eMedicine Specialties > Neurology > Pediatric Neurology

Childhood Migraine Variants: Differential Diagnoses & Workup

Author: Wendy G Mitchell, MD, Professor of Neurology, University of Southern California School of Medicine; Consulting Staff, Division of Child Neurology, Children's Hospital Los Angeles, Los Angeles County-University of Southern California
Contributor Information and Disclosures

Updated: Feb 5, 2009

Differential Diagnoses

Aphasia
Frontal Lobe Syndromes
Brainstem Gliomas
Headache: Pediatric Perspective
Cluster Headache
Inherited Metabolic Disorders
Complex Partial Seizures
Intracranial Hemorrhage
Disorders of Carbohydrate Metabolism
Migraine Headache
Epilepsia Partialis Continua
Migraine Variants
First Seizure: Pediatric Perspective
Focal EEG Waveform Abnormalities
Frontal Lobe Epilepsy

Other Problems to Be Considered

Alternating hemiplegia of childhood
Benign occipital epilepsy of childhood
CADASIL, for alternating hemiplegias presenting in adolescents
Complex partial status epilepticus
Epilepsy: pediatric overview
Ingestions
Intoxications
Organic acidurias

Workup

Laboratory Studies

  • During the first or worst episode, perform appropriate laboratory and neuroradiologic studies to exclude other causes of the symptoms.
  • Laboratory studies generally are not helpful between episodes when a history of multiple, recurrent episodes and complete clearing between episodes exists.
  • Evaluate a child with cyclic vomiting with or without head pain for metabolic disease, particularly mitochondrial cytopathy.
    • Studies performed during attacks have higher yield than those performed while the child is feeling well.
    • During the attack, perform the following investigations: serum lactate, serum pyruvate, urine organic acids, and serum ammonia samples. Samples must be collected carefully and handled appropriately by the laboratory. If suspicion of mitochondrial cytopathy is high, blood may be collected any time to examine the DNA for mitochondrial point mutations and deletions.
  • For aura without headache, the differential diagnosis often includes simple partial (focal) seizures. Therefore, electroencephalography (EEG [sleep-deprived is possible] or video EEG [if episodes are frequent]) may help in the diagnosis.
  • For other migraine variants, EEG generally does not confirm or exclude migraine or other alternatives, since epileptiform EEG changes can be observed in migraineurs.

Imaging Studies

  • Neuroimaging (CT, MRI) is indicated during the first or worst attack that presents with simultaneous focal neurologic deficits or altered mental status and/or if any focal findings persist between attacks. Perform these studies to exclude other acute causes of the symptoms. Neuroimaging is less important if the patient presents during a symptom-free interlude, with a history of multiple attacks with complete recovery. In these patients, the clinician can usually rule out acute, life-threatening conditions and more reasonably make a diagnosis of migraine based on history.
  • During or immediately after an attack, functional neuroimagingmay support the diagnosis, although migraine is most often a clinical diagnosis.
    • Single photon emission computed tomography may show hypoperfusion during an aura or episode.
    • Functional MRI (fMRI), a research technique, also may demonstrate abnormalities of perfusion.
    • Gadolinium-enhanced MRI may show focal enhancement during or immediately after the attack. This can cause confusion with ischemic stroke, inflammatory conditions, or infection.

Other Tests

  • EEG may be abnormal during or immediately after an episode, with slowing in focal or generalized patterns. In general, nonspecific interictal EEG abnormalities, including epileptiform activity, are reported in higher frequencies in migraineurs.
  • Continuous ambulatory or video EEG may be useful in the rare patient with episodic confusion, hallucinations, or focal neurologic deficits; partial seizures or nonconvulsive status epilepticus are included in the differential diagnosis for the attack.

More on Childhood Migraine Variants

Overview: Childhood Migraine Variants
Differential Diagnoses & Workup: Childhood Migraine Variants
Treatment & Medication: Childhood Migraine Variants
Follow-up: Childhood Migraine Variants
References
[ CLOSE WINDOW ]

References

  1. Ahmed MA, Reid E, Cooke A, et al. Familial hemiplegic migraine in the west of Scotland: a clinical and genetic study of seven families. J Neurol Neurosurg Psychiatry. Dec 1996;61(6):616-20. [Medline].

  2. Ahonen K, Hamalainen ML, Rantala H, Hoppu K. Nasal sumatriptan is effective in treatment of migraine attacks in children: A randomized trial. Neurology. Mar 23 2004;62(6):883-7. [Medline].

