Pediatric Migraine mostly goes under-diagnosed. Children suffer in silence while parents and teachers attribute their genuine complaints of headache to 'excuses for laziness/ truancy/absenteeism'. A careful study of symptomatology, elicitation of history and having a broad view can help make a reasonably good diagnosis and help in initiating treatment to ameliorate the condition of the child.
We recently had an 8 year old girl who was brought to our ER with history of febrile illness of 7 days, altered sensorium, recurrent vomiting since 3 days and one episode of generalized seizures (1 hour before entering our ER). She also had tested positive for Dengue and had a platelet count of 36000 cells/cmm (investigated at the referring hospital) . Her examination revealed exaggerated deep tendon reflexes, Bilaterally equal and reacting pupils, hypertonia, positive signs of meningeal irritation,upgoing plantars and altered sensorium. A provisional diagnosis of viral meningo-encephalitis was made.
Neurological imaging studies and fundoscopy were normal. Blood investigations were also normal except for the low platelet count of 62000 (from our lab). Serum electrolytes, LFT, KFT were normal. CSF analysis showed mild pleocytosis with marginally elevated proteins, normal glucose and 18 lymphocytes.
The girl was admitted to the ICU and was started on anticonvulsants, antibiotics and IV fluids. During the course of detailed history elicitation from the mother of the child, it was incidentally reported by her that there was a family h/o seizure disorder (from the child's father's side) and H/o migraine & depressive disorder from mother's side. The mother also had a stroke during her teenage. The child's elder sibling - who was a medical student, also apparently had GI tuberculosis 3 years back and underwent surgery. Both siblings had received 6 months of Anti tuberculosis treatment for a period of 6 months, and were regular. Both siblings were high achieving, brilliant students. The elder sibling had also received some anti-migraine medications and also some treatment for depression. The patient had complained of recurrent headache bouts since childhood- which the parents ignored and scolded her for. She had also recently started avoiding school in spite of getting good grades.
The child was admitted to the ICU and spent the rest of the time till following morning- in sleep.16 hours after admission, I went to the ICU to check on her- and found her in very good spirits- smiling, conversing well and asking for oral feeds. I was absolutely stunned to see the child in this stage, and knew that the diagnosis required a definite and careful revision.
At this stage- probable ideas floating around were those of - viral meningo encephalitis, TB Meningitis- and Migraine. I referred a large amount of literature online and in books and ascertained that it was indeed possible that all the symptoms could be explained by a single diagnosis of migraine- but I had to rule out everything else before confirmation.
CSF pleocytosis probably occured as a result of the seizure event- which in turn could have happened in a 'migraine without aura with status migranosus'. The presence of meningeal signs in migraine has also been reported.
After half an hour of talking to the mother, I went to the library, and immediately received a call from the ICU informing me of a bout of headache the child had- I ordered an Injection of Paracetamol, and by the time I reached the ICU, the attack had abated. The child was drowsy, and did not co-operate for examination.
After a span of 6 hours, she was back to her normal self and again accepted oral feeds. An EEG was done which almost fit the description of EEG changes in migraine word for word. No epileptiform discharges were recorded.
The child was shifted out to the wards, and continued to have frequent bouts of headache (lasting for 20 minutes) in spite of oral Paracetamol. The mother also told me that the child was absolutely normal in between the episodes and that she could accurately predict the coming headache bouts.
I added on Ibuprofen+ Paracetamol for her, and over the next 2 days observed that her headache frequency and severity had reduced dramatically. Her meningeal signs had reduced in expression- save for terminal neck rigidity, and tendon reflexes were normal. Plantar reflex was now flexor bilaterally.
A repeat CSF analysis was done (5 days after the initial check) and revealed almost the same picture - 15 lymphocytes, elevated protein and normal sugars. A sample was sent for PCR as well. Mantoux test was negative, Smear for Malarial parasite was negative on 2 occasions, Blood ESR was normal.
I stopped the anticonvulsant medications altogether, and there were no recurrences. The child seemed reasonably stable and everyone heaved a big sigh of relief when the PCR report came as negative.
Anti migraine prophylaxis was started on discharge, and the mother and child were reassured. Possible triggers for migraine were explained, and they were also directed to convey the same information to the child's school teachers.
On review- it was heartening to see an absolutely brilliant and happy child who would not suffer, and work her way towards success.
How has your experience been with pediatric migraine cases?
Hi and thank you for a very interesting case indeed!
