When you work in a headache clinic, every month is dedicated to headache management. However for the general population, June has been designated Migraine and Headache Awareness month. Headache is such a common condition, every provider has taken care someone with headaches.
Let’s review some information about migraines.
Migraine is the most common and well known type of headache, one of the top 5 disorders of childhood. It often appears during childhood or adolescence, with lifelong implications. Migraine is a neurologic disorder, characterized by headache attacks. According to the International Classification of Headache Disorders 3rd edition (ICHD-3) criteria, migraine is an idiopathic, recurring headache disorder manifesting in attacks that can last from 4-72 hours. Typically in adults, they are unilateral, with moderate to severe throbbing or pulsating pain intensity, aggravated by physical activity, and accompanied by nausea and/or vomiting, photophobia or phonophobia. Compared to adults, migraine presentation in children tends to be shorter in duration, can be bilateral, and have more prominent gastrointestinal complaints.
Since migraine can occur in young children, the symptoms/manifestations of migraine do change over time, as does the child’s ability to describe what is happening, in a developmentally appropriate way. In very young children, parental observation is key in determining the presence of symptoms such as photophobia and phonophobia, since these can be difficult concepts for children to describe and recognize. While a younger child may experience migraine aura, they are often unlikely to be able to describe or make meaning about what is happening to them. It can also be frightening for them and they may be reluctant to talk about it.
The pathophysiology of migraine is complex and not completely understood, involving a primary neuronal dysfunction that leads to sequential changes in the brain, both intracranial and extra cranial. There is a strong genetic component to migraine, often found within families, passed genetically through generations.
How do I explain when happens in a migraine to my patients? Migraine happens at the end of chain reaction within the nervous system. First there is noxious or triggering stimulus, either external (bright light, loud noise, general commotion, smells, weather changes) and/or internal (stress and anxiety, menses, puberty hormonal changes). This stimulus triggers the release of substances in the brain along the nervous system, heading for the nucleus caudalis (migraine central). If there is an aura or ‘early warning alarm’, this is the earliest neurological process, warning of an oncoming migraine. Once the chain reaction reaches migraine central, pain and other symptoms occur and migraine happens.
What is it like having a migraine? There are specific features associated with migraines and many variations of migraine, an experience with very individual aspects.
There can be symptoms (migraine prodrome) that appear 24-48 hours prior to onset of migraine, such as yawning, euphoria, depression, irritability, food cravings, constipation, fatigue, and neck stiffness.
There can be early symptoms (migraine aura) that develop gradually, lasting 5 minutes to 1 hour prior to migraine, are positive or negative, and are completely reversible. Positive symptoms include visual (spots, shapes, colors), auditory (tinnitus), somatosensory (paresthesias, tingling, numbness), or motor (jerking, weakness). Negative symptoms can be loss of vision, hearing, feeling, or inability to move a part of the body.
With or without these pre-migraine phenomena, the next step is the migraine headache. Pain can be felt in one location, such as behind the eyes or temples, or one-sided, bilateral or everywhere (holocephalic) in children; is rated moderate to severe, described as throbbing or pulsing, increasing in intensity. 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), extremity paresthesias, focal numbness, fatigue, sweating, and scalp sensitivity (cutaneous allodynia).
After the migraine resolves, patients may experience a post-dromal period or ‘migraine hangover’, feeling fatigued, out-of-it, not quite themselves, sharp pain with head moving, or even euphoria, which can last for 24 hours or more after migraine is resolved.
In children and adolescents, there are 3 common migraine variants: abdominal migraine, cyclic vomiting syndrome and benign paroxysmal vertigo. These variants do dissipate slowly through adolescents and resolve by adulthood.
Abdominal migraine is often associated with stomach pain and/or nausea, rather than head pain. The pain is diffuse across the abdomen, feels crampy, dull or sharp, with moderate to severe intensity, and can last between 1-72 hours. Associated symptoms are similar to migraine headache, and include loss of appetite, nausea and/or vomiting, pallor, photophobia, phonophobia, and fatigue.
Cyclic vomiting syndrome occurs in school-age children, consists of episodes of forceful and frequent vomiting, and may last from 1 hour or go on for days. As it is a migraine variant, there may be abdominal pain, headache, photophobia or phonophobia and other migraine symptoms. Attacks may be severe enough to cause dehydration, triggering an emergency (ED) or urgent care visit for rehydration
Benign Paroxysmal Vertigo occurs in toddlers, young children, or adolescents and consists of the child suddenly becoming unsteady or off-balance and/or refuse/unable to walk. They will look pale or sick, usually irritable or fussy, refuse to be put down when held and will walk unsteadily. Benign paroxysmal vertigo is often associated with nystagmus or vomiting, may have unilateral throbbing headache. These intermittent attacks last from a few minutes to hours, resolving with sleep.
That’s the experience of pediatric migraine from a clinical point of view. Of course there is so much more that happens, socially, emotionally, and environmentally. The impact of migraine in childhood cannot be downplayed. The experience of migraine affects every member of the family, disrupting family life, school, and activities. The more you know about what happens in migraine, the better able you will be in taking care of these patients with compassion and understanding.