Pediatric migraine equivalents: occurrence and clinical features in practice

Benign Paroxysmal Torticollis

BACKGROUND

The purpose of this review is to clarify the natural course of benign paroxysmal torticollis (BPT) and update the information on the relationship of this disorder with migraine. BPT belongs to a group of "episodic syndromes that may be associated with migraine" and is diagnosed according to diagnostic criteria of the International Classification of Headache Disorders, 3rd edition. BPT affects infants and young children and is often an underdiagnosed manifestation since it is not recognized in cases with a benign evolution, requiring a careful differential diagnosis. It was first described by Snyder in 1969 as a movement disorder, a cervical dystonia consequent to labyrinthic disorder.

MATERIALS AND METHODS

The PubMed and Web of Science databases were consulted from 1968 to 2024, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.

RESULTS

In total, 113 articles were identified, 86 selected, and 25 considered for the purpose of this review. Clinical studies were considered in relation to evolution, cognitive, and motor development; genetic and not genetic etiology; the relationship with migraine with and without aura; vestibular migraine; hemiplegic migraine; and paroxysmal vertigo.

Clinical characterization of pediatric acute confusional migraine: a single-center case series

INTRODUCTION

Acute confusional migraine (ACM) is a rare disorder characteristic of pediatric patients. Our objective was to describe the clinical characteristics of patients diagnosed with ACM who visited our pediatric emergency department (PED).

METHODS

This study was a retrospective review of children who presented to our PED between January 2012 and December 2022 with a discharge diagnosis of ACM.

RESULTS

During the study period, 23 patients were enrolled: 11 males (47.8%) and 12 females (52.2%); median age was 10.8 years (IQR: 8.3-13.6). Eight patients reported a history of headache. The median length of stay of PED was 4.7 h. Onset was abrupt (less than 12 h) in 100% of cases. Changes in the level and content of consciousness occurred in 47.8% and 91.3% of patients, respectively; confusion (73.9%) was the most common neurological manifestation. Eighteen patients had urgent brain CT scans, none showing pathological findings. Four patients required benzodiazepines to control their psychomotor agitation. Nine patients were hospitalized, including one in the intensive care unit. Two patients underwent MRI and one patient underwent EEG during hospitalization, with normal results.

DISCUSSION

ACM is a rare condition in pediatric neurology characterized by acute onset of confusion or altered mental status before, during, or after migraine headache. Clinical features overlap with other neurological disorders, making diagnosis challenging. To improve the diagnosis, treatment, and research of AMC, it is essential to include it in the International Classification of Headache Disorders and establish standardized diagnostic criteria.

The Clinical Relevance of Artificial Intelligence in Migraine

Migraine is a burdensome neurological disorder that still lacks clear and easily accessible diagnostic biomarkers. Furthermore, a straightforward pathway is hard to find for migraineurs' management, so the search for response predictors has become urgent. Nowadays, artificial intelligence (AI) has pervaded almost every aspect of our lives, and medicine has not been missed. Its applications are nearly limitless, and the ability to use machine learning approaches has given researchers a chance to give huge amounts of data new insights. When it comes to migraine, AI may play a fundamental role, helping clinicians and patients in many ways. For example, AI-based models can increase diagnostic accuracy, especially for non-headache specialists, and may help in correctly classifying the different groups of patients. Moreover, AI models analysing brain imaging studies reveal promising results in identifying disease biomarkers. Regarding migraine management, AI applications showed value in identifying outcome measures, the best treatment choices, and therapy response prediction. In the present review, the authors introduce the various and most recent clinical applications of AI regarding migraine.

The kynurenine pathway of tryptophan metabolism in abdominal migraine in children - A therapeutic potential?

BACKGROUND

Abdominal migraine (AM) is a clinical diagnosis specified by Rome IV and ICHD III as a functional gastrointestinal disease (FGID) and a migraine associated syndrome, respectively. Abdominal migraine in childhood and adolescence may continue with migraine headaches in adulthood. This disease is undiagnosed and undertreated, and thus far the FDA has not approved any drug for AM treatment. It was shown that changes in the kynurenine (KYN) pathway of tryptophan (TRP) metabolism played an important role in the pathogenesis and treatment of FIGDs and associated mood disorders. Changes in the KYN pathway were shown in migraine and therefore it may be involved in AM pathogenesis.

FINDINGS

Abdominal migraine reflects an impairment in the communication within the gut-brain axis. Treatment approaches in AM are based on the experience of physicians, presenting personal rather than evidence-based practice, including efficacy of some drugs in adult migraine. Non-pharmacological treatment of AM is aimed at preventing or ameliorating AM triggers and is based on the STRESS mnemonic. Metabolic treatments with riboflavin and coenzyme Q10 were effective in several cases of pediatric migraine, but in general, results on metabolic treatment in migraine in children are scarce and nonconclusive. Modulations within the KYN pathway of TRP metabolism induced by changes in TRP content in the diet, may ameliorate FGIDs and support their pharmacological treatment. Pharmacological manipulations of brain KYNs in animals have brought promising results for clinical applications. Obese children show a higher headache prevalence and may be especially predisposed to AM, and KYN metabolites showed an alternated distribution in obese individuals as compared with their normal-weight counterparts.

CONCLUSIONS

In conclusion, controlled placebo-based clinical trials with dietary manipulation to adjust the amount of the product of the KYN pathway of TRP metabolism are justified in children and adolescents with AM, especially those with coexisting obesity. Further preclinical studies are needed to establish details of these trials.

Mal de Débarquement Syndrome in Children: A Case Series

Currently, mal de débarquement syndrome (MdDS) has been reported only among adults. This case series describes 3 pediatric patients with MdDS. MdDS presentation in children is similar to that of adults, although the frequency of comorbid conditions is greater. Diagnostic delays are common and likely due to under-recognition of MdDS among children.

