Review Question - QID 217653

This 12-year-old boy with unilateral headaches associated with photophobia, phonophobia, aura, and vomiting with a normal neurological exam is likely suffering from migraines, for which the first-line treatment are non-steroidal anti-inflammatory agents.

Migraines are the most frequent primary headache disorder in children and adolescents. The patient must have at least 5 attacks that fulfill the criteria of migraine, which include the duration of at least an hour to 72 hours, unilateral location, pulsating quality, and aggravated by activity. The first-line therapy is nonsteroidal anti-inflammatory agents. If these fail, then triptans may be considered. In the pediatric population, it is also important to screen for triggers that may not be as readily apparent as in adult patients. For instance, stress related to school (e.g., after-school activities, friends, bullying) and family problems may contribute. Addressing and elucidating underlying triggers may be important in the holistic management of pediatric patients with migraines.

Khalili et al. identify the pathophysiology of migraines in children, review the importance of physical exams in the assessment of pediatric migraines, and to help rule out other conditions.

Incorrect Answers:
Answer 1: Lumbar puncture is an appropriate step in evaluating a patient with a headache associated with fever, altered mental status, and nuchal rigidity. These symptoms would be present in a patient with a presentation concerning for meningitis and not diplopia or tinnitus as is the case in idiopathic intracranial hypertension.

Answer 2: Magnetic resonance imaging of the head/brain would be the most appropriate step in the evaluation of an intracranial mass lesion, which would present with early morning headaches and worsening with Valslava (exogenously inducing elevated intracranial pressure).

Answer 4: Oxygen therapy is used in the management of cluster headaches, which classically present with incapacitating unilateral headaches that feel as though they are originating posterior to the eye, ipsilateral conjunctival injection, and ipsilateral rhinorrhea. While there is emerging evidence for the role of oxygen therapy for migraines, it is yet to be considered first-line.

Answer 5: Triptan class medications (e.g., sumatriptan) are used in the management of migraines in patients who fail to respond to nonsteroidal anti-inflammatory agents.

Bullet Summary:
Migraines can present in the pediatric population with similar symptoms as adult patients (unilateral headache with photophobia, phonophobia, nausea, vomiting, and aura) and should be managed initially with nonsteroidal anti-inflammatory agents.