Childhood migraine in general practice: clinical features and characteristics
MJ Mortimer, J Kay, A Jaron
Sherwood House, Sherwood Road, Bearwood, Smethwick, Warley, West Midlands B67 5DE, UK Cephalalgia
Mortimer MJ, Kay J, Jaron A. Childhood migraine in general practice: clinical features and characteristics. Cephalalgia 1992;12:238-43. Oslo. ISSN 0333-1024 Previous studies have evaluated the clinical features and characteristics of migraine in selected children attending hospital clinics. There have, however, been no community studies on the prevalence and characteristics of migraine in children aged 3-11 years in British general practice. In this study, a total of 1,083 children (from 1,104 registered with a general practice) and their parents were interviewed. Possible migraine sufferers took part in an extended interview that assessed various characteristics of the patients and their attacks. The survey showed that migraine attacks started in infancy, and migrainous children were more likely to have mothers with migraine. Some clinical features were found to be age-dependent. Compared with similar hospital surveys there was a lower frequency of attacks recorded but the prevalence of aura was similar to that found in previous studies. • Children, general practice, migraine MJ Mortimer, Sherwood House, Sherwood Road, Bearwood, Smethwick, Warley, West Midlands B67 5DE, UK. Received 16 January 1992, accepted 9 April 1992
Reports from hospital clinics have indicated that, of those children attending with migraine, 34% started their attacks before five years of age (1) and 62% by the time they were seven years (2). Whilst numerous articles have been written concerning migraine in young children, most have reported cases in a retrospective manner while evaluating an older child with headache (3). There have been no community studies on the clinical characteristics of migraine in young children in British general practice (4), and while the prevalence of migraine in schoolchildren over 7 years is 4-10% (5, 6), that for younger children has not been reported. In clinical practice, migraine is regarded as classical or common according to the presence or absence of an aura of focal neurological symptoms typically visual (1). This separation may be artificial; many authors have disputed whether or not they are separate entities, despite the fact that physiological differences exist (7-10). This controversy, however, has been formally addressed only in adults, not in children, and the conclusions drawn tend to support the concept that classical and common migraine are fundamentally similar in their clinical characteristics (11). Delineation of aura is, nevertheless, extremely important for differential diagnosis and management, but not treatment, response to medication being the same (12). Headache can occur any time of day, but some reports have shown that it is more likely to be present on rising (1, 13). Although headache in children may be unilateral, it more frequently is not (1). Furthermore, it has been suggested that the duration of headache is shorter in children (14). In one study 45% of headaches lasted 1-2 h (15), while in another 61% lasted 0.5-5 h (1). Hospital clinics have reported a high frequency of attacks: 57% of the children experienced 12-24 attacks per year and 39% 50 or more attacks in a year (1). Reports of associated nausea and vomiting have varied, ranging from 65.5 to 100% (16, 17). Visual aura has been quoted to occur in between 10 and 50% of childhood cases (16), and associated dizziness in 19 to 47% (5, 13, 14, 17). It is unclear whether migraine subjects are more prone to travel sickness. Some reports have found a higher incidence of travel sickness in migraine subjects (5, 13, 18), while others have not (19, 20). Most studies have described a positive family history among patients with migraine (21), but the vast majority have included patients who were selected from treatment settings. This has resulted in an over-representation of females and of people who may not be representative of the general population. There is only one family study (in adults) in which probands were selected from the general population (22). Reports from hospital practice have indicated that children tend to present early in the course of headache disorders (23), and while 6.8% of all consultations for migraine in general practice are for children under 10 years of age (24) little has been written on the subject. The aim of the present report was to describe the prevalence and clinical features of migraine in children aged between 3 and 11 years attending the authors' practice using a direct interview of all children and their parents; postal questionnaires seemed inappropriate in the present survey.
