MIGRAINE
 
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MIGRAINE

 

DEFINITION:

A recurrent headache separated by symtpom-free intervals accompanied by specific criteria.

EPIDEMIOLOGY:

  • incidence: 4 - 10% of school-aged children
    • most common cause of recurrent headache in children
  • age of onset:
    • rare before age 5
  • risk factors:
    • familial (90%)
    • M=F (before adolescence) and F>M (after adolescence)

PATHOGENESIS:

  • headaches in children first described in 1873 by William Henry Day and thought to be as a result of "bad arrangements in their lives".
  • classification of migraine into 2 groups first proposed by the Ad Hoc Committee on Classification of Headaches in 1962: classic and common
  • migraines may be caused by an inherited predisposition to vasomotor instability resulting in an unusual reactivity of the blood vessels so that initially the BV contract (aura) and then overexpand a few minutes later producing a throbbing headache
  • complicated migraine refers to the development of neurologic signs during a headache that persists following the termination of the HA

TYPES:

1. Classic

2. Common

3. Cluster

4. Complicated

  • basilar artery
  • hemiplegic
  • ophthalmoplegic

5. Migraine Variants

  • acute confusional state
  • benign paroxysmal vertigo
  • cyclic vomiting

CLINICAL FEATURES:

1. Classic Migraines

  • periodic headaches separated by symptom-free intervals and associated with at least 3 of the following criteria:
    • abdominal pain, nausea/vomiting
    • aura (motor, sensory, visual)
    • family history
    • sleep relief
    • unilateral
    • pulsatile (throbbing)
  • 1. Aura
  • 1. Sensory
    • perioral paresthesia, numbness of hands & feet
  • 2. Visual
    • blurring, distortion, fortification spectra, homonymous hemianopsia, photopsia (flashes of bright light), scintillating scotomata (dark or blind spots), tunnel vision

    • 2. Common Migraines

    • rare nausea/vomiting (N/V)
    • no aura
    • family history
    • sleep relief
    • bifrontal or temporal
    • variable quality

    3. Complicated Migraines

    1. Basilar Artery

    • brain stem signs: ataxia, blurred vision, diplopia occipital HA, scotoma, tinnitis, vertigo
    • altered consciousness, dilated pupils, generalized seizure, ptosis

    2. Hemiplegic

    • aphasia, alternating hemiplegia, unilateral sensory or motor signs (i.e., numbness)

    3. Ophthalmoplegic

    • 3rd nerve palsy ipsilateral to headache

    4. Migraine Variants

    1. Acute Confusional State

    • confusion, disorientation, hyperactivity, lethargy, memory disturbances, unresponsiveness, vomiting
    • defects of sensorium - touch & pain

    2. Benign Paroxysmal Vertigo (BPV)

    • ataxia, horizontal nystagmus, nausea and vomiting
    • abnormal vestibular function (abn.ice water caloric test)

    3. Cyclic Vomiting

    • recurrent vomiting, dehydration, electrolyte abnormalities
    • later abdominal pain, diarrhea, fever

    HISTORY AND PHYSICAL

    1. History

    • triggers - foods, stress, allergies
    • organic vs benign

    2. Physical

    • Vitals - BP, temperature, growth parameters
    • cephalic bruits, optic disk, diplopia, papilledema, purulent rhinorrhea, sinusitis, TMJ mobility/tenderness, dental abscesses, nuchal rigidity, neck muscle spasm/ tenderness
    • Skin - exanthems, cafe-au-lait spots

    INVESTIGATIONS:

    1. Radiographic

    • sinus x-rays, CT, MRI

    2. Serum

    • ESR (collagen vascular diseases), lipid profile

    3. Others

    • EEG

    MANAGEMENT:

    1. Avoid Triggers

    • natural history of migraines is a very high remission rate

    2. Pain Behaviour Management

    • pain clinic
    • relaxation-imagery exercises
    • headache diary

    3. Medications

    1. Simple Therapy

    • tylenol +/- codeine, ibuprofen

    2. Abortive Therapy

    • Fioricet
    • Midrin
    • (not ergots)

    3. Prophylactic Therapy

    • propranolol
    • dilantin, phenobarb.
    • amitryptiline
    • cyproheptadine - antiserotonin, antihistamine
    • verapamil

    4. Cyclic Vomiting

    • Gravol (5 mg/kg/d pr qid)

    4. Prognosis

    • good long-term prognosis with more than 2/3rd's showing improvement over time

     

     

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