Pediatric Headache

Commonly, children have periodic syndromes that develop early as precursors to migraine. These periodic syndromes include paroxysmal torticollis of infancy, benign paroxysmal vertigo of childhood, cyclic vomiting syndrome, and abdominal migraine.

Paroxysmal torticollis of infancy is an uncommon disorder characterized by repeated episodes of head tilting associated with nausea, vomiting, and headache. Attacks usually occur in infants and may last from minutes to days. Posterior fossa abnormalities need consideration in the differential diagnosis. Recent data have linked these symptoms to mutations in the CACNA1A gene in some patients. Optimal treatment is unknown, but when necessary, antimigraine preventatives are used.

Benign paroxysmal vertigo of childhood is a condition characterized by brief episodes of vertigo, disequilibrium, and nausea, usually found in children aged 2 to 6 years. The patient may have nystagmus within but not between the attacks. The child does not have hearing loss, tinnitus, or loss of consciousness. Symptoms usually last only a few minutes. These children often develop a more common form of migraine as they mature.

Cyclic vomiting syndrome is manifested by recurrent periods of intense vomiting separated by symptom-free intervals. Many patients with cyclic vomiting have regular or cyclic patterns of illness. Symptoms usually have a rapid onset at night or in the early morning and last 6 to 48 hours. Associated symptoms include abdominal pain, nausea, retching, anorexia, pallor, lethargy, photophobia, phonophobia, and headache. The headache may not appear until the child is older. Cyclic vomiting syndrome usually begins when the patient is a toddler and resolves in adolescence or early adulthood; it rarely begins in adulthood. More females than males are affected by cyclic vomiting. Usually a family history of migraines is present. These children often experience severe fluid and electrolyte disturbances that require intravenous fluid therapy. Some children with cyclic vomiting respond to antimigraine drugs, such as amitriptyline or cyproheptadine. Migraine-associated cyclic vomiting syndrome is a diagnosis of exclusion. Other causes of cyclic vomiting include gastrointestinal disorders (malrotation), neoplasms, urinary tract disorders, metabolic, endocrine, and mitochondrial disorders.

In abdominal migraine, the patient may suffer from recurrent bouts of generalized abdominal pain with nausea and vomiting but often with no headache present. The episodes are often relieved by sleep, and later the child awakens feeling better. Abdominal migraine may alternate with typical migraine and can lead to typical migraine as the child matures. These children respond to migraine prophylactic medication.

The presence of fixed neurologic deficits, papilledema, or seizures should alert the physician to more concerning neurologic processes. In these instances, a neuroimaging study, such as a head MRI, should be considered.

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