Migraine in Children - Naturveda

A MIGRAINE IN CHILDHOOD: SYMPTOMS, DIAGNOSIS AND MANAGEMENT

Migraine is the syndrome of acute and recurrent headaches most common in children . This condition has clinical features unique in the pediatric population, which can change with age and have a significant impact on the quality of life of the child, affecting their education, socialization and family life. The purpose of this article is to describe the different clinical features of migraine in children and discuss the treatment options potential for pediatric migraine , including chronic migraine . In many patients, a multidimensional approach involving lifestyle modifications , treatment of comorbidities and pharmacological treatments is necessary for optimal headache control.

Childhood migraine with and without Aura

Migraine is the most common acute and recurrent headache syndrome in children. The prevalence of episodic migraine is approximately 2-5% in children preschool, 10% in school-aged children and 20-30% in adolescent girls . Approximately 20% of migraine patients experience their first crisis in less than 5 years . There are family history of migraine in the majority of patients. Migraine can have a significant impact on a child's quality of life , affecting their education, socialization and family life.

The differences between the characteristics of pediatric and adult migraine patients have been recognized for many years, as described in the International Classification of Headaches , Third Edition. Headaches in children tend to be reported as being of shorter duration , with a lower limit of 2 hours , are more likely to be bilateral fronto-temporal before adolescence, and the sensitivity to light and sound is generally more important.

Infantile colic, an increased risk of developing a migraine

Even in childhood, Migraine symptoms vary depending on the age of the child . Children with infantile colic run a increased risk of developing a migraine later in life, and some authors suggest it may be a precursor to migraine. In preschool children, migraine often consists of episodes where the child appears sick or pale, stops activities, complains of abdominal pain , vomiting and need to sleep.

The pain may be expressed as irritability, crying , restlessness, or finding a dark room to sleep. THE Migraine patients between the ages of five and ten tend to suffer from bilateral frontal headaches accompanied by nausea abdominal pain , vomiting , of photophobia , phonophobia and a need to sleep . Parents may describe these children as being pale with dark circles under the eyes.

The aura begins to appear in middle-aged children . Older adolescents begin to present with bitemporal and then unilateral headaches, although the location and intensity of pain often change during or between attacks .

Migraine can occur with or without aura .

Migraine auras are classified into the following types: visual, sensory, speech and/or language, motor, brain stem and retinal .
Alone 10 to 20% of children with migraine have an aura, often for the first time after age 8 . The aura usually precedes the headache by less than 60 minutes and lasts 5 to 20 minutes. The aura can manifest without a headache .

Visual disturbances are the most common type of aura in children . They consist of blurred vision, spiking spectra (zigzag lines), scotomas (field defects), scintillations, black dots, kaleidoscopic patterns of various colors, micropsia or macropsia (size distortions) and metamorphopsia (visual distortion in which straight lines appear bent).

Other auras include sensory symptoms (numbness or tingling), speech and/or language deficits (aphasia or dysarthria), motor deficits (hemiparesis), loss of attention, confusion, amnesia, restlessness or brainstem symptoms (vertigo, dysarthria, tinnitus, diplopia, hyperacusis). Aura symptoms vary widely within and between attacks.

Childhood episodic migraine

THE episodic migraines in children can last from 2 to 72 hours, but usually last less than 4 hours . Some young patients report even shorter headaches, 10 to 20 minutes .
The intensity of childhood headaches is often lower than that of adult migraine , with throbbing pain. The headache phase may be associated with cold extremities, nausea, anorexia, vomiting, diarrhea or constipation, dizziness, chills, excessive sweating, ataxia, numbness, photophobia, phonophobia, memory loss or confusion.
Often the patient cannot concentrate or function effectively during or immediately after episodes. Relief is usually associated with sleep. After the headache phase, the patient may experience a postdromic phase, where they may feel either elated and full of energy, or more typically exhausted and lethargic.

This phase of migraine can last from a few hours to a few days.

Pediatric migraine is associated with a variety of comorbid conditions

Migraine is associated with a variety of comorbid conditions. Of the psychiatric symptoms such as depression, panic attacks, anxiety disorders or specific phobias may be present. Epilepsy and migraine are often present in the same individual, although most migraine patients do not have attacks. Patients with mild epilepsy have been shown to have a higher incidence of migraine , and one-third to one-half of children with childhood benign occipital epilepsy report migraine symptoms after an epileptic seizure.

