{
 "topic": "Migraine",
 "slug": "migraine",
 "category_id": 15695,
 "summary": "How pediatric migraine differs from the adult pattern, its episodic childhood equivalents and uncommon subtypes, and the red flags that distinguish it from dangerous secondary headache causes.",
 "written_by": "claude-sonnet",
 "references": [
  {
   "title": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024",
   "author": null,
   "pages": [
    1577,
    2404,
    3677,
    3678,
    3791
   ]
  },
  {
   "title": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "author": null,
   "pages": []
  },
  {
   "title": "Ghai Essential Pediatrics, 9e (Vinod K Paul, Arvind Bagga)",
   "author": "CamScanner",
   "pages": [
    581
   ]
  },
  {
   "title": "Pediatric ICD-10-CM 2023",
   "author": "American Academy of Pediatrics Committee on Coding and Nomenclature;",
   "pages": [
    213
   ]
  },
  {
   "title": "Pediatric Decision-Making Strategies",
   "author": "Pomeranz, Albert J.",
   "pages": [
    200
   ]
  },
  {
   "title": "Illustrated Textbook of Paediatrics (Tom Lissauer, Will Carroll)",
   "author": "Lissauer, Tom,Carroll, Will",
   "pages": [
    514
   ]
  },
  {
   "title": "MedStudy Pediatrics Core 11th Edition 2024-2025",
   "author": null,
   "pages": [
    465
   ]
  }
 ],
 "short": [
  {
   "title": "In short",
   "content": "- Migraine is genetically based and is the most common cause of recurrent headache brought to medical attention in children, yet it remains underrecognized and undertreated in this age group.\n- Migraine without aura accounts for about 90% of pediatric migraine; episodes last 1\u201372 hours in children (vs. up to 24\u201348+ hours more classically described, and often longer in adults); headache is commonly bilateral in children (unlike the classic adult unilateral pattern), though unilateral location occurs in about two-thirds of patients in some series, pulsatile/throbbing, over the temporal or frontal area, with nausea, vomiting, photophobia, and/or phonophobia.\n- Peaks in children aged 5\u201315; below age 7 both sexes are affected equally, but girls are affected more often at older ages.\n- Auras occur in fewer than half of children and, when present, last 5\u201360 minutes and resolve completely; typical auras include visual aberrations (flashing lights, colored lines, blind spots, blurred vision, hemianopia, hallucinations), limb/perioral dysesthesias, and rarely focal motor deficits (hemiplegia, ophthalmoplegia, aphasia).\n- Episodic syndromes that may be migraine equivalents in children: cyclical vomiting syndrome, abdominal migraine, benign paroxysmal vertigo, benign paroxysmal torticollis, and episodic colic \u2014 many of these children go on to develop typical migraine headache later in life.\n- Uncommon migraine subtypes: basilar-type migraine (more common in adolescent girls; vertigo, syncope, dysarthria, visual changes, sometimes loss of consciousness); hemiplegic migraine (unilateral weakness \u00b1 aphasia lasting hours to days, autosomal dominant in some families \u2014 distinct from alternating hemiplegia of childhood, which starts before 18 months and causes intellectual decline); ophthalmoplegic migraine (typically CN3 palsy \u2014 ptosis, pupil dilation, exotropia, diplopia \u2014 resolving over days to weeks); confusional migraine; and retinal migraine (sudden vision loss with headache).\n- Diagnosis is based almost entirely on history and a normal exam; there are no diagnostic labs or imaging studies for migraine itself. Focal neurologic deficits (hemiplegia, ophthalmoplegia) can occur in \"complicated\" migraine but should still prompt exclusion of other causes.\n- Distinguishing migraine aura from stroke: migraine-associated sensory/motor symptoms evolve slowly, marching across body areas over minutes, and auras resolve within 5\u201360 minutes; consider reversible cerebral vasoconstriction syndrome (RCVS) in a patient with migraine history, pregnancy, or exposure to sympathomimetics/SSRIs/migraine abortive drugs presenting with thunderclap headache and multifocal arterial constriction/dilation.\n- Migraine frequently co-occurs with anxiety and depression (anxiety predicts migraine persistence) and interacts bidirectionally with sleep disturbance \u2014 poor sleep can trigger migraine, and migraine itself disrupts sleep.\n- Red flags requiring further workup rather than a migraine diagnosis: neurologic abnormalities, altered mental status, or meningeal signs (nuchal rigidity, Kernig, Brudzinski) warrant evaluation for meningitis; a sudden severe \"thunderclap\" headache can reflect a ball-valve third ventricle cyst or intracranial hemorrhage rather than migraine; and progressive or worsening headache pattern (especially in a child with a right-to-left cardiac shunt, immunodeficiency, or chronic ENT infection) should raise concern for brain abscess."
