Migraine Variants and Chronic Daily Headache in Children and Adolescents

Educational Objectives

The goal of this program is to improve the diagnosis and treatment of migraine and chronic headaches. After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose and manage benign paroxysmal torticollis (BPT), benign paroxysmal vertigo (BPV), and cyclic vomiting in children.

2. Elaborate on the various types of chronic daily headache (CDH) seen in children that may lead to overuse of over-the-counter medications.

3. Educate patients, families, and caregivers about the importance of a multifaceted approach to managing CDH that includes diet, sleep, hydration, and exercise.

Summary

Migraine variants: uncommon, recurrent episodic conditions related to age; 100% reversible (ie, child returns to normal after event); often do not involve headaches; occur in children or adolescents who already have migraine, family history of migraine, or develop migraine later; discussion of disorders in order of age of onset follows; epilepsy equivalent syndrome characterized by abnormal electroencephalography (EEG) results in absence of epilepsy

Benign paroxysmal torticollis (BPT): occurs in infancy and early childhood; possibly associated with other abnormal movements; symptoms include head tilt (not always same side), pallor, vomiting, headache, difficulty with balance, and other abnormal posturing; episodes brief in duration; differential diagnosis — includes gastroesophageal reflux, tumor, or abnormality of posterior fossa; history of worsening symptoms, vomiting between episodes, excessive sleeping, or eyes crossing suggest tumor; consider magnetic resonance imaging (MRI) in evaluation; treatment — speaker rarely treats BPT preventively because episodes usually unpredictable and few in number; if episode lasts several hours, treat with diphenhydramine and nonsteroidal anti-inflammatory drug

Benign paroxysmal vertigo (BPV): common but variable; occurs in clusters (eg, 3 to 4 over 2 wk) in children aged 1 to 5 yr; symptoms include sudden unsteadiness, vertigo, loss of balance, fear, nystagmus, sweating and pallor, and nausea and vomiting; headaches unusual; patients do not lose consciousness (differentiates BPV from epilepsy); imaging not required; if symptoms severe or problematic, treat as for migraine; untreated, condition disappears and changes into migraine; study showed ≈2.5% prevalence among school children (speaker believes prevalence much lower)

Cyclic vomiting: episodic; etiology unknown but considered variant of migraine; recurrent, discrete, stereotypical severe episodes of vomiting interrupt periods of normal health; cannot diagnose at first episode, but periodicity of 30 to 60 days suggests cyclic vomiting; prevalence ≤2%; girls usually affected more than boys; age of onset 5 yr; resolves at 10 to 12 yr of age; morbidity high, and children miss school and often require intravenous (IV) rehydration; symptoms — vomiting begins early in morning, sometimes with abdominal pain, pallor, lethargy, headache, phonophobia, and photophobia; last 1 to 2 days; occur periodically every 2 to 6 wk; precipitating events — include infection, illness, stress, diet, and menses; 80% of patients have positive family history; differential diagnosis — speaker no longer performs MRI of head or endoscopy because of preponderance of negative results; ultrasonography of abdomen important to identify kidney stones, dilated renal pelvis, and malrotation; management — educate parents and recommend Cyclic Vomiting Syndrome Association (CVSA) web site (www.cvsaonline.org); supportive measures — for hospitalized child, nothing by mouth and sedation with either IV diphenhydramine or low dose of IV diazepam (eg, Diastat, Dizac, Valium); if child at home, give ondansetron (Zofran, Zuplenz), either diazepam or diphenhydramine, and possibly triptan or anticonvulsant, valproate (Depacon) if IV placed, and preventive medication between attacks; improvement seen in ≈50% of children treated with cyproheptadine (Periactin) and in those treated with amitriptyline (eg, Amitid, Endep, Elavil); patients often outgrow problem by 10 to 13 yr of age

Alice in Wonderland syndrome: aura that occurs rarely in children with migraine; objects appear larger; may occur with or without subsequent migraine; characterized by bizarre visual illusions and spatial distortions, eg, micropsia, macropsia, metamorphosis, or teleopsia; no association with confusion or altered awareness (as with seizures); headache variable; can occur in complex partial seizures, with mononucleosis, with lysergic acid diethylamide (LSD) and hallucinogens, occipital epilepsy, and represents possible psychiatric manifestation; speaker has seen 2 continuous cases that did not respond to treatment

Abdominal migraine: characteristics — episodic; pallor, periumbilical pain, possibly nausea, vomiting, or headache; pain resolves between attacks; pain dull and lasts ≈1 hr; frequency of episodes similar to that of migraine headache and responds to same medications; prognosis good, but may evolve into migraine headache later

Chronic daily headaches (CDHs): important to refer patient early; definition — daily or near daily headaches (≥15 days per mo); possibly daily continuous or daily intermittent; headache may progress, but no progression of neurologic symptoms and signs seen; present for ≥3 mo; last >4 hr per day; secondary etiologies excluded; types — episodic headache that becomes more frequent and less severe (some patients have never had migraine); new onset; posttraumatic; psychogenic; medication overuse; chronic TTH possibly punctuated with severe headaches (mixed type); chronic transformed migraine; after infection (eg, mononucleosis or aseptic meningitis); or etiology unknown; concerns — overuse of over-the-counter (OTC) medications (speaker limits to ≤2 days/wk), excessive absence from school, psychosocial issues

Transformed chronic migraine: patients have history of episodic migraines that increase in frequency and decrease in severity; may have migrainous features; headaches resemble TTHs that occur daily; full migraines may also occur