Benign paroxysmal torticollis

Benign paroxysmal torticollis is a rare, usually benign, condition classified as an episodic syndrome. It is characterized by episodes of paroxysmal head tilt and associated symptoms, some of which are shared with migraine. It is likely to be the migraine equivalent with the earliest age of onset, starting in some cases in the neonatal period but resolving typically by the age of three or four. It may evolve into other episodic syndromes, migraine, or hemiplegic migraine, and an antecedent history or family history should be sought from migraineurs. Its prevalence and under-recognition has made it difficult to study. There are emerging associations with genes implicated in other paroxysmal syndromes, including hemiplegic migraine and episodic ataxia. Treatment currently centers on supportive care and environmental modification.

Benign paroxysmal vertigo of childhood

Benign paroxysmal vertigo of childhood (or recurrent vertigo of childhood) is the most common cause of vertigo in young children. It is considered a pediatric migraine variant or precursor disorder, and children with the condition have an increased likelihood of developing migraine later in life than the general population. Episodes are typically associated with room-spinning vertigo in conjunction with other migrainous symptoms (e.g. pallor, nausea, etc.), but it is rarely associated with headaches. Episodes typically only last for a few minutes and occur with a frequency of days to weeks without interictal symptoms or exam/test abnormalities. Treatment is rarely necessary, but migraine therapy may be beneficial in cases where episodes are particularly severe, frequent, and/or prolonged. An appreciation of the typical presentation and characteristics of this common condition is essential to any provider responsible for the care of children with migraine disorders and/or dizziness. This chapter will review the current literature on this condition, including its proposed pathophysiology, clinical presentation, and management. This chapter also includes a brief introduction to pediatric vestibular disorders, including relevant anatomy, physiology, embryology/development, history-taking, physical examination, testing, and a review of other common causes of pediatric dizziness/vertigo.

Migraine and Its Equivalents: What Do They Share? A Narrative Review on Common Pathophysiological Patterns

Migraine is the first in order of frequency of the neurological disorders, affecting both adult and paediatric populations. It is also the first cause of primary headaches in children. Migraine equivalents are periodic disorders that can be associated with migraine or considered as prognostic features of a future migraine manifestation. Despite the mechanisms underlying migraine and its equivalents are not entirely clear, several elements support the hypothesis of common pathophysiological patterns shared by these conditions. The aim of this review is thus to analyze the literature in order to highlight which currently known mechanisms may be common between migraine and its equivalents.

Prevalence of Pediatric and Adolescent Balance Disorders: Analysis of a Mono-Institutional Series of 472 Patients

(1) Background: To assess the prevalence and frequency distribution of balance disorders in children and adolescents to delineate the planning of a targeted clinical and instrumental diagnostic work-up; (2) Methods: Retrospective analysis of the clinical documentation of patients under 18 years suffering from balance disorders from 2010 to 2019. Detailed collection of clinical history, accurate clinical examination, including both nystagmus and vestibulospinal signs examinations, and specific instrumental testing were the basis of the diagnostic process. (3) Results: A total of 472 participants were included in the study. Vestibular loss (26.1%) was the most frequent cause of vertigo in children, followed by vestibular migraine (21.2%) and benign paroxysmal positional vertigo (10.2%). In 1.1% of patients, the cause of vertigo remained undefined; (4) Conclusions: The diagnostic process applied was effective in understanding the cause of balance disorders in most cases and prevents more complex and expensive investigations reserved for only a few selected cases.

Outcomes of Migraine and Tension-Type Headache in Children and Adolescents

The aim of our study was to evaluate the long-term outcomes of pediatric migraine and TTH in a clinical setting. We conducted a cohort study. Pediatric patients who visited the pediatric neurology clinic due to diagnoses of migraine or TTH were contacted by phone 8–10 years after their initial diagnosis and interviewed about their outcomes. Of 147 children, we were able to reach 120 (81%) patients. Of these 120 patients, 59 were seen initially due to migraine and 61 due to TTH. For the migraine patients, headaches improved in 48 (81.4%) and worsened in four (6.8%). Regarding diagnosis at follow-up, 59% still had migraine, 17% had TTH, and 23% were headache-free. Aura and photophobia were significantly associated with persistence of a migraine diagnosis. For the TTH patients, headaches improved in 49 (81.7%) and worsened in nine (15.0%). Regarding diagnosis at follow-up, 36.7% still had TTH, 18.3% had migraine, and 45% were headache-free. Of the patients with TTH, 36.7% retained their initial diagnosis compared to 59.3% among the migraine patients. Most pediatric patients presenting with migraine or TTH will experience a favorable outcome over 10 years, with TTH patients having twice the chance of complete resolution.

The childhood migraine syndrome

Migraine is a complex genetic brain disorder with an intricate pathogenesis and polymorphous clinical presentations, particularly in children. In this Perspective, we describe the different phenotypes of migraine in children, including conditions that have been referred to in the International Classification of Headache Disorders as "syndromes that may be related to migraine''. Evidence is presented for the integration of abdominal migraine, cyclical vomiting syndrome, benign paroxysmal vertigo, benign paroxysmal torticollis and infantile colic into the unified diagnosis of 'childhood migraine syndrome' on the basis of clinical and epidemiological characteristics, and shared inheritance. In our opinion, such integration will guide clinicians from specialities other than neurology to consider migraine in the assessment of children with these disorders, as well as stimulate research into the genetics, pathophysiology and clinical features of all disorders within the syndrome. A diagnosis of childhood migraine syndrome would also enable patients to benefit from inclusion in clinical trials of old and new migraine treatments, thus potentially increasing the number of treatment options available.

