Boy With Severe Weekly Headaches Associated With GI Upset

THE CASE:

A 12-year-old boy complains of severe weekly headaches that last 2 to 3 hours. The pain involves both sides ofthe head and the frontal and occipital areas. Occasionally during a headache, the patient complains of some abdominaldiscomfort and pain. He becomes passive and irritable during the headache; he does not want to be aroundpeople, play, or even watch TV. The patient's parents note that a few hours before a headache, he becomes somewhatrestless and agitated. The headaches started about 1 year earlier, and the headache pattern (frequency, duration,location of pain, and associated symptoms) has not changed since that time. The patient's mother and maternalgrandmother suffer from migraine.At the onset of the headache, the patient is usually given acetaminophen, 325 mg, after which he sleeps for 1 or2 hours. When he awakens, he is usually headache-free, and the associated symptoms have dissipated.Starting at age 7 years, the patient had episodes of stomach pains accompanied by moderate to severe nauseaand vomiting; these symptoms occurred approximately once weekly and lasted 2 to 3 hours. The results of severaldiagnostic studies of the GI system and urinary tract were negative. The frequency and severity of these abdominalsymptoms began to subside at about the same time the headaches started.

Is there a connection between this patient's current headaches and the frequent GI symptoms that he had when he was younger? How would you arrive at a diagnosis?What interventions would alleviate both his headaches and his GI symptoms?

THE DIALOGUE:

Primary care doctor:

Because the results of a thoroughGI workup were negative, pathologic organic changesare unlikely to be the cause of this patient's abdominalsymptoms. Do you think that these symptoms and hisheadaches are related?

Headache specialist:

In children, periodic stomach complaintsthat have no obvious physical cause may representabdominal migraine.

Primary care doctor:

What factors in the history pointto a diagnosis of abdominal migraine?

Headache specialist:

First, the results of various diagnosticstudies were normal. Also, the regular occurrenceof his symptoms, the associated signs (such asnausea and vomiting), the absence of fever, and theduration of the symptoms (a few hours)--in conjunctionwith the patient's young age and family historyof migraine--all point to the diagnosis of abdominalmigraine.As this patient grew older, the weekly migrainelikeheadaches that are occasionally associated with abdominalcomplaints eventually "replaced" his weekly episodesof abdominal pain, nausea, and vomiting.

Primary care doctor:

What are the diagnostic criteria forabdominal migraine?

Headache specialist:

In the

International Classificationof Headache Disorders,

2nd edition, which was proposedby the International Headache Society in 2003, abdominalmigraine is described as an idiopathic recurrent disorderseen primarily in children.

¹

To establish the diagnosisof abdominal migraine, the following criteria mustbe met:

• The patient has experienced at least 5 attacks of abdominalpain lasting between 1 and 72 hours.
• Clinical characteristics of the pain include midlinelocation (or poorly localized pain), moderate or severeintensity, and associated nausea or vomiting.
• The patient is pain-free and symptom-free betweenepisodes.
• The pain cannot be attributed to other disorders.

Concomitant migraine and a family history of migraineare also helpful in establishing the diagnosis.

Primary care doctor:

This boy's headaches lack sometypical migraine features, such as unilateral location ofthe pain and a throbbing quality. Why do you think thispatient is experiencing migraine?

Headache specialist:

First, childhood migraine differsfrom migraine in adults. Children rarely complain of asevere, throbbing, unilateral headache located in thetemple. Usually, they describe the headache as an acheor simply continuous moderate or severe pain. In somecases, children complain of pressurelike (rather thanthrobbing) pain. The pain of childhood migraine is typicallynot localized to either side of the head; rather, it isa "global" headache, with pain located bilaterally or involvingthe entire head. Thus, there is no "classic" childhoodmigraine--or at least none that includes all thestandard clinical features of adult migraine.

Primary care doctor:

In this patient, which clinical featuresmost strongly suggest the diagnosis of childhoodmigraine?

Headache specialist:

It is important to look for an overallclinical pattern that suggests migraine rather than focuson specific clinical features; however, some specialistsbelieve that more attention should be paid to pain severity,duration, and associated symptoms.

²

Although clinicalpresentations vary, affected patients tend to ratetheir headaches high on the severity scale. The durationof childhood migraine is close to that of typical adultmigraine--from 4 to 72 hours--although there is a tendencytoward shorter durations, as in this patient. Suchclinical features as pain quality and location have lessdiagnostic value.Pay attention to associated symptoms and behavior.Children typically complain of nausea and vomiting duringa severe migraine episode; they may also complain of lightand sound sensitivity. In addition, you may observe specificbehavior patterns--stopping play, ceasing to watch TV,staying alone in a quiet room and, perhaps, napping.

