Chronic progressive headache in 9 year old boy

[plaity]

My son is 9 years old - diagnosed with Asperger's Syndrome. Never been well.  His history includes Cold Hemolytic Anemia at 4 yrs. with 5 blood transfusions to save his life.  
In December 2001 sudden severe left frontal migraine - left eye swelling and eyelid droop.  Lasted several days over Christmas.  Several trips to emerg. Finally in January did CT Scan and found Subarchnoid cyst 2.1cm x 2.4cm at frontotemporal junction left side.  Did MRI - no contrast and neurosurgeon does not believe cyst to be causing headache - benign finding. Though he could not ensure initial headache was not a bleed as scan was done too late.
For one year now my son has been having severe headaches and they are getting worse. They occur daily - and have a spike pattern - severe pain - left side only - lasting from 5 minutes to two hours then he's ok.  His behaviour is changing - he is very depressed. Lately he is awakened at night with headache (happened once). He has experienced weakness in legs and tingling in fingers he describes as zaps.  He describes his vision as "spiky". He has also experienced fainting spells that last only seconds. He is taking buspar for anxiety and its not helping, nor is the imitrex or any preventative we've tried.  Does this sound like Migraine as the Dr.'s are suggesting?  What tests should I be asking the neurologist to do (we see him in March)? Can you suggest other systemic illness that we should look at - or am I overly concerned?  Can the Cyst be causing any of this?
Thank-you for your help.

[CCF-Neuro-M.D.-JT]

FIrst of all, whenever we see a child with headaches, there are a few things we listen for that are red flags for something potentially serious.  One of them is that the headache has woken your child from sleep and another is that the headaches are worsening - both of which you report. Another thing is that migraines do NOT occur daily. There are a number of headache types that this could represent such as basilar migraine or cluster headahce (very rare in kids), but unless I take a full history and exam myself, it would be difficult to try and guess what this is. It's somewhat reassuring that the MRI just shows a cyst and nothing else that really stands out.  Although I haven't personally seen your son's MRI, I tend to agree with the neurosurgeon in that it's unlikely that the cyst is causing his symptoms. However, there are other tests that may be considered such as an MRI of the arteries and/or veins in the brain to make sure everything else looks ok and one with contrast.  Also, an EEG to help evaluate these fainting spells and possibly some bloodwork may be considered.  A neurology examination should be helpful.  The behavior changes sounds secondary to the underlying problem which appears to be headache.

As for treatment, some pediatric neurologists feel that abortive medications such as a combination of benadryl (to help him sleep it off) and naprosyn (for the headache) are helpful. Other suggestions include midrin and meclofenamate.  Preventive meds such as elavil (usually used for older kids, but if monitored may be used in children  and can help elevate mood), inderal, calcium channel blockers, cyproheptadine and methysergide can also be helpful. If the headaches continue to worsem and your son has nausea, vomiting or other neurological deficits, you ma want to bring him back to the ER just to make sure he's ok. Good luck.