Indian J Pediatr (2010) 77:1247–1251 DOI 10.1007/s12098-010-0210-2
ORIGINAL ARTICLE
Profile of Children with Migraine Mustafa Aydin & Nimet Kabakus & Senol Bozdag & Sabahattin Ertugrul
Received: 9 June 2009 / Accepted: 5 May 2010 / Published online: 1 October 2010 # Dr. K C Chaudhuri Foundation 2010
Abstract Objective To assess the clinical characteristics of patients with migraine. Methods The medical records of 76 patients diagnosed with migraine were reviewed using the ICHD–II 2004 diagnosis criteria. The patients were classified into three age groups: 3–6 yr olds (group I), 7–12 yr olds (group II), and 13–17 yr olds (group III). Results Migraine was the most common cause of headache in the patients of present pediatric neurology outpatient clinic (57.1%, 76/133). The mean age of patients was 11.08±3.27 (3.25–17) yrs. The number of girls as the age increased (groups II and III). The mean headache attacks rate was 2.5±1.5 per wk, which resulted in worsening of school performance (n=26, 34.2%). In the majority of patients (n= 54, 71.1%), there was a family history of migraine or headache in the close relatives. Prophylaxis was found effective for all given medications (flunarizine: 46/54, propranolol: 19/21, topiramate: 10/10, sodium valproate: 1/1).
M. Aydin : N. Kabakus : S. Bozdag : S. Ertugrul Department of Pediatric Neurology, Faculty of Medicine, Firat University, Elazig 23119, Turkey M. Aydin (*) Department of Neonatology, Dr. Sami Ulus Children’s and Maternity Hospital, Babur Street, No: 44 (06080) Altındag, Ankara, Turkey e-mail:
[email protected]
Conclusions These findings indicate that: (a) migraine is the most frequent cause of headache in pediatric patients, (b) it has negative effects on school performance and daily activities, (c) the family history is important for making the diagnosis and (d) prophylaxis is significantly effective. Keywords Children . Headache . Migraine . Prevalence . Prophylaxis
Introduction Migraine is a form of periodic headache usually located on one side of the head with variations in frequency, severity, localization and duration. It can be seen in all age groups at a rate varying from 2% to 35%. Neurological, autonomical and psycho-physiological symptoms may accompany this type headache [1–4]. Migraine is seen in 5% of children aged 7 to 10 yrs and in 17% of adolescents. There is an equal prevalence in girls and boys prior to puberty; however, after puberty, the prevalence is 2-3 times more common in girls. This condition usually begins in adolescence and the prevalence gradually decreases with increasing age [1, 5]. Although the frequency of migraine attacks may show variations, most patients suffer from 1–4 attacks per month [4, 6, 7]. Difficulties may be encountered when making a diagnosis of migraine in childhood [8]. Besides, long lasting attacks may affect daily activities and cause absence from school [9]. Herewith, the authors aimed to emphasize this important health problem of the childhood by assessing the clinical characteristics of patients with migraine.
