Vestibular Function in Migraine

SYNOPSIS
In order to evaluate vestibular function in migraine, electronystagmography (ENG) was used. Twenty migrainous patients in the headache free phase and free of drugs for at least one week prior to study, were studied. The ENG examination included spontaneous eye movements, bithermal caloric tests and rotatory tests.
The results showed vestibular abnormalities in sixteen patients (80%). Spontaneous nystagmus was found in nine patients (45%). Sixteen patients (80%) had adnormal caloric tests and fifteen (75%) had adnormal rotatory tests.
These findings suggest impairment in vestibular function in a large proportion of migrainous patients. The significance and a possible mechanism are discussed.     

Vestibular Pathways Involvement in Children With Migraine: A Neuro-Otological Study

( Headache 2010;50:71-76)
Objective.— To assess, during symptom free intervals, the clinical, audiological, and vestibular findings in a cohort of child migraine sufferers, with or without vertigo or dizziness or both.
Background.— In adults and children, dizziness and vertigo are frequently associated with migraine.
Methods.— Twenty-two child migraine sufferers with vestibular symptoms, aged 7-13 years (group A), and 18 child migraine sufferers without vestibular symptoms, aged 8-13 (group B) entered our study between January 2007 and June 2007. The characteristics of auditory functions and vestibular symptoms and signs were assessed and reviewed by a blinded physician.
Results.— The whole sample was found audiologically normal. In group A, 6 subjects had normal vestibular test results, whereas vestibular testing disclosed either peripheral or central sufferance or both, in the remaining 16 patients (73%). Twelve subjects from group B had normal vestibular test results whereas positive vestibular test results were reported in the remaining 6 subjects (33%).
Conclusions.— This single-blind work outlines the brain stem abnormalities in children with migraine in the form of direct involvement of peripheral or central vestibular pathways or both. Interestingly, some children with migraine but without vestibular symptoms also had abnormal results at vestibular testing. This could demonstrate a subclinical involvement of vestibular pathways without clinical presentation. The subjects are still being followed up to evaluate the evolution of symptomatology.     

IHS Criteria for Migraine and Tension-Type Headache in Children and Adolescents

We investigated the influence of age on the IHS criteria for migraine and tension-type headache in 437 consecutive children and adolescents and found the following age-associated statistically significant differences: migraine duration, occurrence of migraine aura, and bilateral location of tension-type headache were more often fulfilled by adolescents, whereas aggravation of headache by physical activity (in migrainous disorder) and photophobia (in migraine with aura) were more often fulfilled by children, Accordingly, there are only a few, differences concerning the fulfillment of the IHS criteria for migraine and tension-type headache in children and adolescents. Independent of age, the intensity of headache and the presence or absence of nausea are most important for differentiating the two major types of idiopathic headache. The sensitivity of the IHS criteria for migraine could be increased by reducing the minimum duration of migraine and by allowing the diagnosis of migraine when severe headache is associated with nausea, even though the criteria of location, quality, and aggravation by physical activity are not fulfilled.     

Inpatient Treatment of Status Migraine With Dihydroergotamine in Children and Adolescents

Objective.— To assess the effectiveness of aggressive therapy of status migraine in children and adolescents.
Background.— Inpatient management of pediatric status migraine and intractable headache is limited because of a lack of studies and guidelines. Adult treatment is often based on anecdotal experience, although a few controlled studies have been reported. Added to that is the discomfort of general pediatricians and neurologists in using available effective treatments in pediatric patients (such as dihydroergotamine: DHE).
Methods.— Charts of all patients admitted to the neurology service, at Cincinnati Children's Hospital Medical Center—Department of Neurology, for inpatient treatment for intractable headache/status migraine over a 6-week period were reviewed. Demographics, evaluation, diagnosis, and treatment used were tabulated. Data on the effectiveness of the treatments provided were evaluated. Thirty-two total consecutive charts were retrospectively reviewed during that period.
Results.— Upon discharge, 74.4% of the patients were headache-free. The mean severity of the pain upon discharge was 1.02 ± 2.22 (using the 0-10 pain scale).
Conclusion.— From our review, DHE is very effective in treating and aborting an episode of status migraine and should be offered to children and adolescent patients who have failed their usual abortive therapy to prevent further severe disability that mainly affects their schooling and social activities.     

