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Three Part Question

In [children and adolescents with known migraine and persistent nausea/vomiting] is [referral to a neurologist] important to [rule out secondary aetiology]?

Clinical Scenario

A 9 year old girl presents to the Emergency Department with a 2 hour history of a severe throbbing headache and two episodes of vomiting since the onset. She is a known migraine sufferer, who has had several similar episodes with associated nausea and vomiting in the past. After history and clinical examination, a diagnosis of migraine is made. You wonder if referral to neurology is necessary to rule out underlying aetiology.

Search Strategy

Medline 1950-July 2010 Using Ovid interface
EMBASE 1980-July 2010 Using Ovid interface
Cochrane Database of Systematic Reviews (July 2010)

Medline
[(Exp migraine disorders OR exp Headache OR exp Primary Headache Disorders OR exp Headache Disorders) AND (exp “Referral and Consultation” OR referral$.mp.) (LIMIT to English language AND Humans)) AND (LMIT to “All Child (0-18 years)”)]
EMBASE
[(Exp migraine aura OR exp migraine without aura OR exp migraine with aura OR exp migraine OR exp headache OR exp primary headache) AND (exp Nausea OR exp Vomiting OR exp “Nausea and Vomiting”) AND (exp “Patient Referral” OR referral$.m.p.) AND (LIMIT to (Human and English Language)) AND (LIMIT to (child OR preschool child <1 to 6 years> OR school child <7 to 12 years> OR adolescent <13 to 17 years>)
Cochrane Database of Systematic Reviews (July 2010)
Search’migraine’ (ti,ab,kw)

Search Outcome

7 papers found in Medline, 2 relevant
53 papers found in EMBASE, none were relevant
98 papers found in Cochrane, none were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
S. Wilne et al 2007 United Kingdom	74 papers including all case series and cohort studies desribing symptoms and signs of a minimum of ten children diagnosed with a CNS tumour (total of 4171 children)	Systematic Review & Meta-analysis	frequency & variability of signs & symptoms at presentation	56 signs & symptoms recorded, of relevance; 1. intracranial tumours- headache 33% nausea & vomiting 32% 2. intracranial tumours <4years- nausea & vomiting 30% 3. Posterior fossa tumours- headache 67% nausea & vomiting 75% 5. Central brain tumours- headache 49% nausea & vomiting 19%	Weakly related to clinical question; analysis shows symptoms & signs of children who have CNS tumours, not very useful for primary referral. Variation in data detail between studies could bring misinterpretation & bias.
J. Edgeworth et al 1996 United Kingdom	74 Children aged 0-16years with primary brain tumours admitted to Neurosurgical unit between 1990-1994. Different proportions of information were available for each part of the study.	Retrospective study; data from medical case notes, histopathology reports, semistructured parental interviews, psychological questionaires.	Duration of clincial history	68% not correctly diagnosed after 1 month, 20% not diagnosed after 6 months	Weakly related to clinical question. Data statistics are confusing and not fully explained. Retrospective parental interviews only 'semi structured' and have potential to be biased.
			Reasons for delay in diagnosis	Multifaceted, headache particular diagnostic problem, migraine diagnosed in 24%
			frequency of signs & symptoms	Relevant data; headache 64%, nausea & vomting 65%, headaches always associated with nausea &vomiting 34%

Comment(s)

There is little evidence that children presenting with migraine and persistent nausea and vomiting should be referred to neurology since the relevant papers are only vaguely specific to this question. However delay in diagnosis of serious aetiology may be a problem and more research is needed in this area.

Clinical Bottom Line

There is insufficient evidence that referral to neurology is necessary for a child with migraine and persistent nausea and vomiting.

References

1. S. Wilne, J. Collier, C. Kennedy et al Presentation of childhood tumours: a systematic review and meta-analysis Lancet Oncology 2007; 8:685-95
2. J. Edgeworth, P. Bullock, A. Bailey et al Why are brain tumours still being missed? Archives of Disease in Childhood 1996; 74: 148-151