Variants of migraine

The migraine headache

The migraine state is a severe form of migraine in which the headache attack is continuous for more than 72 hours . Patients usually have a history of migraine. Treatment that is often effective is intravenous fluids, an antiemetic such as prochlorperazine, and a non-steroid such as ketorolac.16 Steroids at the time of the migraine state can prevent its recurrence.

Familial hemiplegic migraine in children

Hemiplegic migraine can occur sporadically (without direct link to a triggering factor) or family.
The estimated prevalence of hemiplegic migraine is 0.01%, with familial and sporadic versions occurring with the same prevalence. The sporadic form usually manifests in adolescence , while the familial form may manifest earlier .
The hallmark of hemiplegic migraine is the unilateral muscle weakness that accompanies a migraine attack . Hemiplegia may precede, accompany, or follow the headache, and symptoms may last from a few hours to a few days , and are fully reversible .

Patients may also present with a concurrent non-motor aura, such as visual disturbances, numbness, or aphasia. Severe seizures may be accompanied by encephalopathy or coma .

Pediatric migraine with brainstem aura

migraine with brainstem aura , formerly known as basilar-type migraine , is a subtype of migraine with aura and is observed primarily in adolescents and young adult women . Aura symptoms manifest in the brainstem, but there is no motor weakness. Head pain may be in the occipital region . The episode must present at least two of the following aura symptoms: dysarthria, vertigo, tinnitus, hypacusia, diplopia, ataxia, decreased level of consciousness or bilateral paresthesias. There are often family history of typical migraine . Patients may present with basilar migraine attacks interspersed with typical migraine attacks . preventive treatment with  topiramate has helped some patients with this form of migraine.

There acute confusional migraine is characterized by transient episodes of amnesia, acute confusion, agitation, lethargy and dysphasia. The prevalence of this form of migraine has been estimated at 0.04% of children with migraine . Acute confusional migraine is often precipitated by a head trauma minor, but can occur without a push factor. Some children experience recurring episodes. The patient usually recovers within a few hours, often after a period of sleep. The child may not have a history of headaches but often develops typical migraine attacks when older. This is often a diagnosis of exclusion, with the diagnosis being made when the child wakes up the next morning with symptoms gone.

Childhood Episodic Syndromes

THE episodic syndromes in children are considered as potential precursors to migraine , as many patients with these episodic syndromes will develop more typical features of migraine later in their life.

Cyclic vomiting

THE cyclic vomiting syndrome is characterized by recurrent episodes of intense vomiting separated by symptom-free intervals. The prevalence of this syndrome in white populations is 1.9%.
The cyclic vomiting syndrome associated with migraine usually begins when the patient is a toddler and disappears in adolescence or early adulthood ; it rarely appears in adulthood. Women are more numerous than men to be affected by cyclic vomiting. Many patients with cyclic vomiting present with regular periodicity of their illness , and episodes occur with clockwork regularity once every 1 to 3 months. Symptoms usually come on quickly at night or early in the morning and last 1 to 10 days.

The associated symptoms are as follows:
- abdominal pain,
– nausea, vomiting,
– anorexia,
– pallor, lethargy,
– photophobia, phonophobia and headaches.

Headaches may not appear until the child is older . A family history of migraine is usually present. These children often benefit from intravenous fluid therapy. The cyclic vomiting syndrome associated with migraine is a diagnosis of exclusion. Preventative medications, such as amitriptyline, cyproheptadine, and propranolol, have been recommended.

Abdominal migraine

There abdominal headache is characterized by recurrent episodes of generalized abdominal pain with nausea and vomiting , but often without headache . Episodes are often relieved by sleep And the child wakes up later feeling better. The estimated prevalence in children is 2 to 4% . Abdominal migraine can alternate with typical migraine and can lead to the typical migraine as the child develops. Treatment is focused on avoidance of triggers and on conventional drugs migraine prevention .

Benign paroxysmal vertigo of childhood

THE benign paroxysmal vertigo of childhood is a condition characterized by brief episodes of dizziness, dizziness and nausea , which are usually found in children aged 2 to 4 years old . The patient may have nystagmus within seizures, but usually not between them. The episodes can be accompanied by a sudden and unexplained fear of difficulty with balance or a refusal to stand . Symptoms usually last from a few minutes to a few hours. These children often develop a more typical migraine as they age . Brain magnetic resonance imaging (MRI) may be obtained to rule out posterior fossa abnormalities, especially if neurological examination abnormalities are seen between episodes.
Treatment is often unnecessary due to the short duration of attacks, but if events are frequent or disabling, cyproheptadine has been used.