Patients and methods
From a total list of 13,300 patients, all children (1,104) aged between 3 and 11 years were identified and letters were sent to the parents of all these children requesting that either mother and/or father attend the surgery with their child to assist in completing a health survey questionnaire. After three postal requests non-responders were contacted by telephone or a house visit to arrange a suitable time for an interview. A structured interview had been prepared and a recording sheet printed. All respondents took part in the interview. This included: age of child, history of headache and travel sickness. Parents were asked about occupation (social class (25)) and a lifetime history of migraine using the description of the Ad Hoc Committee (26). They were deemed migrainous if they admitted to having experienced at least two or more attacks so described. It was apprectiated that obtaining clinical histories in young children is dependent on their intellectual development and vocabulary, and thus information in such children was corroborated by a parent. Those children who admitted to having suffered headache were further interviewed regarding the occurrence of paroxysmal headache associated with nausea and/or vomiting, photophobia, phonophobia, dizziness and aura. Children identified as suffering from migraine using the Ad Hoc Committee Classification (26) were deemed migrainous if they had two or more attacks so described. The Ad Hoc criteria were used because they have been found more sensitive in children. They took part in an extended interview, which included details on the nature of the headache, the frequency, duration and predominant time of day of occurrence. The prevalence of nausea, vomiting, photophobia, phonophobia, aura and dizziness was recorded: as was the occurrence of premonitory mood changes and known migraine precipitants. Clinical comparisons between younger (3-7 years) and older (8-11 years) children were made. Parents were interviewed on their interpretations of the children's symptoms and their attitudes and beliefs with respect to migraine. Results
Of 1,104 children registered with the practice 1,083 (549 boys and 534 girls; 98.1%) were interviewed. Sixty percent attended the surgery (clinic) with mother, alone, 20% with both parents, and 20% were interviewed at home with mother and father. All mothers were interviewed directly, whereas 60% of information from fathers was obtained by telephone. Of boys, 4.7% had migraine, and of girls 5%. The prevalence of migraine increased with age (see Table 1). There were more boys than girls with migraine below the age of 8 years, after which this trend reversed. Social class There was no significant difference in social class between the migrainous and non-migrainous children (see Table 2). Table 1. Prevalence of classical and common migraine by age range, gender and population size. Boys Girls Classical Common Classical Common Age range No. % % No. % % 3-5 208 0.48 2.40 194 1.55 5-7 187 1.07 3.21 180 0.56 1.11 7-9 173 1.16 4.05 168 2.38 4.17 9-11 162 3.09 5.56 155 3.23 7.10 3-7 322 0.93 2.48 318 0.31 1.57 8-11 227 3.96 8.81 216 3.24 9.26 Table 2. Number of children with and without migraine by social class. Social class I II III IV Migraine 7 7 17 15 Non-migraine 93 215 370 242 Total 100 222 387 257
V 7 100 107
VI 0 10 10
Age The mean age of the children with migraine was 8.4 years; 4.8 years (age 3-7 years) and 9.7 years (age 8-11 years). Age of onset The mean age of onset was 6.6 years (4 years in those aged 3-7 years and 7 years in those 8-11 years); 26.4% of children had migraine by the age of 4 years, 45.3% by 5 years, 66.0% by 7 years and 98.1% by 9 years. Migraine precipitants A precipitant was identified in 17.6% of the children aged 3-7 years and 44.4% of the children aged 8-11 years. Dietary factors were accountable in 11.8% of the younger age group and 8.3% of the older age group, while stress was a precipitant in 13.9% of the older group compared with 5.9% of the younger one. In children over the age of 8 years, after tiredness (8.3%), exercise (2.8%), noise (2.8%), glaring light (2.8%), missing a meal (2.8%), and studying (2.8%), were all identified as migrainous precipitants. Premonitory mood changes During the 24 h before the migraine attack 25 (47.2%) of the children admitted that they had or were observed by parents to have had mood changes; 64% were inhibitory and 36% excitatory. Mood changes were reported twice as frequently in classical migraine than in common migraine (75% compared with 35%) (Table 3). Interestingly, the younger children (3-7 years) were observed to have more premonitory mood changes (76.5%) than the older (8-11 years) ones (33.3%) (Table 3). Aura The ratio of attacks of migraine with aura to migraine without aura was 30:70 in the whole population of migraineurs. However, the proportion of migraine with aura fell to 23.5% in those children under 8 years of age and rose to 33.3% in those above. More boys than girls had migraine with aura. The ratio of boys to girls who had migraine with aura under 8 years of age (3:1) fell to 9:7 in those above. Nature of headache Headache was described as throbbing in 86% of children