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MIGRAINE HEADACHE IN CHILDREN

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... hemiplegic migraine. Sporadic hemiplegic migraine ... Familial Hemiplegic Migraine (IHS 2004) Migraine with aura ... Sporadic hemiplegic migraine (IHS 2004) ... – PowerPoint PPT presentation

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Title: MIGRAINE HEADACHE IN CHILDREN


1
MIGRAINE HEADACHE IN CHILDREN
  • Suhair Shehadeh-Saieg M.D
  • Pediatric Department
  • Bnai-Zion Medical Center, Haifa

2
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  • Tension headache
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6
Headache classification
  • Primary headache
  • migraine, tension , cluster
  • Secondary headache
  • Infection, trauma, hemorrhage, tumor, high
    intracranial pressure.

7
Tension headache
  • Bilateral, pressing tightness
  • Non-throbbing, mild to moderate
  • Lasts from 30 minutes to several days
  • May be associated with photophobia or phonophobia
  • Is not accompanied by nausea or vomiting

8
Cluster headache
  • More apparent between ages 10-20y
  • MF 91 after age 20y.
  • Always unilateral, mainly frontal-peri-orbital
  • Severe nature, less than three hours
  • Usually associated with ipsilateral autonomic
    findings
  • ( lacrimation, rhinorrhea, ophthalmic
    injection, horner syndrome)

9
Migraine
  • Episodic, periodic, paroxysmal attacks of
    moderate to severe throbbing pain, separated by
    pain free intervals,
  • Associated with nausea, vomiting, photophobia,
    abdominal pain and desire to sleep, motion
    sickness.
  • Family history 70-90

10
Incidence of migraine
  • In 50 of cases lt 20y
  • The youngest age reported was 3y
  • 7y 1-3
  • 7-15 4-11
  • lt 7y gtgtgt MgtF
  • 7-11y MF
  • gt11 FgtM

11
Signs and symptoms of intracranial pathology
  • Sleep related headache
  • Absence of family history of migraine
  • Vomiting\absence of visual symptoms
  • Headache of less than six month duration
  • Confusion
  • Abnormal neurologic examination
  • Growth abnormality ,pulsatile tinitus
  • Lack of response to medical therapy

12
pathophysiology
  • Vascular theory
  • Neuronal theory ( cortical spreading depression)

13
Precipitating factors
  • Anxiety
  • Fatigue
  • Head trauma
  • Stress
  • Menses
  • Illness
  • diet

14
Dietary items and chemical migraine triggers
  • Offending food items
  • Cheese
  • Chocolate
  • Hot dogs,ham, cured meats
  • Yugort, dairy products
  • Asian frozen snack foods
  • Wine, beer
  • Fasting
  • Coffee, tea,cola
  • Food diyes, additives
  • Chemical triggers
  • Tyramin
  • Nitric oxide, nitrites
  • Allergenic proteins (casein )
  • Monosodium glutamate
  • Aspartame
  • Histamine, tyramine sulfite

15
Pathophyiology schema
  • Primary triger
  • Locus ceruleus gtgt cortical deppretion
  • Trigeminal nucleus vasoconstriction
  • Neuronal inflammation aura
  • Vasodilatation
  • pain

16
Serotonin
  • Released from brainstem serotonergic nuclei.
  • Plays an important role in the pathogenesis of
    migraine
  • Direct action upon the cranial vasculature
  • Role in central pain control pathways

17
Classification of migraine (revised
international headache society IHS 2004)
  • Migraine without aura
  • Migraine with aura
  • Migraine with typical aura

18
Migraine without aura (IHS 2004)
  • A. at least 5 attacks fulfilling criteria B
    through D.
  • B. Headache attacks lasting 4 to 72h
  • C. headache has at least 2 of the following
  • -unilateral location
  • -pulsating quality
  • -moderate or severe pain intensity
  • -aggravation by or causing avoidence of
  • routine physical activity
  • D. during headache at least one of the folowing
  • nausea, vomiting, or both, photophobia,
    phonophobia
  • E. not attributed to another disorder.

19
Migraine with aura (IHS 2004)
  • A. at least 2 attacks fulfilling criteria B.
  • B. migraine aura fulfilling criteria B or C for
    one of the following subforms
  • Typical aura with migraine headache
  • Typical aura with nonmigraine pain
  • Typical aura without headache
  • Familial hemiplegic migraine
  • Sporadic hemiplegic migraine
  • Basilar type migraine
  • C. Not attributed to another disorder.

