Migrainous disorders in children

The formal name for “childhood periodic syndromes” has changed from “childhood periodic syndromes that are commonly precursors of migraine” in ICHD-2 to “episodic syndromes that may be associated with migraine” in ICHD-3, partly because some of these disorders can affect adults.

“Recognizing these migrainous disorders can help children get the treatment they need and potentially eliminate extensive and sometimes invasive testing,” said Brian M. Plato, D.O., FAHS, medical director, headache medicine, Norton Neuroscience Institute.

Also, infantile colic was added in the appendix section as one of the syndromes in the ICHD-3.

“As they age, some children may evolve from periodic syndrome to another,” Dr. Plato said. “It’s important to note that between attacks, children have normal neurological exams.”

“Childhood periodic syndromes” listed by age of onset:

Infantile colic – Excessive crying in an otherwise well-fed and healthy infant from birth to 4 months. The diagnostic criteria for infantile colic in the ICHD-III are crying at least three hours acday, at least three days a week, for at least three weeks that is not attributable to another disorder.

Colic traditionally has been associated with abdominal discomfort, but colicky infants’ crying bouts typically are limited to the late afternoon or early evening while they are being fed around the clock. Also, gastrointestinal therapies have failed in several trials.

If colic is a migrainous disorder, the cause of the crying is unclear. It may be colicky infants are experiencing headaches, or that they have the same sensitivity to stimuli as adults with migraines.

There appears to be a genetic component to infant colic and migraines. Mothers with migraines are 2½ times as likely to have infants with colic. Also, infant colic is associated with an increased risk of both migraine with aura and without aura later in life.

Colic typically resolves around three months, possibly because infants’ endogenous melatonin secretion takes on a circadian rhythm, allowing for nighttime sleep consolidation.

Benign paroxysmal torticollis of infancy – Onset typically is around five or six months. The characteristic symptoms are periodic bouts of head tilts to one side, with or without head tilt, and at least one of the following symptoms or signs: pallor, irritability, malaise, vomiting and ataxia. Attack duration can be minutes but more often is hours or days, occurring at regular intervals, typically monthly.

Benign paroxysmal torticollis of infancy may be underdiagnosed, as only 2.4 percent of pediatricians were aware of it, but it also may be the rarest. The disorder usually begins to improve by age 2 and resolves by age 3 or 4.

Benign paroxysmal vertigo of childhood – Typical onset is between ages 2 and 5. Children with benign paroxysmal vertigo of childhood experience sudden and recurrent attacks of vertigo, usually lasting fewer than five minutes. The vertigo can be accompanied by headache, nystagmus, ataxia, pallor, nausea and vomiting. The child also may appear scared.

Because young children have difficulty articulating vertigo, parents can infer vertigo from periodic unsteadiness, just as they can infer sensitivity to light and sound in young children as migraines.

The requirement for a normal EEG in ICHD-2 has been removed. Obtaining an EEG probably is still worthwhile in cases where it is unclear if alteration of mental status is absent.

Some children outgrow the disorder, typically by age 5 or 6. For others, it can persist into adolescence.

Cyclic vomiting syndrome – Mean age of onset is 5.2 years. This syndrome is marked by episodes of frequent vomiting, often occurring at predictable intervals. Under the ICHD-3 criteria, the vomiting must be at least four times per hour. Attack frequency is typically once a month, with an attack duration of several days.

Gastrointestinal pathology should be ruled out. Pediatric neurologists also should consider autonomic seizures, metabolic disorders and, among adolescents, the recently recognized cannabinoid hyperemesis syndrome. Frequent cannabis use can lead to periodic vomiting syndrome accompanied by a predilection for bathing in hot water.

Acute treatment for cyclic vomiting syndrome is oral or IV hydration and antiemetics. Triptans also are effective in some patients, typically nasal spray or subcutaneous sumatriptan. The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition recommends cyproheptadine for children under age 5 and amitriptyline for children age 5 and up. An open label study found aprepitant effective for both acute and preventive therapy.

Abdominal migraine – Typical onset is school-age children. Mean onset is 7 years, with a prevalence of 4.1 percent among children ages 5 to 15. Abdominal migraine is characterized by abdominal pain lasting for two to 72 hours. The pain typically is dull, poorly localized, and often in the midline. Other symptoms during the attacks may include nausea/vomiting, anorexia and pallor.

Treatment with a migraine preventive should be considered. Sumatriptan nasal spray may help with acute attacks.

For pediatric neurology referrals at Norton Children’s, call (502) 588-3650 or make an online referral here.

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