Overview

Migraines are severe, often bilateral, throbbing headaches commonly located in the temples or frontal regions of the head. They affect different age groups with varying prevalence rates: 2-5% in preschool children, 10% in school-aged children, and 20-30% in adolescent girls (Abu-Arafeh and Russell, 1994; Aromaa et al., 1998). Approximately 20% of migraine patients experience their first attack before the age of 5 (Bille, 1997).

Symptoms by Age Group

Preschool Children:

• Symptoms: Episodes of ill appearance, pallor, abdominal pain, vomiting, and the need for sleep.
• Behavior: Expressed through irritability, crying, rocking, or seeking a dark room to sleep.

Children Aged 5-10 Years:

• Symptoms: Bilateral frontal, temporal, or retro-orbital headache, nausea, abdominal cramping, vomiting, photophobia, phonophobia, and a need to sleep.
• Physical Appearance: Pale with dark circles under the eyes.

Older Children:

• Symptoms: Unilateral, temporal headache with variable pain location and intensity within or between episodes.

Migraine with and without Aura

• Aura Prevalence: 10-20% of children with migraines experience an aura, often after the age of 8.
• Aura Characteristics: Precedes the headache by less than 60 minutes, lasts for 5-20 minutes, may occur without headache.
• Types of Aura: Visual auras (blurred vision, fortification spectra, scotomata, scintillations, black dots, kaleidoscopic patterns, micropsia, macropsia, metamorphopsia), attention loss, confusion, amnesia, agitation, aphasia, ataxia, dizziness, vertigo, paresthesia, or hemiparesis.

Duration and Intensity

• Headache Duration: Can last from 60 minutes to 48 hours, typically less than 4 hours. Some report short headaches lasting 10-20 minutes.
• Severity: Generally milder than adult migraines.

Associated Symptoms

• During Headache Phase: Cold extremities, nausea, anorexia, vomiting, diarrhea, constipation, dizziness, chills, excessive sweating, ataxia, numbness, photophobia, phonophobia, memory loss, confusion, difficulty concentrating.
• Relief: Typically associated with sleep.
• Post-Headache Phase: Feelings of elation and energy or exhaustion and lethargy, lasting from hours to days (Gladstein et al., 1993).

Comorbid Conditions

• Psychiatric Symptoms: Depression, panic episodes, anxiety disorders, phobia.
• Epilepsy: Co-occurrence with migraines, though most migraineurs do not have seizures.
• Motion Sickness and Vertigo: More common in migraineurs.
• Cardiovascular Reactivity: Higher reactivity to postural changes, leading to dizziness.
• Other Associations: Sleep disturbances, ice-cream headaches (Raskin and Knittle, 1976; Kuritzky et al., 1981; Schoenen et al., 1998; Dodick et al., 2003; Maizels and Burchette, 2004; Pellock, 2004).

Types of Migraine

Status Migrainosus

Status migrainosus is a severe form of migraine characterized by a continuous headache attack lasting longer than 72 hours. Patients typically have a pre-existing history of migraines. For those who experience vomiting, rehydration is often the first step in treatment. Effective treatments may include intravenous fluids, antiemetics, and dihydroergotamine (DHE) (Linder, 1994).

Familial Hemiplegic Migraine

Familial hemiplegic migraine is an autosomal-dominant form of migraine with aura. Patients experience prolonged hemiplegia, which can be accompanied by numbness, aphasia, and confusion. Hemiplegia may precede, accompany, or follow the headache, with symptoms lasting from hours to days. The headache is usually contralateral to the hemiparesis. Some cases are associated with cerebellar ataxia, and severe forms may present with coma, fever, and meningismus. Treatment may include acetazolamide or calcium channel blockers. Differential diagnosis should consider structural lesions, vasculitis, cerebral hemorrhage, brain tumor, mitochondrial myopathy, encephalopathy, alternating hemiplegia, and lactic acidosis. Mutations in CACNA1A, ATP1A2, SCN1A, and PRRT2 genes are associated with this type of migraine (de Vries et al., 2007).