20
Migraine with typical aura (IHS 2004)
  • A. at least 2 attacks fulfilling criteria B or D.
  • B. Aura consisting at least one of the following,
    but no motor weakness
  • Fully reversible visual symptoms
  • Fully reversible sensory symptoms
    (numbness, pins and needles)
  • Fully reversible dysphasia
  • C. at least two of the following
  • Homonymous visual and/or unilateral
    sensory symptoms
  • At least one aura symptom developes
    gradually over gt5minutes
  • Each symptom lasts gt5 and lt60 minutes
  • D. headache fulfilling criteria B through D for
    Migraine without aura
  • begins during the aura or follows aura
    within 60 minutes
  • E. not attributed to another disorder.

21
Familial Hemiplegic Migraine (IHS 2004)
  • Migraine with aura
  • At least one first or second degree relative who
    has migraine aura that includes motor weakness.
  • AD inheritance

22
Sporadic hemiplegic migraine (IHS 2004)
  • Migraine with an aura of motor weakness with no
    family history

23
Basilar type migraine
  • 3-19 of children with migraine
  • Average age 7y
  • Occipital headache
  • Any combination of vetigo, ataxia,diplopia,tinni
    tus,vomiting,visual symptoms,
  • parasthesias and altered consciousness
  • Absence of weakness.

24
Childhood periodic syndromes( precursors of
migraine according to revised IHS criteria)
  • Cyclic vomiting syndrome.
  • Abdominal migraine.
  • Benign paroxismal vertigo of childhood.

25
Retinal migraine (ocular migraine)
  • Sudden loss of vision, perception of bright light
  • followed within one hour by a migrainous
    headache.
  • Reversible neurologic symptoms.
  • Permanent visual loss may occur.
  • Visual symptoms may occur without headache.

26
Complications of migraine
  • Chronic migraine
  • Status migrainosus (gt 72 h)
  • Persistent aura without infarction
  • Migrainous infarction
  • Migraine-triggered seizure.

27
Migraine variants
  • Alice in wonderland syndrome
  • Confusional migraine
  • Hemisyndrome migraine
  • Menstrual migraine
  • Ophthalmoplegic migraine

28
Approach to the child with recurrent headache
  • History
  • Physical examination
  • Laboratory or imaging studies

29
When to perform neuroimaging study ??
  • Age lt 3 y
  • Abnormal neurological exam
  • Chronic progressive pattern
  • Family reassurance

30
MRI Vs CT
  • There was no sufficient data to make a specific
    recommendation regarding the relative sensitivity
    of MRI compared with CT.
  • Most prefer MRI because of vascular differential
    diagnosis.

31
EEG and migraine
  • EEG is not indicated in the routine evaluation of
    headache
  • It is performed if seizures are suspected.
  • EEG findings in children with migraine
  • -Rolandic spike and wave
  • -Benign focal epileptiform discharges

32
Management of migraine
  • Non-pharmacologic methods (biofeedback,
    relaxation,exercise)
  • Pharmacologic therapy for acute attack
  • Preventive therapy

33
Pharmacologic Treatment
  • General pain medications
  • (acetaminophen, NSAIDS) alone or in
    combination with antiemetic medications
    (migraleve)
  • Vasoconstrictors ergot alkaloids/xanthine
    (cafergot, tamigran)
  • Triptans-5HT1D agonists (imitrex, zomig)
  • Migraine status (gt 72 h in adults) - steroids,
    DHE
  • dihydroergotamin

34
Triptans
  • 5HT1 (hydroxytriptamin) receptor agonist
  • Promote vasoconstriction
  • Block pain pathway in the brain stem
  • Overall efficacy 63-88
  • Efficacy and safety were established in
    adolescents (gt12y)
  • Approved for use in Israel from 18y
  • Side effects feeling of warmth, burning,
    pressure in the head and neck, palpitations,
    arrythmias, hypotension lt1.
  • C.I complicated migraine.

35
American academy of pediatricsoctober 9 2006
  • Symptomatic treatment of migraine in children a
    systematic review of medication trials

36
  • Conclusion
  • Acetaminophen, ibuprofen, and nasal, spray
    sumatryptan are all effective symptomatic
    pharmacologic treatments for episodes of migraine
    in children.

37
Indications for migraine prophylaxis
  • Attacks occur gt2-4 times per month
  • Disability occurs gt 3 days per month
  • Duration of attack gt 48 h
  • Medications for acute attack are ineffective, C.I
    or overused
  • Attacks produce prolonged aura or true migrainous
    infarction
  • Patient preference

38
Duration of prophylactic therapy
  • The optimum duration of prophylactic therapy is
    uncertain
  • The approach is to treat for 6-12 months and then
    taper over the course of several weeks.
  • Data are limited on the effectiveness of
    preventive agents in children

39
Preventive Therapy
  • B blockers
  • Antideppressants
  • Anticonvulsants
  • Ca channel blocker

40
B blocker
  • Propranolol was the prophylactic treatment most
    commonly used in children, primarily based upon
    evidence in adults.
  • C.I asthma
  • Caution depression, diabetes, orthostatic
    hypotension, impotense
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