Psychological and Behavioral Issues in the Management of Migraine in Children and Adolescents

Purpose of Review

It is sometimes assumed that children and adolescents with migraine have a psychiatric or behavioral comorbidity, a belief that can be stigmatizing. This review will examine the recent literature addressing this area to determine if pediatric and adolescent migraineurs are at increased risk for psychiatric comorbidity and to discuss management strategies.

Recent Findings

A large systematic review of pediatric and adolescent studies concluded anxiety and depression were not associated with onset of recurrent headaches. Children with increasing migraine frequency have reduced school attendance. Pediatric migraineurs have mildly lower quality of life (QOL) scores than healthy peers but not abnormally low. Finally, children with higher migraine frequency as well as migraineurs with aura were more likely to report suicidal ideation.

Summary

Migraine is a primary neurologic disorder. Migraine and psychiatric disorders may be comorbid; however, at this time, it can be difficult to clearly delineate some migraine features from psychiatric diagnoses with the current screening tools available. The majority of pediatric migraineurs do not have behavioral comorbidities; however, when such comorbidities occur, they should be addressed and appropriately managed. We need more accurate ways of delineating psychiatric and behavioral comorbidities from the migraine phenotype.

     

Menstrual Migraine in Adolescents

Objective.— To characterize menstrually associated headaches and migraine in adolescent girls and identify any developmental and pubertal changes. Background.— Headache and migraine is a common problem in adolescents with a transition to adult patterns. One pattern of adult migraine is the menstrual association in a significant number of women. Methods.— A retrospective analysis was performed of characteristics of adolescent's headaches including association with menstrual pattern. A detailed analysis of the patient‐ and parent‐reported headache characteristics and patterns of longitudinal change with development and puberty was reviewed, including timing of headache with age and menstrual period and progression of these events over the adolescence. Results.— Of the 896 girls between 9 and 18 years old reviewed at initial evaluation, 331 (50.3% of menarchal girls and 36.9% of all girls) report experiencing headaches with their menstrual period. Of those reporting a menstrual pattern, 63.6% reported migraines starting between day ?2 and +3 of their menstrual period start. Girls with menstrual migraine reported increased associated symptoms compared with girls without menstrual migraine. There was no difference in disability between girls with a menstrual pattern and those without a menstrual pattern (t = 1.64; P = .10). Additionally, 160 girls reported a monthly pattern to their headaches prior to beginning menstruation, suggestive of a menstrually related migraine pattern prior to menstruation. Conclusions.— The pattern of menstrual association begins to become apparent during adolescence. Once the menstrual pattern has developed, this association is stable. Early identification of this pattern has potential long‐term benefit for improved lifelong outcome.     

Migraine Headache Prophylaxis in Adolescents

Migraine headache is estimated to affect up to 28 percent of adolescents, most of whom are female. Chronic migraine in this population has been associated with reduced quality of life and academic disruption due to missed school days. Historically, migraine headache was treated episodically as it occurred. In March 2014 the U.S. Food and Drug Administration approved an existing medication, topiramate (Topamax®), for migraine prophylaxis in adolescents between the ages of 12 and 17. This is the first FDA approval of a drug for migraine prevention in this population. There are several possible adverse effects of taking topiramate, some potentially serious, so adequate education for adolescents and their families on all the potential benefits and risks is imperative.     

Clinical Feature: Migraine in Adolescents

Approximately 10% of children and adolescents suffer from migraines. They typically present to their primary care provider with recurrent, moderate to severe headaches, lasting 2 to 72 hours. Migraines can be disabling, causing adolescents to miss school and extracurricular activities. Taking a thorough history is crucial to making an accurate diagnosis and ruling out more serious conditions. Treatment for adolescent migraines includes lifestyle management, abortive medications, nonpharmacologic interventions such as cognitive behavioral therapy, and preventative medications if necessary. The future of treatment may be enhanced via training of more providers to deliver cognitive behavioral therapy and the development of Web-based delivery.