Basilar-Type Migraine

Basilar-type migraine, a subtype of migraine with aura, primarily affects adolescent and young adult females. Headache pain may be located in the occipital area. This type involves disturbances originating from the brainstem, occipital cortex, and cerebellum. Aura symptoms include dysarthria, vertigo, tinnitus, hyperacusis, diplopia, bi-field visual symptoms, ataxia, decreased level of consciousness, or bilateral paresthesias. Many patients have a family history of typical migraine (Brenner et al., 2007).

Benign Paroxysmal Vertigo of Childhood

Benign paroxysmal vertigo of childhood is characterized by brief episodes of vertigo, disequilibrium, and nausea, usually affecting children aged 2-6 years. Nystagmus may be present during episodes but not between them. There is no associated hearing loss, tinnitus, or loss of consciousness. Symptoms typically last a few minutes, and affected children often develop a more common form of migraine as they mature. MRI can be used to exclude posterior fossa abnormalities (Abu-Arafeh and Russell, 1995).

Acute Confusional Migraine

Acute confusional migraine involves transient episodes of amnesia, acute confusion, agitation, lethargy, and dysphasia. Often precipitated by minor head trauma, this form of migraine may present with receptive or expressive aphasia and a confusional state that precedes or follows the headache. Recovery usually occurs within hours. It is important to exclude other conditions such as hypoglycemia, intoxications, encephalitis, structural lesions, and seizures (Shaabat, 1996).

Migraine-Associated Cyclic Vomiting Syndrome

This syndrome is characterized by recurrent periods of intense vomiting separated by symptom-free intervals. Symptoms often include abdominal pain, nausea, retching, anorexia, pallor, lethargy, photophobia, phonophobia, and headache. The condition typically begins in toddlerhood and resolves by adolescence or early adulthood. These children often require intravenous fluid therapy due to severe fluid and electrolyte disturbances. A diagnosis of exclusion, other causes such as gastrointestinal, metabolic, endocrine, and mitochondrial disorders must be ruled out (Andersen et al., 1997; Rashed et al., 1999).

Abdominal Migraine

Abdominal migraine involves recurrent episodes of generalized abdominal pain with nausea and vomiting, often without headache. Episodes are relieved by sleep, with children feeling better upon waking. This condition may alternate with or evolve into typical migraines as the child matures. Treatment with migraine prophylactic medication is often effective (Dignan et al., 2001; Russell et al., 2002).

Paroxysmal Torticollis of Infancy

An uncommon disorder, paroxysmal torticollis of infancy features repeated episodes of head tilting accompanied by nausea, vomiting, and headache. Episodes usually occur in infants and last from minutes to days. Differential diagnosis should consider posterior fossa abnormalities. Some cases are linked to mutations in the CACNA1A gene (Abu-Arafeh and Russell, 1995; Drigo et al., 2000; Giffen et al., 2002).

Acephalgic Migraine

Acephalgic migraine, also known as migraine sine hemicrania, is characterized by a migraine aura without headache, typically involving visual auras and more commonly affecting females. A family history of migraine is frequent.

Migraine Aura and Retinal Migraine

Migraine aura occurs in about one-third of adult and adolescent patients, featuring symptoms such as blurred vision, fortification spectra, scotomata, scintillations, black dots, kaleidoscopic patterns, micropsia, macropsia, and metamorphopsia. Aura symptoms can include attention loss, confusion, amnesia, agitation, aphasia, ataxia, dizziness, vertigo, paresthesia, or hemiparesis. Retinal migraine is an uncommon condition involving repeated episodes of monocular visual disturbance associated with migraine headache (Lendvai et al., 1999).

Ophthalmoplegic Migraine

Ophthalmoplegic migraine is an inflammatory disorder characterized by ophthalmoplegia, typically a unilateral third nerve palsy, and headache. MRI studies during an attack may show inflammation of the third cranial nerve. Episodes may last for days and can be recurrent (Brenner et al., 2007).