How to manage an 8-year-old child with new onset hemiplegic migraine and elevated Thyroid-Stimulating Hormone (TSH) levels, with normal thyroid ultrasound findings?

Management of New Onset Hemiplegic Migraine with Hyperactive TSH in an 8-Year-Old Child

For an 8-year-old child with new onset hemiplegic migraine and elevated TSH but normal thyroid ultrasound, initiate ibuprofen (7.5-10 mg/kg) for acute migraine treatment and start levothyroxine at 4-5 mcg/kg/day for the hyperactive TSH, with close monitoring of both conditions. 1, 2

Hemiplegic Migraine Management

Acute Treatment

• First-line treatment: Ibuprofen 7.5-10 mg/kg per dose for acute attacks 1
• Acetaminophen 15 mg/kg can be used as an alternative if NSAIDs are contraindicated 1
• For severe attacks unresponsive to NSAIDs, consider:
  • Non-oral routes of administration if nausea/vomiting present
  • Anti-emetics for associated symptoms 1

Important Caution

• Triptans should be used with extreme caution in hemiplegic migraine due to theoretical concerns about vasoconstriction 1, 3
• Some experts recommend avoiding triptans completely in hemiplegic migraine, though evidence is mixed 3, 4

Preventive Treatment

If attacks occur >4 per month or cause significant disability:

• First-line preventive options:
  • Propranolol (age-appropriate dosing)
  • Amitriptyline (10-100 mg at night)
  • Topiramate (50-100 mg daily) 1
• Second-line option: Flunarizine (5-10 mg daily) 1, 3

Thyroid Management

Initial Approach

• For elevated TSH with normal thyroid ultrasound in an 8-year-old:
  • Start levothyroxine at 4-5 mcg/kg/day 2
  • Monitor TSH and free T4 at 2 and 4 weeks after treatment initiation 2
  • Adjust dosage every 2 weeks as needed based on lab results 2

Monitoring Schedule

• After initial stabilization, check TSH and free T4 every 3 months 2
• Evaluate growth and development at regular intervals 2
• Goal: Normalize TSH levels and maintain free T4 in the upper half of normal range 2

Diagnostic Considerations

For Hemiplegic Migraine

• Consider MRI to exclude other causes of focal neurological symptoms 1, 5
• Avoid conventional cerebral angiography as it may trigger an attack 3
• Consider genetic testing for CACNA1A, ATP1A2, and SCN1A mutations, especially with family history or additional symptoms like ataxia 1, 4

For Thyroid Function

• Repeat TSH measurement to confirm elevation 6
• Consider checking thyroid antibodies to evaluate for autoimmune thyroiditis 6
• No need for additional thyroid imaging beyond the normal ultrasound already obtained 6

Integrated Management Approach

1. Address both conditions concurrently - There is evidence of a relationship between migraine and thyroid dysfunction 7
2. Track both conditions with a symptom diary:
   • Frequency, duration, and severity of migraine attacks
   • Associated symptoms during attacks
   • Response to medications
   • Any symptoms of hypothyroidism 1
3. Lifestyle modifications:
   • Regular sleep schedule
   • Regular meal times
   • Adequate hydration
   • Identification and avoidance of migraine triggers 1

Follow-up Plan

• Neurology follow-up within 4-6 weeks
• Endocrinology follow-up within 2-4 weeks
• Adjust levothyroxine dose based on TSH and free T4 levels
• Consider preventive migraine therapy if attacks are frequent or severe
• Educate family that complete elimination of headaches is unlikely, but the goal is reducing frequency, severity, and disability 1

Special Considerations

• Hemiplegic migraine attacks in children tend to be more prolonged than in adults, with motor aura lasting an average of 3.5 hours 8
• Children with sporadic hemiplegic migraine may have less frequent but more severe and prolonged attacks 8
• Monitor for any persistent neurological deficits between attacks 4
• Most pediatric cases have favorable clinical evolution despite early onset and severe attacks 8