What is Migraine in Children?
Migraine is one of the most common forms of cerebral disorders, characterized by recurring bouts of headache. A headache is often localized in one half of the head, is very intense and is sometimes accompanied by nausea, vomiting, hyperesthesia to sound and visual irritants. The duration of the attack varies from 1-2 hours to several days.
Causes of Migraine in Children
In most cases, girls suffer from migraines. Hereditary factors are important. The mechanism of inheritance is still not entirely clear. Apparently, it is not the disease itself that is inherited, but a predisposition to a certain type of response of the vascular system to various types of stimuli.
Migraine affects 2-7% of the child population. Most often, the disease manifests itself in children aged 6 to 10 years. Migraine cases have been recorded in children 1-3 years old, although it is possible to assess the nature of the attack only by repeating typical attacks after 3 years, when the child can express his thoughts on his own or with the help of leading questions, as well as when he constantly complains of a headache. In children under the age of 6 years, the frequency of migraine is 1%, among children 10-12 years old – 4.5%, from 15-18 – 5.3%. Before the onset of puberty, migraine occurs in girls and boys with the same frequency, after puberty in girls 3 times more often.
4 main factors affect the appearance of migraine:
- Computer games and watching TV. The time in front of the monitor reaches more than 6 hours per day. Such a load on the nervous system leads to the manifestation of headache attacks.
- Stressful atmosphere in the family. Quarrels of parents become an injury to the nervous system of the child. Therefore, parents should pay attention to relationships in the family, as well as the relationship of the child with other children, his school performance.
- Hereditary predisposition to morbidity.
- Intolerance to certain products.
Pathogenesis during Migraine in Children
With the development of migraine, vascular disorders, biochemical changes and autonomic disorders are observed. The leading pathogenetic mechanism is a violation of cerebral circulation, leading to a violation of the regional vascular tone, compensatory functions are reduced, maladaptation is observed. A migraine attack is a cerebral vascular crisis, manifested in the form of a spasm of individual vessels of the brain with subsequent hyperemia and edema.
In the pathogenesis of migraine, a certain place is given to metabolic disorders of some vasoactive substances, which include catecholamines, serotonin, prostaglandins, histamine, peptide kinins and other substances. Such a disorder causes the narrowing of large arteries and veins, a decrease in the tone of the arteries and the expansion of their lumen, an increase in the permeability of the vascular wall, which leads to increased pain and vomiting during an attack.
There is another concept of migraine pathogenesis, when an increase in the level of glutamate in the blood leads to the onset of an attack. Also, congenital insufficiency of hypothalamic formations can become the trigger of a migraine attack.
Symptoms of Migraine in Children
Depending on the clinical manifestations and the course of the attack in children, migraine is distinguished with an aura and without an aura. Aura is a complex of focal neurological symptoms with which an attack can begin or which is accompanied. In childhood, migraine without an aura is much more often observed, reaching 60-85%, migraine with an aura is 15-40%. By the nature of the aura, the following forms of migraine are distinguished:
- hemiparesthetic or hemiplegic;
Currently, the following criteria are proposed for the diagnosis of various forms of migraine:
- One-sided headache in any period of the attack.
- The pulsating nature of the headache.
- Decreased performance during an attack.
- Increased headache during normal physical exertion.
- The combination of a headache attack with autonomic disorders.
- Concomitant headache photophobia.
- Concomitant headache phonophobia.
- The duration of the attack is from 4 to 72 hours.
The diagnosis of migraine with aura can be justified if there are the following criteria:
- A history of at least 2 seizures, which are characterized, in addition to the above symptoms, by an aura in the form of visual disturbances or unilateral numbness (or paresthesia) of the limb (s) or unilateral weakness in the limb (s).
- None of the symptoms of the aura last longer than 60 minutes.
- Headache develops up to 60 minutes after the aura.
- Complete reversibility of aura symptoms.
