Migraine Headache in Children Symptoms

A headache may be a symptom of a benign (relatively harmless) condition, or it may be a life-threatening symptom. The patient's medical history and physical examination results are often enough to identify or rule out serious underlying problems or conditions. Testing (laboratory or imaging) is employed to support a suspected diagnosis.

No specific laboratory or radiological test establishes the diagnosis of migraine headache. Doctors make the diagnosis through medical history, physical examination with emphasis on the neurological components, and clinical judgment. When considering a diagnosis of migraine headache, the doctor will ask about a child's medical history, previous tests, allergies, and current and previous medications.

• Children will be asked to describe how the headache feels (for example, throbbing, pounding, squeezing, pressing, pulsating, aching, burning, stabbing, dull).
  
  
• They will also be asked about the headache's location, timing, severity, causal events (for example, concussion, falling down), duration, and whether any relatives have migraine headaches.
  
  
• Other common historical evidence to support the diagnosis of migraine headache includes sensitivity to light and sound, tenderness in the scalp (usually where the pain is most severe) and a strong desire to lie down and sleep.

Conditions that cause severe headaches in children include both primary and secondary disorders.

Primary headaches

Primary headaches are conditions in which the headache is the medical condition and no underlying internal cause is present. Treatment is aimed at the specific headache disorder. Primary types include:

• migraine headaches,
  
  
• tension headaches,
  
  
• chronic daily headaches , and
  
  
• cluster headaches.

The doctor must find out which type of headache a child has, because the best treatments are different for each category. Headaches that come back again and again are usually the result of primary disorders.

Secondary headaches

Secondary headaches are a result of some underlying condition. When that condition is treated, the associated headache usually gets better or goes away. Secondary headaches can be caused by many conditions, from harmless to life-threatening. The following are examples of such conditions:

• Infections (inside the head or elsewhere)
  
  
• Head tumors or masses
  
  
• Injuries to the head or neck
  
  
• Fever (for example, from flu)
  
  
• Meningitis (inflammation of the membranes of the brain or spinal cord)
  
  
• Encephalitis (inflammation of the brain)
  
  
• Sinusitis (inflammation of the mucous membrane of any sinus)
  
  
• Dental abscesses
  
  
• Subarachnoid hemorrhage (bleeding in the brain membranes)
  
  
• High blood pressure

A physician evaluating a patient with headache must consider that a patient with a primary headache disorder may also have a secondary headache disorder.

Phases of a migraine attack

A migraine attack has four possible phases.

1. premonitory phase or prodrome
   
   
2. aura
   
   
3. headache
   
   
4. postdrome
   
   

Premonitory phase or prodrome: Both migraine headaches with aura (see below) and migraines without aura have a premonitory phase (a phase that precedes and forewarns), which may start up to 24 hours before the headache phase. During this prodrome phase many symptoms may develop. These include:

• irritability,
  
  
• joy or sadness,
  
  
• talkativeness or social withdrawal,
  
  
• increased or decreased appetite,
  
  
• food craving or anorexia (lack of appetite, distaste for food),
  
  
• water retention, and/or
  
  
• sleep disturbances.

These prodrome symptoms are often more evident in migraine without aura than in migraine with aura. Children with frequent migraine headaches or migraine variants often have a vague feeling that something is different in their world. They often learn to recognize these early signs but have trouble explaining or describing them to parents or health care practitioners.

Aura

An aura is a focused symptom that happens right before a migraine headache or when one begins. An aura may occur without headache, or it may be more severe than the following migraine headache. Only 15% to 30% of children with migraine headaches experience auras; however, under- reporting may exist due to the inability of young patients to verbally explain their sensations. The aura usually occurs less than 30 minutes before the migraine headache and lasts for 5-20 minutes. Motor auras (those affecting a person's coordination) tend to last longer than other forms. Visual disturbances are the most common form of aura. Numbness and tingling of one side of the face and tingling of fingers on the same side are the second most common type of aura. Disorder of speech is a rare aura presentation. Complete recovery of aura symptoms should be expected.

Children are often unable to recognize or describe their auras; picture cards that show typical visual auras may help the doctor get an accurate history. Visual auras are often reported as moving or changing shapes and are the most common form in children.

