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The characteristics of primary headaches are described in Table 55-2.
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Migraine headaches are an example of recurrent headaches. The mean age of onset is 7.2 years for males and 10.9 years for females, but the prevalence increases from 3% in children aged 3 to 7 years, to 8% to 23% for children aged 11 to 15 years.2,8,9 In the younger age group, males are more affected than females, but this reverses by the older age group.2,9,10 The headache tends to be unilateral, throbbing or pulsating, lasts 1 to 48 hours, is often associated with nausea and vomiting, and is relieved with sleep.9,10 In younger patients, the symptoms include pallor, vomiting, and decreased activity.10 There is a genetic predisposition to migraines, with a positive family history in most cases.2,10
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Several theories exist as to the pathophysiology of migraines. It is a primary neuronal process associated with intracranial and extracranial changes that have a genetic predisposition.9,10
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Antidromic stimulation of the trigeminal nerve releases substance P, calcitonin generated peptide, and other vasoactive polypeptides that cause pain and vasodilatation (neurogenic inflammation). There is also a cortical spreading depression of Leao, which is neuronal and glial hyperpolarization followed by depolarization that causes the aura of migraine, activates trigeminal afferents, and alters blood–brain barrier permeability, resulting in the headache.9,10
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The classification of migraines includes migraine with aura, migraine without aura, and childhood periodic syndromes that are commonly precursors of migraine (abdominal migraines, benign paroxysmal vertigo of childhood, and cyclic vomiting).3,9,11 The IHS classification of pediatric migraine without aura, which accounts for 60% to 85% of cases, includes the following:
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At least five attacks fulfilling criteria B to D.
Headache attacks lasting 1 to 72 hours.
Headache has at least two of the following: either bilateral or unilateral location (frontal/temporal, but not occipital), pulsating quality, moderate-to-severe intensity aggravated by routine physical activities such as walking.
At least one of the following during the headache: nausea and/or vomiting, photophobia, and phonophobia (may be inferred from behavior).2,3,8,9
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Pediatric migraine with aura occurs in 15% to 30% of patients, with the aura occurring before the headache.2 The diagnostic criteria includes the following:
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At least two attacks fulfilling criteria B to D.
An aura consisting of at least one of the following1: fully reversible visual symptoms such as flickering lights or spots,2 fully reversible sensory symptoms such as pins and needles or numbness, or3 fully reversible dysphasic speech disturbances. Motor weakness is not a criteria.
At least two of the following1: homonymous visual symptoms or unilateral sensory symptoms,2 at least one aura symptom develops gradually over ≥5 minutes or different aura symptoms occur in succession ≥5 minutes,3 each symptom lasts ≥5 minutes and ≤60 minutes.
Symptoms are not attributable to another disorder.2,3,9
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Basilar-type migraines are a subgroup of migraines with aura, and accounts for 3% to 19% of childhood migraines, and the headache is often occipital.3,9 Therefore a basilar-type migraine must fulfill the criteria for a migraine with aura, but is accompanied by two or more of the following symptoms: vertigo, ataxia, diplopia, tinnitus, hyperacusis, dysarthria, bilateral paresthesias, decreased level of consciousness, decreased hearing.2,3,9
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Hemiplegic migraines have motor weakness or hemiplegia as part of the aura.9,11 It can be familial, with an autosomal dominant inheritance and due to a mutation in a calcium channel gene.2,3,9,11
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The childhood periodic syndromes that are commonly precursors of migraines include of childhood benign paroxysmal vertigo, cyclic vomiting, and abdominal migraine.3,9,11 Benign paroxysmal vertigo occurs in children aged 2 to 6 years and consists of sudden, brief episodes of ataxia or unsteadiness, when the child cannot stand upright without support. There is no loss of consciousness, but nystagmus or pallor often occurs. The episode lasts for several minutes, and then the child recovers completely.9,11
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Cyclic vomiting syndrome is recurrent episodes of severe vomiting that last for a few hours to days, separated by symptom-free periods. Treatment includes IV fluids with glucose, antiemetic medication, and sometimes sedation.9,11
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Abdominal migraine is recurrent episodes of abdominal pain lasting 1 to 72 hours, usually vague, and midline or periumbilical in location. It may be accompanied by nausea, vomiting, anorexia, or pallor, but there is no fever or diarrhea.9,11
