The aim of this investigation was to identify age specific characteristics of children migraine headaches useful in diagnostic procedure. This research was carried out from 1988 to 2008 in the North Province of Serbia. Study was conducted on 30363 children aged 3-17 years. Migraine headache was reported from 2644 interviewed.
Migraine headache is largely underestimated and misdiagnosed in children, because of the lack of anatomical changes, specific biological markers and specific research tools or brain imaging techniques (1,2,3,4).
Diagnosis of migraine headache in children depends on systematic exclusion of secondary disorders and systematic identification of the specific age dependent migraine headache caracteristics. Migraine phenomena: sensory, vegetative and affective, found only in humans, with marked age dependent quantitative and qualitative variations, are outlining the children migraine headache (5,6,7).
There is not enough knowledge on signs and symptoms in children with migraine headaches, to distinguish clearly all clinical entities of migraine syndrome (8,9,10).
It is hard to define children migraine headaches, mostly because they cannot clearly define their nuisances as well as they have age specific features (11).
In the opinion of a great number of authors today, children migraine headache, as a very complex syndrome, is still a matter of deduction. Different criteria are suggested as diagnostic criteria of migraine headache in children (12).
Children migraine headache is a chronic neurological disorder mostly characterized by episodic attacks of headaches with different intensity, frequency and duration, commonly unilateral and associated with anorexia, nausea, vomiting, phonophobia and photophobia. Very often preceded or accompanied by sensory, motor, vegetative, affective and various combinations of neurological, gastrointestinal and vegetative changes. The degree of their expression and the time of appearance vary age dependent, qualitatively and quantitatively in children. According to the literature data, generally, pain quality and localization, headache duration, behavioral markers accompanying symptoms and remission occurrence rate seem to be age depend (13,14).
This research was carried out in the territory of Vojvodina, North Province of Serbia, which has a total population of 2,031,992, according to the last census (in 2002). During the study, which lasted from 1988 to 2008 each year 2000 questionnaires were given to the participants, who were drawn from 23 preschools and 42 grade schools in 9 cities in Vojvodina (Novi Sad, Subotica, Kikinda, Zrenjanin, Vrsac, Bela Crkva, Melenci, Futog and Temerin). In total 30363 children aged 3-17 years have been included. Recurrent headaches were established in 27.46% (8456), defined as migraine headaches in 8.63% (2644) of interviewed children.
Children were selected according to their month and year of birth, and the first 3 letters of their first name by a multistage, stratified, clustered sampling procedure. This ensured that children could not enter the study twice during the long research period.
The subjects and/or their parents were asked to fill out a questionnaire in their places of residence. Questionnaires were distributed to children and/or their parents, selected by random sampling. The semi structured questionnaire, which was specially developed for this study by the author, was designed according to the International Headache Society criteria. It was a screening questionnaire, which was completed by children and/or their parents together. It included 3 sections: (1) items about the child’s sociodemographic characteristics and his/her family and school; (2) items about the child’s development, and (3) items about headaches including all characteristics, signs and symptoms.
The questionnaire was developed in 3 phases. In the first, semi structured interviews with pediatricians and researchers were organized to select relevant domains. The domains for the section about headaches were selected based on the International Classification of Headache
Disorders – II criteria. More than 150 possible items were identified. Precise, comprehensive and appropriate items were included in the first form. The possible responses were open-ended options or categorical judgments.
In the second phase, the questionnaire was pretested in semi structured interviews on a small group of children who either did or did not suffer from headaches (16 families were included). This phase aimed to evaluate the face and content validity of the questionnaire. Additionally, the sensitivity was evaluated by correlating the data from the questionnaire and the medical records of the children who had headaches. This phase resulted in a revised version, which was evaluated only on healthy children. Fifty children and adolescents completed the questionnaire twice in 3 weeks. The nonresponsive rate, response distributions, graphical response presentation (response inconsistency) and questionnaire burdens (time to complete, formatting, etc.) were analyzed. A number of items were modified or eliminated and the final form included 93 items which required 20 min to complete.
The including criteria were: age 3–17 years, signed informed consent from parents. The excluding criterion was a previous diagnosis of a disease that has headache as a symptom.
The accuracy of the questionnaire used in this survey was based on classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain, and the revised International Headache Society criteria (15).
The mean age of the study subjects was 9 years and 2,5 months (range 3–17 years, standard deviation (SD) 3.44. The large number of children surveyed allowed for definite conclusions. The study was conducted in 2 phases: completion of the questionnaire and, for those with recurrent headache, a face-to-face interview. Based on data gathered by the questionnaire, children who had recurrent headache underwent an extended interview and neurological examination.
The accuracy of the questionnaire used in this survey was based on International Headache Society criteria. Using the society’s classification codes, migraine was accepted as 1.1–1.7, migraine with aura was 1.2.2–1.2.6, migraine without aura was 1.1 and other migraine syndromes were 1.3–1.7. recurrent headache was accepted as all headache types that appeared 1to 3 times per month, without separating them due to specific characteristics. All types of recurrent headaches (idiopathic or cryptogenic recurrent headaches) that were not migraine were considered as non-migraine headaches (16,17,18).