In most children with migraine without an aura, and also with migraine with a visual aura, the frequency of attacks is 1 time in 1-2 months, in children with hemiparesthetic migraine – 1 time in 4-6 months. Among the factors contributing to the occurrence of migraine seizures in children, the most common are mental and physical overwork, weather changes. Usually attacks begin in the afternoon or in the evening.
Headache, mainly pressing, less pulsating, bursting, or breaking, is localized in the frontotemporal, periorbital, less often parietal areas, usually one-sided in older children, two-sided in young children. Headache can alternate left or right with repeated attacks. Headache is characterized as extremely intense, cruel, painful, intolerable. Often a pain attack is accompanied by general hyperesthesia, intolerance to bright light, loud sound, as well as special sensitivity to olfactory and tactile irritation. Head movement, travel in transport affect headache. A migraine attack is characterized by a pallor of the face, conjunctival hyperemia from the side of pain, bruises under the eyes, scanty facial expressions, and a suffering facial expression. In neurological status during a migraine attack, vegetative-vascular disorders are noted in the form of pallor or, less commonly, facial flushing, hyperhidrosis, cyanosis of the hands and feet. Often there are low or high blood pressure, bradycardia, polyuria, thirst, pain in the epigastric region, chills, rapid stools, heart palpitations. In children, especially in preschool age, a headache is localized in the frontotemporal zone, without a distinct side.
Most patients are characterized by focal neurological symptoms (aura) at the height of the headache, and only in 10% of patients the aura is observed before the attack; the aura lasts an average of 20 minutes. Among the focal symptoms, visual disturbances are observed in approximately a third of patients, sensitive disorders in 40%, aphasia in 10% of patients. The average duration of an attack in children with migraine without an aura is usually 2-3 hours, in most children migraine attacks with an aura are much shorter, up to 1 hour. Headache is often accompanied by nausea and, as a rule, vomiting, often repeated, after which the intensity of pain decreases relief comes, and the patient usually falls asleep. After sleep lasting from 30 minutes to 2-3 hours, the attack completely stops, the headache goes away. Thus, in children with various forms of migraine, there is a certain phase pattern during the attack: headache – focal symptoms (in case of migraine with aura) – vomiting, which brings relief, – sleep – awakening, a significant improvement in well-being.
In exceptional cases, in children, seizures can follow during the day or days, one after the other, and are accompanied by repeated vomiting with dehydration. Children need urgent hospitalization. In children with this form of migraine, signs of vegetovascular dystonia are noted: hyperhidrosis; tachycardia, less often bradycardia, fluctuations in blood pressure with a tendency to hypotension, vestibulopathy, neuroendocrine disorders of the hypothalamic level. There are also emotional disturbances, increased anxiety, suspiciousness.
Vasomotor (usual) headache occurs in children often against the background of vegetovascular dystonia, or a genetically determined environment. Vasomotor headache is more often moderate or weak without a clear localization, longer – from several hours to several days, migrating, rarely accompanied by nausea and vomiting. During a headache, hyperhidrosis, a change in the color of the face, is noted. When there is no pain, children complain of general weakness, fatigue, sweating, various unpleasant sensations in the limbs, paresthesia.
Diagnosis of Migraine in Children
It is very difficult to diagnose migraine, because the disease has similar symptoms with many other diseases. The following methods are used to diagnose migraine:
- The study of the history of the child and parents.
- Differential diagnosis. Shows is a migraine a primary disease or occurs against the background, as a symptom, of another disease.
- MRI (magnetic resonance imaging) and CT (computed tomography) are used to detect intracranial pathological processes. Allows you to visualize the structure and functions of the brain. Be sure to be performed before a spinal puncture, which shows changes in pressure and chemical composition.
Migraine Treatment in Children
There are several types of treatment for migraine: treatment of seizures, interictal treatment using drugs, interictal treatment with non-medication.