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Reassurance and patient, and parental education are the first steps. Patients should keep a headache diary in order to see if there are any precipitating factors. These include emotional stress, anxiety, menstruation, missing a meal, lack of sleep, and environmental factors such as bright lights, loud noises, and perfumes. Certain foods such as those that contain tyramine (aged cheese), sodium nitrite (hot dogs, smoked meats), or monosodium glutamate (Chinese food) can precipitate migraines, as can caffeine-containing beverages, chocolate, cheese, citrus fruits, and certain drugs (such as oral contraceptives, antihypertensive medications, cimetidine, and H2-blockers).1,4,9
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ED treatment of migraines consists of providing analgesia and treating associated symptoms such as nausea during the acute attack. Analgesics such as acetaminophen (15 mg/kg), ibuprofen (10 mg/kg), or naproxen (5 mg/kg) are often effective.2,9,12 If the child is unable to tolerate oral NSAIDs, intravenous ketorolac can be used.12
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Triptans are serotonin agonists that inhibit the release of vasoactive peptides, promote vasoconstriction and block pain pathways. Unfortunately most have not been approved for pediatric use, so although studied and used, this is done off-label.12 Sumatriptan is a selective 5-HT agonist that can be given subcutaneously (6 mg) (although not FDA approved for children <16 years) or as a nasal spray for children older than 12 years.8,9,12 Nasal zolmitriptan has also been used in older children.8,9,12 Oral sumatriptan has been used successfully in adolescents.12
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For children older than 10 years who present to the ED with a migraine headache, dihydroergotamine mesylate (DHE) 0.25 to 1.0 mg over 3 minutes intravenously may be beneficial, especially if given with metoclopramide. For nausea, antiemetics such as ondansetron, promethazine, metoclopramide, or prochlorperazine have been used.2,12
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Preventive treatments include cyproheptadine, β-blockers (propranolol), antidepressants (amitriptyline, nortriptyline), anticonvulsants (topiramate, gabapentin, valproic acid, levetiracetam), and calcium channel blockers (verapamil), but conclusive data are lacking regarding their use in children and adolescents.2,8,9,12 Methods such as relaxation therapy, biofeedback, cognitive therapy/stress management, acupuncture, and dietary measures with supplements such as riboflavin (Vitamin B2), magnesium, melatonin or Coenzyme Q10, may have some benefit.2,9 Those children who have frequent headaches and those with headaches that are unresponsive to abortive measures should be placed on prophylactic medications after consultation with a neurologist.
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Tension-Type Headaches
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Tension-type headaches (formerly called muscle contraction or stress headaches) tend to be chronic and nonprogressive in nature, with the pain described as band-like, bilateral, or generalized. There is no accompanying aura, and nausea is rare. The headache can last for 30 minutes to days and can be accompanied by photophobia or phonophobia but is not aggravated by physical activity.1,13 There are three subtypes of tension-type headache: infrequent, occurring less than 1 day a month; frequent episodic, occurring 1 to 14 days a month; and chronic, occurring 15 or more days a month.2,3,13
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The pathophysiology of tension-type headache is unknown but may be due to heightened sensitivity of pain pathways.13
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The diagnosis of tension-type headache is usually based upon clinical criteria, but the differential diagnosis includes infection, increased intracranial pressure, Chiari I malformation, analgesic rebound headache, and chronic sinus infection.13 Of note, the physical and neurologic examination of a child with tension-type headaches is normal.
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Tension-type headaches are generally managed with emotional support, and mild analgesics, such as acetaminophen and ibuprofen. Reassuring the family that the problem is not organic and advising the patient to avoid precipitating factors, such as stress, is an important part of therapy. Behavioral techniques, such as biofeedback, and relaxation exercises may be useful.13
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Cluster headaches are uncommon in children younger than 10 years of age. The headache is unilateral, occurs in the frontal or periorbital region, often beginning behind or around the eye, and always occurs on the same side.1,4 The headache lasts 15 minutes to 3 hours, and is associated with ipsilateral lacrimation, redness of the eye, and ipsilateral nasal congestion; the cheek may become flushed and warm. The patient may develop Horner syndrome—miosis, ptosis, and facial anhidrosis—on the side of the headache.1,4 The headache tends to occur at the same time each day during a cluster. Patients are unable to lie down or rest because of the pain.4 Abortive treatment consists of 100% oxygen at 8 to 10 L/min.4 Recurrences may be managed with prednisone (1 mg/kg) for 5 days followed by a 2-week taper.4