Of the questionnaires, 1.5% due to possible double interview and missing data in the questionnaires have been biased. Separate data according to recurrent headache were analyzed for children who had completely answered the questionnaire. Comparing characteristics of individual headaches in children with migraine and non-migraine headaches, specific age dependent features of children migraine headaches were established.
The demographic, clinical and social characteristics were described by age and sex according to headache presence and type. The Hi2 test, Levin test and ANOVA were used as statistical methods. A significance level of 5% was used (p<0.05). All statistical analyses were performed with SPSS 15.0 (SPSS Inc., Chicago, Ill., USA).
The aim of this investigation was to identify age of appearance for the specific age dependent characteristics and features of child migraine headaches, which would help in diagnostic procedure for children migraine headache.
Out of 30636 observed children 2644 (8.63%) reported migraine headaches (1162 male and 1482 female). Migraine headache was reported for the first time in children aged 5 years 1,8 months (SD 1,47 standard error of the aritmetical mean 0,03).
Pulsating pain was most frequent in children migraine headaches (76.3%), whereas undefined (30.1%), pressure (29.8%) and squeezing pain (24.6%) are more frequent in other recurrent headaches.
Pulsating migraine head pain is the most frequent in children with migraine headache agged 12 years. The younger the child, the more likely is that the pain will be described as undefined. (Table 1. Age and types of migraine pain in regard to the type of migraine syndrome)
Table 1. Age and types of migraine pain in regard to the type of migraine syndrome
Children with migraine headaches and/or their parents assessed headache pain severity using a Pain Assessment Scale of 0 – 5 with 3.12, at age 9 years 5.7months (range 3-17years).
In children of median age 12 year 0,3months migraine head pain was mostly unilateral (79.4%), of median age 11years 2,2 months mostly first unilateral, but spreading to bilateral. Younger children had predominantly various 6,4% (with maximal expression ad median age 6 years 5,9 months) diffuse 3,8% (with maximal expression at median age 6 yeas 8,7 months), and bilateral 1,5% (with maximal expression at median age 10 year and 7 months.). (Table 2. Migraine headache pain location regarding to child age).
Table 2. Migraine headache pain location regarding to child age
ANOVA: F 227.352, DF 5, Sig 0.0001
Migraine headache appears usually several times per year after 11th birthday, but in first decade of life it appears weekly, even daily. In general it appears about one year later than non migraine headache (Table 3 Frequency and type of headache, age of examinees).
Table 3. Frequency of migraine headache
ANOVA F 22.542, DF 7, Sig 0.0001
Migraine headache which affects younger children lasts significantly shorter (at average age of 8 years it lasts omly minutes, at age of 9 years 3.7 months it lasts up to 1 hour, and at the age 12 years 1.2months it lasts 0-2 hours)(Table 4 Children’s age and headache duration)
Table 4. Children’s age and headache duration
Pearson Chi Square: V 417.670, DF 8, Sig 0.0001
Nausea, vomiting impulse and vomiting are much more frequent in younger children. Only 1.3% of children with migraine headaches of average age 6 years and 4.8 months do not have nausea, vomiting instinct and vomiting (Table 5. Headache associated nausea and vomiting in regard to the age of children).
There was no age dependency for other accommpaning migraine headache symptoms (photophobia, phonohobia, vertigo, skin pallor, dark circles under the eyes, sweating, irregular breathing, precordial pain and other vegetative symptoms, noticable behavior changes), as well as in coping with migraine reporting in observed children.
Table 5. Headache associated nausea and vomiting in regard to the age of children
Free sample test: F 24370, t- 9.088 DF 3072, Sig 0.0001
Out of 30636 observed migraine headache was reported in 8.63%, (43.95% boys and 56.05% girls). Our findings are very simillar to other European study groups. Wober Bingol’s population study of migraine in children and adolescents, encountered prevalence of migraine in 1,1-5% of children and 3-17,6% in adolecents (19). In 1983. Sillanapaa described higher headache presence: 37% of 2941 Finland children aged 7-14 (20). Hershey finds pediatric migraine occurs in up to 10.6% of children between the ages of 5 and 15 years and in up to 28% of adolescents between the ages of 15 and 19 years (21). In Turckey Zecir described migraine prevalence was 8.8%: 6.7% in boys and 11.0% in girls (OR: 1.7; 95% CI: 1.3 to 2.3) (22). Raieli V. et al found in 1598 medical records of children who visited Headache Center in the study period, according to the IHS criteria 35.2% migraine headaches (23).
In the observed group of children at the average 9 years 2.5 months (range 3-17), with standard deviation 3.44, first migraine headache attacks vere reported in children of age 5 years 1,8 months (SD 1,47 standard error of the aritmetical mean 0,03). Balottin et al analyzed group of children aged 12 months-6 years; with mean age at the first observation: 4 years and 7 months, and described mean age at onset: 4 years and 2 months, range: 10 months-6 years (24).
Pulsating pain is most frequent in child migraine headaches, dominat at age of 12, whereas undefined, pressure and squeezing pain are equally present up to age of 7. The younger the child, the more likely it is that the pain is described as undefined. There is a clear and statistically significant correlation between the type of pain and the child’s age, which questions the validity of insiting on including type of pain in diagnostic criteria of children migraine headache.
