Diagnosis of childhood migraine

• assessment of a child with a headache is mainly clinical - radiological imaging is rarely required
• history of the headache should assess:
  • nature and quality of pain
  • intensity of pain
  • site and spread of pain
  • frequency and duration of headache
  • associated symptoms
  • trigger or predisposing factors
  • aggravating and relieving factors
• ideally a full neurological examination should be undertaken - including visual field testing and fundoscopy
• growth, blood pressure and visual acuity should be assessed

In general, neurological examination and investigations reveal no abnormalities in children with migraine (1).

Indications for imaging include:

• abnormal neurological findings - especially if accompanied by nystagmus, papilloedema or gait or motor abnormalities
• headaches that repeatedly wake a child from sleep or occur immediately on awakening
• persistent headache associated with substantial episodes of confusion, vomiting or disorientation
• also "imaging is also probably worth carrying out in children whose symptoms develop before the age of 5 years "

Note1: a common fear among parents is that their child's headache may represent symptoms of a brain tumour. There is evidence from a retrospective study of 74 children diagnosed with a primary brain tumour that 24% had been diagnosed as having migraine (2). Also this study suggested that personality and behaviour changes are common in children with brain tumours, and that the associated headaches can differ considerably from the classical brain tumour pattern of early morning headaches and vomiting associated with raised intracranial pressure.

Note2: migraine is approximately 50% more likely in relatives of people with the condition than in those whose relatives do not have migraine.

Reference:

1. Drugs and Therapeutics Bulletin (2004), 42 (4), 25-8.
2. Edgeworth J et al. Why are brain tumours still being missed? Arch Dis Child 1996; 74:148-51