I had a somewhat similar case of a 15 year old girl that was complaining about sudden-onset, constant headache (that rather fit the criteria for TTH) and malaise. Since Borrelia is endemic here (Westcoast of Sweden), a lumbar puncture was done and showed mild pleocytosis and elevated protein. She was put on oral Doxycycline (our treatment of choice for neuroborreliosis in children >8 years), but no improvement occurred and finally, antibodies in CSF were negative. A cranial MRI was negative. When she continued to have headache and pleocytosis, an acute MR of the spinal cord was done to exclude CSF-infection or malignancy.
After all this (and loads of other investigations) I decided to go back to taking a serious history: the patient had had regular migraine attacks before the new form of headache. The last weeks, she had been taking OTC-drugs for her headache to an extent that fulfills the diagnosis of medicament-induced headache. I sent her home for detoxification, not allowing her to take medicaments in more than 9 days per month.
Her headache initially even worsened and then - disappeared! Since then she started to have her regular migraine-attacks that were treated with triptanes with good effect.
This is the good part of the story. I followed her for another year and she was doing fine.
Just by incidence, i happened to look into her journal some year later (when she already was too old for our children's hospital) only to see that she developed a severe and obviously therapy-refractable optic neuritis...
Wether there was any connection between these two dignities is up to speculation!
Thanks for opening the discussion of this interesting topic. One of the interesting cases I diagnosed is 9 year old boy who presented with abdominal migraine. He visited outpatients' clinics and even admitted many time with the diagnosis of Gastroenteritis because of the repeated vomiting.
What attracted may attention is the frequent visiting to the ER with the diagnosis of gastroenteritis. When I reviewed the past history of the child, there was no diarrhea or fever with any of the visit and all the labs were normal.
First I put into consideration abdominal epilepsy versus abdominal migraine.
There was a positive family history of migraine as his mother has typical classic migraine. There was no past or family history of epilepsy. The attacks were accompanied with headache but not followed by any behavioral changes or post-ictal drowsiness. There was also a family history of marital problems and the parents were about to divorce and he was the only child and felt unsecured. EEG proved to be normal.
The child should marked response for antimigraine medications and marital counseling had markedly decreased the frequency of the attack.
It is absolutely wonderful to see physicians sharing their experiences regarding this often underdiagnosed condition afflicting children.
Please keep up the good work and the excellent standards of care.
Colleagues ,How effective do you find simple Ibuprofen + Paracetamol in abating migraine attacks?. Do you use it as first line medication?.
Hi Indrajit, your case must have been quite challenging. We see a large proportion of children with tension headache. Few children did satisfy the International headache society criteria for migraine. Most of these children are usually girls with headache lasting for 1-4 hours, bifrontal type and rarely unilateral with photophobia and phonophobia. Usually a family history of migraine in the mother is forth coming. I am yet to see a child with migraine with any sort of aura. I prescribe paracetamol and domperidone combination for acute attack and if symptoms are severe, rarely sumatriptan in adolescents. For prophylaxis, I use propranolol or flunarizine.
Dear colleagues, I have been diagnosing migraine quite frequently and using paracetamol and ibu profen with reason able success. One clue that I frquently find in these patients is the extreme dislike for nnoise and sounds during the episodes of headache. Also if the treatment is started immediately at the start of the symptoms and child is kept in quiet and less illuminated environmet the duration of episode can be reduced. Sleep also helps. I think the history and proper clinical examination can reduce the requiremnts of excessive investigations.
In my experience there is not much difference between paracetamol and ibu profen. Domperidone does help in selective cases
A really interesting patient presented to us last week.
A 5 year old child with history of sudden onset of abdominal pain (predominantly central), recurrent episodes of non bilious vomiting, No history of fever or dysuria. No Malena. No visual disturbances or ear discharge.
Systemic examination was unremarkable, abdomen was soft, non tender, and no gross organomegaly or discoloration of flanks/ guarding/ rebound was detectable. Bowel sounds were sluggish.
Blood counts were unremarkable, X-Ray abdomen (erect)/ USG Abdomen/ Bladder and CT Abdomen were normal.
Liver enzymes, pancreatic tests were normal.
The surgeon had advised laparoscopy in case of persistence of pain, but on the drive back home, I suddenly had a flash of something I had seen in Nelson Textbook of Pediatrics which hit me suddenly, and I simply HAD to call the kids mother and ask her for history of Migraine- and Bingo!- she did indeed suffer from Migraine and was treated with Sibelium.
A strong possibility of Abdominal Migraine came to the forefront, and thereafter child was put on ibuprofen and significantly improved.
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