Cranial autonomic symptoms in pediatric migraine are the rule, not the exception

Abstract

Objective: The presence of cranial autonomic symptoms often leads to a misdiagnosis of "sinus headache" in adult migraineurs, leading to unnecessary treatments and delaying appropriate migraine therapy. In this study, we examined the frequency of cranial autonomic symptoms in pediatric/adolescent patients with migraine.Methods: This cross-sectional study included all pediatric and adolescent patients with migraine evaluated by a single investigator at 4 different sites over the course of the study period.Results: Of 125 pediatric migraineurs, 62% had at least one cranial autonomic symptom based on current International Classification of Headache Disorders, second edition (ICHD-II) criteria, and 70% based on proposed ICHD-III criteria. The majority had more than one cranial autonomic symptom and the symptoms tended to be bilateral. Age, sex, laterality of headache, presence of aura, and whether migraine was episodic vs chronic did not influence the likelihood of having cranial autonomic symptoms. Conclusions:In pediatric/adolescent migraine, the presence of cranial autonomic symptoms appears to be the rule rather than the exception. Clinicians should be careful to consider migraine when evaluating a child with headache and associated ocular or nasal symptoms so as to avoid giving a misdiagnosis of sinus headache. Cranial autonomic symptoms are typically associated with the trigeminal autonomic cephalalgias, such as cluster headache.1 The anatomy and physiology of these symptoms, consisting of the trigeminal-autonomic reflex, have been described and are well understood.2 However, it is only recently that the implications of the data have been more broadly realized with the relatively high frequency, between 27% and 73%, of cranial autonomic symptoms in adult migraineurs. [3][4][5][6] Recognizing that cranial autonomic symptoms are a common component of migraine is important diagnostically and thus therapeutically. Sinusitis, which also may present with head pain, is one of the most common misdiagnoses given to migraineurs.7-10 In a pediatric study, nearly 40% of pediatric migraineurs were initially mislabeled as having "sinus headache." 11 Misdiagnosis puts these patients at risk of inappropriate treatments and procedures, and delays appropriate treatment of their migraine. In this study, we examined the frequency of cranial autonomic symptoms in pediatric patients with migraine presenting for care.The International Classification of Headache Disorders, second edition (ICHD-II) 12 includes the following cranial autonomic symptoms: 1) conjunctival injection, lacrimation, or both; 2) nasal congestion, rhinorrhea, or both; 3) eyelid edema; 4) forehead and facial sweating; 5) forehead/facial flushing; and 6) miosis, ptosis, or both. In ICHD-III, a sense of aural fullness 13 will be added as a cranial autonomic symptom. 14 METHODS Standard protocol approvals, registrations, and patient consents. This study was approved by the University of California, San Francisco (UCSF) Committee for Human Research (protocol ...

Neural mechanism for hypothalamic-mediated autonomic responses to light during migraine

“…The proportion of migraine patients in which photic stimuli induced autonomic responses was significantly higher during the ictal phase than during the interictal phase and compared with the percentage of control subjects. Building on the widely held view that autonomic regulation is altered during migraine (17)(18)(19)(20)(21), these findings offer insight into the possibility that it is hypothalamic regulation of parasympathetic and sympathetic functions that is abnormal during migraine, rather than the parasympathetic or sympathetic nervous systems themselves. However, because the induction of autonomic symptoms by light was altered during migraine only, when hypothalamic neurons are subjected to a barrage of nociceptive signals they receive from trigeminovascular/trigeminohypothalamic tract neurons (22,23), one must keep in mind the possibility that convergence of nociceptive signals from the meninges and photic signals from the retina are required to produce the abnormal hypothalamic-mediated autonomic responses reported here.…”

Predictors of Triptan Response in Pediatric Migraine

“…Perhaps this difference can be partially explained by the developmental aspects of migraine in the pediatric age group. For example, in children and adolescents with migraine, CAS are most often bilateral 31 , just as migraine headache in this age group is most often bilateral 2 . Given the involvement of the trigeminal autonomic reflex 32 in migraineurs with CAS, these migraineurs may more intensely activate the trigeminal afferent system, resulting in greater engagement of peripheral 5-HT 1B/1D receptors, which are the receptors targeted by triptans.…”

Errors in Recognition and Management are Still Frequent in Patients with Cluster Headache

“…The very different temporal patterns and duration of attacks in migraine and CH are key factors on distinguishing between these two conditions, as it is true that other features of these headaches can overlap. These overlapping features include the development of aura (known to occur in up to 20% of CH cases) [14], the pain intensity (2/3 of migraine patients also have severe pain), the existence of cranial autonomic symptoms (at least one of these symptoms is known to occur in about half of migraine patients) [15,16,17,18,19,20,21,22] or the presence of associated ‘migraine' features in CH attacks (in a large German cohort CH attacks associated photo/phonofobia in 61% and nausea and vomiting in 28% of cases) [13]. The IHS criteria of ‘strictly unilateral pain' may also cause confusion as switching attack sides has been reported in at least 10% of CH cases [23] and also in up to 10% of cases migraine attacks are strictly unilateral for years [24].…”