1. Introduction

Migraine is one of the most disabling conditions affecting both adults and children. In adults, it causes difficulties in personal life, professional activity, and social functioning, whereas in children it may negatively affect academic performance and leisure activities, including frequent school absenteeism [1]. The clinical presentation of migraine differs significantly between adults and children. It is well known that in both age groups especially in children the disease is often accompanied by symptoms not directly related to headache [2]. These may manifest as episodic syndromes associated with migraine. Interestingly, such episodic syndromes were described in pediatric patients much earlier than in adults [3].

The autonomic nervous system (ANS) plays a significant role in the pathogenesis of migraine. It should be noted that ANS disorders are considered the most common comorbid conditions accompanying migraine attacks (94.2%) [4]. Autonomic imbalance is characterized by the predominance of sympathetic over parasympathetic activity, with three principal directions of change identified. First, migraine with aura generally provokes more pronounced autonomic disturbances compared to migraine without aura. Second, autonomic dysfunction is observed more frequently in the sympathetic division than in the parasympathetic division. Third, sympathetic disturbances are often detected in the interictal period, with increased sympathetic tone during attacks, indicating adrenergic receptor hyperreactivity. Despite the available data on the role of the ANS in pediatric migraine, the relationship between migraine and autonomic dysfunction remains insufficiently understood, and it is still unclear which component is primary and which is secondary [5,6].

It is important to understand that the ANS plays a key role in regulating emotional states, adaptation to environmental conditions, and metabolic processes, thereby ensuring optimal mental and physical activity. Its functional state significantly influences the course and prognosis of various pathologies across all age groups. Deviations in ANS function accompany nearly all diseases, including headache disorders, particularly migraine. Early detection of autonomic dysfunction in patients with headaches contributes to more accurate symptom management, improves overall well-being, and enhances quality of life [7,8]. This is especially relevant for children and adolescents, during whom maturation of segmental and suprasegmental brain structures occurs, influencing adaptive processes, disease development and progression, and the formation of pain syndromes, including cephalalgias.

The clinical presentation of vegetative-vascular dystonia (VVD) in children and adolescents with migraine is highly variable and involves multiple organ systems. Several clinical forms may occur independently or in combination: arterial hypertension or hypotension; neurogenic syncope; non-infectious headache; visual and balance disturbances; fever associated with neurological disorders; functional cardiac insufficiency; hyperventilation syndrome; upper gastrointestinal motility disorders; lower gastrointestinal motility disorders (irritable bowel syndrome); vascular-trophic neuralgia; neurogenic bladder dysfunction; functional pulmonary hypertension; hyperhidrosis; neuroendocrine disorders; and episodes of autonomic dysfunction (panic attacks) [9].

During clinical assessment, it is essential to consider the overall pattern of autonomic imbalance sympathicotonic, vagotonic, or mixed. For example, adolescence is characterized by enhanced sympathoadrenal activity, reflecting general activation of the neuroendocrine system associated with age-related changes [10]. Adolescents of the sympathicotonic type are typically slender, with reduced appetite. Their skin is dry and pale, with barely visible vascular patterns and persistent white dermographism. They often report cardialgia and show a predisposition to bradycardia and elevated blood pressure. Complaints may also include constipation and infrequent but abundant urination [11].

Patients with vagotonia commonly demonstrate a tendency toward overweight despite poor appetite. They often experience a persistent feeling of coldness, increased sweating, and low-grade fever. The skin has a marbled appearance, feels cool to the touch; hands and feet remain cold and moist, frequently acquiring a cyanotic tint. Dermographism is pronounced, long-lasting, and sometimes raised. These adolescents frequently suffer from bradycardia or arrhythmias, tend toward hypotension, complain of cardiac pain, experience syncopal episodes, poorly tolerate travel, and report dyspnea. A significant proportion also exhibit abdominal pain, nausea, hypersalivation, flatulence, and frequent but low-volume urination [12].

Objective of the Study. To determine the severity of autonomic disorders in children and adolescents with migraine.

2. Materials and Methods

A total of 102 patients aged 7–18 years with a confirmed diagnosis of migraine (ICD-10: G43) were examined. Group I included 60 patients (58.8%) aged 7–11 years, of whom 33 (58.9%) were boys and 27 (58.7%) were girls. Group II consisted of 42 patients (41.1%) aged 12–18 years, including 23 boys (41.1%) and 19 girls (41.3%).