Children with migraine headaches of mean age 9 years 2,5 months assessed their pain severity using a Pain Assessment Scale of 0 – 5 with 3.12. The assessment of migraine headache severity depends also on the child’s age. Pearson’s coefficient 0.43, p<0.01 confirms a direct association between the child’s age and pain intensity assessment, requiring precise individual clinical assessment of each child.
Migraine headaches are mostly unilateral (79.4%), but in child migraine is up to the 11th birthday mostly bilateral. At age of 11 it is mostly unilateral but with bilateral spreading, and after 12th birthday it is clearly unilateral. Distinct pain location in migraine headaches is significantly connected with the age of children and their ability to interpret it. Maytal found unilateral pain in 34.1% pediatric migraine (25).
The frequency of migraine head pain attacks, as well as other characteristics of migraine syndrome in children, depend on children’s age. Most migraine hradache attacks (78,1%) occur several times per year. in children with average age of 11 years and 1.8 months.
Migraine headaches last much longer (from several minutes in 0.89% to 2h in 27.8%, and whole day or longer in 21.8% children. The percentage of migraine headaches which last a few minutes (0.89%) up to 1h (4.4%) and up to 2h (27.8%), excludes length of migraine headache from diagnostic criteria. Migraine headaches which affect younger children last significantly shorter: at average age of 8 years few minutes, at average 9 years 4.5 months up to 1h, and after 12 years 4 months more than 2h. Wober-Bingol in 1995, analyzung 409 children found duration of migraine attacks was less than 2 h in 19.0% of the migraine patients (19). Maytala described headache duration of 2 hours or longer in 55.7% children with migraine with aura (25).
Migraine is usually evident by the accompanying symptoms which dominate the clinical picture, especially at younger age. Nausea is present in 98,7%, vomiting impulse in 97,7%, vomiting in 77,2%, and nausea and/or vomiting impulse and/or vomiting in 83.7% of children migraine episodes. This clearly defines nausea, vomiting instinct and vomiting as basic elements of migraine attacks in children. Nausea, vomiting instinct and vomiting are much more frequent in younger children. Only 1.3% of children with migraine headaches of average age 6 years and 5.5 months have no nausea, vomiting instinct and vomiting. Maytala described 47.7% children with migraine without aura vomit during migraine attacks (25). Analyzing 409 children Wober-Bingol found that in the differential diagnosis of migraine and tension-type headache the intensity of pain, aggravation of headache by physical activity, nausea and vomiting were the most important features The quality of pain, phono- and phonophobia were less helpful and location least important (19).
There is no clear age dependency for photophobia, phonohobia, vertigo, skin pallor, dark circles under the eyes, sweating, irregular breathing, precordial pain and other vegetative symptoms, oticable behavior changes.
In 2000 analyzing age at onset influence on migraine clinical features. Zambrino found that unilateral pain location and severe intensity, the presence of nausea, vomiting, phonophobia and photophobia were features which varied between migrainous and non-migrainous subjects. He did not find the age at onset is a factor influencing the characteristics of the headache. He concluded, the location and the quality of pain in adolescent migraine are similar to those found in childhood migraine, while the concomitant symptoms were less frequent than in childhood and in adult migraine (26). Battistella et all examined 243 patients and found earlier onset, shorter duration, lower symptom association (photo- or phonophobia, nausea) and no pain increase during physical activity rather in pre school than in prepubertal children (27). Simillar resulths have been shown in population ov Vojvodina (28).
Diagnosing migraine especially in children is not an easy task. The diagnosis of migraine depends on the recognition of the age dependent features specific to the condition.
Pulsating pain is the most dominate from from age of 12years. Undefined pain pressure and squeezing pain are equally present up to the age of 7. Higher pain level is described in older children. Head pain in child migraine is up to 11th birthday mostly bilateral. High significance of unilateral pain in migraine headache clearly justifies its inclusion into diagnostic criteria of child migraine after 12th birthday. Most migraine attacks occur several times a year in children with average age of 11 years and 1.5 months with onset at the age of 5 years and 1.8 months. Migraine head pain appears weekly before 10th, even daily before 9th birthday.
Migraine headaches which affect younger children last significantly shorter. The percentage of migraine headaches which last up to 2 hours (33%), excludes length of migraine headache from diagnostic criteria, Nausea, vomiting impulse and vomiting, usually evident by the accompanying symptoms of children migraine attacks, are much more frequent in younger children. Only 1.3% of children with migraine headaches at average age of 6 years and 4.8 months have no nausea, impulse to vomiting and vomiting.
There is no age dependency for other accommpaning migraine headache symptoms (photophobia, phonohobia, vertigo, skin pallor, dark circles under the eyes, sweating, irregular breathing, precordial pain and other vegetative symptoms, noticable behavior changes).
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Institute for Child and Youth Health Care of Vojvodina, Department for developmental neurology and epileptology Novi Sad, Hajduk Veljkova 10, 21000, Novi Sad, Serbia firstname.lastname@example.org , email@example.com