Elsevier

The Lancet Neurology

Volume 9, Issue 2, February 2010, Pages 190-204
The Lancet Neurology

Review
Current approaches to the diagnosis and management of paediatric migraine

https://doi.org/10.1016/S1474-4422(09)70303-5Get rights and content

Summary

Headache is a common complaint in childhood with up to 75% of children reporting a notable headache by the age of 15 years. Paediatric migraine is the most frequent recurrent headache, occurring in up to 28% of older teenagers. Migraine can have a substantial effect on the life of the child, as well as their family, leading to lost school days and withdrawal from social interactions. Early recognition can lead to successful treatment, improved outcome, and reduced disability. The treatment strategy needs to be multipronged and can include acute therapy (which can vary depending on the severity of the headache), preventive therapy (when the headaches are frequent or causing substantial disability), and biobehavioural therapy (to assist with coping with recurrent headaches). Additional factors can contribute to exacerbations of headaches, including comorbid disorders and pubertal changes, which might lead to the development of menstrual migraine. When all these factors are effectively managed, there should be an improvement in long-term outcome and prevention of disease progression.

Introduction

Headache is one of the most common health complaints in children and adolescents, yet remains under-recognised as a problem by patients, parents, and practitioners. Headaches can result from a secondary cause, such as those that develop acutely alongside or after an injury or infection, or they can be the primary problem itself, such as migraine and tension-type headache (TTH). Secondary headaches can often be recognised by their cause-and-effect association with a specific aetiology. This manifestation can be confusing in patients with a primary headache who have an exacerbation by a secondary cause (eg, post-traumatic headache in a patient with migraine) or because of a misdiagnosis (eg, sinus headache). Recurrent, episodic headaches are more likely to indicate primary headache disorders.

The primary headache that has the greatest effect on a child's quality of life and causes most disability is migraine; therefore, this is the most frequent primary headache brought to the attention of parents and primary care providers, school nurses, and practitioners. Migraine can become a chronic, disabling disorder with a substantial effect on the lives of the patients and their families, affecting millions of individuals globally. Migraine commonly starts in childhood and adolescence; therefore, through early recognition and establishment of acute therapies and lifestyle adjustments, paediatricians and primary care providers can affect the disease progression for the lifetime of the individual, prevent long-term discomfort, and enhance quality of life.

As paediatric migraine has the most substantial effect on the lives of the patients and their families, and consequently has the greatest potential for improvement, migraine is the focus of this Review. Many gaps remain in the recognition and management of paediatric migraine but, through use of current knowledge and by extrapolation from studies in adult headaches, we can begin to address the important features of paediatric migraine. The prevalence of paediatric migraine, its pathophysiology (including unique features of paediatric migraine), evaluation and diagnosis in contrast to other headache disorders, and the effects of comorbid conditions are discussed. Additionally, management strategies, including acute and preventive treatments and biobehavioural therapies, are described. An understanding of these components should result in an improvement in the long-term disabling effects of paediatric headaches. Future studies should aim to fill the current gaps in knowledge to further improve the lives of these children and their families.

Section snippets

Epidemiology

The prevalence of migraine has been studied across all ages starting in early childhood. There is a slight predominance in boys in the pre-pubertal years, and the overall occurrence increases throughout adolescence into young adulthood when there is a transition to a predominance in girls. In 1962, Bille1 reported an extensive study of the epidemiology of paediatric migraine in 8993 children. Although current diagnostic criteria for headaches and migraine were not used, this study did establish

Pathophysiology

The pathophysiology of migraine in children and adolescents is presumed to be the same as in adults. The pathophysiological mechanisms are thought to be based on the interaction between the neural and vascular systems and include cortical spreading depression and trigeminal vascular activation with transmission through the thalamus to higher cortical structures. The study of migraine pathophysiology can be divided into the underlying basis for the risk of having migraine and the biological

Diagnosis and evaluation

The International Headache Society has established diagnostic criteria—the ICHD-II—for all headache subtypes including primary and secondary headaches.3 These criteria have been widely used for the clinical characterisation of headaches and as a basis for research in headaches. A key feature of these criteria is the separation of headaches thought to be intrinsic to the nervous system (primary headaches) and headaches directly attributable to another cause (secondary headaches).

Disability and effect on quality of life

As part of the clinical history, the effect of the headache on the child's quality of life and the specific disabilities caused need to be assessed. A recent review of the effect of paediatric migraine reported 33 studies that investigated this question and the tools used, and showed that, although the quality was inconsistent, there was a substantial effect of migraine on the lives of the patients and their families.80

Comorbid conditions

Additional diseases and conditions can complicate migraine diagnosis, management, and outcome. The understanding of the role of comorbid conditions in paediatric migraine is limited, with interactions between migraine and other conditions yet to be clearly delineated. Recognition of these additional disorders could alter treatment choices, such as use of antiepileptic drugs in patients with seizures or antidepressant drugs when patients have depression, anxiety, or emotional disorders, or might

Treatment

The treatment of paediatric migraine can be divided into pharmacological (both acute and preventive strategies) and biobehavioural interventions to minimise the effects of the attacks (figure). The goals of treatment need to be determined at the initial visit, and should include a rapid return to normal function with acute treatment, and a reduction in the frequency and effect of the migraine with preventive and biobehavioural treatment. These strategies are often not used in general practice.

Outcome

Treatment of paediatric headache generally seems to be effective, with most patients having improvement in their headache characteristics. In a 20-year follow-up study of 60 of 95 patients originally seen in 1983, 27% were headache-free, 33% had TTH, 17% had migraine, and 23% had both migraine and TTH.178 Of those with headaches, 66% felt they were improved, although 80% continued to report moderate to severe headaches.

In a study of children and adolescents (96 at 1 year, 69 at 2 years, and 32

Conclusions and future directions

The study and management of paediatric migraine continues to develop. Our understanding has been greatly advanced by the development of standardised criteria, despite certain limitations. These criteria have provided the basis for outlining the prevalence of migraine, and have enabled the development of a standardised approach to the evaluation, diagnosis, and management of headaches in children and adolescents. Management will be aided by the discovery of new treatments including acute,

Search strategy and selection criteria

References for this Review were identified through searches of PubMed with the search terms “pediatric headache”, “pediatric migraine”, “adolescent headache”, and “adolescent migraine” from July 1, 2004, to September, 2009. Articles were also identified through the review of Headache, Cephalalgia, and Neurology and through the author's own files. Only papers published in English were reviewed.

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