Episodic and chronic migraine in children

Key points

• Episodic migraine affects about 2-5% of preschool children, 10% of school-aged children and 20-30% of adolescent females; about 20% have their first attack before age 5, and only 10-20% of children with migraine have aura.
• Neuroimaging is usually not warranted when the history is consistent with migraine and the neurological examination is normal; it should be considered with seizures, recent head trauma, a significant change in headache, focal deficits or papilledema.
• Mild to moderate attacks respond to NSAIDs such as ibuprofen 10 mg/kg given early; for moderate to severe attacks triptans should be considered, for example oral sumatriptan from 25 mg up to 100 mg, repeatable after 2 hours.
• Preventive treatment should be considered for frequent (more than 2 a week), prolonged or disabling attacks; the best evidence supports topiramate or amitriptyline together with cognitive behavioural therapy.
• In chronic migraine, analgesics should be limited to no more than 2 headache days a week, combined with a preventive drug, better sleep, cognitive behavioural therapy and a school plan.

Overview

This invited review describes the clinical features of migraine in children, which evolve with age, and the treatment options for episodic and chronic migraine. Children have shorter attacks (lower limit 2 hours), more often bilateral frontotemporal pain before adolescence, and light and sound sensitivity inferred from behaviour. Impaired sleep is the most common headache trigger in children.

Variants and episodic syndromes

Status migrainosus lasts longer than 72 hours and may respond to intravenous fluids, an antiemetic such as prochlorperazine and an NSAID such as ketorolac. Hemiplegic migraine (estimated prevalence 0.01%) causes fully reversible unilateral weakness; triptans and ergotamine derivatives are felt to be contraindicated. Other forms include migraine with brainstem aura and acute confusional migraine. Episodic syndromes considered migraine precursors include cyclic vomiting syndrome, abdominal migraine (childhood prevalence 2-4%), benign paroxysmal vertigo (usually ages 2-4) and paroxysmal torticollis of infancy.

Acute treatment

Lying down in a cool, dark, quiet room and sleeping may be the most potent treatment. Children over 10 years and over 50 kg seem to tolerate adult triptan doses, while those aged 6-10 years and under 50 kg should start with the smallest available dose. In the emergency department, first-line parenteral treatment is intravenous fluid (20 ml/kg normal saline) with prochlorperazine (0.15 mg/kg, maximum 10 mg) and ketorolac (0.5 mg/kg, maximum 30 mg); dihydroergotamine is usually reserved for protracted migraine.

Chronic migraine

Chronic daily headache means headache on 15 or more days a month for three consecutive months, lasting more than 4 hours a day; chronic migraine means migraine features on at least 8 days a month. Amitriptyline (0.25-1.0 mg/kg/day) and topiramate (target 1-2 mg/kg/day) are used for prevention, and botulinum toxin A, nerve blocks and neurostimulation are options when standard measures fail. Sleep problems, dizziness, mood and anxiety disorders and other pain are common comorbidities. In a follow-up study, 50% of adolescents with chronic headache improved after 1 year and 75% after 2 years, while 12% still had chronic daily headache 8 years later.

FAQ

Does a child with migraine need brain imaging?

Usually not, if the history is consistent with migraine and the neurological examination is normal; imaging is considered with seizures, recent head trauma, significant change in headache, focal deficits or papilledema.

Which preventive treatments have the best evidence?

Topiramate or amitriptyline together with cognitive behavioural therapy, although placebo responses in children are high (about 60% in the CHAMP trial).

How can medication overuse be avoided?

By limiting analgesics to no more than 2 headache days a week and limiting compounds with caffeine, barbiturates or opiates.

Source

Youssef PE, Mack KJ. Episodic and chronic migraine in children. Dev Med Child Neurol 2020;62(1):34-41. DOI: 10.1111/dmcn.14338. © 2019 Mac Keith Press. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.