Migraine Assessment and Diagnosis

Migraine patients have a history at least five attacks associated with headaches of moderate or severe intensity, to one aversion to strong stimuli (such as bright lights, loud noises, strong odors), at nausea , worsened by exercise, and relieved by rest.

The child with migraine must present a normal neurological examination. Only a small percentage of patients with headache require laboratory and radiological studies. Neuroimaging is usually not warranted in children whose history is compatible with migraine and whose neurological examination is normal.
An imaging study should be considered in patients with a history of seizures, recent head trauma, significant change in headache, signs of focal neurological deficits, or papilledema on physical examination . There are no hard and fast rules for the assessment of patients with headache; the decision to perform a neuroimaging study is ultimately based on clinical judgement. Electroencephalography is not useful in the routine evaluation of patients with headache. It may be considered in patients with an atypical migraine aura, episodic loss of consciousness, or other symptoms suggestive of a seizure disorder. Lumbar puncture is indicated if meningitis , encephalitis, subarachnoid hemorrhage, or high (or low) pressure headache syndromes are being considered.

Pediatric migraine treatment

General precepts of treatment

Treatment strategies migraine in children must include the identification of potential trigger factors , pain control at the time of the headache, and preventive medication . THE treatment of children with mild seizures and infrequent consists mainly of rest , avoid triggers and take pain medication as needed . A adequate sleep, regular meals, proper hydration and avoid overloading the child's schedule are important. Helping the child recognize migraine triggers is helpful but often difficult because many headache episodes do not have specific triggers. It is important that the patient has realistic expectations:  identifying and avoiding triggers reduces the frequency of migraines but does not completely eliminate them.

Psychological triggers

THE psychological triggers of migraine in children can be the stress (busy schedules), anxiety and depression. It is important to emphasize to the patient and his family that migraine is not an imaginary disease. or psychological. Stress isn't the only cause of headaches, even though it makes migraines more difficult to manage. Some patients deny the presence of stress in their lives, but most readily acknowledge the role of a busy schedule.

Physiological triggers include fever or illness, missed meal, fatigue, and lack of sleep.

Non-pharmacological treatment modalities such as self-relaxation, biofeedback and self-hypnosis may be reasonable alternatives to pharmacological treatment for managing childhood migraine, especially in adolescents.

Treatment of migraine in children

Tips for relieving childhood migraine

At the time of the headache, if possible, advise the child to lie down in a cool, dark, quiet room and fall asleep . Sleep may be the most effective migraine treatment. Some patients find that ice or pressure on the affected pain area can provide temporary pain relief.

For the mild seizures to moderate, nonsteroidal anti-inflammatory drugs are effective if administered during the aura or the initial phase of the headache. ibuprofen is administered at an initial dose of 10mg/kg. Gastric stasis occurs in migraine patients and can lead to delayed absorption of oral medications. Occasionally, the soft drinks can improve absorption. There caffeine may help potentiate the effect of migraine pain relief in children. Early use of an antiemetic may help relieve symptoms of associated nausea or vomiting and facilitate sleep. For children with acute migraine and severe nausea and vomiting, rectal promethazine may be given at a dose of 0.25mg/kg to 0.5mg/kg.

When to consider triptans in children?

For the moderate to severe seizures , painkillers over-the-counter may still be effective, but Migraine-specific medications (i.e., triptans) should be considered . A frequently used agent is oral sumatriptan, which can be started at 25 mg, with a maximum dose of 100 mg. This treatment can be repeated every two hours if necessary. Children aged 6 to 10 years and weighing less than 50 kg should start with the smallest dose of triptan available , such as sumatriptan 5 mg nasal spray or 25 mg tablet. For children who are unable to swallow pills, alternatives include orally disintegrating tablet formulations rizatriptan (5mg or 10mg wafer) and zolmitriptan (2.5mg or 5mg), and almotriptan tablet (6.25mg or 12.5mg).

Exceptional long-lasting migraine in children

For patients with unusually severe or long-lasting seizures who present to the emergency room with a migraine, parenteral drugs (intramuscular, intravenous, etc.) should be considered if oral painkillers or triptans have failed .

