Migraines in Children
A migraine headache is considered a vascular headache because it is associated with changes in the size of the arteries within and outside of the brain.
For many years it was thought that a migraine headache was primarily a disorder of the blood vessels. We now know that migraine is a genetic disorder that is inherited. Four out of 5 migraine sufferers have a family history of migraines. If one parent has a history of migraines, the child has a 50% chance of developing migraines, and if both parents have a history of migraines, the risk jumps to 75%.
How common are migraine headaches among children and adolescents?
Migraines affect about 1.5 percent of children by age 7 and about 5 percent of children and adolescents by age 15. Disability from headaches can be significant with many days lost from school or play.
In early childhood and before puberty, migraines are more frequent among boys. In adolescence, migraines affect young women more than young men. As adults, women are three times more likely to suffer from migraines than men.
What causes migraines?
The exact causes of migraines are unknown, although they are related to changes in the brain as well as to genetic causes. People with migraine headaches may inherit the tendency to be affected by certain migraine triggers, such as fatigue, bright lights, weather changes and others.
For many years, scientists believed that migraines were linked to the expanding (dilation) and constriction (narrowing) of blood vessels on the brain’s surface. However, it is now believed that migraine is caused by inherited abnormalities in certain areas of the brain.
There is a migraine “pain center” or generator in the mid-brain area. A migraine begins when hyperactive nerve cells send out impulses to the blood vessels, causing constriction, followed by the dilation of these vessels and the release of prostaglandins, serotonin and other inflammatory substances that cause the pulsation to be painful.
Certain brain cells that use serotonin as a messenger are involved in controlling mood, attention, sleep and pain. Therefore, chronic changes in serotonin can lead to anxiety, panic disorder and depression.
What are some migraine triggers?
In many children and adolescents, migraines are triggered by external factors. These “triggers” vary for each person. Some common migraine triggers include:
Emotional stress is one of the most common triggers of migraine headache. Migraine sufferers are generally found to be highly affected by stressful events. During stressful events, certain chemicals in the brain are released to combat the situation (know as the “flight or fight” response). The release of these chemicals can provoke vascular changes that can cause migraine. Repressed emotions surrounding stress, such as anxiety, worry, excitement and fatigue can increase muscle tension and dilated blood vessels can intensify the severity of migraine headaches.
Carefully reviewing what causes stress can help you determine what stress factors you can avoid. Stress management includes regular exercise, adequate rest and diet, and promoting pleasant activities such as enjoyable hobbies.
Ovulation or Menstruation
Normal hormonal changes caused by ovulation and menstrual cycles can trigger migraines.
Changes in Normal Eating Patterns
Skipping meals lowers the body’s blood sugar and can cause migraines. Eating three regular meals and not skipping breakfast can help.
Excessive caffeine consumption or withdrawal from caffeine can cause headaches when the caffeine level abruptly drops. The blood vessels seem to become sensitized to caffeine, and when caffeine is not ingested, a headache may occur. If you are trying to cut back on caffeine, do so gradually. Caffeine itself is often helpful in treating acute migraine attacks.
Weather changes such as storm fronts, barometric pressure changes, strong winds or changes in altitude can trigger migraines.
Some medications, such as oral contraceptives (birth control pills), and asthma treatments may trigger a migraine. Ask your health care provider if there are other alternatives to these medications.
Sensitivity to Specific Chemicals and Preservatives in Foods
Certain foods and beverages, such as aged cheese, alcoholic beverages, and food additives such as nitrates (in bacon, pepperoni, hot dogs, luncheon meats), phenylethylamine in chocolate and monosodium glutamate (MSG, commonly found in Chinese food) may be responsible for triggering up to 30% of migraines. These foods dilate blood vessels, causing a pain message to be sent back to the brain. Recalling what was eaten prior to a migraine attack may help you identify certain foods that are potential triggers so you can avoid them in the future.
Changes in Regular Routine
Personal routine changes such as lack of sleep, travel, riding in a car or illness can cause migraines. Exercising regularly and getting adequate rest can decrease the number of migraine attacks.
What are the types of migraine in children and adolescents?
Common Migraine or Migraine Without Aura*
This is the most frequent type of migraine in children and adolescents, making up about 80 to 85 percent of all migraines.
Classic Migraine or Migraine with Aura*
Less frequent than common migraine, classic migraine makes up about 15 to 20 percent of all migraines. In young children, classic migraine often begins in the late afternoon. As the child gets older, the onset of migraine may change to early morning.
*Aura is a warning sign that a migraine is about to begin. An aura usually occurs about 10 to 30 minutes before the onset of a migraine, although it can occur as early as the night before the onset. The most common auras are visual and include blurred or distorted vision; blind spots; or brightly colored, flashing or moving lights or lines. Other auras may include speech disturbances, motor weakness or sensory changes. The duration of an aura varies, but it generally lasts less than 20 minutes.