Acute Confusional Migraine: Unusual Great Masquerader-Case Report and Literature Review

Background. Acute confusional migraine (ACM) is a rare variant of migraine, mainly prevalent in children and adolescents. It is not currently indexed as a distinct variant of migraine likely since only a few cases were reported in the adult population. We report a case of delayed ACM diagnosis in a young man and present a concise-related literature review. Case Presentation. A thirty-eight-year-old man with a past medical history of migraine, not on any treatment, presented with headaches accompanied by confusion. Over a two-year period before the current presentation, he experienced two episodes of confusion, which required hospital admission for evaluation: once mislabeled as a psychiatric illness and diagnosed as a migrainous infarct in the second hospitalization. In the current presentation, he reported a similar history of headache accompanied by confusion. The examination was remarkable for disorientation; otherwise, no focal deficit was elicited. Laboratory testing, cerebrospinal fluid, and neurological imaging were all unremarkable. His symptoms improved spontaneously within less than twenty-four hours, similar to his previous presentations. After two-year history of episodic confusion and after excluding other plausible causes of confusion, guided by proposed diagnostic criteria, we diagnosed him as a case of ACM. The patient remains well at the follow-up of two months after discharge. Discussion and Conclusion. ACM is a rare variant of migraine and is often a challenge for clinicians to diagnose appropriately. Until recent years, the disease was thought to be limited to children and adolescents. However, recently few reports also expanded the incidence of this entity to the adult population. There is a significant gap in knowledge about proper identification and treatment of this condition, leading to delayed or overlooked ACM diagnosis. Moreover, the recent edition of the International Classification of Headache Disorders (ICHD-3) does not account for this entity, thereby further adding to physicians' lack of awareness regarding this migraine subtype. The authors emphasize that clinicians be aware of this entity and adequately utilize the existing proposed diagnostic criteria for ACM until standardized and validated tools are available. We also believe that this entity should be acknowledged in the subsequent migraine guidelines and classifications.

Migraine Symptoms Improvement During the COVID-19 Lockdown in a Cohort of Children and Adolescents

Background: Pediatric migraine is among the most common primary or comorbid neurologic disorders in children. Psychological stressors are widely acknowledged as potential triggers involved in recurring episodes of pediatric migraine. As the COVID-19 emergency may have affected the levels of stress perceived by children and adolescents with migraine, the present study was aimed to understand the effect of COVID-19 emergency on symptoms intensity and frequency in pediatric patients.

Methods: A cohort of 142 child and adolescent patients with a diagnosis of migraine was enrolled at the Child Neurology and Psychiatry Unit of the IRCCS Mondino Foundation in Pavia (Italy). Socio-demographic and clinical characteristics were obtained from medical records. An on-line survey was used to collect information on COVID-19 exposure, stress response to the lockdown period, anxious symptoms during COVID-19 emergency, as well as migraine symptoms intensity and frequency before and during the lockdown.

Results: The great majority were outpatients (n = 125, 88.0%), 52 (36.6%) had migraine with aura, whereas, 90 (63.4%) had migraine without aura. All the patients reporting worsening symptoms progression before COVID-19, had reduced intensity during the lockdown (χ² = 31.05, p < 0.0001). Symptoms frequency reduction was observed in 50% of patients presenting worsening symptoms before the lockdown, 45% of those who were stable, and 12% of those who were already improving. All patients who had resolved symptoms before COVID-19 were stable during the lockdown (χ² = 38.66, p < 0.0001). Anxious symptomatology was significantly associated with greater migraine symptoms frequency (χ² = 19.69, p < 0.001). Repeating the analysis separately for individuals with and without aura did not affect the findings and significant associations were confirmed for both the patients' subgroups.

Discussion: A significant reduction of migraine symptoms intensity and frequency was observed in pediatric patients during the COVID-19 lockdown phase in northern Italy. The improvement in both intensity and frequency of the migraine symptoms was especially significant in patients who were stable or worsening before the lockdown. The reduction of symptoms severity during a period of reduced environmental challenges and pressures further highlights the need of providing effective training in stress regulation and coping for these patients.

Topographic changes measured by the swept source optical coherence tomography in retinal nerve fiber layer, optic nerve head and macula in children with migraine

As a vascular-inflammatory disease, migraine affects the brain and some other organs, such as the eye. The aim of this study was to measure and compare the peripapillary retinal nerve fiber layer (RNFL) thickness, macular ganglion cell layer thickness and optic nerve head parameters to detect structural damage in children with migraine using swept-source optical coherence tomography. Twenty-four children with migraine in the painless period and 26 controls were included in the study. The vast majority of the groups consisted of females (75% for patients and 77% for controls). Certain RNFL quadrants and optic disc parameters revealed significant differences between the patients and controls. In the right and left eyes of children with migraine, nasal quadrant RNFL was significantly thicker than that in healthy subjects (88.82 ± 11.03 vs 77.80 ± 13.77, P = 0.004 for right eyes and 87.71 ± 11.79 vs 77.80 ± 13.77, P = 0.01 for left eyes). Temporal quadrant RNFL in the left eyes was thinner (78.67 ± 9.57 vs 84.44 ± 9.68, P = 0.04). Disc area in the left eyes of the patients was greater (2.29 ± 0.46 vs 1.94 ± 0.28, P = 0.003). There were significant expansions in cup volumes in favor of the patients for right and left eyes (0.15 ± .0.19 vs 0.05 ± 0.05, P = 0.03 and 0.17 ± 0.14 vs 0.05 ± 0.05, P = 0.001, respectively). The only significant difference between the left and right eyes of the migraineurs was the RNFL thickness in the superior quadrant. Ganglion cell layer thickness did not differ between the right eyes, left eyes and controls. In conclusion, children with migraine showed significant variations in specific RNFL and optic disc parameters compared to control subjects.

Torticollis in children with enlarged vestibular aqueducts

OBJECTIVES

To evaluate the association between torticollis and enlarged vestibular aqueduct (EVA).

METHODS

An online/phone survey was administered to parents of 133 children diagnosed with the following disorders: EVA, GJB2 (Connexin 26) mutations associated congenital hearing loss and epistaxis (control). The survey included questions regarding symptoms of torticollis, vertigo, and hearing loss.

