Fatigue, Mood Changes May Predict Onset of Pediatric Migraine

Deborah Brauser

June 09, 2017

BOSTON — Symptoms that regularly occur in the hours or days before a migraine have been useful in past research for signalling the onset of the condition in adult patients. A new study suggests that they may also be predictive for pediatric migraine.

The prospective analysis of more than 200 patients aged 5 to 18 years showed that 39% had premonitory symptoms, with the most common being fatigue and mood change.

Dr Howard Jacobs

These symptoms were more common in patients with migraine with vs without aura and in patients 12 years of age or younger. In addition, 45% of the girls vs 34% of the boys had a history of these signs.

"For families with kids who are in that subset who have premonitory signs, if they know to look for them, it's sort of an early warning signal," principal investigator, Howard Jacobs, MD, pediatrician and headache specialist at Nationwide Children's Hospital, Columbus, Ohio, told Medscape Medical News.

"As clinicians, if we're aware that these exist, we should be telling parents to watch out for them and that, 'Hey, your child is about to get a headache.' So this is educational for us, too," he said.

Dr Jacobs presented the findings here at the American Headache Society Annual Scientific Meeting (AHS) 2017.

Adult, Child Literature Differs

Dr Jacobs noted that a 1984 study showed that 30% of 530 adult patients referred for headache had premonitory signs, which were mostly changes in mood, appetite, and alertness. A study published in 2016 showed that 77% had premonitory symptoms, especially yawning.

A retrospective study published in 2016 in 100 pediatric patients with migraine had premonitory signs, with the most common being fatigue, mood change, and neck stiffness.

Dr Jacobs said it was this last study that pushed him into looking at this issue prospectively in young people.

Between July and December 2016, 207 patients (mean age, 12.9 years; 63.3% girls) were enrolled in the current analysis. Exclusion criteria included taking any prescription preventive medications for migraine or supplements.

Of these patients, 185 were diagnosed as having migraine or new daily persistent headache, and 22 had tension-type or chronic tension-type headache, postconcussion syndrome, or primary stabbing headache.

Parents/guardians, or the patients themselves if age 18 years or older, were asked during appointments at a multidisciplinary pediatric headache clinic about six symptoms during the 24 hours before an attack.

These symptoms, chosen because they're commonly referred to in the adult literature, were fatigue, food cravings, increased urination, yawning, neck stiffness, and mood changes.

Significant, Insignificant Symptoms

Fatigue was reported by 68.4% of the participants, and mood changes by  56.6%.

The other four symptoms were highly insignificant, which wasn't that surprising, said Dr Jacobs. "I wonder if they exist more but people don't recognize them. Behavior and fatigue are easy to pick out in kids. Adults may notice that they're going to the bathroom more before a headache, but it might not be as noticed in a child."

He added that yawning could have been seen as part of fatigue, and neck stiffness could have just been assumed to be part of a headache.

In addition, 60% of those with chronic migraine had premonitory signs, as did 57.1% vs 31.2% of those who had migraine with and without aura, respectively.

Furthermore, 42.5% vs 39.8% of those under and over age 12 years, respectively, had the signs, as did 48.4% of the "under 12s" who were girls.

Finally, family history analysis showed premonitory signs for the following:

  • 75% of those who had a mother with current or prior headache history;

  • 92% with a mother or mother's family with current or prior headache history; and

  • 38% with a family or father's family with current or prior headache history.

Dr Jacobs noted that limitations of the ongoing study include recall and suggestion bias. However, further research "may be helpful with possible implications in therapeutic management of acute headache attacks," write the investigators.

During the postpresentation question-and-answer session, an audience member noted that many adults report feeling increased energy and are more talkative right before a migraine and asked whether that was also found in the study's young population.

"No," answered Dr Jacobs. "The reports were mostly that the kids were moodier, crankier, and harder to get along with."

"Let's Fix Their Problem"

"It is critical that we find better ways to help children and adolescents living with the disabling impact of migraine during the most formative years of their lives," AHS scientific program chair Peter Goadsby, MD, PhD, professor of neurology at King's College London, United Kingdom, and the University of California, San Francisco, said in a release.

He told Medscape Medical News that the idea of premonitory symptoms in this young population is interesting and is an area he and his colleagues have looked into in the past, including doing some brain imaging.

"One doesn't excuse bad behavior, but if mood change is part of the premonitory phase, don't be annoyed with the child. Let's fix their problem. Don't get annoyed with someone because of their biology, that's not fair," said Dr Goadsby.

He admitted he used to think "it was a bit silly" when parents said they could tell when their children were going to have a migraine. "But as you start to look at it, it makes a lot of sense. If they're picking up the premonitory change, they probably do know when it's going to happen."

"It goes to show that when you come to grips with the biology of something, what might seem like magic isn't magic at all," Dr Goadsby noted. "Knowledge can be very powerful in that way."

Dr Jacobs has disclosed no relevant financial relationships.

American Headache Society Annual Scientific Meeting (AHS) 2017. Abstract OR-06. Presented June 9, 2017.

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