Anwar Wardy W

Dept.Neurology FK.UMJ

dept.neurology fk.umj.2014 anwar wardy w

MIGRAINE
Migraine without aura, previously called common
migraine or hemicrania simplex

Recurrent headache disorder

Attacks last 472 hours.
Typical characteristics
More often bilateral, orbital, or frontotemporal,
Pulsating quality
Moderate or severe intensity
Aggravation by routine physical activity
Association with nausea, photophobia, phonophobia ,
unexplained paroxysmal abdominal pain
GI symptoms
60-85% of migrainous children

dept.neurology fk.umj.2014 anwar wardy w

Phases of Migraine attack

Premonitory phase or prodrome : may

precede the headache phase by up to 24 hours

irritability, elation or sadness, talkativeness or
social withdrawal, an increase or decrease in
appetite, food craving or anorexia, water
retention, and/or sleep disturbances
Aura: focal cerebral dysfunction that immediately
precedes or coincides with the headache onset
Only 10-20% of children with migraine experience
an aura
dept.neurology fk.umj.2014 anwar wardy w

Phases of Migraine

Aura: precedes the headache by less than 30

minutes and lasts for 5-20 minutes

Motor auras last longer
Children are often unaware or unable to describe
pictorial cards
The visual aura is the most common form in
children,
blurred vision, fortification spectra (zigzag lines),
scotomata (field defects), scintillations, black
dots, kaleidoscopic patterns of various colors,
micropsia, macropsia (distortion of size), and
metamorphopsia ("Alice in Wonderland"
syndrome). moving or changing shapes
dept.neurology fk.umj.2014 anwar wardy w

Cont.
other auras include attention loss, confusion,

amnesia, agitation, aphasia, ataxia, dizziness,

vertigo, paraesthesia, or hemiparesis.
Actual headache phase : usually shorter in
children, 30 min- 48hrs. less severe
Postdrome : patient may feel either elated
and energized or exhausted and lethargic

dept.neurology fk.umj.2014 anwar wardy w

MIGRAINE
Migraine with aura (classic migraine)
Aura consists of visual, sensory, or speech symptoms.
Gradual development
Duration 1 hour
Complete reversibility
In addition to the aura, the headache will have symptoms
of migraine without aura.
Chronic migraine

Frequent headaches (15 times per month for the

previous 3 months)
Presence of migraine features
Cannot be attributed to a secondary cause

dept.neurology fk.umj.2014 anwar wardy w

Cont..
Status migrainosus: severe form of

migraine . Headache continuous for over 72

hours. Hydration imp for those with vomiting.
Iv dihydroergotamine/ valprote is treatment.
Familial hemiplegic migraine : autosomal
dominant form of migraine with aura
prolonged hemiplegia accompanied by
numbness, aphasia, and confusion. precede,
accompany, or follow the headache. headache
is usually contralateral to the hemiparesis
dept.neurology fk.umj.2014 anwar wardy w

Basilar migraine

Subtype of migraine with aura.

Occipital headache.
Disturbances in function originating from the brain

stem, occipital cortex, and cerebellum

Ataxia
Bilateral paresthesias
Deafness
Decreased level of consciousness
Diplopia
Dizziness
Drop attacks
Dysarthria
Fluctuating low-tone hearing loss
Tinnitus
Unilateral or bilateral vision loss
Vertigo
Weakness

dept.neurology fk.umj.2014 anwar wardy w

CYCLIC VOMITING
Migraine-associated cyclic vomiting syndrome
SYNDROME
(periodic syndrome)
Recurrent periods of intense vomiting separated

by symptom-free intervals
Rapid onset at night or in the early morning.
Nausea, anorexia, abd pain, pallor, headache,
photo/phonophobia.
Begins when the patient is a toddler and resolves
in adolescence. family history of migraine
Respond to antimigraine drugs
dept.neurology fk.umj.2014 anwar wardy w

TTH s
Generally considered mild recurrent headaches
Many features are the opposite of those of

migraine.
TTHs can be subdivided based on frequency.