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Material and Methods
Results
The authors assessed the medical records of a total of 5,300 patients that had presented to the pediatric neurology outpatient clinic during the last 6 years. Of these 5,300 cases, 154 patients that had the complaint of headache were followed. Using the ICHD–II 2004 diagnostic criteria for headache [10], the data of 133 patients with the diagnosis of headache were assessed. Of these, 76 patients with the diagnosis of migraine were included in the study. The patients’ medical files were reviewed retrospectively and related data were recorded in the forms. The patients were classified into three age groups: 3– 6 yrs of age (group I), 7–12 yrs of age (group II) and 13– 17 yrs of age (group III). Age, gender, time of onset of headache, frequency, duration, total number of attacks, periodicity (morning-evening), severity, localization, radiation, characteristics, triggers, presence of prodromal symptoms, presence and duration of aura, factors that relieve pain such as drugs or sleep, and accompanying symptoms, medical and family histories were investigated. Physical examination findings, neurological examination findings, and laboratory test results were evaluated. Additionally, the results of electroencephalography (EEG) and imaging studies [Waters X-Ray, computerized brain tomography and magnetic resonance imaging (MRI)] were evaluated. Thereafter, treatment given and clinical outcomes were recorded. After review of medical records, the patients were contacted again to check the accuracy of data and their current condition. Indications for prophylactic medication were proposed to patients who suffer from two or more attacks per month. It was also considered for patients who suffer from less frequent, but prolonged, disabling attacks with a poor response to abortive treatment, and for those who considered that their quality of life is reduced between attacks. Excessive intake of acute medication, more than twice a week, was also proposed a strong indication for prophylactic treatment [11]. The patients were given some medications for prophylaxis: flunarizine hydrochloride 5 mg/day, single dose; propranolol hydrochloride 2 mg/kg/day, bid; topiramate 3–5 mg/kg/day, bid; sodium valproate 10–15 mg/kg/day, bid. Prophylactic therapy continued for at least 3–6 months. Primary outcome measures were the reduction in migraine frequency and severity; secondary outcome measures included number of analgesics taken and the functional disability. At least 50% reduction in the number of headaches was accepted as effective for the prevention of migraine [12]. Deterioration in school performance was assessed by the parents’ statements and the marks obtained. Statistical analyses were performed using the SPSS 12.0 pocket program. Independent Samples test, Mann–Whitney U test and Chi square tests were used for statistical analysis. The data obtained are expressed as mean±standard deviation.
Demographic Details Migraine was found the most common cause of headache in our patients of pediatric neurology outpatient clinic (57.1%, 76/133). The mean age of patients was 11.08±3.27 (3.25– 17)yrs. The patients’ age groups have been presented in Table 1. The majority of patients (46/76, 60.5%) were in the group II (female/male: 27/19). The mean interval time from onset of headache to diagnosis was 18.8±20.6 months (1– 120 months); there was no significant difference between girls and boys (19.8±20.5 vs. 17.4±21 months, respectively) (p> 0.05). The mean number of headache attacks was 2.5±1.5 per week. Sixty seven out of 76 patients (88.2%) had four or more migraine attacks per month. Furthermore, one third of patients (31.6%) had migraine attacks every day (Table 2). The medical history was positive in 62 patients (81.6%). These were motion sickness in 29 (38.2%), worsening of school performance in 25 (32.9%), history of trauma in 7 (9.2%) and history of trauma+motion sickness + worsening in school performance in one patient (1.3%). In the majority of patients (n=54, 71.1%), there was a family history of migraine or headache in the close relatives. The mothers of 20 patients (26.3%), the fathers of 9 patients (11.8%), and close relatives of 12 patients (15.8%) had migraine. There was undefined headache in the close relatives of 13 patients. The parents of three patients (3.9%) were relatives and there was a family history of epilepsy in two patients (2.6%). Clinical Findings Of patients diagnosed with migraine, 66 (86.8%) had simple migraine, and 10 (13.2%) had classical migraine. The character of headache was mainly pulsatile (n=61, 80.3%) and less frequently dull (n=15, 19.7%). While 60 patients (78.9%) had unilateral headache and six patients (7.9%) had bilateral headache, 10 patients (13.2%) could not define the side. The localization was mostly in the
Table 1 Age groups of patients with migraine Age group (yr)
