vascular distention and spasm

Of intra- and extracranial vessels
Pain Mechanisms

Muscle contraction


Of neck and scalp muscles
Pressure
- changes in ICP
- Within nasal or paranasal cavities, orbits,
ears and teeth, and on nerve-containing
fibers
Temporal profile of headache
Acute
Acute Recurrent
Chronic
progressive
Chronic
nonprogressive
0
30
Time (days)
60
Migraine
most important and frequent type of
headache in the pediatric population
 Prevalence

Girls - adolescents
 Boys - younger than 10 yr

50 % spontaneous prolonged remission
after the 10th birthday
 Adults, 5–10% of men and 15–20% of
women have migraine headaches

Migraine without aura

the most prevalent type of migraine in children
 headache is throbbing or pounding and tends
to be unilateral at onset or throughout its
duration but may also be located in the
bifrontal or temporal regions
 It may not be hemicranial in children and is
less intense compared with the migraine in
adults
Migraine without aura
headache usually persists for 1–3 hr
although the pain may last for as long as
72 hr
 pain may inhibit daily activity, because
physical activity aggravates the pain
 characteristic feature


intense nausea and vomiting
Migraine without aura

Additional symptoms


extreme paleness, photophobia, lightheadedness, phonophobia, osmophobia
(aversion to odors), and paresthesias of the
hands and feet
positive family history on the maternal
side in ≈90% of children with migraine
without aura
Migraine without aura

Additional features






near synchrony with perimenstrual or periovulation
timing
gradual appearance after sustained exercise
relief with sleep
stereotypical prodromes (hypersomnia, food
craving, irritability, moodiness)
precipitation by food or odors
onset after a letdown or high period of stress
Diagnostic Criteria
Migraine without aura
A
B
At least five attacks
Headache attack lasts 1–72 hr (untreated or
unsuccessfully treated)
C Headache has at least two of the following characteristics:
Unilateral location, may be bilateral
Pulsating quality
Moderate or severe intensity
Aggravation by or avoidance of routine physical activity (i.e.,
walking or climbing stairs)
D During headache at least one of the following:
Nausea, vomiting, or both
Photophobia and Phonophobia
E Not attributed to another disorder
Migraine with aura

Aura precedes the headache
 Visual aura are uncommon in children but
when they occur they may be in the form of



Binocular visual impairment with scotoma (77%)
Distortion or hallucinations (16%)
Monocular visual impairment or scotoma (7%)

[hachinshi et al., 1973]
Migraine with aura

Vertigo and light headedness
 Sensory symptoms



Perioral paresthesias
Numbness of the hands and feet
Distortion of body image (alice in wonderland)
DIAGNOSTIC CRITERIA
WITH AURA (CLASSIC MIGRAINE)
A At least two attacks
B Migraine aura fulfills criteria for typical
aura, hemiplegic aura,
or basilar-type aura
C Not attributed to another disorder
DIAGNOSTIC CRITERIA
WITH AURA (CLASSIC MIGRAINE)
TYPICAL AURA
1 Fully reversible visual, sensory, or speech
symptoms (or any combination) but no
motor weakness
2 Homonymous or bilateral visual symptoms
including positive features (e.g., flickering
lights, spots, lines) or negative features (e.g.,
loss of vision), or unilateral sensory symptoms
including positive features (e.g., visual loss,
pins and needles) or negative features (i.e.,
numbness), or any combination
DIAGNOSTIC CRITERIA
WITH AURA (CLASSIC MIGRAINE)
3
At least one of:
a) At least one symptom develops gradually
over a minimum of 5 min, or different
symptoms occur in succession, or both
b) Each symptom lasts for at least 5 min and
for no longer than 60 min
4 Headache that meets criteria for migraine
without aura begins during the aura or
follows aura within 60 min
Hemiplegic Migraine
A migraine aura
 Sudden onset of unilateral sensory or
motor signs during the migraine episode
 Characterized as numbness of the face ,
arm, leg, unilateral weakness and aphasia
 May be transient or may persist for days

Hemiplegic Migraine
Good prognosis
 (+) family history of hemiplegic migraine

Basilar-type migraine
Brainstem signs predominate because of
the vasoconstrictor of the basilar and
posterior cerebral arteries
 Vertigo, tinnitus, diplopia,blurred vision,
scotoma, ataxia and occipital headache
 Pupils may be dilated, ptosis
 Alteration in consciousness followed by
seizures may occur

Basilar-type migraine
There is complete resolution of the
neurologic signs and symptoms
 Minor head injury can precipitate the
headache
M=F
 Girls < 4 years old of higher risk

Childhood Periodic Syndromes—Migraine Precursor
Cyclic vomiting
Recurrent episodic attacks, usually
stereotypical in the individual, of vomiting
and intense nausea.
 Attacks are associated w/ lethargy and
pallor
 There is complete resolution of symptoms
between attacks


International Classification of Headache
Disorders Criteria for Cyclic Vomiting
Periodic Syndromes—Migraine Precursor
Cyclic vomiting