aged 8-11 years compared with 41% in those aged 3-7 years. A similar proportion of children complained of unilateral headache (33% vs 35%) in both age groups. More children (53%) aged 3-7 years complained of central forehead pain than those aged 8-11 years (36%), while bifrontal headache occurred in fewer (12%) of the younger group than the older (28%). Attacks of migraine occurred more often in the morning in those children aged 8-11 years (52.7%) compared with those aged 3-7 years (17.6%). Duration of attack The duration of attacks varied from I to 72 h in common migraine and from 2 to 48 h in classical migraine. In those children aged 3-7 years the mean duration of classical and common migraine was 7.9 h and 18.1 h respectively; while in those aged 8-11 years it was 13.1 h and 17.8 h respectively; 5.9% of those children under 8 years and 11% of those above experienced migraine attacks for less than 2 h. Equal proportions of children above and below (33% vs 35%) 8 years experienced attacks lasting up to 6 h, while the majority of children above or below 8 years (82% vs 83%) experienced attacks for less than 24 h. Frequency of attacks The mean frequency of attacks in the previous year for children aged 3-7 years was 6.8 and for Table 3. Premonitory mood changes in 53 children with classical or common migraine by age range. Migraine Migraine Age range 3-7 years Age range 8-11 years Classic Common Classic Common Mood change n=4 n = I3 n = 12 n = 24 Low in spirit 2 5 3 1 Quiet 1 2 Withdrawn 1 1 Irritable 2 1 3 1 Very active 1 1 (high)
those aged 8-11 years, 11.3 (ranges 1-50 attacks per year). Less than six attacks per year occurred in 59% of the younger group compared with 36% of the older one, while less than 12 attacks per year occurred in 82% of the younger group compared with 64% of those older. Severity It was remarkable that 59% of those children aged 3-7 years and 44% of those aged 8-11 years cried with pain during an attack. Similar proportions in both younger (41%) and older (44%) age groups had lost time from school/playschool due to migraine. Most children in both the younger (88%) and older (81%) groups tended to sleep after an attack. Associated symptoms Nausea occurred in similar proportions in both theyounger (94%) and older (92%) groups, while slightly more children vomited in the older (67%) compared with the younger ones (47%). Fewer younger children (53%) experienced photophobia than those over 8 years (84%), but more older children (75%) complained of phonophobia than the younger ones (59%). Far more older children experienced dizziness (44%) than those under 8 years (24%). Travel sickness A total of 26 (49.1%) children complained of travel sickness, 17 of whom suffered from common migraine and 9 from classical. The number of migrainous children with travel sickness was significantly higher [c2 1 df, 21.78, p
MJ Mortimer, J Kay, A Jaron
Sherwood House, Sherwood Road, Bearwood, Smethwick, Warley, West Midlands B67 5DE, UK Cephalalgia
Mortimer MJ, Kay J, Jaron A. Childhood migraine in general practice: clinical features and characteristics. Cephalalgia 1992;12:238-43. Oslo. ISSN 0333-1024 Previous studies have evaluated the clinical features and characteristics of migraine in selected children attending hospital clinics. There have, however, been no community studies on the prevalence and characteristics of migraine in children aged 3-11 years in British general practice. In this study, a total of 1,083 children (from 1,104 registered with a general practice) and their parents were interviewed. Possible migraine sufferers took part in an extended interview that assessed various characteristics of the patients and their attacks. The survey showed that migraine attacks started in infancy, and migrainous children were more likely to have mothers with migraine. Some clinical features were found to be age-dependent. Compared with similar hospital surveys there was a lower frequency of attacks recorded but the prevalence of aura was similar to that found in previous studies. • Children, general practice, migraine MJ Mortimer, Sherwood House, Sherwood Road, Bearwood, Smethwick, Warley, West Midlands B67 5DE, UK. Received 16 January 1992, accepted 9 April 1992
Reports from hospital clinics have indicated that, of those children attending with migraine, 34% started their attacks before five years of age (1) and 62% by the time they were seven years (2). Whilst numerous articles have been written concerning migraine in young children, most have reported cases in a retrospective manner while evaluating an older child with headache (3). There have been no community studies on the clinical characteristics of migraine in young children in British general practice (4), and while the prevalence of migraine in schoolchildren over 7 years is 4-10% (5, 6), that for younger children has not been reported. In clinical practice, migraine is regarded as classical or common according to the presence or absence of an aura of focal neurological symptoms typically visual (1). This separation may be artificial; many authors have disputed whether or not they are separate entities, despite the fact that physiological differences exist (7-10). This