Management of New Onset Hemiplegic Migraine in an 8-Year-Old with Low TSH
For an 8-year-old child with new onset hemiplegic migraine and a low TSH of 0.4, initiate ibuprofen (7.5-10 mg/kg) for acute migraine treatment and refer for thyroid evaluation, but avoid triptans as they are contraindicated in hemiplegic migraine. 1, 2
Initial Assessment and Management
Acute Treatment
- Use ibuprofen (7.5-10 mg/kg) as first-line treatment for acute migraine attacks 2
- Acetaminophen (15 mg/kg) can be used as an alternative if ibuprofen is contraindicated 2
- Important: Triptans are contraindicated in hemiplegic migraine due to theoretical concerns about vasoconstriction 1, 2
- For attacks with nausea/vomiting, add an anti-emetic medication 2
Thyroid Evaluation
- Repeat TSH measurement to confirm low level (0.4) 2
- Check free T4 and free T3 to determine if this represents subclinical or overt hyperthyroidism 2
- Consider thyroid antibodies to evaluate for autoimmune thyroiditis 2
- Consult pediatric endocrinology for management of the thyroid dysfunction
Treatment Plan
Migraine Management
Acute treatment:
- Ibuprofen 7.5-10 mg/kg per dose at onset of migraine
- Ensure medication is taken early in the attack
- Provide a quiet, dark environment during attacks
Preventive treatment (if attacks occur ≥2 times per month or cause significant disability):
Thyroid Management
- For low TSH (0.4) suggesting hyperthyroidism:
- If confirmed hyperthyroidism with elevated T3/T4: Consider methimazole under endocrinology guidance 3
- Monitor for side effects of methimazole including agranulocytosis, rash, and liver dysfunction 3
- Avoid propranolol for migraine prevention if hyperthyroidism is severe and untreated, as it may mask symptoms of thyroid storm 3, 4
Important Clinical Considerations
Relationship Between Thyroid Function and Migraine
- Research shows a relationship between thyroid dysfunction and migraine 5, 6
- Treatment of thyroid dysfunction may improve migraine symptoms 6, 7
- In a study of children with subclinical hypothyroidism and migraine, levothyroxine treatment significantly reduced headache frequency and severity 7
Hemiplegic Migraine Specifics
- Hemiplegic migraine attacks in children tend to be more prolonged than in adults, with motor aura lasting an average of 3.5 hours 8
- Consider genetic testing for CACNA1A, ATP1A2, and SCN1A mutations, especially if there are additional symptoms like chronic ataxia or epilepsy 2, 9
- Sporadic hemiplegic migraine (SHM) cases often experience more prolonged attacks than familial hemiplegic migraine (FHM) cases 8
Follow-up and Monitoring
- Maintain a headache diary to track:
- Frequency, severity, and duration of migraine attacks
- Response to treatment
- Potential triggers
- Schedule follow-up with neurology within 4-6 weeks 2
- Schedule follow-up with endocrinology within 2-4 weeks to monitor thyroid function 2
- Evaluate treatment response after 2-3 months for migraine preventive medications 2
- Monitor for side effects of medications, particularly with topiramate (cognitive effects, weight loss) and amitriptyline (sedation, weight gain) 2
Lifestyle Modifications
- Regular sleep schedule
- Regular meal times
- Adequate hydration
- Identification and avoidance of migraine triggers
- Stress management techniques appropriate for children
Cautions and Contraindications
- Avoid triptans in hemiplegic migraine 1
- Use caution with beta-blockers in hyperthyroidism until thyroid function is controlled 3
- Monitor for medication side effects, particularly with preventive medications 2
- Communicate to parents that complete elimination of headaches is unlikely; the goal is reducing frequency, severity, and disability 2