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Management of migraine.

Definition and diagnosis Uncertainties about the definition of migraine and the absence of any 'test' or marker make its diagnosis difficult at any age. The difficulty is greater in children whose ability to recount previous or changing symptoms may be limited. Most importantly, children tend to present early in the course of headache disorders (because of parental anxiety) so that the reassurance of continued wellbeing in the face of a long history is unlikely. Though diagnostic criteria are necessary for epidemiological study, they are unsatisfactory for clinical use, particularly in childhood, because for example, the visual phenomena of classical migraine are uncommon, and prostration, vomiting, and abdominal discomfort may overshadow the headache.' 2 In clinical practice it is simpler, and safer, to accept as migraine recurrent headaches which are paroxysmal (an essential characteristic), provided that there is return to full normal healthboth mental and physical-between attacks, that development continues normally, and that other causes of headache have been excluded (indications for investigation are given below). This demands a period of observation to establish that normal health is indeed maintained between attacks. Diagnosis is thus by exclusion, and longitudinal observation.' A family history of migraine is not a reliable pointer to the diagnosis: the detail is often vague and the prevalence of migraine in the community is too high. The distinctions between common migraine (migraine without aura) and tension, and psychogenic, headaches may not be clear, and these disorders can coexist in children as well as adults. Their clinical management, however, overlaps. There are probably no essential differences between migraine in childhood and that in adult life, though before puberty boys slightly outnumber girls. Basilar migraine is commoner in childhood, and other variants are probably also more often seen in childhood than in adults. It is also often stated that migraine equivalents are commoner in children.