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Pediatric Migraine
844
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE, 1983
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Fig. 2 (English and Cohn). Left, Low-power view of sebaceous gland shows acute (short arrow) and chronic (long arrow) reactions (hematoxylin and eosin, X 40). Right, Higher-power view of chronic granulomatous reaction identical to a chalazion (hematoxylin and eosin, X 240).
foreign-body giant cells surrounding lipid spaces and associated with many chronic inflammatory cells, including plasma cells (Fig. 2, right). Study of these sections disclosed many mites in the lumen of the terminal ductules of the sebaceous gland. At this site their presence appeared to be well tol erated. However, in the stroma of the gland an inflammatory reaction was in duced with many polymorphonuclear leukocytes contributing to this process. We also noted a granuloma identical to a chalazion, an entity encountered in the meibomian gland, which is a modified sebaceous gland. Interestingly, in the early 1920s this parasite was implicated as a causative agent of chalazion. 1
REFERENCE
1. Duke-Elder, S., and MacFaul, P. A.: The Ocu lar Adnexa. Diseases of the Eyelids. In Duke-Elder, S. ed: System of Ophthalmology, vol. 13, pt. 1. London, Henry Kimpton, 1974, p. 246.
PEDIATRIC MIGRAINE T H O M A S R.
HEDGES, JR.,
M.D.
Pennsylvania Hospital, Eighth and Spruce Sts., Philadelphia, PA 19107
Migraine in childhood is a most difficult diagnosis, but I have made certain obser vations that are helpful in diagnosing mi graine in children whose chief complaints
VOL. 95, NO. 6
LETTERS TO THE JOURNAL
are headache or blurred vision. Key symptoms include episodic occurrence of headache, nausea, anorexia, and lassi tude, not necessarily occurring together. Psychogenic headache is the most com mon type of headache in children and adolescents. 1 The "continuous daily" course typical of psychogenic headache must be distinguished from the more significant headache of migraine, espe cially when the patient also reports blurred vision. Periodicity with symp toms that occur at definite times in a recurring sequence, is the hallmark of such migraine syndromes. The most important questions to ask both the child and the parent are the specific times and settings in which the headaches or blurred vision occur. This questioning may require some patience, but the parent often gives a clue to the diagnosis by saying: "It happens in school, then gets worse, may or may not throb but lasts several hours. My child comes home from school, does not want dinner, and then goes to b e d . " This infor mation is seldom offered all at once, but the patient and the parent are usually well aware of the headache's periodicity, the accompanying nausea or anorexia, and the intense desire to sleep after the headache begins to wear off. The diagnosis of pediatrie migraine is often missed for several reasons. Rarely does the child describe a full-blown at tack similar to adult migraine. In most cases, the recognizable pattern of adult migraine is missing from the vague and inconsistent impressions given by the child. Periodic symptoms of headache, blurred vision, mild nausea, and ensuing lassitude are often present at different times. A family history of migraine is an important clue to the diagnosis, but it may be difficult to obtain because the parents often deny having had such head aches. After reflection, however, they may remember that they did have severe headaches in childhood or may recall
845
relatives who had periodic, severe head aches thought to be of the nervous or sinus type. It is important to recognize the condition and to reassure the parents and the patient. The ultimate prognosis is excellent in children because the head aches run their course within six years of onset. J Drug treatment other than aspirin is rarely necessary. Rothner 1 pointed out that a thorough neurologic evaluation is in the patient's best interest only when recurrence or severity demand it. I always refer the patient back to the pediatrician or family physician along with a careful explanation of my impressions. REFERENCE
1. Rothner, A. D.: Headache in children. A re view. Headache 18:109, 1978.
CONJUNCTIVAL INVOLVEMENT I N PRIMARY SYSTEMIC NONFAMILIAL AMYLOIDOSIS J O H N J. P U R C E L L , J R . , M.D., RAYMOND BIRKENKAMP, M.D., C H E N G C. T S A I , M.D., AND R O N A L D N. R I N E R , M.D.
Suite 315, 6744 CL·!/^ Rd, Richmond Heights, MO 63117 (Dr. Purcell)
There have been few descriptions of external ocular involvement in primary systemic nonfamilial amyloidosis. When amyloid is deposited in the dermis of the eyelid, slight trauma can lead to eyelid ecchymosis. 1 Confluent waxy yellow pap ules on the eyelids may be diagnostic of primary systemic amyloidosis. Hemor rhage into the conjunctiva is rare, 2 and occurs only in advanced cases with liver failure. 3 One of our patients with recurrent subconjunctival hemorrhages was found to
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE, 1983
*r>-J&v#?$, ·. '■·'■* Λ Α 4 - * -
►.'AM
' ' ιλ'Λ' • Ti·. >**¥
Fi!
