M V Francis
Eye and Migraine Centre, Cherthala, Alleppey

Corresponding Author: Dr. M V Francis, MS, Chief Consultant, Eye and Migraine Centre, Cherthala, Alleppey 688527. Phone: 0478 2821091. E-mail: mvfrancis@rediffmail.com

ABSTRACT

Background: The International  Headache Society (IHS) diagnostic criteria (International  classification of headache  disorders  edition 1 and  2- ICHD 1 and 2) for  headache in children   and  adults    improved the   accuracy    of   migraine     diagnoses. However many  short  duration  headaches  in  children, receive an  a typical  migraine   diagnosis -probable migraines according to ICHD 2 published in 2004 or migrainous disorders in ICHD1(1988). This study  is to diagnose children and adolescents  who presented with such atypical  migraines of less  than one hour duration. Methods: 1402 children and adolescents aged 5 to 15 years who presented with recurrent brief activity affected bead pain, were studied. Common  migraine triggers and family history of migraine were recorded. Diagnosis was done according to ICHD2 and HIS(R) criteria.

Objective: To diagnose early or brief migraine episodes in children and  adolescents and  to propose a modification to  pediatric migraine diagnostic criteria of the International  headache society.

Design: Prospective study.

Setting:  Eye and Migraine Centre, Cherthala and St Sebastians Visitation Hospital, Arthunkal, Kerala.

Results: All the children studied had moderate to severe headache lasting 5 to 45 minutes which forced them motionless during the attacks. At least one of the International Headache Society pediatric migraine diagnostic symptoms (nausea/vomiting/photophobia/phonophobia) was  present in  all.  Two  additional features were diagnostic of early or brief migraines in all of them- one of the parents or siblings was a migrainer and one of the common  migraine triggers as a precipitating factor.

Conclusion: This study concludes that  if  duration of head pain is less than one hour, two additional features to be included  to diagnose definitive migraine in children and  adolescents are: one migraine parent or sibling and one of the common migraine triggers precipitating the head pain.

Introduction

Prior to the publication of I H S Headache classification system in 1988,1 several classifications were  used for headache diagnosis in children. These dealt mainly with migraine and included the criteria established  by  Vahlquist,2 Deubner3 and Prensky  and Sommer.4 During the last 15 years, several  studies5,6,7,8,9  have proposed revisions to the I H S criteria for children and  adolescents with   migraine. The major suggestions were to shorten  the duration  of the migraine attack to one hour and to remove hemicrania as a criterion since many children have headaches  that  are  bitemporal or  bifrontal. An additional suggestion was  to  require either photophobia or phonophobia instead of both.10 However, when   I H S   criteria  and  the  various modifications are applied, a sizable  proportion of headache  children with  migrainous  features  fail to  fully  meet I H S migraine criteria  and  thus they receive an atypical migraine diagnosis (migrainous  disorder or probable migraine). Many children report brief episodes of head pain which resemble  migraine but these migraine episodes of less than one hour duration are not well documented. Little is known  about the frequency  of these head pain attacks  in the child hood   and adolescent  age groups. Moreover  there are overlapping  statements in the diagnostic criteria of migraine and tension type headaches-  number of   episodes,  duration  of pain, bilaterality, moderate intensity and either phonophobia or photophobia- all these features  are common for making both diagnoses.

Present study is undertaken  to document  early or brief migraine episodes  lasting less  than one hour duration in children   and to   suggest clear-cut differentiating features to distinguish migraine from tension type   headaches and to propose  a modification to  pediatric  migraine (without  aura) diagnostic criteria.

Methods

9620 children  and  adolescents  aged  5 to 15 years who presented with recurrent short duration headpain at The Eye and Migraine  centre and St  Sebastians Visitation Hospital,  Arthunkal in Cherthala. Alleppey were  studied   prospectively, spanning 4  years. Patients  attending  the free eye and headache camps were  also  included. The  inclusion criteria were recurrent headpain (minimum 5 episodes) of less than one hour duration, activity affected (motionless) during the  headpain episodes,  one  associated feature (phonophobia, photophobia, nausea or vomiting), one common migraine trigger precipitating the attacks and one parent or sibling suffering from I H S Migraine (with or without aura)  head aches.  Information regarding the duration, severity, quality and location of headpain  and behaviour during headpain episodes were also recorded.  Children  with  typical   IHS tension type headaches and other headaches of eye, ENT and   dental origin  were excluded   so   also fever and other systemic and organic illnesses.

Results

1402 children and adolescents fulfilled the inclusion criteria  to diagnose brief migraine episodes of  less than one hour duration (5 minutes to 45 minutes). There were  842 girls and 560 boys. The headache characteristics, common migraine triggers and family history of 1402 children are given below.  Headache characteristics

Duration: 5 to 1 5 minutes-ll2 (8%), 15 to 30 minutes – 21 l (15%), 30 to 45 minutes –  1079 (77%)
Location:  always unilateral 448 (32%), bilateral 785 (56%), unilateral spreading to bilateral l69 (12%)
Quality:  pulsating 518 (37%), non pulsating  617 (44%), just ache (not able to explain) 267 (19%)
Behaviour during attack: sit quiet 588 (42%), lie down (with or without pressing on temples) 449  (32%), applying balm and sleep off 365 (26%)
Associated features: nausea 252 (18%), vomiting 196 (14%), phonophobia 883 (63%), photophobia 798 (57%)

