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Three Part Question

In [children who present to the emergency department] is a [throbbing headache and vomiting] sufficient enough to make a [diagnosis of migraine].

Clinical Scenario

An 11 year old child comes to the emergency department accompanied by her mother. The child complains of a bilateral severe throbbing headache which started an hour ago but is still present. She has also vomited in the last hour. You wonder whether these two symptoms are adequate to make a diagnosis of migraine.

Search Strategy

Medline 1950-June 2007 using Ovid interface
Embase 1980 to 2007 Week 25 using Ovid Interface
[(exp headache OR exp migraine OR exp migraine without aura OR exp migraine with aura OR exp migraine aura OR throbbing headache.mp. OR pulsating.mp. OR pulsatile.mp. dull.mp.) AND (exp vomiting OR vomiting.mp. vomit.mp OR emesis) AND (LIMIT to children AND english)]

Search Outcome

106 papers were identified on Embase of which 1 was relevant and 113 papers were found on medline of which 3 were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Necdet Karli et al, 2006 Turkey	1064 adolescents aged between 12-17 years.	Multistep stratified cluster sampling method.	Common features of migraine with/without aura.	Moderate to severe intensity found in 92.4% of patients. Pulsating headache found in 79.2% of patients.	Some adolescents had features of both migraine and tension type headcahe, therefore making it difficult to make a firm diagnosis.
			Common features of migraine without aura	Nausea, vomiting, photophobia, phonophobia, osmophobia, headache worsened by routine exercise
			Highest sensitivity factors for migraine	Migraine duration 100%. Moderate to severe pain and pulsating quality of pain.
			Highest specificity factors for migraine	Highest for vomiting and trigger factors.
			Trigger factors for migraine	Bright light, smoking, cigarette smoke odour, hunger, certain foods, sleep pattern changes
Knezevic-pogancer, 2006 Serbia	30,636 children aged 3-17 years old.	Multistage stratified clustered sampling procedure	Symptoms with a high correlation to migraine.	Nausea and phonophobia	Results were from a questionnaire which was given out once. Frequency of vomiting and other symptoms were not recorded. Therefore a patient may have experienced a symptom once and this may have been interpreted as being part of the migrainous symptom.
			% of patients who experienced symptoms during a migraine episode.	Vomiting impulse 98.7%. Nausea 83.8%. Vomiting 99.4%. Nausea, vomiting impulse, and vomiting 83.7%. 0.7% have migraine with no nausea or vomiting impulse. Relief after sleep 76.7%.
			Specificity of associated symptoms in young children	74.46% reported abdominal pains at an average age of 6.23 years. 97.4% had changes in stool consistency. 70.2% have dark circles under the eyes and 96.1% had skin pallor.
			Time of migraine attack	78% occurred in the morning
P.Winner et al, 2003 UK	Data from 8 migraine clinical trails conducted on 1932 patients aged 12-17 years old.	Review and retrospective analysis	Time of migraine attack	73% had migraine attacks between 6am-6pm.	Review were on articles that did not concentrate specifically on symptoms of migraine. All articles were studies done on the treatment of migraine.
			% of children who had following features during migraine.	Migraine aggravated by activity 88%. Unilateral pain 58%, Pulsating pain 74%, Nausea 53%,Vomiting 5%, Photophobia or phonophobia 80%.
Lai H.Lee, karen N.Oleness, 1996 Ohio	222 children aged 5-13 years old	Self administered questionnaire survey	% of children with prodromal symptoms.	74.3% had prodromal symptoms. Hypoactivity 23.1%. Hyperactivity/irritability 37.5%. Depression 18.5%. Food cravings 8.3%, Repeated yawning 12.5%.	In total 18000 patients were given questionnaires. Only 2572 patients replied and from these patients 222 were diagnosed with migraine.
			% of children with auras	54.1% had auras. 31.0% had blurred vision. 29.6% saw shimmering lights circles or other shapes. 17.6% had numbness/tingling of lips, tongue, fingers or legs. 9.2% had difficulty speaking. 12.6% had weakness in one side.
			Quality of pain.	Throbbing/pulsating 61.8%. Sharp pain 19.6%. Dull pain 18.6%.
			Location of migraine headaches.	Frontal 35.2%. One/two temples 22.0%. All over the head 23.8%. Occipital 6.7%. Unilateral 12.3%
			Duration of headache.	14.8% 30 minutes to 2 hours. 70.7% 2-24 hours. 6.3% 24-48 hours. 2.3% 2-3 days
			Associated symptoms with migraine	Nausea 57.7%, Vomiting 34.2%, Photophobia 62.3%, Phonophobia 69.8%
			Aggravating factors	Physical activity/motion 36%, Noise 33.3%, Bright light 26.1%
			Severity of attacks	43.7% stayed in bed during the attack. 27.5% were not able to attend school. 37.4% went to school but were not able to perform normally. 20.7% found a limit to daily life.

Comment(s)

Only one review was found.

Clinical Bottom Line

Using two of the studies 61.8- 79.2% of the children described the pain as throbbing/pulsating in migraine. The quality of pain was found to be a high sensitive marker for migraine whereas vomiting was found to be specific for migraine. The percentage of children who vomited varied between 5-99.4%. Therefore in conclusion a report of throbbing pain and vomiting maybe sufficient to make a diagnosis of migraine, but other factors such as the severity and duration of pain and the presence of aggravating factors should be enquired about in order to make a firm diagnosis of migraine.

References

1. Necdet Karlý, Semra Akgöz, Mehmet Zarifoðlu, Nalan Akýþ, Sevda Erer. Clinical Characteristics of Tension-Type Headache and Migraine in Adolescents: A Student-Based Study. Headache 399–412, 2006
2. Knezevic-Pogancev M. Specific features of migraine syndrome in children. Journal of Headache & Pain 206-210, 2006
3. P. Winner, A. D. Rothner, D. G. Putnam, M. Asgharnejad. Demographic and Migraine Characteristics of Adolescents with Migraine: Glaxo Wellcome Clinical Trials' Database. Headache 451-457, 2003
4. Lai H. Lee, Karen N. Olness Clinical and Demographic Characteristics of Migraine in Urban Children. Headache 269-276, 1997 June