Treating Migraine in Teenagers

Given this, a thorough history, family history, physical exam, and detailed neurologic exam including fundoscopy are imperative. In addition to the general neurologic exam, a focused headache exam should be performed, including Mueller’s maneuver, auscultation for cranial bruits, evaluation of the temporomandibular joint, palpation of possible trigger points, and maneuvers to assess for cervical spine disease [4].

Classification of Symptoms

Once establishing the likelihood of a primary headache disorder, the International Classification of Headache Disorders, 3rd edition, beta version (ICHD IIIβ) [5]should be used to classify the headache diagnosis. Note that while this classification system was established for adults, most criteria are similar for children and adolescents, and the typical differences are noted in the comments of the ICHD IIIβ [5].Migraine is the most common type of primary headache brought to medical attention [1]. Migraine without aura is described as a recurrent headache disorder (at least 5 lifetime attacks) with attacks lasting 4 to 72 hours, typically unilateral, throbbing in nature, moderate to severe in intensity, aggravated by routine physical activity, and associated with nausea and/or photophobia and phonophobia. In young children, migraine is more frequently bilateral, the gastrointestinal symptoms often more pronounced than photophobia and phonophobia, and migraines may be shorter, lasting at least 2 hours without treatment [5].As patients reach adolescence, migraine features typically start to evolve into patterns described in adults. Differentiating migraine from other primary headaches, such as tension-type, can be challenging, especially in children in whom migraines are more likely to be shorter and bilateral. Tension-type headaches are bilateral or diffuse, pressing or tightening pain that is non-pulsatile lasting at least 30 minutes. The pain is described as mild to moderate in intensity and not aggravated by activity [5].They may be associated with photophobia or phonophobia (not both) and they may not be associated with nausea or vomiting [5].

• Is any further workup indicated?

The patient has recurrent headaches which have been present for 5 years. While they have increased in frequency, there has not been any change in their quality. His headache description and history have no “red flag” features, and a thorough examination is normal. Therefore, neuroimaging and further workup would not be indicated in this case.

• What is the diagnosis?

The patient’s headaches are throbbing in nature, exacerbated by activity, associated with nausea, photophobia, and phonophobia, and are moderate to severe. Using the ICHD IIIβ, he meets criteria for migraine without aura. While his headaches are frequent, he is having less than 15 headache days per month, so this is episodic migraine. Note that he complains of forehead and periorbital pain and occasional rhinorrhea with his headaches, leading him to have been placed on loratadine for treatment of presumed allergic sinusitis. Children meeting criteria for migraine are very frequently misdiagnosed as having sinusitis [6]due to the overlap in location of migraine pain and proximity to the frontal and maxillary sinuses, as well as the presence of autonomic features frequently present in migraine, reportedly present in 70% of pediatric migraine patients [7].The negative headache examination, including Muller’s maneuver, points against sinus disease as well.