Acute treatments for childhood migraine

The evidence for acute treatments for childhood migraine was recently reviewed in a practice guideline from the American Academy of Neurology .

THE prophylactic or preventative medications are taken daily to reduce the frequency or severity of headaches and associated symptoms. A good response to prophylactic drugs is often considered a 50% reduction in frequency or severity of seizures .

The use of Prophylactic (modifier) ​​medications should be considered for children with frequent (>2/week), prolonged, and/or disabling migraine attacks that do not respond adequately to other treatments. Often, several weeks are necessary before observing therapeutic gains with prophylactic drugs. Possible preventive medications include amitriptyline, propranolol, gabapentin, topiramate, flunarizine, verapamil, and riboflavin. Unfortunately, there are few high-quality data on the best preventative treatment for migraine in children. In part, it is difficult to demonstrate the effectiveness of a single approach due to traditionally high placebo response rates in children, approaching 50-70% in some studies. This was demonstrated in a recent high quality randomized controlled trial (CHAMP study) which compared amitriptyline, topiramate and placebo for pediatric migraine. In this study, the placebo response rate approached 60%, with topiramate and amitriptyline failing to exceed this success rate.

Nevertheless, the best available evidence supports the use of topiramate or amitriptyline and cognitive behavioral therapy in the preventive treatment of migraine.

Treatment of chronic migraine in children

There chronic daily headache is a disorder whose diagnosis is based on the presence of headaches for a duration greater than or equal to 15 days of headache in 1 month , over a period of three consecutive months, and without underlying organic pathology .

Many adolescent patients with chronic daily headaches have a history of episodic migraine . There transformation into chronic migraine can occur over a period of several weeks to several months, or occur suddenly in a few hours. About 25% of adolescents with chronic daily headaches have no significant history of headaches, whereas an infection such as mononucleosis or minor head trauma can trigger a new, persistent daily headache. A smaller number of patients will have history of tension headaches before their chronic daily headache.

Most of the time, the child with chronic migraine complains of at least two distinct types of headache:

#1: The first type, the most important, consists of severe intermittent headaches that resemble migraines . They are often associated with nausea during the most severe periods, and the patient frequently presents with photophobia, phonophobia and osmophobia. For these more severe headaches, sleep can sometimes reduce the intensity, but the patient will always have a persistent headache on waking. The frequency of these severe headaches varies between individuals, but they usually occur several times a week in an untreated patient.

#2: In addition to these severe intermittent headaches, the chronic daily headache patient often complains of a more continuous daily headache . This headache continues can vary in intensity , often being worse in the morning or at the end of the school day . The characteristics of continuous headache are similar to those of severe headache episodes, but much less intense. Some patients may also describe this permanent headache as having the characteristics of a tension headache , the pain being banding or crushing rather than throbbing.

Sleep, dizziness, anxiety and mood disorders

THE chronic headaches are often associated with a pentagram of difficult comorbid symptoms, including sleep disturbances, dizziness, anxiety and mood disorders , muscle aches and abdominal problems. THE sleep is disturbed in at least two-thirds of children with chronic daily headaches . Patients often report a delay in falling asleep , not being able to fall asleep until 30 minutes to several hours after going to bed. Some teens report frequent nocturnal awakenings . In general, headache syndrome does not go away until sleep is improved. We can consider advice on sleep hygiene or a formal sleep consultation , as lack of sleep can be a significant contributing factor to headache symptoms.

Patients with chronic migraine also complain dizziness, which is associated with feeling weak, nausea, and blurred or lost vision. In our experience, a common form of vertigo is often positional, and may involve syncope or near syncope after standing. Orthostatic vertigo is particularly marked in the morning. A difference in pulse or blood pressure between sitting and standing may be noted if the patient is standing for several minutes in the office. One can observe either a significant tachycardia when standing (postural orthostatic tachycardia syndrome) and/or a decrease in systolic blood pressure when standing (neurocardiogenic syncope). Severe migraine days may also be accompanied by dizziness (migraine vertigo). Finally, some patients present with vertigo independent of position and unrelated to migraine pain. In this patient group, the role of anxiety needs to be explored.

