The prevalence and characterization of premonitory symptoms have not been rigorously studied in children and adolescents. Using a questionnaire, we retrospectively studied the prevalence of 15 predefined premonitory symptoms in a clinic-based population. In 103 children and adolescents fulfilling the International Classification of Headache Disorders, 2nd edn criteria for paediatric migraine, at least one premonitory symptom was reported by 69 (67%). The most frequently reported premonitory symptoms were face changes, fatigue and irritability. The mean number of premonitory symptoms reported per subject was 1.8 (median 2.2). Age, migraine subtype (with or without aura) and mean attack frequency per month had no effect on the mean number of premonitory symptoms reported per subject. In conclusion, premonitory symptoms are frequently reported by children and adolescents with migraine. Face changes seem to be a premonitory symptom peculiar to paediatric migraine.

The study explored the awareness of the Haute Autorité de Santé (High Health Authority, HAS) guidelines for migraine management in children among a random sample of 100 general practitioners (GPs) dichotomised in an urban and a rural group. A questionnaire conducted by phone included questions on knowledge of pediatric migraine acute treatment and preventive therapy, referral to a child neurologist as well as GPs awareness of HAS recommendations in general. Although 45% of GPs argued they were prescribing ibuprofen as first-line abortive drug, only 3% were aware of the recommended dose. Only 48% of GPs were agreeing to initiate preventive therapy. Fifty percent of GPs stated that they knew HAS guidelines but only 24% stated that they had read them. The only significant difference between urban and rural GPs concerned the initiation of preventive therapy. Continuing educational programmes on the implementation of pediatric migraine guidelines is strongly needed.Electronic supplementary materialThe online version of this article (doi:10.1007/s10194-009-0111-9) contains supplementary material, which is available to authorized users.

Premonitory symptoms in migraine patientsDear Sir, We read with interest the paper by Cuvellier et al. in a recent issue of Cephalalgia on premonitory symptoms (PS) in pediatric migraine (1). They retrospectively found a prevalence of 67% of PS in 103 children/adolescents with migraine attending their clinic. To our surprise, they comment on other retrospective studies analysing PS in adults, but they do not mention our study, published in the same journal in 2006, in which we prospectively investigated the nosology of PS (and also of resolution symptoms) in 100 unselected adult migraineurs consulting their general physician (2). Two key methodological aspects of our study were that, to be considered as having a true PS, we discounted, intrapatient, the symptoms experienced by these subjects when they were headache-free, and also that, we analysed the consistency of PS in three attacks. True PS were reported by 84% of migraine patients in our series. The higher percentage of PS found in our work has at least two potential explanations: either PS are more frequent in adults or, more probably, this difference is due to our prospective assessment. Regarding the profile of PS, face changes, fatigue and irritability were the most frequent PS in the French study, but anxiety, phonophobia and irritability showed the highest frequency on our study. Assuming that PS are an integral part of a migraine attack, the PS profile suggests that migraine attack probably begins primarily as a rather diffuse cerebral disturbance, which then may spread to discrete areas, such as the hypothalamus or to the brainstem dopaminergic nuclei. Face changes, probably difficult to interpret, have not been described in adults as PS and, in our study, asthenia was the most frequent resolution symptom, but was not among the most frequent PS, thus highlighting the potential differences between children/adolescents and/or the difficulties of the retrospective assessment especially in children. In any case, the two studies confirm the high prevalence of PS in migraine at all ages, which should be taken into account in future studies both for an accurate diagnosis and for planning future preemptive clinical trials. References 1. Cuvellier JC, Mars A, Valle´e L. The prevalence of premonitory symptoms in paediatric migraine: a questionnaire study in 103 children and adolescents. Cephalalgia 2009; 29: 1197-1201. 2. Quintela E, Castillo J, Mun˜oz P, Pascual J. Premonitory and resolution symptoms in migraine: a prospective study in 100 unselected patients.

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