All participants underwent a comprehensive clinical and neurological examination to identify key signs of involvement of the central, peripheral, and autonomic nervous systems [13]. Particular attention was paid to aggravating factors, including a history of frequent acute respiratory viral infections, chronic somatic diseases, vascular disorders, and emotional or physical stress.

Autonomic nervous system (ANS) activity was assessed using clinical methods. Autonomic tone was evaluated according to the Guillaume–Wayne scale, where scores were assigned based on manifestations of sympathetic and parasympathetic activity across various organs and systems, followed by determination of the predominant orientation (sympathetic vs. parasympathetic). To diagnose autonomic dystonia syndrome (ADS), we used an 11-item patient questionnaire (a total score of ≥15 suggesting ADS) and a 13-item physician-completed checklist for detecting autonomic deviations (in individuals without pathology, the total score should not exceed 25) [14]. Statistical analysis was performed using the software package Statistica 8.0 (StatSoft, USA, Windows XP).

3. Results and Discussion

According to medical history data, 24 patients (23.5%) had a complicated perinatal history, 28 patients (27.4%) demonstrated hereditary predisposition, and 51 patients (50.0%) had migraine attacks of unclear etiology. During interictal clinical neurological examination, no gross focal neurological deficits were detected; only scattered microfocal signs were observed.

Paraclinical investigations revealed signs of angioencephalopathy on brain MRI in 32 patients (31.3%), demyelinating lesions in 11 patients (12.0%), and no detectable pathology in 58 children (57.0%). EEG findings showed brainstem dysfunction in 38 children (37.2%), epileptiform activity in 19 patients (18.6%), and diffuse brain changes in 45 children (44.1%). Transcranial Doppler ultrasonography identified vertebrobasilar insufficiency in 64 patients (62.7%) and congenital vascular anomalies in 17 children (16.6%).

Analysis of baseline autonomic status according to the Guillaume–Wayne scale (modified for children) demonstrated a predominance of sympathicotonia in both groups: 20 patients (33.3%) in Group I and 15 patients (35.7%) in Group II. Although sympathetic predominance was more pronounced in the older group, no statistically significant intergroup differences were found (p = 0.187). Vagotonia was significantly more common in younger children 12 patients (20.0%) compared to 4 patients (9.5%) in the older group. Eutonia was recorded in 28 patients (46.6%) in Group I and 23 patients (54.7%) in Group II (Table 1).

Table 1. Baseline autonomic parameters in children and adolescents

Thus, the predominance of sympathetic orientation in patients with migraine in both groups indicated a state of chronic tension in adaptive mechanisms, which is typical for migraine as a stress-dependent disorder. The greatest expression of sympathetic influences in older children reflected increasing maladaptation with longer disease duration and more complex academic demands.

The relatively high frequency of vagotonia in children aged 7–11 years can be explained by the clinical features of migraine attacks in this age group, such as more pronounced abdominal symptoms, nausea, and post-attack somnolence. In addition, the approximately twofold higher prevalence of vagotonia may be due to age-related maturation of the autonomic nervous system (ANS) and neurohumoral regulatory processes.

According to many authors, the predominance of sympathicotonia in older children with migraine is expected and can be attributed to several important factors. First, the pubertal period involves hormonal restructuring accompanied by increased reactivity of the sympathoadrenal system, which lowers the pain threshold and may contribute to migraine chronification. Second, the presence of psycho-emotional stress due to increasing academic workload and social demands during this age places natural strain on adaptive resources. In migraine, sympathicotonia acts as a kind of “anticipatory marker” of an attack, maintaining pathological readiness of the trigeminovascular system. Third, disease duration is also significant: more pronounced sympathetic orientation in adolescents may reflect depletion of parasympathetic (compensatory) mechanisms due to prolonged headaches [15,16].

Regarding the higher frequency of vagotonia in younger children, authors attribute this to the physiological immaturity of autonomic regulation. Clinically, this is confirmed by the observation that migraine attacks in younger children are more often accompanied by pronounced autonomic components, including vomiting, pallor, hypersalivation, and the need for deep sleep to relieve pain [17,18].

Autonomic dysfunction, assessed using the A.M. Wayne questionnaire, complemented the overall picture of pathology. The overall high percentage of pronounced ANS dysfunctions (approximately 60%) served as a strong clinical marker of autonomic system disorders specifically in patients with migraine (Fig. 1).