Chronic TTH: patients never had migraines but have daily or near daily headaches (>15 days per mo); do not have migrainous features; may evolve from episodic TTH

New-onset daily persistent headaches (NDPH): patients have daily unremitting headache from onset; no previous history of headaches; pain bilateral, moderate, and pressing; ≈40% of patients have antecedent viral illness, trauma, intense emotional event, or surgery; no underlying etiology

Clinical characteristics of CDH: possibly mixture of migraine and TTH; associated symptoms include fatigue and dizziness; may cause overuse of OTC medication and absences from school; occurs in 4% of adults, 1% to 2% of adolescents, and seen in ≈30% of new patients in speaker’s clinic

Pathophysiology: primary headache; no known underlying etiology; no genetic component (except possibly fibromyalgia); no biochemical abnormalities; family pathology may exist; lifestyle frequently disordered (eg, poor sleep, diet, and stress); comorbidities include deteriorating academic function in some patients, decreased participation in athletics, obesity, deconditioning, and 1° or 2° family stress; associated symptoms — dizziness, postural hypotension (treat with water and salt), abdominal pain, personality problems, aches and pains, and decreased concentration; other findings — no underlying disease, symptoms of increased intracranial pressure, neurologic symptoms, symptoms of progressive disease, or abnormal laboratory tests; arachnoid cysts or Chiari seen on MRI do not cause CDH; examinations — general and neurologic give normal results; psychologic examination valuable; concerns — no objective diagnostic marker; pathophysiology unknown; speaker considers psychopathology important; serious morbidity for parents and children; no specific treatment and poorly understood natural history; excessive absences from school — occurs in 1 of 6 to 7 children; more common in girls or women; most often with CDH rather than migraine; medication overuse — ≥3 doses (days)/wk for >6 wk; leads to rebound or transformed migraine; most common with CDH and in girls or women; more common in adolescents; psychosocial issues common

Management: use multifaceted approach; exclude caffeine, chocolate, luncheon meats, aged cheese, monosodium glutamate (MSG), corn chips, and ramen noodles from diet for first 6 wk; advise 8 hr of sleep, no missed meals, 6 to 8 glasses of water per day, and 3 hr of exercise per wk; recommend no absences from school; provide education and support; discuss alternative medications and pharmacology; reassure patients and parents

Combined psychological and medical treatment: most effective; medications — speaker uses cyproheptadine for underweight patients who can’t sleep, amitriptyline for anxiety and (or) depression, topiramate for obese patients, and gabapentin (Gralise, Neurontin) if others fail; emphasize importance of changes in lifestyle

Inpatient rehabilitation: developed by speaker to get patients back in school; lasts 3 wk; highly successful

 

Readings

Babineau SE, Green MW: Headaches in children. Continuum (Minneap Minn) 18:853, 2012; Bernstein C, Burstein R: Sensitization of the trigeminovascular pathway: perspective and implications to migraine pathophysiology. J Clin Neuro 8:89, 2012; Brandes JL: Migraine in women. Continuum (Minneap Minn) 18:835, 2012; Evans RW: New daily persistent headache. Headache 52 (Suppl 1):40, 2012; Lee LY et al: The management of cyclic vomiting syndrome: a systematic review. Eur J Gastroenterol Hepatol 24:1001, 2012; Kaniecki RG: Tension-type headache. Continuum (Minneap Minn) 18:823, 2012; Lionetto L et al: Emerging treatment for chronic migraine and refractory chronic migraine. Expert Opin Emerg Drugs 17:393, 2012; Maleki N et al: Common hippocampal structural and functional changes in migraine. Brain Struct Funct Jul 4, 2012 [Epub ahead of print]; Messlinger K et al: CGRP and NO in the trigeminal system: mechanisms and role in headache generation. Headache Jun 15, 2012 [Epub ahead of print]; Ravid S et al: Headache in children: young age at onset does not imply a harmful etiology or predict a harsh headache disability. J Child Neurol Aug 21, 2012 [Epub ahead of print]; Seshia SS: Chronic daily headache in children and adolescents. Curr Pain Headache Rep 16:60, 2012; Tepper SJ: Medication-overuse headache. Continuum (Minneap Minn) 18:807, 2012; Tonini MC, Frediani F: Headache at high school: clinical characteristics and impact. Neurol Sci 33 (Suppl 1):S185, 2012; Van Driessche A et al: Cyclic vomiting syndrome: case report and short review of the literature. Acta Clin Belg 67:123, 2012; Wagner D et al: Long-range inhibitory mechanisms in the visual system are impaired in migraine sufferers. Cephalalgia Aug 13, 2012 [Epub ahead of print]; Ward TN: Migraine diagnosis and pathophysiology. Continuum (Minneap Minn) 18:753, 2012.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Rothner is a consultant for GlaxoSmithKline and MAP Pharmaceuticals and receives research support from AstraZeneca, GlaxoSmithKline, and Merck & Co. The planning committee reported nothing to disclose. In this lecture, Dr. Rothner presents information related to off-label use of a product, therapy, or device.

Acknowledgements

Dr. Rothner spoke at Headache Update 2012, held July 12-15, 2012, in Lake Buena Vista, FL, and presented and jointly sponsored by Diamond Headache Clinic Research and Educational Foundation, Diamond Inpatient Headache Unit at Saint Joseph Hospital, Rosalind Franklin University of Medicine and Science, and Resurrection Health Care (to learn more about CME meetings presented by the Diamond Headache Clinic Research and Educational Foundation, visit www.dhc-fdn.org). The Audio-Digest Foundation thanks the speaker and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

NE032102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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