RESULTS

Patients with EVA had a 10-fold greater odds of having torticollis than controls (31% vs. 4%; OR = 10.6; 95% CI: 2.9, 39.2). No patients with GJB2 had a reported history of torticollis. Torticollis preceded the diagnosis of hearing loss in most (87%) patients with EVA who had a reported history of torticollis. EVA patients were more likely to have reported motor delay than controls (40% vs. 15%; p = 0.002). EVA patients with prior torticollis (80%; 12/15) were more likely to have balance impairment than EVA patients without prior torticollis (12%; 4/33; p < 0.001). Twelve patients had a reported history of paroxysmal torticollis, all of whom had EVA.

CONCLUSION

Torticollis in infants may be a marker of EVA. Infants with torticollis should be monitored closely for hearing loss and motor delay, especially when the torticollis is paroxysmal.

[Confusional migraine in a young adult female: Is it a subtype of migraine with aura?]

A 22-year-old female was admitted to our hospital due to acute onset of severe headache, confusion, and deterioration of consciousness. Results of initial examinations did not suggest cerebrovascular diseases, encephalitis, or nonconvulsive status epilepticus. Over the next several weeks, her level of consciousness fluctuated in parallel with the severity of headache. The electroencephalogram, recorded during a symptomatic episode, showed lack of posterior dominant rhythm, and the single-photon emission CT (SPECT) also revealed a decrease in cerebral blood flow predominantly in the occipital lobes. Administration of sodium valproate and topiramate, recommended as treatment for migraine, dramatically ameliorated her headache and consciousness. Although this was an adult-onset case, her symptoms and clinical course were similar with the diagnosis of ICHD-3-unlisted confusional migraine rather than other listed subtypes of migraine with aura. Further accumulation of similar adult-onset cases is necessary to clarify the nature of this illness.

Pediatric Vestibular Rehabilitation: A Case Study

BACKGROUND

A 9-year-old child with a 9-month history of complaints of dizziness, headache, and motion sensitivity came to physical therapy. The child complained of difficulties playing on a playground, running, riding in a car, watching "action movies," sitting under fluorescent lights, and making quick head movements.

METHODS

An initial evaluation included a clinical oculomotor examination, vergence testing, static and dynamic visual acuity testing, head impulse testing, subjective visual vertical, balance testing, the pediatric vestibular symptom questionnaire, the Dizziness Handicap Inventory-child caregivers version (DHI-PC) and a visual vertigo analog scale. Physical therapy included virtual reality with Xbox games plus adaptation, habituation, and balance exercises. She was seen once per week and given a home program of exercises 2 to 3 times a day.

RESULTS

After 10 treatment sessions, she reported that playing was easier, headaches had reduced, she could travel as a passenger in a car for long distances without complaints, and that she could watch 3-dimensional action movies without symptoms. Her pediatric vestibular symptom questionnaire scores had reduced from 0.7 to 0.1. The DHI-PC had decreased from 22 to 12 points and her visual vertigo analog scale scores were improved.

CONCLUSIONS

Vestibular rehabilitation improved this child's quality of life. She was able to return to her daily living activities with fewer symptoms.

Vertigo in children; a narrative review of the various causes and their management

Vertigo is a not an uncommon symptom in children, but often the treating doctors are unsure of the diagnosis and the management of these cases. This narrative review of the literature discusses the brief etiopathology, the clinical manifestations and the management algorithm of most of the conditions causing vertigo in children. The relevant information has been condensed into a table for the perusal of the readers, which would assist in the appropriate management of these children.

Considerations for Testing and Treating Children with Central Vestibular Impairments

This perspective explores common pediatric diagnoses that could present with central vestibular pathway dysfunction, leading to delays in motor development and postural control, and gaze instability. Specifically, the following diagnoses are considered: cerebral palsy, myelomeningocele, vestibular migraine, attention-deficit hyperactivity disorder, developmental coordination disorder, concussion, childhood cancer, congenital muscular torticollis, adolescent idiopathic scoliosis, and autism. Suggestions for clinical screening, vestibular function testing, and vestibular rehabilitation for children with these diagnoses are based on evidence for the efficacy of testing and interventions for children with peripheral vestibular hypofunction. More research is needed to explore peripheral and central vestibular function in children with these diagnoses. Testing and intervention methods may need to be modified to accommodate for the specific behavior and motor challenges that some children might present. Researchers should develop technology so that gaze stabilization exercises can be delivered in a fun, functional, and effective way.

Benign paroxysmal migraine variants of infancy and childhood: Transitions and clinical features

INTRODUCTION

Migraine variant disorders of childhood include benign paroxysmal torticollis of infancy (BPTI) and benign paroxysmal vertigo of childhood (BPVC). This study aimed to review our experience with BPTI and BPVC and determine the incidence of children transitioning between each of these disorders and to vestibular migraine (VM).

METHODS

We retrospectively reviewed the medical records of patients seen at the Balance and Vestibular Program at Boston Children's Hospital between January 2012 and December 2016 who were diagnosed with BPTI, BPVC, and/or VM.

RESULTS

Fourteen patients were diagnosed with BPTI, 39 with BPVC, and 100 with VM. Abnormal rotary chair testing was associated with progression from BPTI to BPVC (n = 8, p = 0.045). Eight (57.1%) patients with BPTI and 11 (28.2%) with BPVC had motor delay. Eleven (78.6%) patients with BPTI and 21 (53.8%) with BPVC had balance impairment. Six BPTI patients developed BPVC (42.9%), six BPVC patients developed VM (15.4%), and two patients progressed through all three disorders (2%). One BPTI patient progressed directly to VM.

DISCUSSION

Most patients with BPTI will experience complete resolution in early childhood, but some will progress to BPVC, and similarly many patients with BPVC will progress to VM. Parents of children with these disorders should be made aware of this phenomenon, which we refer to as "the vestibular march." Children with BPTI and BPVC should also be screened for hearing loss, otitis media, and motor delay.