  }
 ],
 "long": [
  {
   "title": "Definition",
   "content": "Migraine is a genetically based disease presenting as episodic attacks, most often experienced as headaches, though in children a range of periodic syndromes can also represent migraine attacks even without headache. Headaches may be moderate to severe, focal, throbbing, and associated with nausea, vomiting, photophobia, and/or phonophobia. Formal classification (ICHD-3) divides migraine into migraine with or without aura, migraine with typical aura, migraine with brainstem aura, hemiplegic migraine (sporadic or familial), retinal migraine, and chronic migraine, along with complications (status migrainosus, persistent aura without infarction, migrainous infarction, migraine aura-triggered seizure) and episodic syndromes that may be associated with migraine in children (recurrent GI disturbance/cyclical vomiting syndrome, abdominal migraine, benign paroxysmal vertigo, benign paroxysmal torticollis, episodic colic)."
  },
  {
   "title": "Epidemiology",
   "content": "Migraine is the most frequent cause of recurrent headache brought to pediatric attention, typically peaking between ages 5 and 15 years. Below age 7, migraine affects both sexes equally; at older ages, girls are affected more often than boys. Migraine without aura is about twice as common as migraine with aura among school-age children, though both patterns can occur in the same individual, and migraine without aura accounts for roughly 90% of pediatric migraine overall."
  },
  {
   "title": "Clinical features",
   "content": "In children, migraine attacks last 1\u201372 hours (shorter than the more classic adult description of up to several days) and are more often bilateral than the classic unilateral adult pattern, though unilateral headache still occurs in about two-thirds of pediatric patients in some series; the pain is characteristically pulsatile/throbbing, located over the temporal or frontal area, and accompanied by nausea, vomiting, abdominal pain, photophobia, and/or phonophobia. Attacks can occasionally wake a child from sleep. Auras occur in fewer than half of affected children, evolve slowly (sensory disturbance or weakness marching across body regions over minutes, distinguishing them from the abrupt onset of stroke), and last between 5 and 60 minutes with complete resolution; typical auras include visual aberrations (flashing lights, colored lines, blind spots, blurred vision, hemianopia, visual hallucinations), dysesthesias of the limbs or perioral region, and less commonly focal motor deficits such as hemiplegia, ophthalmoplegia, or aphasia. A family history of migraine is a useful diagnostic clue, and children with migraine disproportionately also experience motion sickness, dizziness, vertigo, or other paroxysmal events \u2014 nearly 20% of children with migraine report vertiginous symptoms during their aura. Migraine equivalents/episodic syndromes in children \u2014 cyclical vomiting syndrome, abdominal migraine, benign paroxysmal vertigo, benign paroxysmal torticollis, and episodic colic \u2014 frequently precede the later development of typical adult-like migraine headache. Uncommon subtypes include basilar-type migraine (more common in adolescent girls; occipital throbbing headache with brainstem dysfunction signs \u2014 vertigo, ataxia, tinnitus, dysarthria, visual disturbance, sometimes syncope or loss of consciousness), hemiplegic migraine (unilateral weakness with or without aphasia, lasting hours to days, with autosomal dominant inheritance in some families \u2014 distinct from alternating hemiplegia of childhood, which begins before 18 months, causes intellectual decline, and features paroxysmal, repeated hemiplegic episodes), ophthalmoplegic migraine (typically third cranial nerve involvement \u2014 ptosis, pupillary dilation, exotropia, diplopia \u2014 appearing as the headache resolves and taking days to weeks to fully clear), confusional migraine (profound confusion), and retinal migraine (sudden vision loss with headache). Migraine frequently co-occurs with anxiety and depression, and anxiety specifically predicts migraine persistence over time; sleep disturbance and migraine interact bidirectionally, with poor sleep able to trigger a migraine or cluster of migraines, and migraine itself disrupting sleep."