  3. Baloh RW, Honrubia V. Childhood onset of benign positional vertigo. Neurology. May 1998;50(5):1494-6. [Medline].

  4. Beauvais K, Cave-Riant F, De Barace C, et al. New CACNA1A gene mutation in a case of familial hemiplegic migraine with status epilepticus. Eur Neurol. 2004;52(1):58-61. [Medline].

  5. Blaik Z, Hiremagular S. Episodic unilateral mydriasis and headaches. Tenn Med. Mar 1998;91(3):107-8. [Medline].

  6. Boles RG, Adams K, Ito M, Li BU. Maternal inheritance in cyclic vomiting syndrome with neuromuscular disease. Am J Med Genet A. Aug 1 2003;120(4):474-82. [Medline].

  7. Ducros A, Joutel A, Vahedi K, et al. Mapping of a second locus for familial hemiplegic migraine to 1q21-q23 and evidence of further heterogeneity. Ann Neurol. Dec 1997;42(6):885-90. [Medline].

  8. Evans RW, Taylor FR. "Natural" or alternative medications for migraine prevention. Headache. Jun 2006;46(6):1012-8. [Medline].

  9. Evers S, Rahmann A, Kraemer C, et al. Treatment of childhood migraine attacks with oral zolmitriptan and ibuprofen. Neurology. Aug 8 2006;67(3):497-9. [Medline].

  10. Freitag FG, Collins SD, Carlson HA, et al. A randomized trial of divalproex sodium extended-release tablets in migraine prophylaxis. Neurology. Jun 11 2002;58(11):1652-9. [Medline].

  11. Gardner K, Barmada MM, Ptacek LJ, Hoffman EP. A new locus for hemiplegic migraine maps to chromosome 1q31. Neurology. Nov 1997;49(5):1231-8. [Medline].

  12. Golomb MR, Sokol DK, Walsh LE, et al. Recurrent hemiplegia, normal MRI, and NOTCH3 mutation in a 14-year-old: is this early CADASIL?. Neurology. Jun 22 2004;62(12):2331-2. [Medline].

  13. Haan J, Terwindt GM, Maassen JA, et al. Search for mitochondrial DNA mutations in migraine subgroups. Cephalalgia. Jan 1999;19(1):20-2. [Medline].

  14. Jurkat-Rott K, Freilinger T, Dreier JP, et al. Variability of familial hemiplegic migraine with novel A1A2 Na+/K+-ATPase variants. Neurology. May 25 2004;62(10):1857-61. [Medline].

  15. Kim JS, Yue Q, Jen JC, et al. Familial migraine with vertigo: no mutations found in CACNA1A. Am J Med Genet. Sep 1 1998;79(2):148-51. [Medline].

  16. Lampl C, Buzath A, Klinger D, Neumann K. Lamotrigine in the prophylactic treatment of migraine aura--a pilot study. Cephalalgia. Jan 1999;19(1):58-63. [Medline].

  17. Lendvai D, Monteleone F, Melpignano G, et al. Familial hemiplegic migraine in developmental age: report of two cases. Riv Eur Sci Med Farmacol. Jul-Aug 1996;18(4):143-7. [Medline].

  18. Lewis D, Ashwal S, Hershey A, et al. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology. Dec 28 2004;63(12):2215-24. [Medline].

  19. Lewis DW, Ashwal S, Dahl G, et al. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. Aug 27 2002;59(4):490-8. [Medline].

  20. Li BU, Murray RD, Heitlinger LA, et al. Heterogeneity of diagnoses presenting as cyclic vomiting. Pediatrics. Sep 1998;102(3 Pt 1):583-7. [Medline].

  21. Li BU, Murray RD, Heitlinger LA, et al. Is cyclic vomiting syndrome related to migraine?. J Pediatr. May 1999;134(5):567-72. [Medline].

  22. Lipton RB. Diagnosis and epidemiology of pediatric migraine. Curr Opin Neurol. Jun 1997;10(3):231-6. [Medline].

  23. Mark AS, Casselman J, Brown D, et al. Ophthalmoplegic migraine: reversible enhancement and thickening of the cisternal segment of the oculomotor nerve on contrast-enhanced MR images. AJNR Am J Neuroradiol. Nov-Dec 1998;19(10):1887-91. [Medline].

  24. Nezu A, Kimura S, Ohtsuki N, et al. Acute confusional migraine and migrainous infarction in childhood. Brain Dev. Mar 1997;19(2):148-51. [Medline].

  25. O''Hara MA, Koller HP. Migraine in a pediatric ophthalmology practice. J Pediatr Ophthalmol Strabismus. Jul-Aug 1998;35(4):203-8; quiz 227-8. [Medline].

