Pediatric Episodic Syndromes Associated With Migraine: Expert Q&A (Part II)

little boy being examined in hospital
little boy being examined in hospital
Nearly 10% of pediatric patients with migraine also experience various episodic syndromes. Drs Amy Gelfand and Diana Lebron weigh in on what to look for to help you achieve the right diagnosis.
This article is the second in a 2-part series on pediatric episodic syndromes that may be associated with migraine. Read Part I here, which includes a detailed review of the episodic syndromes you might encounter in your practice.

As many as 9.8% of pediatric patients with migraines also experience episodic syndromes involving symptoms such as gastrointestinal pain, vomiting, or vertigo.1 These debilitating episodes have an abrupt onset followed by complete resolution, and patients are healthy between episodes. They often occur before migraine attacks, although that is not always the case.

“Migraines and the episodic syndromes share autonomic dysfunction as part of the clinical manifestations,” wrote the authors of a review on the topic that was published in 2016 in Seminars in Pediatric Neurology.2 “Individuals with migraines can experience autonomic dysfunction without the headache.”

Diagnosis and treatment of these disorders, termed “episodic syndromes that may be associated with migraine” in the International Classification of Headache Disorders-3 Beta (ICHD-III beta), can be challenging. Before diagnosis, affected patients may undergo extensive testing and frequent hospitalization, and there is little evidence to guide treatment.

Neurology Advisor spoke with 2 experts who have authored reviews on the topic2,3: Amy Gelfand, MD, assistant professor of neurology and pediatrics, and director of pediatric headache at the University of California, San Francisco; and Diana Lebron, MD, associate professor of pediatrics at Texas Tech University Health Sciences Center School of Medicine and medical director of the Headache Clinic at Texas Children’s Hospital.

Neurology Advisor: How are these episodic syndromes typically diagnosed?

Dr Lebron: There is no biological marker at this time to identify these conditions. The history, family history, and normal neurologic examination are critical for the diagnosis. It is also important to rule out things that can mimic these conditions.

Dr Gelfand: For CVS, it is important to ask about things such as developmental delay and regression, as some inborn errors of metabolism can cause a recurrent vomiting clinical presentation that might be confused with CVS. For adolescents in whom CVS is suspected, it is important to ask about hot water bathing behavior during the episodes, and if this is present, to query about cannabis use, as cannabinoid hyperemesis syndrome can look like CVS.

Neurology Advisor: What are some treatment options for these disorders?

Dr Lebron: There is no specific treatment for these conditions. In patients with CVS and abdominal migraines, we often use the same medications we use for migraines, such as Zofran, Promethazine, Reglan, and Benadryl, and we use the same preventative medications as well.

Dr Gelfand: For abdominal migraine and CVS, acute treatment with a nonsteroidal anti-inflammatory drug and triptan may be helpful. There is some evidence that the neurokinin-1 receptor antagonist aprepitant (Emend) can be helpful both as a preventive and an acute treatment for CVS.

For infant colic, as they are so young, at this point the best approach to management is probably nonpharmacologic. Reassurance that infant colic is transient and will pass may help the parents or caregivers cope better. Decreasing stimuli might also help. For example, there are some data to suggest that babies with colic are more sensitive to sounds and smells than babies without colic, so turning down the volume on the television and airing things out while cooking and cleaning might help minimize these stimuli.

Above all, parents and caregivers should be advised to never shake the baby: it is better to lay the baby down on their back in the crib or bassinet and walk out of the room for a few minutes and let them cry if they ever feel they are losing control.

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Neurology Advisor: Can you speak to the importance of multidisciplinary collaboration in managing these patients?

Dr Lebron: Patients with CVS and abdominal migraines often present to a gastrointestinal physician, and children with benign vertigo of childhood present to an ear-nose-and-throat specialist for vertigo. These specialists perform tests to rule out conditions in their specific disciplines. Patients with episodic syndromes often have comorbid conditions such as anxiety, insomnia, mood disorders, learning disabilities, and attention-deficit/hyperactivity disorder. Addressing the comorbid conditions using physicians from multiple disciplines — sleep specialists, psychiatrists, and psychologists, for example — can potentially help reduce the symptoms.

Dr Gelfand: I think for abdominal migraine and CVS, it is very helpful to have a gastrointestinal physician and a neurologist working together. For infant colic, the primary care pediatrician or family practice provider is probably the clinician who manages this most, but I would like to see child neurologists take more of a role in helping with this where it is troublesome.

Neurology Advisor: What should be next steps in terms of research in this area?

Dr Lebron: It is critical to identify biological markers so we can limit the testing in these patients and figure out appropriate treatment strategies.

Dr Gelfand: I think we need proper randomized placebo-controlled treatment trials for these conditions, both for acute treatments and preventive therapies. For some of the episodic syndromes that are rarer, for example, benign paroxysmal torticollis, we will likely need multicenter collaborations to be able to enroll enough patients. Mechanisms such as the NeuroNext trials network that the National Institute of Neurological Disorders and Stroke has might help facilitate this.


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