Visual auras consist of the following:

• Blurred vision



• Fortification spectra (zigzag lines)
  
  
• Scotomata (defects in the field of vision)
  
  
• Scintillations (sparks or flashes of light)
  
  
• Black dots
  
  
• Kaleidoscopic patterns of various colors
  
  
• Micropsia (perception of objects as smaller than they are)
  
  
• Macropsia (perception of objects as larger than they are)
  
  
• Alice in Wonderland syndrome [the illusion of dreams, feelings of levitation (floating or rising), and altered sense of the passage of time]
  

Other auras include the following:

• Attention loss
  
  
• Confusion
  
  
• Amnesia (forgetfulness, memory failure)
  
  
• Agitation
  
  
• Aphasia (impaired or absent understanding or production of or communication by speech, writing, or signs)
  
  
• Ataxia (an inability to coordinate muscle activity during voluntary movement)
  
  
• Dizziness
  
  
• Vertigo (a sensation of spinning or twirling, implying a definite feeling of rotation)
  
  
• Paresthesia (an abnormal feeling of burning, pricking, tickling, tingling, etc)
  
  
• Hemiparesis (weakness affecting one side of the body)
  

Aura symptoms can vary widely within and between attacks.

Headache

The actual headache phase of a migraine attack is usually shorter in children than in adults. Children's headaches can last 30 minutes to 48 hours but usually last less than four hours. Some children report short headaches lasting 10-20 minutes. The headache phase is often associated with the following:

• Cold extremities
  
  
• Nausea
  
  
• Anorexia
  
  
• Vomiting
  
  
• Diarrhea
  
  
• Increased urination
  
  
• Constipation
  
  
• Dizziness
  
  
• Chills
  
  
• Excessive sweating
  
  
• Ataxia
  
  
• Numbness
  
  
• Photophobia (sensitivity to light)
  
  
• Phonophobia (sensitivity to sound)
  
  
• Osmophobia (sensitivity to smell)
  
  
• Memory loss
  
  
• Confusion

Postdrome

After the headache phase, the migraineur (person who has migraines) may feel elated and energized or, more typically, exhausted and lethargic (weary, tired). This stage of migraine may last from hours to days.

Types of migraines

Migraine with aura: This type of migraine, also known as classic migraine, is characterized by a visual aura followed by a unilateral (one-sided), throbbing headache, which may later spread to both sides. It lasts from half an hour to 48 hours. Migraine with aura occurs in 15%-40% of children who experience migraine headaches. The typical aura is manifested by various abnormalities of the visual, auditory and/or sensory systems. These symptoms are progressive in intensity, usually last for about one hour, and resolve completely.

Common migraine: Common migraines lack an aura. Migraine without aura in children is traditionally described as a recurring (happening over and over), bilateral (two-sided) headache disorder with a throbbing and/or pulsating pain quality, moderate-to-severe intensity, and severe stomach symptoms. Common accompanying symptoms in children are irritability and paleness with dark circles under the eyes. In younger children, the pain is more often on both sides and around the eyes and temples. Migraine without aura occurs in 60%-85% of migrainous children.

Chronic migraine: Persons with chronic migraine have headache attacks at least 15 days of every month for at least two months. Chronic migraine may affect up to 4% of teenage girls and 2% of teenage boys.

Status migrainosus: This is a severe form of migraine headache in which the attack is continuous over 72 hours. People who have such an attack usually have a history of migraine. In those who vomit, rehydration (restoring adequate fluid levels) is often the necessary first step in treatment.

Complicated and variant migraines: These are classified as migraines because they often have the same triggers. They are brief, recurrent, episodic disorders that are made worse by physical activity and relieved by deep sleep or typical anti-migraine medications.

Complicated and variant migraines cause some of the same symptoms as typical migraines, including pain, stomach problems, autonomic symptoms (for example, abnormal sweating, changes in pupil size), neurologic symptoms (for example, tingling, numbness, weakness), and changes in mood or emotion. These benign (relatively harmless) disorders are frightening because they often seem to be life-threatening emergency situations.

Migraine equivalents are under-recognized and under-reported expressions of childhood migraine. They are often forerunners of the typical migraine, and complicated and variant migraines occasionally alternate with typical migraines.

