Migraine in children and adolescents

Estimated prevalence: 1-2 % in children less than 10 years old,  and 4 to 5 % later. Female preponderance appears at puberty.

Traditionally, migraine could be the consequence of a vasomotor disorder that evolves in two phases: first a vasoconstriction of cerebral arteries explaining the premonitory phenomena or aura, followed with their vasodilation causing the throbbing pain. A familial history is often present: the disorder of the vasomotor regulation of the cerebral arteries could be the result of a genetically transmitted biochemical anomaly. A more recent hypothesis associates migraine with a disorder of the excitability of sensory neurons as a result of a mutation of the TRESK gene.

Since 2003, the international diagnostic criteria of migraine in children are (see tables):

-        the minimum duration of the crisis is 1 hour, thus shorter than the adult form (4 hours).

-        the localization is bilateral in the majority of cases.

The crisis usually ends after a period of sleep.

These are often anxious, perfectionists, hardworking and conscientious children. Most of the authors observe a specific emotional personality in the majority of these children


International classification of childhood migraines

(according to the International Headache Society)

       ♦        1.     migraine without aura

       ♦        2.    migraine with aura

       ♦        3.    complicated migraine

                       -          hemiplegic migraine

                       -        basilar migraine

                       -        ophthalmoplegic migraine

       ♦        4.    migrainous equivalents

                       -        cyclic vomiting syndrome

                       -        benign paroxysmal vertigo of childhood

                       -        retinal migraine

                       -        paroxysmal torticollis

                       -        abdominal migraine and infantile colic

                       -        Alice in Wonderland syndrome (see this term)


Diagnosis criteria of childhood MIGRAINE without AURA

A

at least 5 crises meeting the B - D criteria

B

crisis lasting for 1 to 48 hours

C

headache with at least two of the following characteristics:
       -               bilateral location
       -        pulsatile in 50 % of cases
       -               moderate or severe intensity
       -               aggravated by physical activity

D

presence, during headache, of at least:
       -               nausea or vomiting
       -               photophobia (70 %)

       -               phonophobia (80 %)

E

exclusion by the anamnesis, clinical and neurological examination or complementary investigations, of an organic disease that could be causing the headache.


Three childhood periodic syndromes are considered precursors of future migraine in adulthood:


1.        crisis of benign paroxysmal Vertigo (labyrinthic migraine ?)

√        sudden severe vertiginous crisis lasting from a few minutes to a few hours with spontaneous resolution. Nystagmus and vomiting may be present.

√        with normal EEG and neurologic examination.

2.        abdominal migraine attack

√        crisis lasting 1 to 72 hours.

√        variable intensity

√        median or periumbilical or poorly defined location

√        with at least 2 of the 4 following signs:

-        pallor.

-        loss of appetite.

-        vomiting.

-        nausea.

3.        crisis of cyclic vomiting (see this term)

                       √        episodic and stereotypical bouts of intense nausea and vomiting
                       for 1 to 5 days.

                       √        at least 4 episodes of vomiting every hour for an hour at least.

                       √        no other event between attacks.


Treatments:

-  of the crisis:

o        ibuprofen for children more than 6 months of age

o        diclofenac for children weighting more than 16 kg

o        naproxen for children more than 6 years of age or weighting more than 25 kg

o        aspirin alone or in association with metoclopramide

o        paracetamol alone or in association with metoclopramide

o        sumatriptan nasal spray (10 to 20 mg) for adolescents 12 to 17 years old


-  preventive:

in case of failure of non-medicinal treatment or of frequent crisis: vitamin B2 (riboflavin) ?, a beta blocker (propranolol, metoprolol), amitryptilline 3-5 mg / day, flunarizine 5 mg/day if > 10 years



Anesthetic implications:

-        clinical history: what are the usual triggering factors for a crisis in the patient ? duration of the crisis ? acute treatment ?

-        usual treatment until the day of the procedure

-        avoid stress and pain (systematic NSAIDs if no contraindications are present)

-        prevention of nausea/vomiting


References : 


Updated: December 2018