à' \y-\}^^mm
fi
Fig. 2 (English and Cohn). Left, Low-power view of sebaceous gland shows acute (short arrow) and chronic (long arrow) reactions (hematoxylin and eosin, X 40). Right, Higher-power view of chronic granulomatous reaction identical to a chalazion (hematoxylin and eosin, X 240).
foreign-body giant cells surrounding lipid spaces and associated with many chronic inflammatory cells, including plasma cells (Fig. 2, right). Study of these sections disclosed many mites in the lumen of the terminal ductules of the sebaceous gland. At this site their presence appeared to be well tol erated. However, in the stroma of the gland an inflammatory reaction was in duced with many polymorphonuclear leukocytes contributing to this process. We also noted a granuloma identical to a chalazion, an entity encountered in the meibomian gland, which is a modified sebaceous gland. Interestingly, in the early 1920s this parasite was implicated as a causative agent of chalazion. 1
REFERENCE
1. Duke-Elder, S., and MacFaul, P. A.: The Ocu lar Adnexa. Diseases of the Eyelids. In Duke-Elder, S. ed: System of Ophthalmology, vol. 13, pt. 1. London, Henry Kimpton, 1974, p. 246.
PEDIATRIC MIGRAINE T H O M A S R.
HEDGES, JR.,
M.D.
Pennsylvania Hospital, Eighth and Spruce Sts., Philadelphia, PA 19107
Migraine in childhood is a most difficult diagnosis, but I have made certain obser vations that are helpful in diagnosing mi graine in children whose chief complaints
VOL. 95, NO. 6
LETTERS TO THE JOURNAL
are headache or blurred vision. Key symptoms include episodic occurrence of headache, nausea, anorexia, and lassi tude, not necessarily occurring together. Psychogenic headache is the most com mon type of headache in children and adolescents. 1 The "continuous daily" course typical of psychogenic headache must be distinguished from the more significant headache of migraine, espe cially when the patient also reports blurred vision. Periodicity with symp toms that occur at definite times in a recurring sequence, is the hallmark of such migraine syndromes. The most important questions to ask both the child and the parent are the specific times and settings in which the headaches or blurred vision occur. This questioning may require some patience, but the parent often gives a clue to the diagnosis by saying: "It happens in school, then gets worse, may or may not throb but lasts several hours. My child comes home from school, does not want dinner, and then goes to b e d . " This infor mation is seldom offered all at once, but the patient and the parent are usually well aware of the headache's periodicity, the accompanying nausea or anorexia, and the intense desire to sleep after the headache begins to wear off. The diagnosis of pediatrie migraine is often missed for several reasons. Rarely does the child describe a full-blown at tack similar to adult migraine. In most cases, the recognizable pattern of adult migraine is missing from the vague and inconsistent impressions given by the child. Periodic symptoms of headache, blurred vision, mild nausea, and ensuing lassitude are often present at different times. A family history of migraine is an important clue to the diagnosis, but it may be difficult to obtain because the parents often deny having had such head aches. After reflection, however, they may remember that they did have severe headaches in childhood or may recall
845
relatives who had periodic, severe head aches thought to be of the nervous or sinus type. It is important to recognize the condition and to reassure the parents and the patient. The ultimate prognosis is excellent in children because the head aches run their course within six years of onset. J Drug treatment other than aspirin is rarely necessary. Rothner 1 pointed out that a thorough neurologic evaluation is in the patient's best interest only when recurrence or severity demand it. I always refer the patient back to the pediatrician or family physician along with a careful explanation of my impressions. REFERENCE
1. Rothner, A. D.: Headache in children. A re view. Headache 18:109, 1978.
CONJUNCTIVAL INVOLVEMENT I N PRIMARY SYSTEMIC NONFAMILIAL AMYLOIDOSIS J O H N J. P U R C E L L , J R . , M.D., RAYMOND BIRKENKAMP, M.D., C H E N G C. T S A I , M.D., AND R O N A L D N. R I N E R , M.D.
Suite 315, 6744 CL·!/^ Rd, Richmond Heights, MO 63117 (Dr. Purcell)
There have been few descriptions of external ocular involvement in primary systemic nonfamilial amyloidosis. When amyloid is deposited in the dermis of the eyelid, slight trauma can lead to eyelid ecchymosis. 1 Confluent waxy yellow pap ules on the eyelids may be diagnostic of primary systemic amyloidosis. Hemor rhage into the conjunctiva is rare, 2 and occurs only in advanced cases with liver failure. 3 One of our patients with recurrent subconjunctival hemorrhages was found to