controversy, however, has been formally addressed only in adults, not in children, and the conclusions drawn tend to support the concept that classical and common migraine are fundamentally similar in their clinical characteristics (11). Delineation of aura is, nevertheless, extremely important for differential diagnosis and management, but not treatment, response to medication being the same (12). Headache can occur any time of day, but some reports have shown that it is more likely to be present on rising (1, 13). Although headache in children may be unilateral, it more frequently is not (1). Furthermore, it has been suggested that the duration of headache is shorter in children (14). In one study 45% of headaches lasted 1-2 h (15), while in another 61% lasted 0.5-5 h (1). Hospital clinics have reported a high frequency of attacks: 57% of the children experienced 12-24 attacks per year and 39% 50 or more attacks in a year (1). Reports of associated nausea and vomiting have varied, ranging from 65.5 to 100% (16, 17). Visual aura has been quoted to occur in between 10 and 50% of childhood cases (16), and associated dizziness in 19 to 47% (5, 13, 14, 17). It is unclear whether migraine subjects are more prone to travel sickness. Some reports have found a higher incidence of travel sickness in migraine subjects (5, 13, 18), while others have not (19, 20). Most studies have described a positive family history among patients with migraine (21), but the vast majority have included patients who were selected from treatment settings. This has resulted in an over-representation of females and of people who may not be representative of the general population. There is only one family study (in adults) in which probands were selected from the general population (22). Reports from hospital practice have indicated that children tend to present early in the course of headache disorders (23), and while 6.8% of all consultations for migraine in general practice are for children under 10 years of age (24) little has been written on the subject. The aim of the present report was to describe the prevalence and clinical features of migraine in children aged between 3 and 11 years attending the authors' practice using a direct interview of all children and their parents; postal questionnaires seemed inappropriate in the present survey.
Patients and methods
From a total list of 13,300 patients, all children (1,104) aged between 3 and 11 years were identified and letters were sent to the parents of all these children requesting that either mother and/or father attend the surgery with their child to assist in completing a health survey questionnaire. After three postal requests non-responders were contacted by telephone or a house visit to arrange a suitable time for an interview. A structured interview had been prepared and a recording sheet printed. All respondents took part in the interview. This included: age of child, history of headache and travel sickness. Parents were asked about occupation (social class (25)) and a lifetime history of migraine using the description of the Ad Hoc Committee (26). They were deemed migrainous if they admitted to having experienced at least two or more attacks so described. It was apprectiated that obtaining clinical histories in young children is dependent on their intellectual development and vocabulary, and thus information in such children was corroborated by a parent. Those children who admitted to having suffered headache were further interviewed regarding the occurrence of paroxysmal headache associated with nausea and/or vomiting, photophobia, phonophobia, dizziness and aura. Children identified as suffering from migraine using the Ad Hoc Committee Classification (26) were deemed migrainous if they had two or more attacks so described. The Ad Hoc criteria were used because they have been found more sensitive in children. They took part in an extended interview, which included details on the nature of the headache, the frequency, duration and predominant time of day of occurrence. The prevalence of nausea, vomiting, photophobia, phonophobia, aura and dizziness was recorded: as was the occurrence of premonitory mood changes and known migraine precipitants. Clinical comparisons between younger (3-7 years) and older (8-11 years) children were made. Parents were interviewed on their interpretations of the children's symptoms and their attitudes and beliefs with respect to migraine. Results
Of 1,104 children registered with the practice 1,083 (549 boys and 534 girls; 98.1%) were interviewed. Sixty percent attended the surgery (clinic) with mother, alone, 20% with both parents, and 20% were interviewed at home with mother and father. All mothers were interviewed directly, whereas 60% of information from fathers was obtained by telephone. Of boys, 4.7% had migraine, and of girls 5%. The prevalence of migraine increased with age (see Table 1). There were more boys than girls with migraine below the age of 8 years, after which this trend reversed. Social class There was no significant difference in social class between the migrainous and non-migrainous children (see Table 2). Table 1. Prevalence of classical and common migraine by age range, gender and population size. Boys Girls Classical Common Classical Common Age range No. % % No. % % 3-5 208 0.48 2.40 194 1.55 5-7 187 1.07 3.21 180 0.56 1.11 7-9 173 1.16 4.05 168 2.38 4.17 9-11 162 3.09 5.56 155 3.23 7.10 3-7 322 0.93 2.48 318 0.31 1.57 8-11 227 3.96 8.81 216 3.24 9.26 Table 2. Number of children with and without migraine by social class. Social class I II III IV Migraine 7 7 17 15 Non-migraine 93 215 370 242 Total 100 222 387 257