Pediatric migraine with aura in an Italian case series

The aim of the present study was to describe the characteristics of migraine with aura (MwA) in a case series of patients with headache onset before 12 years of age. We considered all consecutive patients referred to the Parma Headache Centre between 1975 and 2015 affected by MwA, diagnosed by our team of trained neurologists; the cases were subsequently reviewed applying the ICHD3-beta criteria. We then identified those cases with headache age-of-onset <12 years (i.e., "pediatric" cases), which were compared to all remaining cases. We identified 283 cases with pediatric onset (87 males and 196 females). The male-to-female ratio was 1:2.3 in both "pediatric" and "non-pediatric" cases. The time lag between MwA onset and our first evaluation was significantly higher among the pediatric cases (18.7 ± 13.3 vs 10.4 ± 10.4 years). In both groups of patients, visual aura was the most common type of aura, followed by sensory and speech disturbances; however, these two latter aura symptoms were significantly more common among pediatric cases. In this group of patients, aura without headache was significantly less frequent (1.8 vs 5.3%); furthermore, headache had migraine characteristics in a higher proportion of cases (90.1 vs 82.6%). A family history of MwA was significantly more frequent among cases with pediatric onset (31.1 vs 16.9%). Males but not females with pediatric MwA had more frequently a comorbid migraine without aura (27.6 vs 16.8%). Among cases with pediatric onset, we did not find any significant differences between males and females. In conclusion, in our very large case series of MwA, patients with headache onset before 12 years of age seem to have a specific clinical phenotype, without significant gender differences.

Acute Confusional Migraine: Distinct Clinical Entity or Spectrum of Migraine Biology?

The goal of this review is to explore the literature reports of acute confusional migraine (ACM) including patient characteristics, migraine symptomatology, and proposed diagnostic criteria. A literature review was conducted using PubMed, Scopus and Web of Science using the terms “confusional migraine” and “confusional state in migraine”. All the relevant articles from 1970 to 2016 were included. A total of 120 patients were found in the literature. Most of the cases were seen in the pediatric population with a slight male predominance. Personal or family history of migraine was common. Most patients had a headache prior to the confusional state. In addition to confusion and agitation, some developed visual (32.5%) and/or sensory symptoms (19%) and/or speech problems (39%) either prior to or during the confusional state. Data on treatment outcomes is lacking. Patients with most common forms of migraine report attention and cognitive disturbances but awareness remains intact as opposed to patients with ACM. ACM is a distinct entity and should be included as part of the appendix of International Classification of Headache Disoders-3 beta version (ICHD-3β) criteria. Prospective studies are needed to further study this disorder and its association with other migraine forms.

Migraine Variants in Children

Migraine in children can manifest in ways that are markedly different from adult migraines. In children, migraine variants are often unaccompanied by headache and include conditions such as cyclic vomiting and abdominal migraine. Children who experience these conditions are often thought to have a disorder of the gastrointestinal tract, and when evaluation is unremarkable they may be diagnosed as having a conversion reaction. Complicated migraines, on the other hand, are often accompanied by focal neurological symptoms such as ataxia, hemiparesis, or altered level of consciousness that evoke great consternation in the examining clinician. Certain episodic syndromes that may hold interest to pediatricians are also discussed in this article, mostly to emphasize the ambiguity that still surrounds these disorders, such as migraine triggered by trauma. The cardinal rule that most of these disorders are diagnoses of exclusion and can only be confirmed after extensive evaluation, either by the pediatrician or pediatric neurologist, is emphasized. [Pediatr Ann. 2018;47(2):e50-e54.].

Brain Imaging Findings in Children with Headache

Background:

Headache is a common problem in children, but a small percentage of them have positive findings on CT scan and MRI, and considering that CT scan and MRI is costly and risks of radiation is high for children. Therefore the aim of this study is evaluating CT scans and MRI finding in children with headache.

Materials and Methods:

This cross-sectional study was performed on 353 children with headaches that 217 patients underwent CT and 136 patients underwent MRI. The data collected through the report sheet of CT scan and MRI and analyzed using SPSS software and chi-square test.

Results:

According to the study, 88.9% of MRI and 75.7% of CT scan were normal. Abnormal findings on CT scan was significantly higher in boys (12.2% vs. 9.5%) (P= 0.03) and it was determined that MRI findings was also significantly higher in boys (26.3% vs. 21.5%) (P=0.04). The most common abnormal findings on CT scan was mass (16.6%) and hematoma (16.6%) and the most common abnormal findings on MRI was cysts (26.3%).

Conclusion:

The results of our study showed that the majority of imaging results in patients with headache was normal or benign lesions. Therefore, imaging should be performed only in children with abnormal findings on physical examination.

Experts' opinion about the pediatric secondary headaches diagnostic criteria of the ICHD-3 beta

Background

The 2013 International Classification of Headache Disorders-3 was published in a beta version to allow clinicians to confirm the validity of the criteria or suggest improvements based on field studies. The aim of this work was to review the Secondary Headache Disorders and Cranial Neuralgias and Other Headache Disorders sections of ICHD-3 beta data on children and adolescents (age 0–18 years) and to suggest changes, additions, and amendments.

Methods

Several experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the available literature on pediatric headache, they made observations and proposed suggestions for the mentioned headache disorders on children and adolescents.

Results

Some headache disorders in children have specific features, which are different from adults that should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psychosocial basis in children and adolescents making primary headache disorders in children distinct from those in adults.

Conclusions

Several recommendations are presented in order to make ICHD-3 more appropriate for use in children.

From 0° to 18°: how headache changes over time

Recognize the presence of headache at early age is essential to prevent that the disorder interferes with physical, psychological and social functioning. However, there are several differences between adults and children in the clinical manifestation of headache such as quality and severity of pain, trigger, associated symptoms, gender, duration of attacks, number of daytime attacks, comorbidities and red flags of secondary headache. These differences can make the diagnosis more complex in early ages than in adults, so it is essential to know how headache changes over time to identify its presence in the earliest phases of childhood.

Prevalence of vestibular and balance disorders in children and adolescents according to age: A multi-center study

OBJECTIVES

Children differ from adults in the expression of dizziness symptoms and the causes of dizziness. In several studies, benign paroxysmal vertigo of childhood (BPVC) and vestibular migraine (VM) were seen exclusively in children with vertigo, but the age threshold used to define 'children' varies, and there are few reported studies about adolescents with dizziness. In this study, we investigated the prevalence of vestibular and balance disorders according to age category in a multi-center study (otolaryngology departments of 11 hospitals) of children and adolescents.

