Pediatric Migraine Headache: An Evidenced-Based Approach

Condra, Cole S. MD, MSc, FAAP
Knapp, Jane F. MD, FAAP, FACEP
Gerardi, Michael MD, FAAP, FACEP
Khine, Hnin MD
Rust, Robert S. Jr. MA, MD

¹Authors
²Assistant Professor of Pediatrics, Division of Emergency Medical Services, Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
³Associate Chair of Education, Children's Mercy Hospitals and Clinics, Professor of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
⁴Peer Reviewers
⁵Clinical Assistant Professor of Medicine, University of Medicine and Dentistry of New Jersey; Director, Pediatric Emergency Medicine, Children's Medical Center, Atlantic Health System; Department of Emergency Medicine, Morristown Memorial Hospital, Morristown, NJ
⁶Associate Professor of Clinical Pediatrics, Albert Einstein College of Medicine, Attending Physician, Children's Hospital at Montefiore, Bronx, NY
⁷University of Virginia Thomas E. Worrall, Jr. Professor in Epileptology and Neurology, and Professor of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia

Prior to beginning this activity, please see “Physician CME Information” on the back page.

Pediatric Emergency Medicine Practice 7(2):p 1-22, February 2010.

Case #1

Prior to beginning this activity, please see “Physician CME Information” on the back page. It's a gorgeous June day in Kansas City, and a 12-year-old girl is the first patient of your evening emergency department (ED) shift. She reports a severe headache over the left side of her head for the past 4 hours that has not been relieved with acetaminophen and ibuprofen at home. According to the patient, this headache “gets worse when my brother talks to me,” “makes me squint my eyes,” and “makes me feel like I'm going to throw up.” This is her first headache like this in her entire life. The patient's examination is unremarkable with a completely normal neurological examination. She rates her headache a 9 out of 10.

On further history, her mother reports that both the mother and the patient's older sister have a diagnosis of migraine headaches. The mother states, “I know she's having a migraine, but I couldn't fix it at home.” Although you agree with the mother's assessment, you aren't sure if you can classify her daughter as a migraineur just yet.

Case #2

You're in the middle of your third overnight shift in as many days when you walk into a darkened examination room. You find a 9-year-old boy lying on the stretcher with his eyes closed and a grimace on his face. His mother sits in the chair next to him appearing anxious and worried. When you ask how you can help them, his mother quickly blurts out, “I wish someone would take his headaches seriously.”

She goes on to say that her son has reported headaches every “couple of weeks” for the past year. He has been seen several times by his pediatrician, who recommends ibuprofen which “doesn't work anymore.” He often vomits when he gets his headaches, but he never has neck pain, sore throat, or a fever with these episodes. The headaches last for “about a day” and sometimes get better when he takes a nap. He has missed 10 days of school this year for his headaches, and the school is “threatening to kick him out.” He states that his current headache has been ongoing for 8 hours.

Your examination shows a child in apparent pain. His vital signs are all normal, and his examination is completely benign, including a normal neurological examination. He rates his headache (which is bilateral fronto-temporal in location) as an 8 on the Faces Pain Scale-revised (FPS-R).

His mother admits to having headaches herself “every month, like clockwork” with her period. As you prepare to discuss your likely diagnosis, she interjects, “You're going to x-ray his head, aren't you? I worry that he might have…you know…a tumor.”

Case #3

You're working a busy evening shift in your ED, when the charge nurse approaches you about a 17-year-old female that was just placed in the trauma room. The charge nurse states that she is not sure what's wrong with the girl, but her presentation reminds the charge nurse of her mother's stroke. You walk into the resuscitation room and find her lying on the stretcher holding the back of her head. All of the lights are off in the room, except for the glow of the radiology light-boxes. Out of habit, you turn the lights on in the room as you walk in, eliciting a cry from the patient to “turn them back off!” She and her mother state that she has had this type of headache before, and she says it always hurts the back of her head. She started seeing “floaters” yesterday, and she took some ibuprofen without relief. This morning, she “couldn't see straight,” and she reports that she “sometimes sees double.” There is a constant ringing in her left ear, and she gets “dizzy when [she] stands up.”

Your examination from head to toe is normal, except for her neurological examination. Upon standing, she states that she is dizzy and leans against you. When you assist her walking, she is grossly ataxic. A Snellen eye test is unable to be completed since she reports doublevision. At this point, her mother states that her daughter “usually speaks more clearly” than this, and it sounds like she is “slurring her words.” She then whispers to you, “Could she have taken something?”

At this point, you wish that you hadn't signed up for this extra moonlighting shift…