V 7 100 107
VI 0 10 10
Age The mean age of the children with migraine was 8.4 years; 4.8 years (age 3-7 years) and 9.7 years (age 8-11 years). Age of onset The mean age of onset was 6.6 years (4 years in those aged 3-7 years and 7 years in those 8-11 years); 26.4% of children had migraine by the age of 4 years, 45.3% by 5 years, 66.0% by 7 years and 98.1% by 9 years. Migraine precipitants A precipitant was identified in 17.6% of the children aged 3-7 years and 44.4% of the children aged 8-11 years. Dietary factors were accountable in 11.8% of the younger age group and 8.3% of the older age group, while stress was a precipitant in 13.9% of the older group compared with 5.9% of the younger one. In children over the age of 8 years, after tiredness (8.3%), exercise (2.8%), noise (2.8%), glaring light (2.8%), missing a meal (2.8%), and studying (2.8%), were all identified as migrainous precipitants. Premonitory mood changes During the 24 h before the migraine attack 25 (47.2%) of the children admitted that they had or were observed by parents to have had mood changes; 64% were inhibitory and 36% excitatory. Mood changes were reported twice as frequently in classical migraine than in common migraine (75% compared with 35%) (Table 3). Interestingly, the younger children (3-7 years) were observed to have more premonitory mood changes (76.5%) than the older (8-11 years) ones (33.3%) (Table 3). Aura The ratio of attacks of migraine with aura to migraine without aura was 30:70 in the whole population of migraineurs. However, the proportion of migraine with aura fell to 23.5% in those children under 8 years of age and rose to 33.3% in those above. More boys than girls had migraine with aura. The ratio of boys to girls who had migraine with aura under 8 years of age (3:1) fell to 9:7 in those above. Nature of headache Headache was described as throbbing in 86% of children aged 8-11 years compared with 41% in those aged 3-7 years. A similar proportion of children complained of unilateral headache (33% vs 35%) in both age groups. More children (53%) aged 3-7 years complained of central forehead pain than those aged 8-11 years (36%), while bifrontal headache occurred in fewer (12%) of the younger group than the older (28%). Attacks of migraine occurred more often in the morning in those children aged 8-11 years (52.7%) compared with those aged 3-7 years (17.6%). Duration of attack The duration of attacks varied from I to 72 h in common migraine and from 2 to 48 h in classical migraine. In those children aged 3-7 years the mean duration of classical and common migraine was 7.9 h and 18.1 h respectively; while in those aged 8-11 years it was 13.1 h and 17.8 h respectively; 5.9% of those children under 8 years and 11% of those above experienced migraine attacks for less than 2 h. Equal proportions of children above and below (33% vs 35%) 8 years experienced attacks lasting up to 6 h, while the majority of children above or below 8 years (82% vs 83%) experienced attacks for less than 24 h. Frequency of attacks The mean frequency of attacks in the previous year for children aged 3-7 years was 6.8 and for Table 3. Premonitory mood changes in 53 children with classical or common migraine by age range. Migraine Migraine Age range 3-7 years Age range 8-11 years Classic Common Classic Common Mood change n=4 n = I3 n = 12 n = 24 Low in spirit 2 5 3 1 Quiet 1 2 Withdrawn 1 1 Irritable 2 1 3 1 Very active 1 1 (high)
those aged 8-11 years, 11.3 (ranges 1-50 attacks per year). Less than six attacks per year occurred in 59% of the younger group compared with 36% of the older one, while less than 12 attacks per year occurred in 82% of the younger group compared with 64% of those older. Severity It was remarkable that 59% of those children aged 3-7 years and 44% of those aged 8-11 years cried with pain during an attack. Similar proportions in both younger (41%) and older (44%) age groups had lost time from school/playschool due to migraine. Most children in both the younger (88%) and older (81%) groups tended to sleep after an attack. Associated symptoms Nausea occurred in similar proportions in both theyounger (94%) and older (92%) groups, while slightly more children vomited in the older (67%) compared with the younger ones (47%). Fewer younger children (53%) experienced photophobia than those over 8 years (84%), but more older children (75%) complained of phonophobia than the younger ones (59%). Far more older children experienced dizziness (44%) than those under 8 years (24%). Travel sickness A total of 26 (49.1%) children complained of travel sickness, 17 of whom suffered from common migraine and 9 from classical. The number of migrainous children with travel sickness was significantly higher [c2 1 df, 21.78, p
