Headache and migraine in children: Viva

Branch 1: Confirming the diagnosis

The candidate should confirm the diagnosis by applying the ICHD-3 criteria. This boy has had more than five attacks of headache lasting two to three hours, which falls within the two to 72 hour paediatric duration, with a throbbing quality, an intensity that forces him to stop and sleep (moderate to severe), and accompanying nausea and photophobia. He is fully well between attacks. These features meet the criteria for migraine without aura, and the family history of migraine in his father strengthens the diagnosis. A strong candidate notes that in children the pain is more often bilateral and frontotemporal, as it is here, and that the photophobia may be inferred from behaviour rather than reported. [1]

If the examiner presses on what else it could be, the candidate should distinguish migraine from tension-type headache, which is bilateral, pressing, mild to moderate, not worsened by activity, and lacks nausea, and should hold the boundary firmly. The key teaching point is that the diagnosis is clinical and that no investigation is needed once the criteria are met, provided the red-flag screen is negative. [1]

Branch 2: The imaging decision

If asked whether to image, the candidate should state that neuroimaging is not routine for a primary paediatric headache. This boy meets the ICHD-3 criteria, his neurological examination is normal, and the red-flag screen is negative, so he does not need a scan. The candidate should then name the red flags that would change that decision, using the SNNOOP framework: systemic symptoms, a history of neoplasia, a neurological deficit or depressed consciousness, a sudden or thunderclap onset, a very young or older age at onset, and a change in the pattern. In children the candidate should add occipital location, papilloedema, early-morning vomiting, a headache that wakes the child from sleep or is worse on waking, and a progressive course or a new headache under five years. [1]

A strong candidate then distinguishes the migraine aura from a fixed deficit. An aura is fully reversible and resolves within an hour, while any deficit lasting beyond an hour is not an aura and demands imaging. A thunderclap headache reaching maximum intensity within one minute is subarachnoid haemorrhage until proven otherwise and is never a primary migraine. The candidate should explain that over-investigation of a clear primary headache exposes the child to radiation and incidental findings and delays the lifestyle and behavioural plan that is the real treatment. [1]

Branch 3: Acute treatment

If asked how to treat an acute attack, the candidate should give ibuprofen 10 mg per kg or paracetamol 15 mg per kg, taken early in the attack while the pain is still building, as first-line. The candidate should cite the 2016 Cochrane review, which found ibuprofen and paracetamol the best-supported acute agents, with a number needed to treat of about three for ibuprofen. For a moderate-to-severe attack that does not respond to simple analgesia, the candidate should add a triptan, naming sumatriptan nasal spray 10 to 20 mg or rizatriptan as the triptans with the strongest paediatric evidence, and an antiemetic such as ondansetron when nausea is prominent. [8]

The candidate should then state the two governing principles: give the dose early, because an analgesic taken while the pain is building works far better than one taken once the attack is established; and exercise restraint, because acute medication on two or three days a week or more risks medication-overuse headache. Opioids and codeine have no place in routine paediatric migraine, and their prescription is a marker of a plan that has gone wrong. [8]

Branch 4: Prophylaxis and the CHAMP evidence

If asked about the role of drug prophylaxis, the candidate should build the plan in a stepped sequence, beginning with what is not a drug. The foundation is lifestyle medicine: regular sleep, hydration, meals that are not skipped, exercise, and trigger recognition, supported by a headache diary. For a child with frequent or disabling attacks, the most effective single addition is cognitive behavioural therapy, which the Powers trial showed roughly halved headache days and disability when added to a preventive drug in chronic migraine. [7]

The candidate should then confront the CHAMP trial directly. The CHAMP trial found that neither amitriptyline nor topiramate was superior to placebo for paediatric migraine, because the placebo response in children reaches up to 60 per cent, and the 2019 AAN and AHS guideline therefore frames these drugs as options to consider rather than established preventives. If a drug is started, it is after the lifestyle and behavioural platform has been built, the family is counselled on the high placebo response and the uncertain drug benefit, and the response is judged over eight to twelve weeks. The goal is a return to function and school, not a headache-free child. [6]