A pediatric migraine diagnosis starts with a thorough patient history. I start by having the child or adolescent characterize their headache. What is its location, what does it feel like, how long does it last, and is there associated light or noise sensitivity or nausea? For the young children, this is ascertained by asking if they want to be in a dark or quiet room, or if they complain of stomach upset. I also find out about the onset and temporal course of the headache: When did the headaches start, have they become more frequent over time, and has there been a progression in the intensity of the headaches?
It is also quite important to identify headache triggers. I always ask about sleep schedule, eating habits, and fluid intake, as well as potential stress triggers, as these frequently impact on headaches.
It is appropriate to manage children in the primary care setting when they respond to fairly benign, over-the-counter medications, such as ibuprofen or acetaminophen, or triptan medications in the older kids. Refer to a specialist when your patient is not responding to these types of medications, when the headaches are becoming more frequent or severe, or if you have concerns about your patient’s neurologic status.
Also check family history because migraine is strongly genetically based. A family history of migraine headaches coupled with a typical headache character and normal neurologic exam can support your diagnostic suspicion.
In addition to taking a good history, it is critical to perform a detailed neurological examination to exclude any abnormalities that might suggest a more serious underlying cause for the headaches. It is especially important to look at their optic disks to rule out any evidence of increased intracranial pressure or papilledema. If you are unable to perform this type of exam, it is best to refer your patient to an ophthalmologist for a complete ophthalmologic exam. Any focal neurologic abnormalities should prompt a neuroimaging evaluation such as an MRI.
Evaluate for other headache types. Ask about stress triggers. Kids get stress- or tension-type headaches just like adults. When I see children who report frequent headaches that occur predominantly at school and infrequently on weekends, I’m more suspicious of a stress trigger. If headaches occur shortly before mealtimes, they could be caused by transient hypoglycemia and may be prevented by adding a snack or changing the child’s eating schedule.
Another scenario is headaches that occur after football or soccer practice or other vigorous activities. Here, I consider fatigue, dehydration, or perhaps excessive sun exposure as potential triggers. Ask about fluid intake – particularly how much water, not soft drinks, the child drinks. Sodas do not help with dehydration and are frequently loaded with caffeine. Educate them about hydration and how drinking enough fluids can make a huge difference in their headache frequency and severity.
Headaches that occur infrequently or that do not disrupt the child’s typical activities are less worrisome. For example, I am much less concerned when a child or adolescent reports headaches, but they still go outside to play, or go about their regular routine, and stay engaged in family activities.
A headache calendar filled out by the patient, preferably over weeks or months, is very helpful to your headache specialist. This helps us to better characterize the frequency and severity of episodes, what time of day they occur, and any potential precipitating triggers.
I become concerned when headaches get progressively more severe over time, or become more frequent over a short period. Headaches that awaken kids in the middle of the night, or those associated with nausea and vomiting on awakening, may point to a more serious condition, such as a tumor or other expanding mass inside the head causing increased intracranial pressure.
Probably the most over-ordered tests in the children I see with headaches are neuroimaging studies. The majority of young kids with headaches do not require an expensive MRI scan. Most require only a good history and neurologic exam for appropriate diagnosis.
However, a CT or MRI scan is indicated if you suspect a more serious etiology and/or the patient is younger. For example, I am much more likely to get an imaging study when a 3- or 4-year-old child complains of frequent or severe headaches. Historical information will be more limited in the preschoolers because they frequently can’t tell you as much about their headaches, and your examination might be less reliable as well – as the younger kids may be less cooperative and more difficult to examine. I also perform blood tests on some headache patients, looking for infectious, inflammatory, or metabolic derangements as a cause for headaches, but those are infrequently helpful.