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Diagnostic Criteria:
A. At least five attacks fulfilling criteria B and C
B. Episodic attacks, stereotypical in the individual
patient of intense nausea and vomiting lasting 1-5
days
C. Vomiting during attacks occurs at least 5 times/
hour for at least 1 hour
D. Symptom-free between attacks
E. Not attributed to another disorder. History and
Physical Examination do not reveal signs of
gastrointestinal disease.
Childhood Periodic Syndromes—Migraine Precursor
Cyclic vomiting

Treatment
rectally administered or injected
antiemetics such as dimenhydrinate or
ondansetron
 careful attention to fluid replacement if the
vomiting is excessive

Precursors of migraine
Abdominal migraine
Description:
 An idiopathic recurrent disorder seem
mainly in children & characterized by
episodic midline abdominal pain
manifesting in attacks lasting 1-72 hours
with normality between episodes. The
pain is of moderate-to-severe intensity &
associated with vasomotor symptoms,
nausea and vomiting.

Precursors of migraine
Abdominal migraine
Diagnostic Criteria:
A. At least 5 attacks fulfilling criteria B through D
B. Attacks of abdominal pain lasting 1-72 hours
C. Abdominal pain has all of the ff. characteristics
A.
Midline location, periumbilical or poorly localized
B.
Dull or “just sore” quality
C.
Moderate or severe intensity
D. During abdominal pain, at least two of the ff:
A.
Anorexia
B.
Nausea
C.
Vomiting
D.
Pallor
Management of Pediatric Migraine
Goals of Treatment
1.
2.
3.
4.
5.
6.
Reduction of headache frequency, severity, duration,
and disability
Reduction of reliance on poorly tolerated, ineffective,
or unwanted acute pharmacotherapies
Improvement in quality of life
Avoidance of acute headache medication escalation
Education and enabling of patients to manage their
disease to enhance personal control of their
migraine
Reduction of headache-related distress and
psychological symptoms
Treatment of Pediatric Migraine
Acute attack

Analgesic
1.
2.

acetaminophen (15 mg/kg)
ibuprofen (7.5–10 mg/kg)
Antiemetic
1.
2.
dimenhydrinate by rectal suppository
5 mg/kg/24 hr in four divided doses
Parenteral metoclopramide
Treatment of Pediatric Migraine
Acute attack

Triptans (e.g., Sumatriptan)




are specific and selective 5-hydroxytryptamine
receptor agonists that are effective abortive drugs
Sumatriptan may be administered
subcutaneously, nasally, or orally
suggested dose is 5 mg in children <25 kg,
10 mg (two sprays) in those weighing 25–50 kg,
and 20 mg sumatriptan in children ≥50 kg
Treatment
Acute attack

Triptans (e.g., Sumatriptan)


dose may be repeated 2 or more hours
after the initial dose, limited to two doses
per 24 hr
adverse effects are usually minor and
transient, and include hot flushes, nausea
and vomiting, fatigue, and drowsiness

Children may develop severe intractable
migraine attacks or status migrainosus
(persistent headache lasting longer than
3 days) that are unresponsive to
conventional drug regimens

Intravenous prochlorperazine, 0.15 mg/kg
(max 10 mg)
continuous daily medication
(prophylactic therapy)
severity and frequency of the headaches
 on the impact of the migraine on the
child's daily activities, including school
attendance and performance as well as
participation in recreation
 if a child experiences more than two to
four severe episodes monthly or is
unable to attend school regularly

continuous daily medication
(prophylactic therapy)

Ppropranolol
10–20 mg tid (beginning with 10 mg/24 hr
and gradually increasing the drug to the
maximum dose or until the desired
therapeutic effect is achieved) in children 7–
8 yr and older.
 A common mistake is to discontinue the
drug prematurely, because it often takes
several weeks to a month until the drug is
effective.

continuous daily medication
(prophylactic therapy)

Flunarizine
initial dose is 5 mg at bedtime and
increased if necessary to 10 mg
 most frequent side effect is drowsiness

Behavioral Management
effective method for the treatment of
migraine in some children and
adolescents
 Biofeedback can be mastered by most
children older than 8 yr and has been
effective in many clinical trials

Indications for Neuroimaging in a Child
with Headaches
Abnormal neurologic sign
 Recent school failure, behavioral
change, fall-off in linear growth rate
 Headache awakens child during sleep;
early morning headache, with increase in
frequency and severity
 Periodic headaches and seizures
coincide, especially if seizure has a focal
onset

Indications for Neuroimaging in a Child
with Headaches

Migraine and seizure occur in the same
episode, and vascular symptoms precede the
seizure (20–50% risk of tumor or
arteriovenous malformation)
 Cluster headaches in child; any child <5–6 yr
whose principal complaint is a headache
 Focal neurologic symptoms or signs
developing during a headache (i.e.,
complicated migraine)
Indications for Neuroimaging in a Child
with Headaches

Focal neurologic symptoms or signs (except
classic visual symptoms of migraine) develop
during the aura, with fixed laterality; focal signs
of the aura persisting or recurring in the
headache phase
 Visual graying-out occurring at the peak of a
headache instead of the aura
 Brief cough headache in a child or adolescent