  },
  {
   "title": "Diagnostics",
   "content": "The diagnosis of migraine rests almost exclusively on history, supported by an examination free of focal abnormalities; there are no diagnostic laboratory tests or imaging studies for migraine itself. Hemiplegia or ophthalmoplegia can occur in \"complicated\" forms of migraine but warrant careful exclusion of other causes before being attributed to migraine. Distinguishing a migraine aura from an acute ischemic stroke relies on the tempo and duration of symptoms: migraine-associated sensory disturbance or weakness evolves slowly, marching across body regions over minutes, and resolves within 5\u201360 minutes, whereas stroke symptoms are typically abrupt and persistent. A group of uncommon \"acephalic\" migraine subtypes \u2014 familial hemiplegic migraine, basilar migraine, and migraine aura without headache \u2014 can occur without headache and more closely mimic stroke, adding diagnostic difficulty in this specific scenario; migraine can also, rarely, cause a true ischemic stroke (migrainous infarction)."
  },
  {
   "title": "Differential diagnosis",
   "content": "Several features should prompt evaluation beyond a presumed migraine diagnosis. Neurologic abnormalities, altered mental status, or meningeal signs (nuchal rigidity, Kernig sign, Brudzinski sign) warrant workup for meningitis. A sudden, severe \"thunderclap\" headache from transiently increased intracranial pressure can reflect a ball-valve-mechanism third ventricle cyst, while other intracranial cysts (arachnoid, epidermoid, dermoid) may present with progressive headache or seizures. Hydrocephalus is more likely to cause headache in older children (whose cranial sutures have closed), producing generalized headache of acute or gradual onset depending on the rate of progression. Children with immunodeficiency, right-to-left cardiac shunts (especially tetralogy of Fallot), chronic ENT infections, penetrating head injury, or facial/scalp soft tissue infection carry increased risk of brain abscess, another important secondary headache cause to exclude. Reversible cerebral vasoconstriction syndrome (RCVS) should be considered in a patient with a migraine history, pregnancy, or exposure to sympathomimetic agents, SSRIs, or migraine abortive medications who presents with thunderclap headache, migraine-like symptoms, seizures, or focal deficits from multifocal arterial constriction and dilation. Broader secondary causes of headache to keep in the differential include head/neck trauma, cranial or cervical vascular disorders (vascular malformation, intracranial hemorrhage), medication overuse headache, and \u2014 for headache accompanied by other systemic symptoms \u2014 renal disease (obstructive uropathy, renal insufficiency, renal tubular acidosis), infection (meningitis, UTI, hepatitis, upper respiratory infection with postnasal drip), and metabolic derangement (diabetic ketoacidosis, Reye syndrome, adrenal insufficiency, inborn errors of metabolism)."
  }
 ],
 "clinical": [
  {
   "title": "Evaluation at the bedside",
   "content": "Take a careful history as the primary diagnostic tool, since migraine diagnosis rests almost entirely on history plus a normal exam rather than any test or scan. Ask specifically about family history of migraine, associated motion sickness or vertigo, headache duration and location, throbbing quality, and associated nausea/vomiting/photophobia/phonophobia, and note whether the pattern fits an episodic syndrome (cyclical vomiting, abdominal migraine, benign paroxysmal vertigo or torticollis) rather than a typical headache, particularly in a younger child.\n\nReserve neuroimaging and further workup for red flags rather than ordering them routinely for a classic migraine history: neurologic abnormalities, altered mental status, or meningeal signs should prompt evaluation for meningitis; a thunderclap headache pattern should prompt evaluation for a ball-valve intracranial cyst, intracranial hemorrhage, or RCVS (especially with a history of migraine, pregnancy, or relevant drug exposure); and a child with a right-to-left cardiac shunt, immunodeficiency, chronic ENT infection, or penetrating head injury presenting with new or worsening headache should be evaluated for brain abscess. When aura is present, use the tempo (slow march over minutes, resolving within 5\u201360 minutes) to distinguish it from stroke, and consider the acephalic migraine subtypes (familial hemiplegic migraine, basilar migraine, migraine aura without headache) when a stroke-like presentation lacks headache.\n\nScreen for and address coexisting anxiety, depression, and sleep disturbance as part of migraine management, since anxiety predicts migraine persistence and poor sleep can trigger migraine attacks \u2014 addressing sleep hygiene and mental health may reduce migraine frequency independent of headache-specific therapy. Reassure families that episodic childhood syndromes such as cyclical vomiting, abdominal migraine, and benign paroxysmal vertigo commonly evolve into typical migraine headache later, so a consistent family/personal history across these patterns supports the migraine diagnosis even when the current presentation doesn't look like a classic headache."
  }
 ]
}