  26. Ojaimi J, Katsabanis S, Bower S, et al. Mitochondrial DNA in stroke and migraine with aura. Cerebrovasc Dis. Mar-Apr 1998;8(2):102-6. [Medline].

  27. Ophoff RA, Terwindt GM, Vergouwe MN, et al. Familial hemiplegic migraine and episodic ataxia type-2 are caused by mutations in the Ca2+ channel gene CACNL1A4. Cell. Nov 1 1996;87(3):543-52. [Medline].

  28. Ramelli GP, Sturzenegger M, Donati F, Karbowski K. EEG findings during basilar migraine attacks in children. Electroencephalogr Clin Neurophysiol. Nov 1998;107(5):374-8. [Medline].

  29. Rothner AD, Winner P. Headaches in children and adolescents. Wolff's Headache and other head pain. 2001;539-561.

  30. Schreier HA. Auditory hallucinations in nonpsychotic children with affective syndromes and migraines: report of 13 cases. J Child Neurol. Aug 1998;13(8):377-82. [Medline].

  31. Shaabat A. Confusional migraine in childhood. Pediatr Neurol. Jul 1996;15(1):23-5. [Medline].

  32. Soriani S, Feggi L, Battistella PA, et al. Interictal and ictal phase study with Tc 99m HMPAO brain SPECT in juvenile migraine with aura. Headache. Jan 1997;37(1):31-6. [Medline].

  33. Spranger M, Spranger S, Schwab S, et al. Familial hemiplegic migraine with cerebellar ataxia and paroxysmal psychosis. Eur Neurol. 1999;41(3):150-2. [Medline].

  34. Swoboda KJ, Kanavakis E, Xaidara A, et al. Alternating hemiplegia of childhood or familial hemiplegic migraine? A novel ATP1A2 mutation. Ann Neurol. Jun 2004;55(6):884-7. [Medline].

  35. Terwindt G, Kors E, Haan J, et al. Mutation analysis of the CACNA1A calcium channel subunit gene in 27 patients with sporadic hemiplegic migraine. Arch Neurol. Jun 2002;59(6):1016-8. [Medline].

  36. Ueberall MA, Wenzel D. Intranasal sumatriptan for the acute treatment of migraine in children. Neurology. Apr 22 1999;52(7):1507-10. [Medline].

  37. Vanagaite J, Pareja JA, Storen O, et al. Light-induced discomfort and pain in migraine. Cephalalgia. Nov 1997;17(7):733-41. [Medline].

  38. Welborn CA. Pediatric migraine. Emerg Med Clin North Am. Aug 1997;15(3):625-36. [Medline].

  39. Withers GD, Silburn SR, Forbes DA. Precipitants and aetiology of cyclic vomiting syndrome. Acta Paediatr. Mar 1998;87(3):272-7. [Medline].

  40. Worawattanakul M, Rhoads JM, Lichtman SN, Ulshen MH. Abdominal migraine: prophylactic treatment and follow-up. J Pediatr Gastroenterol Nutr. Jan 1999;28(1):37-40. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

abdominal migraine, acute confusional migraine, basilar migraine, benign paroxysmal vertigo of childhood, cyclic vomiting of childhood, hemiplegic migraine, migraine, migraine aura without headache, ophthalmoplegic migraine, vascular headache, childhood migraine variants, migraine in children

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Wendy G Mitchell, MD, Professor of Neurology, University of Southern California School of Medicine; Consulting Staff, Division of Child Neurology, Children's Hospital Los Angeles, Los Angeles County-University of Southern California
Wendy G Mitchell, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, Child Neurology Society, and International Child Neurology Association
Disclosure: Questcor Honoraria Consulting

Medical Editor

James J Riviello Jr, MD, George Peterkin Endowed Chair in Pediatrics, Professor of Pediatrics, Section of Neurology and Developmental Neuroscience, Professor of Neurology, Peter Kellaway Section of Neurophysiology, Baylor College of Medicine; Chief of Neurophysiology, Director of the Epilepsy and Neurophysiology Program, Texas Children's Hospital
James J Riviello Jr, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Kenneth J Mack, MD, PhD, Senior Associate Consultant, Department of Child and Adolescent Neurology, Mayo Clinic
Kenneth J Mack, MD, PhD is a member of the following medical societies: American Academy of Neurology, Child Neurology Society, Phi Beta Kappa, and Society for Neuroscience
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Amy Kao, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Neurology, Department of Neurology, Oregon Health and Science University; Consulting Staff, Shriners Hospital for Children
Amy Kao, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, and Child Neurology Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.