Section of Pediatric
Neurology, Nationwide Children's Hospital,
Columbus, Ohio
Abstract
Objective: We evaluated the frequency of six
commonly reported adult migraine premonitory
symptoms in children and adolescents with
episodic and chronic migraine and elicited
psychological or behavioral comorbidities that
may be associated with these symptoms.
Background: Premonitory symptoms are
commonly reported in the adult migraine
population; however, little information is
available for the pediatric population.
Methods: Data were collected on new patients
being evaluated in our multidisciplinary
pediatric headache clinic over a six-month time
interval. The data collected from patients
diagnosed with migraine were then reviewed for
the following premonitory symptoms: yawning,
neck stiffness, fatigue, increased urination,
mood changes, and food cravings. History was
obtained regarding the frequency of headaches
and other associated behavioral or psychological
problems.
Results: A total of 176 patients were
enrolled over a six-month interval, ranging in
age from four to 18 years (mean age 12 years);
64% were female, and 42% (74 of 176) of the
subjects had at least one premonitory symptom.
Patients with migraine with aura were noted to
have a significantly higher association with
premonitory symptoms (59%, 30 of 51) (P <
0.05). Anxiety disorder was also significantly
associated with premonitory symptoms (55%, 11 of
20) (P < 0.05). Fatigue and mood changes were
the most commonly reported premonitory
symptoms.
Conclusions: Premonitory symptoms occurred
frequently in our population of pediatric
patients with migraine. Fatigue and mood changes
were the most frequent symptoms. There were no
significant differences in premonitory symptoms
by gender or age group (less than 12 years
versus greater than 12 years). Anxiety and
migraine with aura were correlated with an
increased likelihood of premonitory symptoms.
Les auteurs ont évalué la
fréquence de six symptômes
prémonitoires de migraine chez l'adulte,
fréquemment rapportés, chez les
enfants et les adolescents atteints de migraine
épisodique et chronique, ainsi que des
comorbidités psychologiques ou
comportementales pouvant être
associées à ces symptômes.
Les symptômes prémonitoires sont
fréquemment rapportés dans la
population migraine adulte ; cependant, peu
d'informations sont disponibles pour la
population pédiatrique.
Les données ont été
recueillies chez les nouveaux patients en cours
d'évaluation dans leur clinique
multidisciplinaire de traitement des
céphalées pédiatriques sur
une période de six mois. Les
données recueillies chez les patients
diagnostiqués comme souffrant de migraine
ont ensuite été
sélectionnés pour rechercher les
symptômes prémonitoires suivants :
bâillement, raideur de la nuque, fatigue,
augmentation de la fréquence des
mictions, changements d'humeur et fringales. Des
antécédents ont été
recherchés concernant la fréquence
des maux de tête et autres
problèmes comportementaux ou
psychologiques associés.
Au total, 176 patients ont été
inscrits sur un intervalle de six mois,
âgés de 4 à 18 ans
(âge moyen : 12 ans); 64% étaient
des femmes et 42% (74 sur 176) des sujets
présentaient au moins un symptôme
prémonitoire. Les patients migraineux
avec aura présentaient une association
significativement plus élevée de
symptômes prémonitoires (59%, 30
sur 51) (p <0,05). Les troubles anxieux
étaient également associés
de manière significative aux
symptômes prémonitoires (55%, 11
sur 20) (p <0,05). La fatigue et les
changements d'humeur étaient les
symptômes prémonitoires les plus
souvent signalés.
Les symptômes prémonitoires
sont fréquents dans notre population de
patients migraineux pédiatriques. La
fatigue et les changements d'humeur sont les
symptômes les plus fréquents. Il
n'y a pas de différence significative
pour les symptômes prémonitoires
selon le sexe et le groupe d'âge (moins de
12 ans par rapport à plus de 12 ans).
L'anxiété et la migraine avec aura
sont corrélées à une
probabilité accrue de symptômes
prémonitoires.
Introduction
Migraine is a common neurological condition
in the pediatric population. Prevalence rates of
about 10% are generally seen in school-aged
children with increasing prevalence in the
adolescent population. Migraine attacks can
frequently cause absences from school, and
family stressors can become magnified when
caring for an ill child. Compared with children
with tension-type headaches, children with
migraine often have more severe, disabling
headaches. In addition, about 25% patients with
migraine have an aura preceding their headaches
manifested by transient symptoms, often a visual
or sensory disturbance, which may also
contribute to the overall disability of these
headaches.
In the adult migraine population,
premonitory symptoms (PSs) have been
self-reported by most patients before their
migraine headaches. These generally precede the
migraine by two to 48 hours. These symptoms may
be varied in their presentation, both subjective
and objective, and can include fatigue, mood
changes, and excessive yawning. In two different
series of adult patients, the presence of at
least one PS ranged from 30% to 80% before the
onset of their headaches.
PSs in pediatric patients with migraine are
less well characterized. Previous studies have
been small and retrospective, but PSs were
frequently present. Karsan et al, in a
retrospective study of 100 patients with
predominantly chronic migraine, primarily noted
fatigue, mood change, and neck stiffness.7 There
were no differences related to age, sex, or
headache diagnosis. In another retrospective
study evaluating 103 patients, 67% reported at
least one PS.8 The most frequently reported
symptoms were face changes, fatigue, and
irritability. The presence of PSs and the
specific symptom reported did not vary with age
or migraine subtype.
Discussion
Our study revealed that PS was frequent,
with nearly half of our subjects experiencing
these symptoms before their migraine. Fatigue
and mood changes were the most commonly reported
symptoms. Previous pediatric studies reported
higher percentages of PSs, and this may be
attributed to the fact that our study limited
the symptoms to the six most commonly reported
ones in adult studies.7,8 PS also had a mild but
not significant association with increasing
frequency of migraine attacks with a majority of
patients with chronic migraine reporting
PS.
Aura symptomatology was significantly
associated with PS in our study. Fifty-nine
percent of patients with migraine with aura had
PS. In adult studies, a majority of patients
with migraine with aura also acknowledged PS,
with 79% and 81% noted in prior studies.
Variable results were noted with relationship to
aura and attack frequency in adult reports.5,6
One pediatric chart review study did not report
an increase in PS with aura,7 and another large
study did not categorize aura symptomatology in
their chart review study of 100 patients.8
PS occurred slightly more often in
individuals with more frequent migraine attacks,
but the increase failed to reach significance.
Patients with medication overuse also had
greater prevalence of PS, although the numbers
were small and the association was not
significant impact of sleep deprivation or
missing meals. These symptoms can serve as a
reminder to parents or guardians that a migraine
attack may be imminent and appropriate abortive
treatments should be readily available.
Conclusion
PSs were common in our pediatric patients
with migraine. Fatigue and mood changes were the
most commonly reported symptoms, similar to
previous studies. Anxiety and migraine with aura
were significantly associated with an increased
likelihood of PSs in our group of patients.
Elicitation of these symptoms may improve
management and lessen the effect of migraine
headaches in children and adolescents.