The treatment of seizures. Ergotamine hydrotartrate is the most effective way to relieve migraine pain in adolescents and older children. The drug is prescribed for oral administration, it contains 1 mg of ergotamine, in children a single dose is 0.25-0.5 mg of the drug. It is not recommended to prescribe once more than 1 mg of ergotamine, repeatedly during the attack – no more than 2 mg of the drug per day or in the form of rectal suppositories 1-2 mg. Ergotamine is contraindicated in case of arterial hypertension, diseases of the liver, kidneys, peripheral vessels. Use ergotamine in combination with caffeine – cofetamine. It is advisable to use ergotamine in combination with acetylsalicylic acid or indomethacin and caffeine; combinations with other analgesics are possible. Side effects – diarrhea, muscle cramps in the legs, discomfort in the abdomen, rarely spasm of the coronary and peripheral arteries. Possible idiosyncrasy. The drug is not used in pregnant women.
Dihydroergotamine is prescribed in the form of a 0.2% solution of 2-10 drops orally or parenterally, it has a strong narrowing property. Currently, dihydroergotamipa mesylate has been distributed in the form of a spray for intranasal administration called “Dihydergot”. It must be emphasized that the drugs are used in adults and older children; in children under 12 years of age, the above drugs are not recommended.
Sumatriptan (imigran) – serotoninomimetic for the relief of migraine attacks, both in the early and in the expanded stage. It is available for oral administration, for sc administration, as well as in the form of a spray for intranasal administration. A single dose for adults is 50-100 mg, the maximum daily dose is 300 mg. Side effects are usually mild and include local skin reactions, hot flashes, sensation of heat, tingling, neck pain. In 3-5% of cases, discomfort occurs in the chest. Sumatriptan is contraindicated in coronary heart disease, arterial hypertension, it can not be prescribed together with ergotamine or other vasoconstrictor agents.
According to many researchers, migraine attacks in children are quite effectively stopped by taking analgesics or non-steroidal anti-inflammatory drugs, as well as rest, sleep. To stop the attack, antihistamines, sleeping pills, sedatives are also used.
With a severe protracted attack, dehydrating, antihistamines are prescribed parenterally, drip; prednisone.
Treatment of children in the interictal period with drugs is carried out in the presence of more than 2 attacks per month. In recent years, the greatest positive effect has been noted with the use of aitiserotonin agents – metisergide, sandomigran, divaskan long-term courses. Cyproheptadine (peritol), which has a pronounced antiserotonin, antihistamine, and anticholinergic effect, has been widely used in childhood.
Amitriptyline is also used, the effect of which during migraine is associated with its serotonergic effect; the daily dose ranges from 8 to 50 mg per day, the course of treatment lasts up to 1-1.5 months. In case of especially severe migraine and prolonged paroxysms, it is advisable to include antiepileptic drugs – derivatives of valproic acid or carbamazepine.
Calcium antagonists (verapamil in adults, 80 mg 3-4 times a day) are used for the prevention of migraine as second-line drugs – with the ineffectiveness of p-adrenergic blockers and tricyclic antidepressants. Contraindications: sinus node weakness syndrome, atrioventricular block II-III art., Heart failure. Side effects: edema, arterial hypotension, fatigue, dizziness, headache, constipation, atrioventricular block.
Valproic acid (250-500 mg 2 times a day) can reduce the frequency of migraine attacks.
An important place in the treatment of migraine and vasomotor headache is given to interictal treatment with non-pharmacological agents, which include acupuncture, physiotherapy, and psychotherapy methods. Methods based on biofeedback are also used. The efferent impulses from the scalp, skin of the hands, and the external temporal artery are recorded, since during the attack tension of the muscles of the scalp, an increase in the temperature of the ruts of the hands, and also the amplitude of pulsations of the external temporal artery occur. In patients with the effect of the biological feedback treatment, the psychoemotional status improves. The course of auto-training leads to an improvement in most patients with migraine, which lasts for 6 months.
Migraine Prevention in Children
In the prevention of migraine attacks in children, an important role is given to observing the daily routine of regular nutrition, a full night’s sleep. Hypoglycemic conditions caused by a long interval between meals contribute to the occurrence of headaches. It is recommended to avoid excessive stress, emotional stress.