THE mood disorders and anxiety also frequently coexist with chronic migraine. Mood problems may precede or follow the onset of the headache. Headache and mood symptoms should be treated. If mood and anxiety issues are significant, it is difficult to control headaches until these symptoms improve. However, chronic migraine should be considered a primary headache syndrome and not a mood disorder. It is not uncommon to see patients suffer from post-traumatic stress disorder, generalized anxiety disorder, or social anxiety disorder with school avoidance.

There are interesting environmental factors that play a role in headache burden, including variability over the school year . Most of our patients do better in the summer when school is not open, and frequently experience worsening headaches at the start of the school year.36 School Truancy and School Functioning life in general can be a significant problem.

Other common comorbid symptoms include nonspecific abdominal pain, back pain, neck pain, and diffuse muscle and joint pain. Often, no additional organic etiology is found to explain these additional pain symptoms.

Pediatric assessment for migraine

Assessment of the pediatric patient with chronic migraine includes a thorough history (detailed questionnaire) and physical examination , as well as consideration of a neuroimaging study and, occasionally, a lumbar puncture. In patients with certain comorbidities, a tilt table test or formal sleep assessment may be helpful.

Neuroimaging studies will be normal in the vast majority of patients with chronic headaches. These patients sometimes have white matter abnormalities, arachnoid cysts, or pineal cysts. which are generally considered to be of no clinical significance in relation to headache.

There chronic migraine is maybe the most common chronic headache disorder , but several other chronic headache diagnoses should also be considered. Chronic tension headache is distinguished by the absence of migraine features. New daily persistent headache is defined as the sudden onset of head pain in an individual with no significant history of headache. In idiopathic intracranial hypertension, most (but not all) patients have papilledema and a cerebrospinal fluid opening pressure greater than 28 cm of water. Of the Eye pain, visual dimness, and throbbing tinnitus are common symptoms in addition to headache .

Several brain MRI findings have been associated with Idiopathic intracranial hypertension , including the appearance of an empty sella, dilation of the optic nerve sheath, and cleft ventricles , although a recent study showed that bilateral transverse sinus stenosis on conventional MRI was more reliable than other previously described MRI findings in idiopathic intracranial hypertension. L

Treatment of chronic migraine in children

Chronic migraine is often difficult to control and drug therapy may take weeks or even months to achieve a significant change in headache burden . The cornerstones of treatment are education, preventative medications, attention to environmental triggers and time.

It is difficult for many families to understand that head pain can persist for so long , that no abnormalities appear in the diagnostic tests and that the medications prescribed to them are not immediately effective .

It is also not uncommon for these patients to see multiple doctors because of this frustration. It is therefore helpful to spend enough time with the patient and family to discuss the diagnosis of chronic migraine, how secondary causes of the headache have been ruled out, the role of drugs , when do not use painkillers , the role non-drug approaches (such as biofeedback or physiotherapy and osteopathy) and what the family should expect in the short and long term.

Preventive drugs

Preventive medications are used in episodic migraines to reduce the frequency of migraines . However, in the case of chronic daily headaches, a reasonable short-term treatment goal would be to make severe intermittent headaches less frequent and permanent headaches less intense. Unfortunately, there have been few prospective, randomized, controlled studies in children to give us insight into the most effective or safest drug to use in chronic migraine in children .

Studies in adults and children have shown that Tricyclic antidepressants , such as amitriptyline, are helpful in chronic daily headaches. Consideration should be given to changes in the electrocardiogram, as this drug may prolong the QT interval. Weight gain is a big concern for teens taking these drugs, and it affects some children more than others. Amitriptyline can also be useful for falling asleep. The typical dose of amitriptyline is 0.25mg/kg/day to 1.0mg/kg/day (25-100mg for most teenagers), although higher doses can be used. Other tricyclics, such as nortriptyline or protriptyline, may cause less sedation.

others serotonergic agents such as selective serotonin reuptake inhibitors or selective norepinephrine reuptake inhibitors have also been shown to be effective in some adults with chronic headaches.39 Selective serotonin reuptake inhibitors appear to be less effective than tricyclics for pain control, although they may be more useful in children for their positive effects on mood.

Acute pain relievers are often not very effective for chronic migraine . Many patients report that acute treatments are not effective for their daily and continuous headaches. It is reasonable to discourage patients from trying to use painkillers to treat their permanent headache, as this can lead to overuse of painkillers and a possible rebound headache. The fight against the rebound of these substances is part of the treatment. Drugs implicated in this overuse syndrome are opioids, butalbital, isometheptene, benzodiazepines, ergotamine, and triptans.

