Epidemiology
worldwide prevalence 7.7%, school age prevalence 10%, increases w/ age, +c boys before puberty, +c girls during and after puberty
Headache classification
According to ICDH-3 (international classification of HA disorders 3rd edition):
Primary
Secondary
Due to cranial neuropathies
Primary HA
Migraine (with or without aura), tension type headache (TTH), trigeminal autonomic cephalalgias (TACs)
Migraine pathophysiology
Ion channel dysfunction in brainstem that modulates sensory input and meningeal blood vessels
Cranial dilation of blood vessels causing further nerve activation and pain
Pediatric migraine criteria
ICDH-3. 5-2-1
5 or more attacks not due to other medical diagnosis or medication overdose
2 or more: bilateral location, frontotemporal, pulsating quality, moderate to severe intensity, aggravated by regular physical activity
1 or more: nausea, vomiting, photophobia, phonophobia
Tension type headache (TTH)
Bilateral Mild to moderate in intensity Tightening, pressing, squeezing quality Increased pericranial tenderness Not aggravated by regular physical activity May or not be associated w nausea Photophobia or photophobia may occur
Trigeminal autonomic cephalalgias
TACs
Unilateral
Moderate to severe to very severe
Stabbing quality
Parasympathetic autonomic features: conjunctival lacrimation/injection, nasal congestion, facial sweating. Ipsilateral
Multitiered approach to migraines
4 tiers
- Lifestyle modifications
- Integrative approaches
- Pharmacologic tx
- Other tx
What is key to Dx pediatric migraines?
Thorough medical history
Questions to ask when taking the Hx? 1-4
- Pattern of HA and what time do they occur? 2. How and when did the HA begin? 3. How often do they happen and how long do they last? 4. Where is the pain located?
Questions to ask when taking the Hx? 5-8
- What is the quality of the pain? 6. What other symptoms accompany the HA? 7. Anyone in the family has HA? 8. What do you think may be causing your HA?
HA patterns?
- Acute onset of 1st episode w/o prior Hx 2. Recurring HA with symptom free intervals 3. Chronic pattern of progressively increasing HA 4. Nonprogressive daily or near daily HA 5. Mixed pattern of daily HA with + intense attacks superimposed
How and when did your HA begin? Rationale
Try to establish origin/history of attacks
How often? How long? Rationale
ID characteristic patterns
Pattern of Migraine or TTH (tension type HA)
Could be weekly 4 h attack
Pattern of TACs (Trigeminal Autonomic Cephalalgias)
Brief attacks happening multiple times daily
Pain locations for HAs?
Holocephalic, bifrontal, unilateral, posterior (occipital)
Qualities of HAs
Throbbing/pounding, squeezing/pressure, stabbing, other
Symptoms that could accompany HAs?
Nausea, vomiting, abdominal pain Visual aura, diplopia photophobia, photophobia Vertigo, dizziness Motion sickness, nocturnal leg cramps Numbness, weakness
What word should you use when taking family Hx?
Use the open ended term headache (no migraines) to see if there are other types of HA in the family
What do you think maybe causing your HA?
Possibly the most important question, MC fear: Brain tumor, but w/ a normal physical and neurological exam you can reassure pt and family