By Matthew S. Robbins, MD, FAAN, FAHS

Assistant Professor of Neurology (Interim), Weill Cornell Medical College, NewYork-Presbyterian Hospital

Dr. Robbins reports no financial relationships relevant to this field of study.

SYNOPSIS: Cyclic vomiting syndrome and benign paroxysmal torticollis in children frequently predict the subsequent onset of migraine later in life.

SOURCE: Moavero R, Pepetti L, Bernucci MC, et al. Cyclic vomiting syndrome and benign paroxysmal torticollis are associated with a high risk of developing primary headache: A longitudinal study. Cephalalgia 2019;39:1236-1240.

Moavero and colleagues aimed to better define the clinical spectrum of cyclic vomiting disorder (CVS) and benign paroxysmal torticollis (BPT) and to assess the subsequent rates of developing migraine. They used a clinic-based sample surveying the parents of 82 patients already diagnosed with a history of these disorders. CVS did not feature a consistent pattern of attack frequency and duration but typically featured several vomiting episodes per attack. BPT episodes were described as lasting hours, days, or weeks.

On average, CVS started at 4 years of age and BPT at 5 months of age. Migraine ultimately developed in 71% with CVS and 81% with BPT. Mean age of headache onset was 6 years in those with CVS and 5 years in those with BPT. Both groups featured very high rates of migraine family history and coexisting episodic syndromes potentially related to migraine as well.

COMMENTARY

There is great interest to identify early-life precursors of migraine to better understand genetic and epidemiological factors that may have counseling and therapeutic implications. CVS and BPT are two such precursors recognized along with infant colic, abdominal migraine, benign paroxysmal vertigo, and alternating hemiplegia as such in the third edition of the International Classification of Headache Disorders. Periodic disorders not yet recognized in the classification include recurrent limb pain, motion sickness, and recurrent sleep disturbances.

The study results reinforce the strong link between CVS, BPT, and the later development of migraine. BPT, in particular, has been linked to mutations in CACNA1A, a voltage-dependent calcium channel, which is also the most common genotypic association with familial hemiplegic migraine. The generalizability of the results to patients in less specialized practice settings and other demographic backgrounds should be questioned, as this sample was derived from a single pediatric headache center in Italy. CPT and BPT generally are uncommon conditions, unlike infant colic, which has a much higher prevalence and has been the subject of more recent and larger scale investigations regarding a migraine link. In infant colic, there may be more of an influence of a maternal migraine history on its prevalence, whereas for other disorders like CVS and BPT, a parental-specific influence remains largely unexplored.