Infrequent, episodic
Frequent, episodic
Chronic
Diffuse in location
Having a pressing quality
No secondary causes are identified
dept.neurology fk.umj.2014 anwar wardy w

Cluster headache
histamine headache
severe and unilateral, sudden onset
typically are located at the temple and periorbital
region
ipsilateral lacrimation, nasal congestion, conjunctival
injection, miosis, ptosis, and lid edema
few moments to 2 hours
grouping of headaches, usually over a period of
several weeks.
at least 5 attacks occurring from 1 every other day to
8 per day and no other cause for the headache.
Distribution - First and second divisions of the
trigeminal nerve
dept.neurology fk.umj.2014 anwar wardy w

Danger Signs and Symptoms of Life

Threatening Conditions that Can
Present
History: with a Headache
No family history in presence of other signs &
symptoms
Lack of response to medical therapy
Early morning pain, with/without headache
Night time awakening with pain
Persistant vomiting
Increased pain with coughing/bowel movt/voiding
Chronic progressive pain
Worst headache that has ever had
Personality change (depression &migraine indicate
temporal lobe tumor)
dept.neurology fk.umj.2014 anwar wardy w

Physical exam
Age <3yrs
Known risk for intracranial pathology

V-P shunt malfunction

Neurofibromatosis
Tuberous sclerosis
Abnormal Neurologic exam
Seizures, lethargy, ataxia
hemiparesis, abn reflexes, diplopia, papilledema,
meningeal signs
dept.neurology fk.umj.2014 anwar wardy w

Imaging
If abnormalities on the neurologic examination cannot

be explained by medical history, then neuroimaging

may be required to identify a medically or surgically
treatable cause of the headaches.
The decision to perform neuroimaging on a child with
headache is made based on the history and physical.
Neuroimaging in children with recurrent headache but
a normal examination routinely is not recommended
Neuroimaging should be considered for children with
headaches with abnormal neurologic examinations
and/or seizure, recently occurring severe headaches,
change in headaches, or associated neurologic
dysfunction
dept.neurology fk.umj.2014 anwar wardy w

Treatment Approach
In patients with secondary headaches, the

treatment goal is to address the underlying cause.

Headaches should resolve once the underlying

cause is addressed.

Treatment of primary headache disorders in

children must be 3-fold.

Acute therapy
Preventive therapy
Biobehavioral therapy

Clear goals of treatment must be discussed with

the patient and parents

dept.neurology fk.umj.2014 anwar wardy w

Short-term therapy
To ameliorate episodic headache and return to

N baseline.
NSAIDS: Ibuprofen, Naproxen
Mainstay for the acute treatment of
childhood
headaches and migraines
Good tolerability, Effective in clinical trials.
Proper use of ibuprofen needs:
Initiation of rapid treatment
Proper dosing
Avoidance of overuse; limited to 3 times per week
dept.neurology fk.umj.2014 anwar wardy w

Cont.
When NSAIDs are ineffective or not

completely effective, switch to migrainespecific therapy

dept.neurology fk.umj.2014 anwar wardy w

Triptans
5-HT1B-1D agonist migraine-specific medications
Relieve not only pain but also nausea, vomiting, photophobia, and

phonophobia.
Sumatriptan, zolmitriptan, rizatriptan
Use of these drugs for migraine relief in children has not been
formally approved.
Sumatriptan nasal spray (especially in the teenage population) has
been among the most extensively studied; sumatriptan
subcutaneous in small doses for severe migraine can be
considered. Use in persons <8 y not recommended
Two treatment methods
Rescue therapy or Stepwise treatment within an attack.
Starts with NSAID at the onset & if it fails, use triptan
Step wise Rx:
Mild /moderate pain: NSAID
Severe headache: triptan
dept.neurology fk.umj.2014 anwar wardy w

Dihydroergotamine (DHE)

Long history of usefulness in migraines

Frequently used in the emergency
management of
childhood headaches
Breaks status migrainosus or prolonged
migraines in children
Has significant adverse effects, including
vomiting
The effect may be enhanced if patients are
premedicated with dopamine antagonists

dept.neurology fk.umj.2014 anwar wardy w

Dopamine antagonists (prochlorperazine,

metoclopramide)
Used for nausea and vomiting effects of migraine
headaches
Combines an antiemetic effect but also a direct
antimigraine effect because of antidopamine action
Dopamine antagonists should be given intravenously.
Their utility is limited by extrapyramidal side effects.
It is suggested that prochlorperazine can be used to

break an acute episode of status migrainosus.