Group I (3–6) Group II (7–12) Group III (13–17) Total
Patient numbers (n)
Total
F (n)
R (%)
M (n)
R (%)
Patients (n)
R (%)
1 27 17 45
1.3 35.5 22.4 59.2
3 19 9 31
4 25 11.8 40.8
4 46 26 76
5.3 60.5 34.2 100
F Female, M Male, R Rate
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Table 2 Mean number of attacks in patients with migraine Attack numbers Every day Three days per week Two days per week One day per week Two days per month One day per month Total
Patient numbers (n)
Rate (%)
24 20 13 10 6 3 76
31.6 26.3 17.1 13.2 7.9 3.9 100.0
frontal (n=35, 46%) and parietal (n=29, 38.2%) regions; it was total (n=6, 7.9%), periorbital (n=4, 5.3%) and occipital (n=2, 2.6%) in a lower number of patients. Fifty four patients (71.1%) did not define radiation of the headache and 22 (28.9%) did. There were no triggering factors in the majority of patients (n=47, 61.8%), whereas 29 patients (38.2%) defined triggers. The main triggers were exercise (n=10, 13.2%), light (n=6, 7.9%), stress (n=5, 6.6%), noise (n = 5, 6.6%), caffeinated drinks (n = 2, 2.6%), insomnia (n=2, 2.6%), scent of perfume (n=1, 1.3%), and hunger (n=1, 1.3%). A few patients with migraine had prodromal symptoms (n=9, 11.8%), [decreased activity (n=4), increased activity (n=2), depression (n=1), increased appetite (n=1) and decreased appetite (n=1)] and aura symptoms (n=10, 13.2%; loss of vision in five, seeing bright objects in four and hearing voices in one patient). Symptoms accompanying to the migraine attacks have been presented in Table 3. The most common accompanying symptoms during the migraine attacks were nausea (n=64, 84.2%),
vomiting (n=40, 52.6%), photophobia (n=40, 52.6%), and dizziness (n=30, 39.5%). Of the patients with aura symptoms, seven had aura for 4–30 min, three had aura for 30–60 min. The duration of headache was less than 2 h in the majority of patients (71.1%), while it was more than 2 h in the remainder (28.9%). Although the mean duration of headache in girls was longer than that of boys (216.89±347.82 min and 137.42±116.32 min., respectively), the difference was not significant (p>0.05). Overall mean duration of headache was 184.47±279.16 min. (30 min in 24 h). The headache was felt by the patients as mild (n=4, 5.3%), moderate (n= 51, 67.1%), or severe (n=21, 27.6%). Electroencephalographic studies (n=65, 85.5%) revealed normal findings in the majority of patients (n=46, 60.5%), but temporooccipital sharp–slow wave activity (n=13, 17.1%), and posterior slow wave discharges (n=6, 7.9%) were found in others. Of the cerebral computed tomography studies performed in patients (n=28, 36.8%), only a few (14.3%) had abnormal findings (arachnoid cyst in two patients, bilateral slit ventricle in one patient and frontal asymmetry in one patient). Additionally, cranial MRI scan revealed abnormal findings only in five out of 26 patients (19.2%), These were lacunar infarcts, cortical dysplasia, arachnoid cyst, thickening of the hypophysis infundibulum, and hypophysis microadenoma in each one. Prophylactic treatment was given to all the patients and prophylaxis was found effective for all medications (flunarizine: 46/54, 85.2%; propranolol: 19/21, 90.5%; topiramate: 10/10, 100% and sodium valproate: 1/1, 100%), (Fig. 1).
Table 3 The symptoms accompanying to the headache in patients with migraine Clinical symptoms
Dizziness Photophobia Stomachache Nausea, vomiting, and dizziness Nausea, insomnia, red eye Nausea, photophobia, and phonophobia Nausea, vomiting, and photophobia Dizziness and photophobia Nausea, vomiting Stomachache and anorexia Nausea, dizziness, and diplopia Nausea, dizziness, and photophobia Nausea, vomiting, and stomachache Total
Patient numbers (n)
Rate (%)
2 1 1 13 6 10 19 7 6 1 5 3 2 76
2.6 1.3 1.3 17.1 7.9 13.2 25.0 9.2 7.9 1.3 6.6 3.9 2.6 100.0
Fig. 1 Response to prophylactic treatment in patients with migraine
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Discussion Headache is a common symptom in childhood, the prevalence of which increases in adolescence. Epidemiological studies have shown that 15–20% of school children have headache and 3–5% of these are migraine headache [2, 3]. In a study 9,000 school children [13], at least one third of children at age seven and at least half of children at age 15 reported headaches. In the same study, the prevalence of headache was 37–51% for the 7-yr-old and 57–82% for the 14-yr-old group. In another study [9], it was found that 8% of patients in the pediatric neurology department suffered from headaches. The lower prevalence of headache in the present study may be related to the selectiveness of patients’ population. It has reported that migraine is the most important cause of headache in childhood with rate of 28–44.2% [14, 15]. Similarly, it was found that migraine was the most common cause of headache in the present patients of pediatric neurology outpatient clinic. Migraine headache is more common in girls at 12 yrs of age, which is twice when compared to boys at