METHODS

Children and adolescents aged under 18 who visited the otolaryngology departments of 11 hospitals for dizziness were included. We classified the patients into three categories: preschool (up to and including 6-year-olds), school age (7- to 12-year-olds), and adolescents (13- to 18-year-olds). These patients were reviewed retrospectively based on their clinical charts.

RESULTS

In the preschool age group, BPVC was most common, followed by VM. In the school-age group, BPVC and VMs were most common, followed by psychogenic vertigo and benign paroxysmal positional vertigo (BPPV). In adolescents, VM was the most common, and Ménière's disease, cardiogenic vertigo, and BPVC, which are seen primarily in adults, were also seen in some adolescents.

CONCLUSION

In children and adolescents with dizziness, VM and BPVC were the most common diseases, and prevalence of disease by age showed differing distributions. These findings will help in diagnosing and managing children and adolescents with vertigo.

Migraine Variants or Episodic Syndromes That May Be Associated With Migraine and Other Unusual Pediatric Headache Syndromes

PURPOSE

To provide an overview of the clinical course for children and adolescents with migraine variants (M.V.), childhood periodic syndromes or the episodic syndromes that may be associated with migraine using the International Classification of Headache Disorders, 3rd Edition Beta version [ICHD-3] International Headache Society criteria for the diagnosis of each disorder.

METHOD

Migraine is a complex set of neurological symptoms. This review encompasses the subtypes of M.V. or episodic syndromes that may be associated with migraine within the children and adolescent population.

CONCLUSION

The episodic syndromes that may be associated with migraine or migraine variant is multilayered neurological disorder in young children and adolescents. Within the these generally pediatric syndromes there are associated disorders described in this review, to provide a clinical overview and including the less common forms of migraine, such as acute confusional migraine, trauma-triggered migraine, and transient global amnesia.

Magnetic resonance imaging arterial-spin-labelling perfusion alterations in childhood migraine with atypical aura: a case-control study

AIM

Atypical migraine with aura can be challenging to diagnose. Arterial-spin-labelling (ASL) is able to non-invasively quantify brain perfusion. Our aim was to report cerebral blood flow (CBF) alterations using ASL, at the acute phase of atypical migraine with aura in children.

METHOD

Paediatric patients were retrospectively included if (1) referred for acute neurological deficit(s), (2) underwent brain magnetic resonance imaging (MRI) at presentation with ASL sequence, and (3) had subsequent diagnosis of migraine with aura. Neurological symptom-free controls were matched for age. Twenty-eight regions of interest (ROIs) were drawn on CBF maps for each participant/control.

RESULTS

Ten patients were included (median age 13y, range 8-16y). Eight of 10 had multiple aura symptoms during the episode. For every patient, CBF was decreased in a brain region consistent with symptoms when MRI was performed less than 14 hours after onset (n=7 patients) and increased if the MRI was performed 17 hours or more after (n=4 MRIs).

INTERPRETATION

MRI-ASL appears to be a promising tool for the diagnostic workup and differentials exclusion in paediatric migraine with aura. Constant and time-consistent non-territorial CBF modifications were found in our sample providing additional insight to migraine with aura pathophysiology. The authors encourage implementing this sequence at the acute phase of unexplained paediatric neurological deficits, with or without accompanying headache.

The Genetics of Benign Paroxysmal Torticollis of Infancy: Is There an Association With Mutations in the CACNA1A Gene?

Benign paroxysmal torticollis of infancy is an unusual movement disorder, often accompanied by a family history of migraine. Some benign paroxysmal torticollis cases are associated with CACNA1A mutations. The authors sought to determine the frequency of CACNA1A mutations in benign paroxysmal torticollis by testing 8 children and their parents and by searching the literature for benign paroxysmal torticollis cases with accompanying CACNA1A mutations or other disorders linked to the same gene. In our 8 benign paroxysmal torticollis cases, the authors found 3 different polymorphisms, but no pathogenic mutations. By contrast, in the literature, the authors found 4 benign paroxysmal torticollis cases with CACNA1A mutations, 3 with accompanying family histories of 1 or more of familial hemiplegic migraine, episodic ataxia, and paroxysmal tonic upgaze. Thus, CACNA1A mutations are more likely to be found in children with benign paroxysmal torticollis if accompanied by family histories of familial hemiplegic migraine, episodic ataxia, or paroxysmal tonic upgaze.

Pediatric migraine variants: a review of epidemiology, diagnosis, treatment, and outcome

Pediatric migraine variants, previously known as childhood periodic syndromes, migraine equivalents, or migraine precursors, are a group of periodic or paroxysmal disorders occurring in patients who also have migraine with or without aura, or who have an increased likelihood of developing migraine. They have common key clinical features including periodic or paroxysmal character, normal neurological examination between attacks, family history of migraine, and clinical evolution to classic types of migraine. This article aims to review the pathophysiology, evaluation, and management of the pediatric migraine variants including abdominal migraine, benign paroxysmal vertigo, cyclic vomiting syndrome, and benign paroxysmal torticollis as well as the episodic syndromes that may lead to migraine, infantile colic, alternating hemiplegia of childhood, and vestibular migraine.

Pediatric mixed headache -The relationship between migraine, tension-type headache and learning disabilities - in a clinic-based sample

Background

Headache is a common complaint among children. The most common primary headache syndromes in childhood are migraine and TTH. However many times they seem to overlap. The purpose of our study was to assess the relationship between pediatric migraine, tension-type headache (TTH) and learning disabilities.

Methods

Children presenting with headache to three pediatric neurology clinics in the last 5 years were assessed. Two hundred sixty-two children, 5–18 years of age, who met the criteria for migraine were included.

