Cranial Autonomic symptoms, neck pain: Challenges in pediatric migraine

Abstract

Objectives: More than just a headache, migraine attack is a severe, prolonged head pain preceded and/or followed by a constellation of symptoms. Getting a proper diagnosis will be the most challenging step of migraine care. When cranial autonomic symptoms (CASs), and/or neck pain are observed, children are often exposed to advanced tests for additional diseases. The aim of this study was to investigate the frequency of these symptoms in migraine and to compare the clinical characteristics of patients with and without these symptoms. Frequency of the patients that exposed to the additional investigations was searched. Materials and Methods: In this prospective study between February 2016 and March 2017, 170 pediatric patients who were referred to our tertiary teaching hospital with migraine were enrolled. Results: A total of 170 children, 61 male (35.9%) and 109 female (64.1%) were included in the study. CASs were present in 68 patients (40%), single symptom in 31 (45.6%), and multiple symptoms in 37 (54.4%) patients. Of 68 patients with CAS, 24 (35%) patients were referred to allergists and all were tested for inhaler specific IgE and skin tests. Seventy (32.9%) patients had neck pain/stiffness in which 28 (40%) were exposed to radiation. CAS and neck pain were more frequent in patients with frequent attacks ( P = 0.04 and P = 0.032, respectively). Neck pain was more frequent in patients with CAS ( P = 0.029). Conclusions: It is important for pediatricians and primary care physicians to be aware of the common nature of CASs and neck pain/stiffness in children with migraine to prevent unnecessary procedures. High frequency of migrain attacks was associated with high frequency of CAS and neck pain.

Cranial Autonomic Symptoms and Migraine: What Relationship and What Meaning? A Review

“…These data [7,28] confirmes those coming from the clinical series [4][5][6][8][9][10][11][12][13][14][15][17][18][19][20][21][22][23][24][25][26][27]. Further the prevalence may be sometimes undervalued because some researches only look for the unilateral CAS while in clinical series they may be also present bilaterally as well as migraine pain may have bilateral lateralization.…”

“…Almost all studies tried to correlate the presence of CAS in migraine attacks with the other clinical features of migraine. Several studies have shown a positive correlation between CAS and chronic migraine [18,25], history of disease [6,11], frequency of attacks [13,21,26], severe intensity of pain [4,17], duration of attacks [6,17], unilaterality of pain [4,11,16,17,25,26], allodynia [17,22], phono/photophobia [6,17] and osmophobia [22]. However the different studies, compared among them, often conflict with each other, not confirming the correlations reported by the other studies and vice versa.…”

“…There are only 4 studies conducted in pediatric age, they don't show a predilection for female sex (in prepuberal age male/female ratio is about equal in migraine), but the prevalence is in a range between 40% and 67% moreover they are present in about 50% of children under seven years, often bilaterally. Pediatric studies [12][13][14]21] are summarized in Table 4 (Ref. [12][13][14]22]).…”

“…The prevalence of CAS in subjects with chronic migraine versus those with episodic migraine [8,[19][20][21][22] suggested that the increased frequency of attacks may induce sensitization and greater involvement of the autonomic component due to the greater severity of disease. How- ever, the evidences (1) that CAS, can also be induced in the absence of pain [39], (2) that this difference between episodic and chronic migraines is not always present in the studies, and (3) that they are already present in pediatric age and with no significant differences between preschool and school age children [12][13][14], also suggest the alternative hypothesis that CAS are an independent endophenotypic migraine subgroup.…”

Premonitory symptoms in migraine: a systematic review and meta-analysis of observational studies reporting prevalence or relative frequency

“…Of the 29 studies, 15 assessed prevalence or relative frequency of premonitory symptoms as the primary outcome [ 17 , 19 , 21 – 25 , 28 , 31 – 33 , 35 , 37 – 39 ]. Nine of the 22 clinic-based studies collected data prospectively [ 17 , 18 , 22 , 23 , 26 , 27 , 35 , 36 , 39 ], while 14 [ 19 – 21 , 24 , 25 , 28 , 30 – 34 , 37 , 38 , 40 ], and all six population-based studies [ 13 – 16 , 41 , 42 ], acquired data retrospectively.…”