puberty. This may be due to the trigger effect of menstruation. It has been reported in the literature that cyclic changes in female sex hormones is related to migraine [10, 16]. In the retrospective case series of Lewis et al. [17], the prevalence of migraine was reported as 1.2–3.2% at ages 3–7 (more common in boys), 4–11% at ages 7–11 (equal for boys and girls), and 8-23% at 11–15 ages (more common in girls). In an another study [2], it was reported that headache was more common in girls at ages 11–16, whereas it was more common in boys at ages 5–10. In concordance with the other studies, the present findings support the idea that headache is more common in girls with an increase in age, and this may be related to pubertal development. The most important characteristic of the headache in migraine is its pulsatility. However, in some cases it may not be pulsatile [7, 18]. In a study of 750 migraine patients [19], 47% of patients reported that the headache was pulsatile, and others reported that it was a kind of pressure or that it was just like it would explode. The majority of patients in present study described it as pulsatile proving that pulsatile headache is specific for migraine. Unilateral headache in the majority of present patients with migraine was concordant with the diagnostic criteria of migraine [10]. The pain was moderate or severe [7]. Headache was moderate in two thirds of present patients and was severe in majority of remainders. The pain lasted for 30–120 min in about two third of the cases. The duration and severity of pain was concordant with the diagnostic criteria of ICHD–2004 [10]. It is obvious that localization, duration and severity of headache are useful in determining the etiology. More than half of patients with migraine have 1–4 attacks per month, 35% have three attacks per week, and
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less than 15% have 1–2 attacks per yr, thus interfering with their daily activities [7, 20]. The majority of present patients had four and more attacks per month; furthermore one third of them had migraine attacks every day. These findings show that migraine attacks are quite frequent and that they have a negative effect on the quality of life. Some studies reported significant decrease in the days of attendance to school due to headache and that this impacted significantly on the success in school these children [21, 22]. One third of present patients had a negative effect on school performance because of headaches. Therefore, accurate diagnosis and treatment can provide significant improvement, both in the quality of life and success in school. In the literature, the majority of patients with migraine (70–81.1%) were found to have a positive family history [14, 23, 24]. Approximately, two thirds of present patients defined a history of headache in their first degree relatives. Headache or diagnosis of migraine in the family of patients has shown the important role of heredity in the etiology of migraine and the significance of a family history in making the diagnosis. It is possible to observe non-specific changes and benign epileptiform activities in the EEGs of 10% of children with migraine [25]. The results of eight studies assessed by the American Academy of Neurology showed that EEGs of the majority of children with migraine were assessed as normal or with non-specific changes. Besides, no changes in EEG can be shown to differentiate migraine from other causes of recurrent headache [17]. Although two thirds of cases had normal EEG findings, there were non-specific findings and findings consistent with vascular headaches in remainders. This suggests that EEG has low sensitivity for diagnosing migraine. Therefore, it should keep for selected cases. The frequency, duration and severity of headache are important in making the decision for prophylaxis in patients with migraine headache. Prophylaxis is required if the patient has three or more attacks per month or has severe pain despite the low number of attacks. The aim of prophylaxis is not only to prevent acute migraine attacks, but also to prevent acute attacks converting to a chronic condition [26]. In the present study, it was found that prophylaxis was effective for all agents. These findings indicate that: (a) migraine is the most common cause of headache, (b) it has negative effects on school performance and daily activities, (c) the family history is important for making the diagnosis and (d) prophylaxis is significantly effective. Therefore, we can conclude that comfort of these patients may be improved by early diagnosis and proper prophylaxis. But the findings may not be generalisable as the study population may vary from place to place.
Indian J Pediatr (2010) 77:1247–1251 Contributions to the article.
The authors report that each author has contribution
Conflict of Interest None. Role of Funding Source None.
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