Results

Of 262 children (54 % female) who had migraine, 26.2 % had migraine with aura. 59 children (22.5 % of the full sample) reported also having headaches that met the criteria for episodic TTH/mixed headaches. Females were more than 2.8 times more likely to experience mixed headaches than males (OR: 2.81, 95 % CI: 1.43–5.54; p <.003). Multiple logistic regression analysis revealed that older age (p <0.02), family history of aura (p <.02), and (lack of) TTH (p <.003) were significant predictors of aura, whereas gender was not significant (p >0.20). Children who had migraine with aura were less likely to have mixed headaches than children who did not have aura (OR: 0.26, 95 % CI: 0.11–0.63; p <.003). Children with mixed headaches were 2.7 times more likely to have a learning disability than children with migraine alone.

Conclusions

Episodic TTH and migraine without aura (mixed headaches) in children might be part of a continuum, which can explain the high incidence of their co-occurrence as opposed to migraine with aura. Children with mixed headaches have a higher incidence of learning disability compare to those with migraine alone.

Migrainous Aura, Visual Snow, and "Alice in Wonderland" Syndrome in Childhood

Migraine is a condition that is common in the pediatric and adolescent population. Among children with migraine, visual aura can consist of either negative or positive features or both. Reports of sensory auras can also be elicited with a careful history. The understanding of the types of aura, as well as their relation to the more typical features of migraine, are discussed. The similar phenomena of visual snow and Alice in Wonderland syndrome in children are also described in detail.

Frequency of pediatric migraine with aura in a clinic-based sample

OBJECTIVE

To assess the prevalence and risk factors for pediatric migraine with aura (MWA) among patients presenting to pediatric neurology clinics.

BACKGROUND

Headache is a common complaint among children, and the prevalence of migraine is about 8%. Up to one third of adults with migraine report experiencing aura; however, the exact percentage in children is unknown.

METHODS

Medical records of children presenting with headache to three pediatric neurology clinics in Haifa in the last 5 years were retrospectively reviewed. Inclusion criteria were a diagnosis of migraine headache at 5-18 years of age.

RESULTS

Of 260 children (140 female) who had migraine, 26.2% experienced aura. MWA was more common among females compared to males (32.6% vs 18.9%, P < .01) and among older children (OR: 2.50, 95% CI: 1.20-5.20; P < .01). Among those who experienced aura, visual aura was more common in females than males (66.7% vs 33.3%, P < .04). Family history of migraine was strongly related to MWA (P < .02): the odds of MWA were 2.46 times greater in children who had a family history of migraine. (OR: 2.46, 95% CI: 1.08-5.62; P < .03).

CONCLUSIONS

MWA is as common in children as in adults. Aura is more common in older children. Children who have MWA are more likely to have a family history of migraine.

Migraine equivalents and related symptoms, psychological profile and headache features: which relationship?

Background

Migraine equivalents are common clinical conditions in children suffering from headache. Very few studies dealt with the psychological profile of children/adolescents with migraine equivalents. Our main aim was to compare the psychological profile between migraine children with and without migraine equivalents. Moreover, as secondary aim, exclusively in children with migraine equivalents, we investigated the possible relationship between migraine attack frequency and intensity and psychological factors.

Methods

We enrolled 136 young migraineurs. They were divided in two groups (patients with and without migraine equivalents). The psychological profile was assessed by means of SAFA Anxiety and Somatization questionnaires.

Results

Migraine equivalents were present in 101 patients (74.3 %). Anxiety (p = 0.024) and somatization (p = 0.001) levels, but not hypochondria (p = 0.26), were higher in patients with migraine equivalents. In children with migraine equivalents, a low frequency of attacks was related to separation anxiety (p = 0.034).

Conclusions

Migraine equivalents patients tend to feel more fearful and to experience more shyness. This, together with the tendency to somatization, may lead them to become vigilant in attachment relationships with their caregivers.

A review of episodic and chronic pediatric headaches of brief duration

BACKGROUND

Headaches that last less than an hour in duration are uncommon, except for atypical migraine, and without a practitioner's appropriate knowledge, may result in misdiagnosis. Although most of these headaches are classified as primary headache syndromes, some have secondary etiologies such as structural lesions.

METHODS

This pediatric-specific review updates these headache syndromes. Included are atypical migraine, the trigeminal autonomic cephalgias, idiopathic stabbing headache, cranial neuralgias, occipital neuralgia, thunderclap headache, nummular headache, the red ear syndrome, and the numb-tongue syndrome.

CONCLUSION

Knowledge of the clinical characteristics of these headache patterns in children allows physicians to quickly establish the headache diagnosis and develop the optimal treatment plan.

Paroxysmal nonepileptic events in infancy, childhood, and adolescence

There are a wide variety of paroxysmal nonepileptic events (PNEEs) in children that can mimic seizures. The type of PNEEs that need to be considered in the differential diagnosis depends on the age of symptom onset and the clinical features. In infants and toddlers, conditions that are relatively common in clinical practice such as apnea, jitteriness, shuddering attacks, and breath-holding spells may not present much of a diagnostic conundrum, whereas unusual conditions such as hyperekplexia may cause concern. Similarly, although most types of migraine are easily distinguished from seizures in school-aged children, certain variants such as the "Alice in Wonderland" syndrome or basilar migraine can create diagnostic confusion. Most types of PNEE are exclusive to childhood; therefore, the pediatrician must be familiar with a variety of physiological processes and pathological entities that can raise concern in parents. The pediatrician is in the unique position of being able to reassure families and/or guide further work-up. Many of the PNEEs in young children require no treatment and resolve spontaneously. It is important to distinguish these episodes from true seizures as to avoid unnecessary testing and pharmacological treatment. This review highlights common PNEEs in children, beginning with the neonatal age group and moving upward to adolescence.

Migraine equivalents as part of migraine syndrome in childhood

BACKGROUND

Migraine equivalents are common clinical conditions without a headache component, occurring as repeated episodes with complete remission between episodes. They include abdominal migraine, cyclical vomiting, benign paroxysmal vertigo, and benign paroxysmal torticollis. Other clinical entities, such as motion sickness and limb pain have been associated with migraine. We aimed to investigate the prevalence of migraine equivalents in a large population of children referred to a pediatric headache center and to analyze the possible relationship between migraine equivalents and headache features.