Listed below are examples of some of these variant migraine patterns.

• Familial hemiplegic migraine (FHM): FHM is an uncommon form of migraine with aura. Persons with FHM have long-lasting hemiplegia (paralysis of one side of the body) along with numbness, aphasia, and confusion. The hemiplegia may come before (as part of the aura), accompany, or follow the headache, and symptoms may last for hours or as long as a week. FHM is very rare and may run in families (usually another first- or second-degree relative is affected in these cases).
  
  
  • The headache is usually opposite from the paralyzed side. Some cases of FHM are associated with cerebellar ataxia [a loss of muscle coordination caused by disorders of the cerebellum [a part of the brain)]. People with other types of severe FHM may experience coma, fever, and meningismus (pain caused by irritation of the membrane layers (meninges) surrounding the brain and spinal cord).
    
    
  • A third type of FHM involves progressive ataxia, nystagmus (uncontrollable, rapid horizontal or vertical movement of the eyeballs), clumsiness, and dysarthria (a speech disturbance due to emotional stress, to brain injury, or to paralysis, incoordination, or spasticity of the muscles used for speaking)
    
    

• Basilar migraine (basilar artery migraine or Bickerstaff syndrome): Basilar migraine is a subtype of migraine with aura that is mostly observed in adolescent and young adult females. The headache pain is located in the back of the head. The headache must have at least two of the aural symptoms listed below:
  
  
  • Ataxia
    
    
  • Bilateral paresthesias (abnormal feeling of burning, pricking, tickling, tingling, etc, on both sides of the body)
    
    
  • Deafness
    
    
  • Decreased level of consciousness
    
    
  • Diplopia (double vision)
    
    
  • Dizziness
    
    
  • Drop attacks (atonic seizure)
    
    
  • Dysarthria
    
    
  • Fluctuating low-tone hearing loss
    
    
  • Tinnitus [noises (ringing, whistling, hissing, roaring, etc.) in the ear]
    
    
  • Unilateral (one-sided) or bilateral (two-sided) vision loss
    
    
  • Vertigo
    
    
  • Weakness

A history of typical migraine exists in 86% of families studied. Many people experience basilar migraine attacks intermingled with typical migraine attacks. Three to 20% of children with migraine will suffer from basilar migraine. The most common age of onset is seven years of age. A chromosomal marker has been demonstrated to be shared with patients who experience FHM. The significance of this observation is not fully understood.

• Ophthalmoplegic migraine: This form of migraine is associated with paralysis of the extraocular muscles (muscles which control eyeball movement) and is rare. People with this type of migraine experience severe one-sided headaches. Ophthalmoplegia (paralysis of one or more of the eye muscles) may precede, accompany, or follow the headache.
  
  
• Retinal migraine: This is an extremely rare migraine type during which there is a unilateral (one sided) sudden loss of vision preceded by a sensation of bright lights. A migraine headache generally follows within one hour of the visual impairment and is commonly on the same side as the affected eye. Full vision recovery is expected - it is rare to have any permanent loss or impairment of vision.
  
  
• Benign paroxysmal vertigo of childhood: This condition is probably not a true migrainous disorder. It is the most frequent cause of vertigo in childhood and is characterized by brief episodes of vertigo, disequilibrium (poor balance), and nausea. Episodes tend to be brief, have a sudden onset, and may occur in clusters for several hours and then spontaneously stop. Children with this problem are usually aged 2-6 years. Nystagmus may occur during but not between attacks. Hearing loss, tinnitus, or loss of consciousness does not occur. Symptoms usually last only a few minutes. Parents observe that an attack is characterized by a sudden onset of fear, refusal to walk, or need to hold onto supporting structures for stability. They may have a sudden loss of alertness ("space out"). No headache occurs in benign paroxysmal vertigo. Children with benign paroxysmal vertigo often develop a more common form of true migraine as they mature.
  
