The most common acute-recurrent headache syndrome The principal underlying phenomenon is a hyperexcitable cerebral cortex One of the

striking features noted during an attack is activities such as coughing, walking up the stairs, or bending over greatly intensifies the pain Only about 30% of children and adolescents experience aura

By Age Prevalence Gender ratio

3-7 years 1.2%-3.2 % Boys>Girls

7-11 years 4%-11% Boys=Girls

15 years 8%-23% Girls>Boys

Abnormal cortical hyperexcitability

CORTICAL SPREADING DEPRESSION

Activation of trigeminovascular system

Sterile neurogenic inflammation Central and peripheral sensitization

MIGRAINE ATTACK

Migraine Without Aura The most frequent form Accounts for 60-85% of all migraine in children and adolescents Prodromal features: mood changes (euphoria to depression), irritability, lethargy, yawning, food cravings, or increased thirst The most frequent heralding feature: change in behavioral patterns or withdrawal from activities

Pediatric Migraine without Aura A. At least 5 attacks fulfilling criteria B through D B. Headache attacks lasting 1-72 hours C. Headache has at least 2 of the following characteristics: 1. Unilateral location, may be bilateral, frontotemporal (not occipital) 2. Pulsing quality 3. Moderate or severe pain intensity 4. Aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs) D. During the headache, at least one of the following: 1. Nausea and/or vomiting 2. Photophobia and phonophobia, which may be inferred from behavior E. Not attributed to another disorder

Migraine with Aura Accounts for approximately 14-30% in migraine headaches Typically, the aura is a visual phenomenon but may disturb virtually any cortical region including language, motor, or sensory areas

Visual

Negative scotoma Fortification scotoma Field deficits: Hemianopsia Quadrantanopsia Photopsia Visual distortions: Teichopsia Metamorphopsia Prosopagnosia Alice in Wonderland Parestheias; Dysesthesias; Peri-oral and /or hand numbness (chiro-oral) Hemiparesis; Monoparesis

Sensory Motor Aphasia

Psychic

Confusion, Dysphasia, Amnesia, Disequilebrium

Headache Database
1. How and when did your headache(s) begin? 2. What is the time pattern of your headache: sudden first headache, episodes of headache, an everyday headache, gradually worsening, or a mixture? 3. Do you have one type of headache or more than one type? 4. How often does the headache occur and how long does it last? 5. Can you tell that a headache is coming? 6. Where is the pain located and what is the quality of the pain: pounding, squeezing, stabbing, or other? 7. Are there any other symptoms that accompany your headache: nausea, vomiting, dizziness, numbness, weakness, or other? 8. What makes the headache better or worse? Do any activities, medications, or foods tend to cause or aggravate your headaches? 9. Do you have to stop your activities when you get a headache? 10. Do the headaches occur under any special circumstances or at any particular time?

11. Do you have other symptoms between headaches? 12. Are you taking or are you being treated with any medications (for the headache or other purposes)? 13. Do you have any other medical problems? 14. Does anyone in your family suffer from headaches? 15. What do you think might be causing your headache?

There is inadequate documentation in the literature to support any recommendation as to the appropriateness of routine laboratory studies (e.g., hematology or chemistry panels) or performance of lumbar puncture. Routine EEG is not recommended as part of the headache evaluation

Recommendations: 1. Obtaining a neuroimaging study on a routine basis is not indicated in children with recurrent headaches and normal neurologic examination. 2. Neuroimaging should be considered in children in whom there are historical features to suggest the following: a. Recent onset of severe headache b. Change in the type of headache c. Neurologic dysfunction 3. Neuroimaging should be considered in children with an abnormal neurologic examination (e.g., focal findings, signs of increased intracranial pressure, significant alteration of consciousness) and the coexistence of seizures.

Fundamental goals of long-term migraine treatment: 1. Reduction of headache frequency, severity, duration, and disability 2. Reduction in reliance on poorly tolerated, ineffective, or unwanted acute pharmacotherapy 3. Improvement in the quality of life 4. Avoidance of acute headache medication escalation 5. Education and enablement of patients to manage their disease 6. Reduction of headache-related distress and psychologic symptoms

Pharmacologic For acute treatment of migraine: ibuprofen, acetaminophen, sumatriptan nasal spray For preventive or prophylactic treatment: flunarazine, topiramate, sodium valproate, levetiracetam, cyproheptadine (antihistamine) and amitriptyline (antidepressant)

COMPLEMENTARY AND ALTERNATIVE TREATMENTS Identification of migraine triggers Biobehavioral Biofeedback Electromyographic feedback Electroencephalography Thermal hand warming Galvanic skin resistance feedback Relaxation therapy Progressive muscle relaxation Autogenic training Meditation Passive relaxation Self-hypnosis Cognitive therapy/stress management Cognitive control Guided imagery

COMPLEMENTARY AND ALTERNATIVE TREATMENTS Dietary measures Avoidance diets Caffeine moderation Herbs Feverfew (Tanacetum parthenium) Ginkgo Valerian root Minerals Magnesium Vitamins Riboflavin (B2) Acupuncture Massage therapy Aroma therapy