Figure 1. Severity of autonomic dysfunction syndrome depending on age

According to the presented data, pronounced autonomic deviations, as assessed using A.M. Veyna’s questionnaire, predominated in both groups, with a slight predominance observed in the older cohort of children (61.7%) compared to those aged 7–11 years (59.5%). A similar pattern was observed for moderately expressed dysfunctions, which were more frequent among patients aged 12–18 years than in younger children (19.1%). In contrast, mild autonomic dysfunction was more commonly documented in the 7–11-year-old group (14.3%) than in the 12–18-year-old group (10%). The complete absence of autonomic dysfunction was recorded in only 7% of cases across both groups.

Thus, detailed assessment of autonomic status in children and adolescents with migraine revealed a high degree of autonomic regulation decompensation. Pronounced autonomic dysfunction was identified in over 60% of patients, irrespective of age, which against the background of predominant sympathicotonia indicates substantial strain on the body’s adaptive systems. Age-related dynamics were characterized by an increase in the severity of autonomic deviations during adolescence, with a corresponding rise in moderate and pronounced dysfunctions and a reduction in mild forms of autonomic dysfunction. The minimal proportion of patients without signs of autonomic impairment underscores the obligatory involvement of the autonomic nervous system in the pathogenesis of migraine in pediatric and adolescent populations, highlighting the necessity of incorporating vegetotropic interventions into standard therapeutic protocols for this condition.

To verify autonomic dysfunction and evaluate its clinical severity, the validated Guyomard-Veyna scale was employed. The study demonstrated a marked age-dependent variation in the frequency of specific autonomic dysfunction signs. The results of the comparative analysis of autonomic disorders across age groups are presented in Table 2.

Table 2. Comparative characteristics of autonomic dysfunctions in children and adolescents of the studied groups (Guyomard-Veyna questionnaire)

In the course of a comparative analysis of autonomic status in the two observation groups, we found a significant predominance of systemic and pronounced autonomic symptoms in adolescents, across almost all evaluated parameters. Highly significant intergroup differences (p < 0.001) indicated that with increasing age or disease severity, autonomic lability ceases to be localized and begins to affect multiple organ systems, particularly cardiovascular, thermoregulatory, and emotional domains. For example, localized sweating in the 12–18-year-old group reached 97.6%, compared to 53.3% in the younger group, while generalized hyperhidrosis was observed in 92.8% of adolescents versus only 30.0% in the 7–11-year-old group. The presence of a “vascular collar” and acrocyanosis of the hands and feet was 1.5–2 times more frequent in the adolescent group than in the younger group. These findings indicate the development of pronounced sympathicotonia or a sharp decline in vascular adaptive capacity with increasing age.

At the same time, persistent red dermatographism was observed in 73.8% of adolescents, reflecting marked vasomotor lability and predominant parasympathetic influence in the periphery. Blood pressure variability and heart rate variability also statistically significantly predominated in the adolescent group (p < 0.001), at 90.4% and 85.7%, respectively. Additionally, highly significant intergroup differences (p < 0.001) were recorded for weather sensitivity, affecting nearly all patients in the adolescent group. Emotional disturbances, present in 92.8% of adolescents, combined with autonomic dysfunction, form a vicious cycle of psychosomatic complaints.

Interestingly, the only statistically significant parameter predominating in the 7–11-year-old group was the presence of typical autonomic crises and migraines (p = 0.022), the so-called “crisis” phenomenon. This represents an important diagnostic finding, as many authors note that younger migraine patients typically experience acute paroxysms, whereas adolescents are more likely to experience persistent discomfort [19,20].

Our study revealed a clear age-related evolution of autonomic deviations, ranging from localized paroxysmal manifestations, such as crises or migraines in 7–11-year-old patients, to total systemic maladaptation in 12–18-year-old patients. The statistically significant predominance of nearly all domains of the Guyomard-Veyna questionnaire in the adolescent group (p < 0.001) indicates the development of a stable pathological background, in which autonomic dysfunction ceases to be episodic and becomes a permanent state of the organism.

4. Conclusions

Analysis of the autonomic profile in an age-related context allowed us to identify a fundamental pattern: the development of autonomic dysfunction progresses from the so-called “stormy” type (rare but intense crises) to the “diffuse” type (persistent lability of blood pressure, heart rate, and psychoemotional sphere). This pattern indicates a pronounced depletion of adaptive reserves with age in children with migraine and necessitates a shift in therapeutic focus from merely controlling acute migraine episodes to comprehensive neuroprotection and psychoautonomic correction. Finally, it should be emphasized that autonomic dysfunction in children with migraine is not a secondary symptom but an important predictor of disease severity.