  
• Acute confusional migraine: This type of migraine is characterized by short-lived episodes of amnesia (memory loss), confusion, agitation, lethargy, and dysphasia (speech difficulties) brought about by minor head trauma. The child may have aphasia, and the confusional state may either precede or follow the headache. Some children also experience recurrent episodes of temporary amnesia and confusion. Recovery almost always occurs within six hours. A recent paper points out that brain CT studies of those whose migraine is associated with head trauma are normal. The child may not have a history of headache but usually develops typical migraine attacks at some point in the future.
  
  
• Migraine-associated cyclic vomiting syndrome (periodic syndrome): This syndrome is characterized by recurrent periods of intense vomiting separated by symptom-free intervals. Many people with cyclic vomiting have regular or cyclic patterns of illness. Symptoms usually come on quickly at night or in the early morning and last 6-48 hours. Associated symptoms include abdominal pain (80%), nausea (72%), retching (76%), anorexia (74%), paleness (87%), lethargy (91%), photophobia (32%), phonophobia (28%), and headache (40%).
  
  
  • Headache often does not appear until the child is older. Migraine-associated cyclic vomiting syndrome usually begins when the person is a toddler and disappears in adolescence or early adulthood. (It rarely begins in adulthood.) This syndrome affects more females than males.
    
    
  • Infections, psychological or physical stress, and dietary triggers are often clearly associated. Examples of triggers include cheese, chocolate, monosodium glutamate (MSG), emotional stress, excitement, or infections. Usually, a family history of migraines in the parents or siblings is present. Children with this condition often need intravenous fluids.

• Abdominal migraine: The child may have recurrent bouts of generalized stomach pain with nausea and vomiting. No headache is present. After several hours, the child can sleep and later awakens feeling better. Abdominal migraine may alternate with typical migraine and usually leads to typical migraine as the child matures. Some studies indicate that abdominal migraine may affect as many as 12% of school-aged children.
  
  
• Paroxysmal torticollis of infancy: Probably not a true migrainous condition, paroxysmal torticollis means a convulsive contraction or shortening of the neck muscles. This rare disorder is characterized by repeated episodes of head tilting and is associated with nausea, vomiting, and headache. Attacks usually occur in infants and may last from hours to days.
  
  
• Acephalic migraine of childhood (migraine sine hemicrania): This condition is characterized by a migraine aura (usually visual) without headache. Females are more likely than males to have this type of migraine.
  
  
• Alice in Wonderland Syndrome: The syndrome is characterized by headache that is preceded by visual hallucinations or delusions, distortions of body image and abnormalities in the experience of time. Such experiences may wax and wane over several days to months, and children generally recover without residual problems. It is most commonly seen in the young school-aged child.
  
  
• Menstrual migraine: Menstrual migraine occurs in close approximation to the onset of menstruation and will commonly last for two to three days. The cause of such migraine headaches has been postulated to be associated with the reduction of estrogen and progesterone levels that are associated with menses. No aura is appreciated with menstrual migraines. Women who suffer from menstrual migraines may also experience more traditional migraines (either with or without aura) at other times of their menstrual cycle.

Associated diseases and conditions

• Psychiatric diseases
  
  
  • Many migraineurs report anxiety (excessive worrying) or sadness.
    
    
  • Whether the headache or the mood or anxiety symptoms appear first is unclear.

• Asthma, allergies, and seizure disorders
  
  
• Epilepsy
  
  
  • Epilepsy and migraine headaches often occur in the same person and may be related.
    
    
  • About 70% of individuals with partial complex seizures have migraines, but most people with migraines do not have seizures.
    
  
  

Miscellaneous migraine facts

• Migraineurs are more prone to motion sickness than people without migraine.
  
  
• Intermittent vertigo is found in 63% of people with classic migraine and in 21% of those with common migraine.
  
  
• A higher degree of cardiovascular reactivity to postural changes (blood circulation responses to standing or sitting) has been shown in those with cyclic vomiting and migraine.
  
  
• Diarrhea is common in migraineurs and is sometimes severe enough to cause excessive fluid loss and dehydration.
  
  
• Migraines are associated with sleep disturbances, and sleepwalking (somnambulism) is found in 20%-30% of migraineurs.
  
  
• An aversion (dislike) of striped patterns is found in 82% of tested migraineurs.
  
  
• One study found that eating ice cream caused headache in 93% of migraineurs and was typically located at the usual site of migraine pain.