Definition
- Paediatric migraine is a chronic neurological disorder with a strong genetic component, characterised by episodic, moderate-to-severe attacks of headache, nausea, vomiting, and sensitivity to light and noise.
- Functional impairment during attacks is common, with normal function returning between episodes.
- Onset can occur at any time during childhood and adolescence.
- According to the International Headache Society (IHS), migraine episodes last 2-72 hours, are unilateral or bilateral, have a gradual onset (15-30 minutes), pulsating quality, and moderate-to-severe intensity aggravated by routine physical activity.
- Associated symptoms: nausea, vomiting, photophobia, phonophobia.
- IHS criteria limitations: rely on patient descriptions; in children, many features are inferred from behaviour rather than direct reports.
Epidemiology
- Prevalence varies:
- Systematic review: ~11% prevalence in paediatric population.
- Other sources: 1%-3% in 3-7-year-olds; 4%-11% in 7-11-year-olds; 8%-25% by age 15.
Aetiology
- Combination of genetic, environmental, and unknown factors.
- Results in central nervous system hyperexcitability and episodic decompensation causing headache and associated symptoms.
Pathophysiology
- Exact mechanisms are unclear despite recent advances.
- Genetic predisposition: generalised neuronal hyperexcitability; family history positive in ~50%.
- Genes involved: CACNA1A, ATP1A2, PRRT2, SCN1A.
- Phases: premonitory, aura, ictal, postdromal, inter-ictal.
- Premonitory: fatigue, yawning, neck stiffness, mood changes, food cravings, muscle aches, photophobia; hypothalamic activation implicated.
- Aura: self-resolving cortical neurological symptoms (visual, sensory); caused by cortical spreading depression.
- Ictal phase: headache due to trigeminovascular pathway activation.
- Postdrome: fatigue, concentration difficulties.
Risk factors for Paediatric Migraine
Strong Risk Factors
- Family history of migraine
- Migraine is 50% more likely in relatives of people with the condition than in those without migraines in their family.
- The majority of migraine cases are inherited on a polygenic basis. The susceptibility genes identified through genome-wide association studies often encode proteins affecting complex, poorly understood neuronal and vascular networks.
Weak Risk Factors
- While before puberty the incidence of migraine is equal between the two sexes, after puberty more females are affected than males. In mid-adolescence, twice as many females as males experience migraine.
- Perimenstrual migraine incidence increases during adolescence and can precede the occurrence of menses, as demonstrated by their monthly, recurring pattern.
Classification (ICHD-3)
- There is a strong association between various sleep disorders and migraine both in adults and in children.[19][20] Moreover, poor sleep is associated with increased migraine attack frequency.
Clinical Approach
- Stress, usually related to academic difficulties and interpersonal relationships, may play a role in frequency and severity of migraine attacks in up to 25% of children with migraine.
- Much of the evidence for risk factors in paediatric migraine has been extrapolated from data from adult studies.
History and Examination: Key Diagnostic Factors for Paediatric Migraine
- Frequent use of abortive drugs often leads to rebound headaches and is one of the factors responsible for the transformation of episodic migraine to chronic migraine.
Physical Examination
- Periodic syndromes
- There is an association between various periodic childhood syndromes and the development of migraine headaches. Better-characterised entities that precede the development of migraine include benign paroxysmal torticollis, benign paroxysmal vertigo of childhood, abdominal migraine, and cyclical vomiting.[23]
- Other entities, such as epistaxis and motion sickness, are often associated with paediatric migraine.
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