Can We Really Stop Pediatric Migraine?

Abstract

Pediatric primary headache is one of the leading health care issues in high-income countries that is rising in prevalence. 1 Frequent headaches are strongly associated with a lower quality of life and poorer academic performance and are a leading cause of school absence. 2 The classification system of the International Headache Society provides a navigation system to phenomenologically diagnose migraines, tension-type headaches, and other primary headaches (http://www.ihs-classification.org/_downloads/mixed/ International-Headache-Classification-III-ICHD-III-2013-Beta. pdf); however, pediatric-specific factors have not been considered sufficiently. 3 A migraine is not just a headache-it is a complex neurological condition. More than 60% of children with migraine display a premonitory phase before the migraine attack. It is characterized by various symptoms, such as pallor or shadows under the eyes, fatigue, irritability, anxiety, phonophobia, yawning, photophobia, nausea, and, less commonly, concentration problems, food craving, cacosmia, hyperactivity, stiff neck, neck pain, sadness, and sleep problems. 4 More than 50% of children with migraine show cranial autonomic symptoms, such as a red ear, facial flushing, conjunctival injection, lacrimation, nasal obstruction, facial sweating, ptosis, yawning, rhinorrhea, eyelid edema, or miosis. The cranial symptoms are bilateral in 70% of cases. 5 A migraine attack may also be accompanied by other autonomic symptoms (nausea, vomiting, frequent urination, and diarrhea), affective symptoms (depression and irritability), cognitive symptoms (eg, attention deficit, difficulty finding words, or transient amnesia), and sensory symptoms (photophobia, phonophobia, osmophobia, and cutaneous allodynia). 6 Patients with migraine, especially those with migraine with aura, more often experience various transient sensory and neuropsychological symptoms like visual illusions (eg, autokinesis, corona phenomenon, cinematographic vision, double vision, metamorphopsia, visual splitting, dyschromatopsia, and illusionary visual spread) or complex higher cortical dysfunctions (altered perception of body size, weight, or position in space). 7 Therefore, a useful rule for pediatricians and pediatric neurologists is to believe a child with a migraine who tells you strange stories.Some key differences between children and adults in migraine presentation are evident. For example, during the migraine attack, children often show bifrontal or bitemporal pain instead of the clear pain laterization reported in adults. Additionally, the migraine attack duration in children can be shorter than in adults, for whom it typically lasts many hours. 3 Fur-

Treating Migraine in Children and Adolescents

“…As experts, we agree with Zernikow that “migraine is not just a headache” and thus struggle with the advice that the “…cornerstone of treatment… is pain education.” Rather, it is education based on the underlying problem, which is very rarely education just about pain. Moreover, we agree that “globally, migraine experts recommend the regular use of pharmacologic prophylactic treatment in childhood.” However, this is where our agreement ends.…”

“…To the Editor We read with interest the Editorial by Zernikow regarding the meta-analysis published in JAMA Pediatrics on pharmacologic migraine prevention in children and adolescents. As experts, we agree with Zernikow that “migraine is not just a headache” and thus struggle with the advice that the “…cornerstone of treatment… is pain education.” Rather, it is education based on the underlying problem, which is very rarely education just about pain. Moreover, we agree that “globally, migraine experts recommend the regular use of pharmacologic prophylactic treatment in childhood.” However, this is where our agreement ends.…”

“…Zernikow recommends we “reconsider recommendations and rewrite guidelines.” In 2019, after conducting a systematic review, the American Headache Society and the American Academy of Neurology rewrote the guidelines on migraine preventive treatment in children and adolescents. These recommend that “clinicians should engage in shared decision-making regarding the use of short-term treatment trials (a minimum of 2 months) for those who could benefit from preventive treatment (Level B) …”

“…The implication is that lifestyle choices are responsible for the current migraine frequency, and failure to change will cause migraine frequency to persist. We are aware of no randomized clinical trial evidence to suggest, for example, that “becoming active in sports to reduce the number of migraine attacks” is an evidence-based recommendation in these age groups. We also take issue with the emphasis “behavioral factors” were given in guidelines provided evidence for these is based on observational data, with no systematic review conducted.…”

Treating Migraine in Children and Adolescents—Reply

“…For many years they have striven to lessen the pain of children with chronic headaches. Their letter in response to my Editorial on the excellent article from Locher et al provides me with the opportunity to differentiate my biopsycho-social perspective on migraine.…”