Best given with rehydrating fluids in the emergency
room setting

dept.neurology fk.umj.2014 anwar wardy w

Prophylactic
treatment
Second component
Started when headache becomes frequent /

disabling
Goal: minimize the effect & number of headaches
Having >23 headaches per month typically
warrants treatment
For all prophylactic medications, titrate doses
slowly to an effective level
This may be a lengthy process (weeks, months)
Migraine preventives: flunarizine, gabapentin ,
riboflavin , metoprolol.
dept.neurology fk.umj.2014 anwar wardy w

Antiepileptics

Only divalproate sodium and topiramate are

currently approved for the prevention of migraines

in adults; they are not approved for children
Divalproate: Has not been formally approved for
use in migraine in persons <16 y . safe use
younger than that age has been reported
Topiramate : initial studies point to good efficacy
and tolerability
Antidepressants :
Most widely used tricyclic antidepressant for
headache prevention is amitriptyline.
First recognized in the 1970s as an effective
migraine therapy
dept.neurology fk.umj.2014 anwar wardy w

Cont.
Amitriptyline was found to be effective in 5060% of

children in a cross-over study comparing amitriptyline

with propranolol and cyproheptadine
There are no placebo-controlled studies with
amitriptyline.
Titrate slowly over 8-10 weeks to minimize somnolence
Cannot be formally recommended for individuals <12 y
Nortriptyline : Potential for increased arrhythmias
Regular EKG is needed.
SSRI s not yet studied, , not as effective as more
global decrease in neurotransmitter reuptake inhibition
is needed to treat childhood headache disorders

dept.neurology fk.umj.2014 anwar wardy w

Cyproheptadine
An antihistamine that has been used for

migraine prevention in children more than in

adults.
Antihistamine with antiserotonergic effects
May have some calcium channelblocking properties
Tends to be well tolerated
Increased weight gain is the most significant side
effect.
Because weight gain is substantial, use of this
medication tends to be limited to younger children

dept.neurology fk.umj.2014 anwar wardy w

-Blockers have a long history of use for

preventing childhood headaches.

Propranolol was found to provide mixed
responsiveness when used for childhood headaches.
.Tolerated best with a titration of the dose over 1-2
wk.
They cause a decrease in blood pressure.
There is a risk for exercise-induced asthma.
They can result in depressive effects

dept.neurology fk.umj.2014 anwar wardy w

Calcium-channel blockers
Flunarizine

Baseline headache frequency was significantly

reduced in flunarizine-treated children. not
scheduled to be approved in the United States
Verapamil: drug has not been FDA approved

for use in migraine

dept.neurology fk.umj.2014 anwar wardy w

Biobehavioral therapy
Essential for children to maintain a lifetime response to

the treatment and management of their headaches .

Treatment adherence
Clear understanding by the patient and parent about the
importance of the treatment is essential.
Biofeedback-assisted relaxation therapy

For children, single-session biofeedback-assisted relaxation

therapy has been demonstrated to be learned quickly and
efficiently

Relaxation techniques with biofeedback of either cutaneous

temperature with a finger probe or muscular contraction

with an electromyography (EMG) needle are very helpful as
adjunct therapy or can even prevent headache on their own
in the older child granted that an adequate cooperation can
be obtained.
Recommended treatment is 2-3 times a week for 4-8 weeks.
Usually, a physical therapist or sometimes a psychologist
with cognitive-behavioral skills performs this technique.
dept.neurology fk.umj.2014 anwar wardy w

Lifestyle changes
Adequate

fluid hydration, with limited use of caffeine

Regular exercise
Adequate nutrition through regular meals and a
balanced diet
Adequate sleep
The patient and parents must understand that these
objectives are lifetime goals that can control the effect
of migraines and minimize the use of medication.
Lifestyle changes may result in an overall long-term
improvement in quality of life and may reverse any
progressive nature of the disease.
dept.neurology fk.umj.2014 anwar wardy w

When to refer
Headaches that do not respond routinely to acute

treatment
Headaches that are increasing in frequency,
severity, or duration

Headaches in which the features acutely change

Side effects of medications that limit increasing the

medication to an effective dose

Psychological factors that interfere with
management
Disability that impairs functioning
dept.neurology fk.umj.2014 anwar wardy w

Follow up
Important to assess regularly the morbidity of

headaches and effectiveness of treatment

Regular measurement of both disability and quality
of life are helpful in assessing treatment strategies
and improvement in outcomes.
Disability
Pediatric Migraine Disability Assessment (PedMIDAS) uses a
patient-based disability scale.
Quality of Life
Pediatric Quality of Life Inventory version 4.0 (PedsQL 4.0)
uses both parent and child input.
Evaluates functioning in health, emotional, social, and
school domains
Headaches have been found to substantially affect
emotional development and school functioning.
dept.neurology fk.umj.2014 anwar wardy w

PEDMIDAS
Developed to assess migraine disability in
pediatric and adolescent patients
validated for ages 4 to 18
Pedmidas score
Disability grade
0 to 10
little/none
11 to 30
mild
31 to 50
moderate
> 50
severe

dept.neurology fk.umj.2014 anwar wardy w