On the other hand, for more severe intermittent headache episodes with migraine-like features, analgesics should be considered. Approaches may include the use of migraine painkillers such as triptans, indomethacin, or other nonsteroidal anti-inflammatory agents. Compounds that contain caffeine, barbiturates, opiates, or have high rebound potential should be limited or avoided. Patients generally find that when the preventative medications start to work, the pain relievers also become more effective.

Natural treatment for childhood migraine

Natural migraine treatments can help relieve attacks in children. The use of the feverfew can be very effective.
Innovative treatments like MIG SPRAY can be used from the age of 12 . Nevertheless, the therapeutic effect will be gradual and an evaluation over a minimum of 3 months will be necessary .
Osteopathy has also shown favorable effects in the management of migraine in children. Several sessions, between 3 and 6 are however necessary.
THE sophrology technique And hypnosis also allow to stimulate the placebo effect and according to the child to control his pain.

What to do when this strategy does not work?

What to do when this strategy does not work? Not all patients respond to the above suggestions. When this happens, it is useful to question the diagnosis of migraine , of treat comorbidities that interfere with recovery and consider BoNT-A i.e. the use of butulin toxin , trigger point injections, neurostimulation, or behavioral programs that focus on multiple targets: symptoms and return to functioning.

Use of BoNT-A may reduce the number of headache and migraine days in patients suffering from chronic migraine. Retrospective chart reviews also showed a positive response in children. In the United States, it is an expensive treatment, and many insurance companies require the patient to have tried and failed at least three preventative therapies before considering BoNT-A. This treatment is especially useful for patients with complicated medical regimens or who seem extremely sensitive to the side effects of oral medications.

CGRP: The Calcitonin Gene-Related Peptide is a 37 amino acid peptide neurotransmitter associated with pain and is the target of a new migraine treatment . Early studies used small molecule antagonists (telcagepant), but these early attempts were associated with liver problems. Anti-calcitonin gene-related peptide antibodies have recently been developed for use as preventive therapy. Positive effects are seen in early adult studies, but their use in pediatrics is still being studied and not readily available.

The best evidence for the therapeutic use of nerve blocks is seen in post-traumatic headaches. A small retrospective study involved 15 patients who received an occipital nerve block for chronic post-traumatic headache. In the follow-up of 14 patients 5 months after injury, nine of them reported a long-term response to occipital nerve blocks43.

The approaches biobehavioral have been shown to be effective in managing headache pain.

It has been demonstrated that the biofeedback reduces pain levels and frequency of headaches. Multidisciplinary behavioral programs, which draw on the expertise of physical medicine, psychology and neurology, help restore function to patients and improve pain control. One of the strongest levels of evidence observed in a study on Pediatric migraine treatment has been seen when cognitive behavioral therapy has been added to standard migraine treatment .

In conclusion, chronic migraine in children can cause significant pain and functional disability. There is no single treatment to help everyone. Pharmacology is helpful, but a more holistic approach is often needed.

Conclusion :

The frequency of migraines can change as children grow into adulthood . In one of the longest longitudinal studies of pediatric migraine patients, children with migraine were followed for 40 years. Migraines appeared on average at 6 years of age. By puberty or early adulthood, 62% of children had been migraine free for at least 2 years and about 33% of them had regular attacks again after an average of 6 years without migraine. A startling 60% of the original 73 children still suffered from migraines after age 30, while 23% of participants never had a migraine-free year. Among patients who became parents, 52% had at least one child in their current or previous family who developed recurrent migraine headaches47.

The prognosis for chronic headaches is also not entirely bleak. In a follow-up study of a community sample of middle school students with chronic headaches, 50% were shown to have improved after one year and 75% after two years. Unfortunately, 12% of them suffered from chronic daily headaches 8 years later. Some vacillated between chronic and episodic headaches.

When patients get better, their sleep often improves first, then the frequency of severe migraine episodes decreases, followed by continued improvement in headache. When patients manage to resolve the daily headache, they often revert to their premorbid state as an episodic migraine patient. The field of headache medicine is optimistic that with successful identification of the primary headache syndrome and aggressive pharmacological and non-pharmacological management, the average duration and severity of symptoms can be significantly reduced.