METHODS

A total of 1134 of children/adolescents (73.2% with migraine and 26.8% with tension-type headache) were included. Patients were divided into two groups according to the episode frequency (high and low). Pain intensity was rated on a three-level graduate scale (mild, moderate, and severe pain).

RESULTS

Migraine equivalents were reported in 70.3% of patients. Abdominal migraine (48.9%), limb pain (43.9%), and motion sickness (40.5%) were the most common migraine equivalents. Although headache type (migraine or tension-type headache) did not correlate with migraine equivalents presence (χ(2) = 33.2; P = 0.27), high frequency of headache episodes correlated with the occurrence of migraine equivalents. Moreover, migraine equivalents indicated a protective role for some accompanying feature of the headache episode.

CONCLUSIONS

Our results suggest that migraine equivalents should not be considered merely as headache precursors, but they as part of the migrainous syndrome. Thus, their inclusion among the diagnostic criteria for pediatric migraine/tension-type headache is useful.

Migraine equivalents in childhood

Migraine equivalents are a group of periodic and paroxysmal neurologic diseases. Because headache is not a prominent symptom, the diagnosis might be challenging. The objective of the study was to evaluate the frequency and outcome of migraine equivalents. This was a retrospective study. We included benign paroxysmal torticollis of infancy, benign paroxysmal vertigo of infancy, abdominal migraine, cyclic vomiting, aura without migraine, and confusional migraine. We evaluated the frequency of events, treatment, and outcome. Out of 674 children with headache, 38 (5.6%) presented with migraine equivalents. Twenty-one were boys and the mean age was 6.1 years. Fifteen had abdominal migraine, 12 benign paroxysmal vertigo, 5 confusional migraine, 3 aura without migraine, 2 paroxysmal torticollis, and 1 cyclic vomiting. Prophylactic treatment was introduced in 23 patients; 4 lost follow-up and 19 had significant improvement. We conclude that the correct diagnosis of migraine equivalents enables an effective treatment with an excellent outcome.

A curable and probably often-overlooked cause of cyclic vomiting syndrome

Cyclic vomiting syndrome is a disorder of many causes. The major challenge is to label the disorder as idiopathic or primary only when all possible etiologies, particularly those that can be specifically treated, have been ruled out. In retrospect, our patient had subtle prenatal and early postnatal radiological findings supportive of a urological cause for his symptoms, the importance of which was initially missed. It would probably be wise to include an abdominal ultrasound examination (looking for hydronephrosis) in the "must-do" battery of tests for the investigation of all cases of recurrent cyclic vomiting without apparent cause. Otherwise, it seems likely that many cases of ureteropelvic junction obstruction will be missed, cases in which surgical intervention can be curative.

Prevalence and diagnosis of vestibular disorders in children: a review

OBJECTIVES

To systematically review and discuss the main pathologies associated with vertigo and dizziness in children, paying particular attention to recent advances in diagnosis and therapy.

METHODS

One appropriate string was run on PubMed to retrieve articles dealing with the topics mentioned above. A cross-check was performed on citations and full-text articles found using the selected inclusion and exclusion criteria. A non-comparative meta-analysis concerning the rate of singular vertiginous forms was performed.

RESULTS

Ten articles were identified comprising a total of 724 subjects. Overall, the articles we analyzed indicated benign paroxysmal vertigo of childhood (18.7%) and migraine-associated vertigo (17.6%) as the two main entities connected with vertigo and dizziness in children. Head trauma (14%) was the third most common cause of vertigo. The mean (95% CI) rate of every vertiginous form was also calculated in relation to the nine studies analyzed with vestibular migraine (27.82%), benign paroxysmal vertigo (15.68%) and vestibular neuritis (9.81%) being the three most common forms. There appeared to be a paucity of recent literature concerning the development of new diagnostic methods and therapies.

CONCLUSIONS

On the basis of the literature study, when evaluating a young patient with vertigo and dizziness, the otolaryngologist should be aware that, in children, these symptoms are often connected to different pathologies in comparison to the entities observed in the adult population.

Modes of onset of epilepsy and differential diagnosis

Epilepsy has protean manifestations and may be diagnosed when two unprovoked seizures have occurred. This determination is nearly always based on the available history because most seizures have stopped long before patients arrive at medical care. Great care must be taken, even by experts, to correctly interpret the history and there is strong evidence that incorrect diagnoses are frequent. An abnormal EEG cannot rule epilepsy in or out unless an actual seizure is recorded. When the diagnosis of epilepsy is based only on two seizures, the seizures are usually generalized tonic-clonic. Less "severe" seizure types usually occur multiple times before prompting a medical visit. Some patients present with what seems to be a first generalized tonic-clonic seizure but have a history of less severe attacks that have not brought them to medical attention - epilepsy can then be diagnosed. Others present with staring spells, episodes of confusion, body jerks, spasms, drops, loss of speech and social interactions and/or cognitive function, paroxysmal events during sleep, and febrile seizures. This chapter examines and considers the differential diagnoses for each of these modes of presentation. The consequences of a missed alternate diagnosis, such as cardiac arrhythmia, may be profound.

Special concerns in defining, studying, and treating dystonia in children

Dystonia is movement disorder with many diverse underlying etiologies. Some of those etiologies manifest at specific stages of development or at specific ages. Others may present early in life and evolve as the individual develops. The appearance of symptoms during a time of nervous system development poses special challenges to the neurologist. Normal functions change appearance, dysfunction may manifest in an age-dependent manner, and age-dependent differences in beneficial and toxic effects of treatments all introduce complexities to the process of diagnosis, functional assessment, and therapeutics. Consideration of these developmental differences is essential in assuring a universal definition of dystonia, and for developing valid and reliable assessment tools that can be compared across the lifespan, and more effective therapeutics. © 2013 Movement Disorder Society.