Steven T. DeRoos, MD, Division Chief, Pediatric Neurology
Helen DeVos Children's Hospital 

A recent article in Pediatrics about the heterogenous treatment of pediatric migraine in emergency departments throughout Canada is responsible for this blog post. For migraine is probably one of the most common things we, as pediatric neurologists, see in our practice, and yet it's one that with few exceptions could be  managed by primary care physicians. 

But too often we find that the children and adolescents we see have not been treated at all, or have been severely undertreated after months, sometimes years of suffering. Our understanding of migraine and the available,  effective treatments have increased significantly in the past decade. Nonetheless, I think there is still a lot of misinformation about the condition, particularly pediatric migraine. So here is my attempt to address what we see in our practice as some of the "myths" about migraine to help you better manage the condition in your own practice.

Myth: A headache isn't a migraine unless it is preceded by an aura.
Reality. Most (64%) of migraine in children and adults are not preceded by aura.

Myth: Migraines are not as intense in children as they are in adults.
Reality: Migraine significantly impacts daily activities in between 65% and 85% of pediatric migraineurs, responsible for a significant number of lost school days and emotional changes such as anxiety or dysphoria.  By definition, migraines are moderate to severe in intensity, while tension headaches are mild to moderate.

Myth: Identifying and removing migraine triggers is the best way to prevent migraines.
Reality: It is often difficult to identify reversible triggers, and while avoiding them may reduce the frequency of migraine,  alternative management should be sought quickly if they persist beyond two or more a month. Several medications, particularly tricyclic antidepressants and anti-epileptics, are very effective as secondary prophylaxis. There are also some non-prescription medications and alternative treatments that have proven efficacy.

Myth: Intense headache in children requires a complete neurological workup, including MRI, and treatment should be delayed until the patient is referred and differential diagnoses are investigated.
Reality: Treatment for suspected migraine should be considered upon presentation if it fulfills diagnostic criteria even if additional tests are ordered. Treating migraine will not mask evidence of other, more serious conditions like brain lesions and, in fact, studies find that just 3% of significant headaches in children are related to pathologic brain lesions.

Myth: The "triptan" family of migraine medications are not appropriate for children.
Reality: While none of the triptans (sumatriptan, rizatriptan, naratriptan, zolmitriptan, eletriptan, almotriptan, and frovatriptan) have a pediatric indication, they are being used in this population with increasing frequency and success. The primary concern with triptans is that it is a vasoconstrictor and so could, conceivably, trigger stroke or myocardial infarction in high-risk individuals (which is primarily the adult population). 

But children's vessels are more patent, so the risk of these events is even lower in kids than in adults. But really, we find that most medications we use for migraine in children show some efficacy, even over-the-counter analgesics. This could be aided by the very high placebo effect seen in migraine treatment.

Myth: Very young children don't get migraines.
Reality. We've seen toddlers with migraines. Studies suggest that about 20% of pediatric migraineurs experience their first attack before age 5. Obviously, such young children can't describe a unilateral, throbbing pain (the hallmarks of migraine), but we can usually infer migraine by the child's behavior and symptoms, including recurrent vomiting without fever, eventual diarrhea, or negative GI workup. In fact, cyclical vomiting, abdominal migraine, benign paroxysmal torticollis, and benign paroxysmal vertigo are all considered precursors of pediatric migraine.  

The official International Classification of Headache Disorders (ICHD) criteria for migraine is:

At least 5 attacks with the headache lasting 4 to 72 hours and involving at least 2 of the following (and not attributed to another disorder):

• Unilateral location
• Pulsating quality
• Moderate-or-severe pain
• Pain aggravated by or causing avoidance of routine physical activities like walking or going up and down stairs.

During the headache, at least one of the following must be present:

• Nausea and/or vomiting
• Photophobia
• Phonophobia

However, please keep in mind that a migraine diagnosis in kids may be modified. Migraine duration in kids is often shorter and the pain may be bilateral in younger kids. Our rule of thumb is that if a child tells us they have a bad headache and want to lie down in the dark (photo- or phonophobia), or if they're nauseated with headache, we assume migraine.

Clues that something more ominous may be present include: new onset of headache, no family history of migraine, children younger than 6, atypical presentation such as vertigo or intractable vomiting, recurrently waking up from sleep with headache, or abnormal neurological exam. Those symptoms should warrant consideration of a full workup and, possibly, referral. Otherwise, even neuroimaging is not absolutely indicated.

Have a question about diagnosing, treating or preventing migraine in your patients? Post it here and I promise to respond.

Steven T. DeRoos, MD, is the chief of Pediatric Neurology at Helen DeVos Children's Hospital in Grand Rapids, Michigan and sees patients in  a dedicated pediatric  headache clinic.

Source used: Robertson WC. Migraine Headache, Pediatric Perspective. eMedicine. Available at: ttp://emedicine.medscape.com/article/1179268-overview. Accessed August 19, 2010.