Headache and migraine in children: Viva

Branch 1: Confirming the diagnosis

The candidate should confirm the diagnosis by applying the ICHD-3 criteria. This boy has had more than five attacks of headache lasting two to three hours, which falls within the two to 72 hour paediatric duration, with a throbbing quality, an intensity that forces him to stop and sleep (moderate to severe), and accompanying nausea and photophobia. He is fully well between attacks. These features meet the criteria for migraine without aura, and the family history of migraine in his father strengthens the diagnosis. A strong candidate notes that in children the pain is more often bilateral and frontotemporal, as it is here, and that the photophobia may be inferred from behaviour rather than reported. ^[1]

If the examiner presses on what else it could be, the candidate should distinguish migraine from tension-type headache, which is bilateral, pressing, mild to moderate, not worsened by activity, and lacks nausea, and should hold the boundary firmly. The key teaching point is that the diagnosis is clinical and that no investigation is needed once the criteria are met, provided the red-flag screen is negative. ^[1]