Common  migraine   triggers – exposure to sunlight 1290 (92%), travelling  by bus 673 (46%), strenuous physical exercises like dancing and cycling 590 (42%), sleep disturbances 336 (23%), missing meal at the right time 296 (21%). 1010 (72%) reported more than one trigger.  Anxiety situations like examinations and funerals were another significant common trigger but omitted in this study, not to confuse with tension type headaches.
Family history: mother  – 1148 (82%),  father – 155 (1l%), siblings or second degree  relatives like aunts – 99 (7%)

Discussion

In children and adolescents, migraine tends to be of shorter  duration. The  duration  of  head  pain was reported to be less than 2 h in 11-81 %  and less than one  hour  in  8 to 25%.12,13 Similarly Metsahonkala6 reported that when duration was omitted as a criterion the prevalence of migraine increased by 25.9%.  In fact Gherpelli and colleagues14 found that entirely excluding duration criterion increased the sensitivity without decreasing the specificity of pediatric migraine diagnosis.  This  study supports the suggestion of decreasing the criterion on the minimal duration of head  pain to less than  one  hour for  migraine in children.

Diagnostic Criteria

Diagnostic Criteria

In this study, 1402 children reported recurrent activity affected head pain lasting 5 to 45  minutes with one of the associated diagnostic migraine features of nausea/vomiting/phonophobia/photophobia.  IHSR recommends either phonophobia or photophobia  for diagnosing migraine  in young age group. This study is also based on either phonophobia  or photophobia for migraine diagnosis, but many children were complaining of both when repeatedly questioned and the behaviour during head pain episodes were  also suggestive of both (switching off Television and radio, closing the door and putting  off lights, covering the head with clothes or blanket while lying down etc). All of them were getting the head pain attacks when exposed  to one or more of the common  migraine triggers9,15 in this region. Exposure  to sunlight and  traveling   by  bus   were  the   most  common triggers. Mortimer13 et al reported that a migraine trigger could be identified in 44.4 % of the children aged 8 -11  years. In children  more than 8 years tiredness, exercise, noise, glaring light, missing a meal were all reported as migraine precipitants by different studies. This is the first study to document common migraine triggers in a region to aid in the migraine diagnostic work up. Majority of the children and their parents reported same  common  triggers  with exposure to sunlight precipitating migraine in nearly 90% of them. Family history revealed mother (82%), father or one first or second degree relative suffering from IHS migraine with or without aura. Migraine is a familial  disorder, although  disagreement exists regarding  the  mode  of  inheritance. If one  looks at  the  families of  children   with  migraine, 50 to 90% of relatives  also have  migraine. Parents must be questioned in detail to find out migraine symptoms. Most  of them  considered their  headaches are different from what their children are getting. The diagnosis as told to them by their medical practitioners are – sinus, low (especially if  dizzy   spells are associated  with headaches) or high blood pressure, tension, spectacle related or functional. Therefore leading questions like  whether they get headache when exposed  to sunlight, bus traveling or other migraine triggers must be specifically asked to unravel migraine symptomatology.

This study shows that reducing the time duration  to less than one hour would considerably increase the number of children  diagnosed with migraine. One can argue that   this time   reduction might increase the overlap between the diagnostic criteria  of migraine and tension  type headaches but it can be easily overcome   by adding one common migraine  trigger and one family member suffering from  IHS  migraine to the present diagnostic features. One cannot  consider  any  other  diagnosis in   these  children. Other   short   duration   activity affected   headaches  like cluster  headaches  and paroxysmal  hemicranias, though reported in children, are  very   rare.

Many  headache specialists  all over    the world have accepted  the   concept that primary headache  is a spectrum, where migraine  is at one extreme  and pure  tension  type headache  is at the other, with most patients having both at times. Another opinion is that they are both the same disease when it is mild it is tension type headache and when it gets bad it is migraine16

A  critical analysis of the  IHS diagnostic criteria   for   migraine and tension, exposes    more than  one   overlapping  statements. In this  study majority of the  children presented with bilateral(68%) non throbbing (63%) headaches  (this fulfills  two diagnostic pain  features for  tension type headaches) and  with the duration of  more  than 30 minutes and one associated feature (phonophobia or photophobia) one tends to diagnose episodic tension type headaches in these children. At the same time migraine too can be diagnosed because of moderate to severe intensity with activity affected  head pain and  one  associated feature. In  these clinically confusing  situations  the following   three features clearly  differentiate migraine from tension type headaches. 1) activity affected (motionless) head pain 2) one common migraine trigger precipitating pain 3) one family member  suffering  from  I H S migraine (definite or  probable).

Thus this study shows that both migraine and tension are different  and can be distinguished easily from  a thorough  clinical  history. Therefore it  is proposed that brief or early migraine attacks to be diagnosed in children and adolescents with less than one hour duration  and must be differentiated  from episodic  tension  type  headaches.   I H S R and ICHD2  to be modified as – if duration of head pain is less than one hour, two additional features  to be added to diagnose  migraine  in  children.

  1. One common migraine trigger precipitating the attacks
  2. One parent or sibling (first or second degree relative) suffering from I H S migraine.

End Note

Author Information

Dr.  M V Francis, MS, Chief Consultant,
Eye and Migraine Centre, Cherthala,
Alleppey 688527.  Phone: 0478 2821091.
E-mail: mvfrancis@rediffmail.com

Conflict of Interest: None declared

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