The 3 most common subtypes of primary headaches commonly seen in pediatric patients are: migraine, tension-type, and new daily persistent headache. Children often have a combination of types, such as chronic mixed type headache, which generally combine migraine and tension-type headache. All primary headaches present differently and are often treated differently. Migraine is a well-known type of headache, so I will cover that first, in a number of posts. There are also migraine variants, particular to children, such as abdominal migraine and cyclic vomiting syndrome.
Migraine is a neurologic disorder, characterized by headache attacks. Headaches are episodic or chronic, are recurrent, can last from 4-72 hours, with moderate to severe throbbing pain. Migraine pain occurs due to dilation and inflammation of the intracranial blood vessels, which irritates the adjacent nerves. Pain can be felt in one location, such as behind the eyes or temples, or one-sided, or everywhere (holocephalic). Pain can occur suddenly or be preceded by warning symptoms, called an aura. Along with head pain, patients can experience nausea and/or vomiting, photophobia, phonophobia, osmophobia (sensitivity to smell), pallor, lightheadedness or dizziness, visual changes (blurred vision, loss of vision, seeing colors), hearing changes (tinnitus), paresthesias, focal numbness, fatigue, sweating, and scalp sensitivity (allodynia). The only constant in migraine is that every migraine patient experiences their migraines differently- different location, constellation of symptoms, triggers. Diagnosis is made based on symptoms and history and in the majority of cases, migraine is clearly identified.
Migraine is often found within families, passed genetically through generations. The incidence is more common in women (17%) than men (6%). Most people have their first migraine between the ages of 6 and 25 years, so it is likely that their pediatric provider will be the first person to evaluate for migraine. Imaging is not required to diagnose migraine, especially if there is a strong family history. However, imaging (MRI) can be helpful for presentations without family history, unusual, complex or variant-like symptoms. Most families are comfortable without imaging when there is family history of migraine.
Most migraineurs have missed school, social or sports activities, or work during a migraine, and about 50% have difficulty functioning at all during an attack. As you can imagine, having 1 migraine episode per week and having to miss 1 day/week of school, is going to have significant consequences.
The next step, after making the diagnosis, is to decide on a treatment plan. Does this patient need a preventive or daily medication? What is the rescue plan? And even more importantly, what about the lifestyle factors that can trigger migraine or reduce the incidence of migraine? We will start to cover this topic in my next post.