Primary care doctor:

How often do you see abdominalmigraine in your clinical practice?

Headache specialist:

Abdominal migraine is one of anumber of pediatric migraine equivalents; these occurin about 10% of children with migraine and in almost2% of all children..

³

Primary care doctor:

What are some other pediatric migraineequivalents?

Headache specialist:

Other common migraine equivalentsare benign paroxysmal vertigo of childhood andcyclic vomiting.

^1,3

Migraine equivalents do not occur asoften in adults.Benign paroxysmal vertigo of childhood is the mostcommon migraine equivalent. Episodes are usually notdangerous and are short-lasting (from a few minutes tohours). These recurrent episodes of vertigo in otherwisehealthy children may sometimes be associated with nystagmusand vomiting. Tests of the vestibular and auditoryfunctions, as well as an electroencephalogram (performedbetween attacks), should not reveal any abnormalities.

¹

Cyclic vomiting refers to recurrent attacks of severenausea and vomiting with a frequency of 4 episodesper hour for at least 1 hour. The duration of an attackranges from 1 hour to several days. Patients are otherwisehealthy.

¹

A thorough headache history can often help withthe diagnosis of migraine equivalents. It usually revealsa family history of migraine. In addition, approximately70% of children in whom abdominal migraine is diagnosedhave coexisting typical migraine.

³

Primary care doctor:

If the patient cannot provide all theinformation you need--such as the severity of the painor its location--what tools might be used to facilitatediagnosis?

Headache specialist:

When a patient is unable to provideimportant information that would help establish the diagnosis--either because he or she is very young or forsome other reason--ask the child to draw his headache.Children can produce very insightful headache drawings.The most significant elements in such drawingsare those that suggest a throbbing and pounding qualityand the presence of associated symptoms such as nauseaand vomiting. One study demonstrated that thismethod has 93% sensitivity and above 80% specificity.

⁴

This inexpensive and convenient method can be usedby any practitioner.

⁴

Primary care doctor:

What are the treatment options?

Headache specialist:

In general, the strategy in childrenis the same as that used in adults, although the medicationsare different. If a child has episodic uncomplicatedmigraine, find an effective and safe abortive medication.For children with chronic migraine (15 or more days ofmigraine per month for 3 consecutive months), considerpreventive medications as well.For abortive therapy, we recommend isometheptenemucate, ketorolac, or prochlorperazine.

⁵

On occasion,children's preparations of ibuprofen or acetaminophenmay be helpful. In children older than 8 years, sumatriptannasal spray may be used, but only after otherabortive medications have proved ineffective. In a double-blind, placebo-controlled study that included childrenolder than 8 years who had migraine, sumatriptannasal spray was effective and generally well tolerated.

⁶

The most frequently prescribed prophylactic medicationsin children are tricyclic antidepressants (amitriptyline,protriptyline) and the serotonin/histamineantagonist cyproheptadine..

⁷

In addition, some studieshave shown that valproate sodium is effective in thispopulation.

⁸

Consider medications with sedating features,such as amitriptyline, in children who also have asleep disturbance. With all agents, evaluate liver functionregularly and, if needed, obtain drug serum levelsto monitor for possible complications and side effects.

References:

REFERENCES:

1.

International Headache Society.

International Classification of Headache Disorders.

2nd ed. Oxford, England: Blackwell; 2003:94-95.

2.

Dominguez SM, Santiago GR, Campos CJ, et al. Childhood headache. A diagnosticapproach.

An Esp Pediatr.

2002;57:432-443.

3.

Al-Twaijri WA, Shevell MI. Pediatric migraine equivalents: occurrence andclinical features in practice.

Pediatr Neurol.

2002;26:365-368.

4.

Stafstrom CE, Rostasy K, Minster A. The usefulness of children’s drawings inthe diagnosis of headache.

Pediatrics.

2002;109:460-472.

5.

Brousseau DC, Duffy SJ, Anderson AC, et al. Treatment of pediatric migraineheadaches: a randomized, double-blind trial of prochlorperazine versus ketorolac.

Ann Emerg Med.

2004;43:256-262.

6.

Ahonen K, Hamalainen M, Rantala H, et al. Nasal sumatriptan is effective intreatment of migraine attacks in children. A randomized trial.

Neurology.

2004;62:883-887.

7.

Lewis DW, Diamond S, Scott D, et al. Prophylactic treatment of pediatric migraine.

Headache.

2004;44:230-237.

8.

Serdaroglu G, Erhan E, Tekgul H, et al. Sodium valproate prophylaxis inchildhood migraine.

Headache.

2002;42:819-822.