Headaches at the age of less than 3 years are rare and when they occur, they are due to organic causes - that is, they are secondary. By the age of 15, however, 75% of the children reported having a headache at least once. It has been estimated from large epidemiological studies that especially childhood migraine concerns the 5% of school children. In practice this means that in every school class there is at least one child who has a migraine. In this text, answers are given to some simple but basic questions regarding the diagnosis of migraine at this age.

What other diseases or conditions should be ruled out before making a diagnosis of migraine in children or adolescents?

• wounding,
• infections (viruses, pharyngitis, otitis media),
• allergies
• should be asked if there are co-existing conditions: epilepsy, Tourette's syndrome, diabetes mellitus, depression, obesity.
• The family memento must be asked: first and second degree relatives
• The souvenir should be asked from the social and school environment.
• A detailed neurological examination should be performed. Findings on exam could be increased blood pressure so we check for pheochromocytoma, increased head circumference so there may be increased intracranial pressure, Kerning/Brudzinski sign then we think about meningitis.

When do we do imaging (magnetic or axial) of the CNS in children with migraine and which imaging?

If the psychological, social and family pressure in a child with migraine for a CT scan or magnetic resonance imaging (MRI) is great, it is true that it also applies to adults: a headache that does not meet the "red flags" and has no neurological deficits on neurological assessment do not need imaging. Imaging should be performed in children and adolescents with severe new-onset headache, with neurologic deficits on examination or seizures, or in children with a recent change in the characteristics of their headache attacks. It is generally true that CT is less sensitive than MRI and administration of contrast or paramagnetic substance are more sensitive than without. However, in emergency department conditions, performing a CT scan (even without contrast) is sufficient in cases where a child is examined with a severe first-onset headache, with neurological deficits, neck stiffness, convulsions or mental impairment. Intracerebral hemorrhage, subdural or epidural hematoma, large subarachnoid hemorrhage, brain abscess or tumor, and hydrocephalus should be ruled out in the emergency setting. An MRI in the second year could help to investigate a headache when we suspect an aneurysm, small structural abnormalities of the vessels, structural damage to the brain stem.

Lumbar puncture (LUP) and headache in children and adolescents.

ONP should be performed in cases where an inflammatory process (Gullain-Barre) or acute lymphocytic leukemia or infection such as meningitis or encephalitis is suspected. In the event that the headache is accompanied by a decreased level of consciousness or neurological deficits, an urgent CT scan should be performed to rule out increased intracranial pressure.

Treatment of migraine in children and adolescents

Migraine treatment, just as in older adults, should be individualized taking into account the young patient's symptoms, response to treatment, and lifestyle (eg school) preferences of the patient and family. It may take a couple of treatment attempts before maximum therapeutic effect is achieved. Treatment options can be divided into the following categories:

1. Non-pharmacological approach
2. Pharmaceutical approach
3. Behavioral approach
4. Alternative approaches

1. Non-pharmacological approaches

• A headache diary to be completed by the patient or (in the case of children) by their guardians and in which daily habits should also be recorded (times of eating, sleeping, physical and mental activity, tutorials, hours on the computer, etc.).
• It is very important to regulate the sleep schedule in young migraine patients. A child should sleep 8-10 hours a night in a quiet and comfortable environment with the onset of sleep before midnight. Before going to bed they should avoid watching scary movies on TV. If the child wishes, he can have a dim light on in his room. For teenagers, it is true that they can sleep a little later on the weekends, but avoid - if possible - prolonged use of the computer, the Internet and games (2 hours is enough).
• Every child and teenager (and especially if there is a migraine) should have three meals a day and 1-2 snacks at set times. In no case should breakfast be skipped before the child or teenager leaves for school in the morning. In general, the avoidance of deprivation diets should be avoided unless a specific food is a "trigger" for the migraine. Thus caution is recommended for these children in the consumption of chocolate, cheese, some fruits, prepared foods, fast food, foods containing glutamate and/or aspartame and foods containing alcohol. Coffee should be avoided because it can lead to sleep disorders and mood disorders which are trigger points for migraines.
• All children should be adequately hydrated. Teenagers need at least 2 liters of water (not carbonated or sugary drinks) a day, which increases to at least 3 liters in the summer or with intense physical activity.
• All children or adolescents with migraine should be encouraged to do aerobic physical activity (of their choice) for at least 30 minutes a day for 3-6 days a week. Sports or activities that subsequently trigger migraine attacks should be avoided.
• In developed Western societies, the expectations that exist from children or teenagers are often too high and fill our young fellow citizens with additional intense anxiety and often melancholy and fear of failure. It is easy to understand that these conditions are not the best for people who have migraines. A discussion with migraine sufferers and family about more realistic and less stressful goals will certainly contribute to migraine improvement as well.

2. Pharmaceutical approach

• The following medications are currently approved by the FDA for the episodic treatment of migraine: ibuprofen, naproxen, and the triptan rizatriptan. In general, in children older than 12 years, the use of triptans can be considered safe when they do not respond to simple painkillers.
• For prophylactic treatment, it is generally given to children who have 4 or more pain attacks per month or who have such severe headache that it prevents them from their daily activities. It is valid to start with a low dosage and slowly titrate. Amitriptyline reduces the frequency of migraine attacks and their intensity but not their duration. Sodium valproic acid is effective in migraine prophylaxis in children and adolescents, but its side effects such as hair loss, weight gain, effect on liver functions should be taken seriously.

3. Behavioral approach

• Relaxation and biofeedback programs and techniques can have a positive effect on the frequency and intensity of migraines. Especially combination helps all children, if and usually these techniques are done in children and teenagers with very intense migraines.
• For relaxation techniques the child must be at least 7 years old and includes muscle relaxation, diaphragmatic or deep breathing.
• Biofeedback is mainly used as an adjunct to relaxation techniques.

4. Alternative approaches

• Very little research has been done in children and adolescents regarding the effectiveness and safety of alternative treatments, either preventive or symptomatic for migraines. Ginkgo Biloba, magnesium and the vitamin riboflavin have been used in the treatment of migraine.

Bibliography

1. GunnerKB, Smith HD, Cromwell PF, Yetman RJ. Practice Guideline for Diagnosis and management of Migraine Headaches in Children and Adolescents. Part One. J Pediatr Care 2007
2. Gunner KB, Smith HD, Ferguson LE. Practice Guideline for Diagnosis and Management of Migraine Headaches in Children and Adolescents: Part Two
3. Pauline Anderson. Rizatriptan Safe, Effective for Migraine in Children. American Headache Society 54th Annual Scientific Meeting: Abstract 011. Poster 31.