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Intense bilateral frontal headache accompanied by severe retching followed by frequent bouts of emesis despite a normal neurological exam. What is going on in this 10-year-old?
A 10-year old child presents with episodes of intense bilateral frontal headache accompanied by severe retching at onset that is followed by frequent bouts of emesis. She is well between headaches and results of her neurologic examination are normal. She cannot tolerate oral medications.
What diagnosis do you suspect and what options are available to treat this child?
Answer and Discussion on Next Page
Diagnosis: Episodic migraine
Features of episodic migraines differ in children and adults. In children, such headaches are of shorter duration and tend to be bilateral. Children also have a lower threshold for vomiting, which can be a significant component of their “migraine symptomatology.” These symptoms may result in school absences and loss of time at work for parents who may have to pick up a sick child.
First-line treatment is usually a simple analgesic, such as ibuprofen. A dose of 10mg/kg of body weight is usually effective. When used in appropriate doses, this is a straightforward option and one that has been studied rigorously.1 For children who cannot tolerate oral medications, the serotonin agonists (“triptans”) in a non-oral delivery form can be an valuable alternative. The child neurology society guidelines suggest a role for nasal sumatriptan (Imitrex) in children as young as age 6 years.2 The nasal route makes it easy to use in a child who cannot take medication by mouth and absorption through the nasal mucosa allows for rapid onset of action. Sumatriptan’s 2-hour half-life also allows repeat dosing after 2 hours if the first dose does not resolve symptoms.3 It is available in 2 dose formulations-5- and 20-mg spray. Oral sumatriptan is available in doses of 25, 50, and 100 mg.
Only 2 triptans are approved for use in children-almotriptan (Axert)4 and rizatriptan (Maxalt).5 Almotriptan is approved by the FDA for use in adolescents over 12 years in doses of 12.5 mg. Rizatriptan, which is available in a sublingual formulation, is approved in children age 6 to 17 years. Adverse effects common to all triptans include chest heaviness and discomfort. These symptoms may not have a cardiac basis and may be related to esophageal spasm. Ideally doses should not be repeated more than twice over 24 hours. Triptans should not be used in children who have uncontrolled hypertension or those at risk for cardiac ischemia.6
1.Lewis DW, Kellstein D, Burke B, et al. Children’s ibuprofen suspension for the acute treatment of pediatric migraine headache. Headache. 2002;42:780-786.
2. Lewis D, Ashwal S, Hershey MD, et al. Practice Parameter: Pharmacological treatment of migraine headache in children and adolescents. Neurology. 2004;63:2215-2224.
3. Schenker S, Yang Y, Perez A, et al. Sumatriptan (Imitrex) transport by the human placenta. Proc Soc Exp Biol Med. 1995;210:213-220.
4. Linder SL, Mathew NT, Cady RK, et al. Efficacy and tolerability of almotriptan in adolescents: a randomized, double-blind, placebo-controlled trial. Headache. 2008;48:1326-1336.
5. Ahonen K, Halmalainen ML, Eerola M, et al. A randomized trial of rizatriptan in migraine attacks in children. Neurology. 2006;67:E1135-E1140.
5. Erbilen E, Ozhan H, Akdemir R, et al. A case of myocardial infarction with sumatriptan use. Pediatr Cardiol. 2005;26:464-466.