Pediatric emergency medicine trisk 2620 2620
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“cortical spreading depression,” a slowly propagating wave of neuronal
hyperpolarization followed by depolarization. This in turn triggers a neuronally
mediated vascular instability that results in intracranial hypoperfusion (which
may produce the migraine aura of premonitory motor, visual, or sensory
symptoms), followed by vasodilation and a sterile, neurogenic inflammation,
which are responsible for the headache.
Clinical Considerations
Clinical Recognition. Prolonged (up to 24 to 48 hours), moderate to severe
headache is characteristic of migraine. The headaches may be pulsating and
unilateral but this pattern is less common in children than in adults. Migraine is
commonly associated with nausea, vomiting, abdominal pain, and photophobia or
phonophobia. Auras occur in less than half of children. Occasionally, the attacks
awaken the children from sleep.
A family history of migraine is helpful in diagnosis, and a disproportionate
number of children who experience migraines have episodes of motion sickness,
dizziness, vertigo, or frank paroxysmal events.
Initial Evaluation. The diagnosis of migraine is based almost exclusively on the
history and is supported by the absence of abnormalities on examination. There
are no diagnostic laboratory tests or imaging studies. The physical examination
usually shows no focal neurologic deficits, although hemiplegia and
ophthalmoplegia may occur in complicated migraine.
Common trigger factors for migraine in children include emotional stress,
lighting changes, and minor head trauma. Particularly in adolescents, it is useful
to screen for depression or other psychosocial stressors that may warrant separate
treatment. Nitrates (e.g., lunch meats) and tyramine (cheeses) are less common
but important food triggers.
Given an accurate history, differentiation from tension headaches, sinusitis, and
headaches secondary to intracranial lesions is usually possible; studies such as
EEG, CT, and MRI are rarely indicated. In children with focal neurologic deficit
and no prior history of such episodes due to migraine, urgent neuroimaging
should be considered.
Initial evaluation should include a determination of the level of pain using a
validated scale. For patients with known migraine, establishing a target pain level
for acute treatment is also helpful.
