A 7-year-old girl presenting with a one year history of intermittent migraine auras without headache, a maternal grandfather similarly affected, and a mother with common migraine are reported from McGill University and the Montreal Children’s Hospital, Canada. The child’s auras consisted of intermittent brief episodes of visual disturbance, white spots, flashes of colors, and metamorphopsia, with faces appearing smaller or larger than normal. The episodes lasting up to 5 minutes often occurred daily. Headache was denied, and the neurologic exam, EEG, VER, and CT were normal. The grandfather’s migraine auras consisted of a shimmery white line moving across the visual field from left to right, they lasted up to one hour, were never associated with headache, and attacks resolved spontaneously in his mid-50s. 
COMMENT. “Migraine-sans-migraine” was first described by Whitty CWM (1967), at the Radcliffe Hospital, Oxford, England. Subsequently termed acephalgic migraine (migraine aura without headache) in the International Headache Society (IHS) classification (1988), the entity has recently been described in a series of children and estimated at a frequency of 2% among children with migraine (Shevell MI, 1996). The author cites only one other published report of familial acephalgic migraines (Ziegler DK, 1995).
Migraine without aura, diagnosed by clinical criteria, was not confirmed by IHS criteria in more than two thirds of a group of children whose records were analyzed at the Schneider Children’s Hospital, New Hyde Park, NY . IHS criteria for diagnosis of migraine without aura in children may be too specific and complex and poorly sensitive in practice. The authors suggest that IHS criteria should be modified to accommodate clinical pediatric manifestations and omit those symptoms infrequently observed in children, eg unilateral headache, phonophobia. The restrictive nature of IHS adult criteria for migraine diagnosis in children is discussed in Progress in Pediatric Neurology III, PNB Publ, 1997.
Effective migraine management is reviewed from the Institute of Neurology, Queen Square, London . Acute treatment of migraine with dihydroergotamine nasal spray is reported from the University Headache Center, Moorestown, NJ . Newer and experimental treatments for migraine are generally inappropriate for use in children. Analgesic or analgesic/antiemetic combinations are first-line acute treatments. Greater attention might be given to precipitating factors, including diet, school-related stress, and negative parent responses to the headache.