Migraine in Children: Diagnosis and Management
Diagnostic Approach
In children presenting with recurrent headaches, suspect migraine when attacks are moderate to severe, particularly if accompanied by nausea, vomiting, photophobia, or phonophobia, with a positive family history strengthening the diagnosis. 1
Key Clinical Features in Pediatric Migraine
- Duration differs from adults: Attacks last 2-72 hours (versus 4-72 hours in adults) 1
- Pain location: More commonly bilateral (bifrontal or bitemporal) rather than unilateral 1, 2
- Pain quality: Less often pulsating compared to adults 1
- Gastrointestinal symptoms: Commonly prominent and may dominate the clinical picture 1
- Attack duration: Often shorter than in adults 1, 2
- Age patterns: Less common before age 3; males predominate before puberty, females after puberty 2
Essential History Elements
- Age at onset, attack frequency and duration 1
- Pain characteristics: location, quality, severity, aggravating/relieving factors 1
- Accompanying symptoms: photophobia, phonophobia, nausea, vomiting 1
- Aura symptoms if present (visual, sensory, speech disturbances) 1
- Family history of migraine (often positive and under-reported) 1, 3
- Current medication use patterns 1
When to Obtain Neuroimaging
Neuroimaging is NOT routinely indicated for primary headaches in children with normal neurologic examination. 4
Red flags requiring neuroimaging include: 4
- Sudden onset "thunderclap" headache
- Rapidly increasing headache frequency or severity
- Headache awakening patient from sleep
- Focal neurologic signs on examination
- Fever with headache
- Headache worse with Valsalva maneuver
Acute Treatment Strategy
For mild to moderate attacks, use ibuprofen at weight-appropriate doses as first-line therapy; bed rest alone may suffice for short-duration attacks in young children. 1
First-Line Acute Medications
- Ibuprofen: Recommended first-line for children 1
- Acetaminophen: Alternative first-line option 5, 6
- NSAIDs: Effective for mild-to-moderate attacks 4, 6
Second-Line Acute Medications (Adolescents 12-17 years)
- Triptans: Multiple formulations approved for adolescents 1
- Nasal spray formulations: Sumatriptan and zolmitriptan nasal sprays are most effective 1, 2
- Antiemetics: Domperidone can be used for nausea in adolescents 12-17 years (oral administration unlikely to prevent vomiting) 1
Critical Pitfall to Avoid
Limit acute medication use to ≤2 days per week to prevent medication-overuse headache, which occurs with ≥15 days/month of NSAID use. 4
Preventive Therapy
Initiate preventive therapy when migraines adversely affect the child on ≥2 days per month despite optimized acute treatment, or when attacks cause significant school absenteeism or quality of life impairment. 3, 4
First-Line Preventive Options
- Propranolol: 80-160 mg daily in long-acting formulations 1, 7
- Topiramate: 50-100 mg oral daily (in children >6 years) 1, 7
- Candesartan: 16-32 mg oral per day (in older children) 1, 7
Second-Line Preventive Options
- Amitriptyline: 10-100 mg oral at night (contraindicated in children <6 years) 1, 7
- Flunarizine: 5-10 mg oral once daily (significantly reduces frequency and duration of attacks) 1, 7
Important Contraindications
- Amitriptyline: Age <6 years, heart failure, co-administration with MAO inhibitors and SSRIs, glaucoma 1
- Topiramate: Nephrolithiasis, pregnancy, lactation, glaucoma 1
- Flunarizine: Monitor for depression and extrapyramidal symptoms 7
Treatment Duration and Monitoring
- Assess efficacy after 2-3 months at therapeutic dose; benefits may take several weeks to become apparent 4
- Consider discontinuing preventive medication after 3-6 months of stability to determine if prophylaxis is still needed 3, 4, 7
- Use headache calendars to monitor attack frequency, severity, and acute medication use 1, 3, 4
Non-Pharmacological Management
Implement lifestyle modifications and behavioral interventions as essential components of treatment, not optional adjuncts. 3, 4
Lifestyle Modifications
- Regular meals and consistent sleep patterns 3, 4
- Adequate hydration and stress management 3, 4
- Maintain headache diary to identify triggers and monitor treatment effectiveness 3, 4
Behavioral Interventions with Proven Efficacy
- Cognitive behavioral therapy (CBT) 3, 4
- Relaxation training and biofeedback 3, 4
- Regular exercise: 40 minutes three times weekly (as effective as relaxation therapy or topiramate for prevention) 3
Family and School Involvement
Active help from family members and teachers is necessary for clinical management in children and young adolescents; education of both is essential. 1
- Parents provide more reliable descriptions of features than young children 1
- Parents give better account of lifestyle factors needing to be addressed 1
- Schools play important role in management of young children 1
Follow-Up and Monitoring
Schedule follow-up within 2-3 months to assess treatment response using standardized measures. 1, 4
Key Outcome Measures to Evaluate
- Attack frequency (headache days per month) 1, 4
- Attack severity and migraine-related disability 1, 4
- Adverse effects from medications 1, 4
- Adherence to treatment plan 1, 4
- Symptomatic days and acute medication use via headache calendar 4