Complicated migraine syndromes are associated with neurological symptoms, including:
- A stroke-like weakness on one side of the body, associated with hemiplegic migraine
- Drooping eyelid and dilated pupil, associated with ophthalmoplegic migraine
- Pain at the base of the skull with numbness, visual changes and balance difficulties associated with basilar artery migraine
- A temporary period of confusion often initiated by minor head injury, associated with confusional migraine
Patients with complicated migraine syndromes require a complete neurological evaluation, which may include a magnetic resonance imaging (MRI) scan. Most patients with complicated migraine recover completely, and a structural abnormality is rarely the cause.
Migraine variants are disorders that cause periodic symptoms that come and go. Migraine variants include:
- Paroxysmal vertigo — dizziness that is marked by sudden, intense symptoms
- Paroxysmal torticollis — sudden contraction of one side of the neck muscles that causes the head to lean to that side
- Cyclic vomiting — uncontrolled vomiting that occurs repeatedly over a certain period of time
The key to diagnosing these migraine variants, which can be confused with other neurological syndromes, is their tendency to recur at intervals. The person does not have symptoms in between attacks.
What are the symptoms of migraine?
The symptoms of migraine headaches can occur in various combinations and include:
Type of Pain
The pain of a migraine can be described as a pounding or throbbing. The headache often begins as a dull ache and develops into throbbing pain. The pain is usually aggravated by physical activity.
Severity/Intensity of Pain
The pain of a migraine can be described as mild, moderate or severe.
Location of Pain
In children and adolescents, the pain usually affects the front or both sides of the head. In adults, the pain usually affects one side of the head.
Duration of Pain
Most migraines last about 4 hours although severe ones can last up to a week.
Frequency of Headaches
The frequency of migraines varies widely among individuals. It is common for a migraine sufferer to get 2-4 headaches per month. Some people, however, may get headaches every few days, while others only get a migraine once or twice a year.
- Sensitivity to light, noise and odors
- Nausea and vomiting, stomach upset, abdominal pain
- Loss of appetite
- Sensations of being very warm or cold
- Paleness (pallor)
- Blurred vision
- Diarrhea (rare)
- Fever (rare)
How are migraines diagnosed?
The correct headache diagnosis is needed to begin an effective treatment plan. The most important aspect of the headache evaluation is the headache history which should be obtained from both the patient and his or her parents.
The history includes the clinical description of headaches in which the patient describes how he or she feels with the headache and what happens when a headache occurs.
A history of prior headache treatments is also an important part of the headache evaluation, including what medications have been taken in the past and what medications are currently being taken. If any studies or tests were previously performed, it is important to bring them with you to the headache evaluation in order for the doctor to prescribe the most specific effective treatment.
After completing the medical history part of the evaluation, your physician will perform physical and neurological examinations.
After evaluating the results of the headache history, physical examination and neurological examination, the physician should be able to determine what type of headache you have, whether or not a serious problem is present and whether additional tests are needed.
How are headaches treated in children and adolescents?
The proper treatment will depend on several factors, including the type and frequency of the headache, its cause and the age of the child. Treatment may include patient/parent education, stress management, biofeedback and medications.
Education includes reviewing information about the type of headaches, learning and recording what triggers the headaches (such as lack of sleep, a poor diet, environment or stress), and how to use medicine safely and appropriately. Your health-care provider will give you a “headache diary” to record the characteristics of the headaches and will recommend ways of managing the headache triggers. Bring this diary to all doctor appointments; this information will help your health care providers correctly treat your child’s headaches.
Learning relaxation techniques can help reduce headaches. If your child has a headache, he or she should lie down and relax, and stretch and relax the muscles. Also, the child should take breaks from activities that trigger or provoke headaches, such as using the computer for long periods of time or exercising strenuously.
Medications may be recommended to manage headache pain. Headache medications can be grouped into three different categories: symptomatic relief, abortive therapy and preventive therapy. Each type of medication is most effective when used in combination with other medical recommendations, such as dietary and lifestyle changes, exercise and relaxation therapy.
Symptomatic relief is used to relieve symptoms associated with headaches, including the pain of a headache or the nausea and vomiting associated with migraine. These may include simple analgesics, ibuprofen or acetaminophen, antiemetics or sedatives. Many of these are available without a prescription (over the counter), while others require a prescription from your health-care provider. Important: If symptomatic relief medications are used more than twice a week, you should see your health care provider who can prescribe preventive headache medications. Overuse of these symptomatic medications can actually cause more frequent headaches or worsen headache symptoms.
Abortive therapy medications are most effective when used at the first sign of a migraine to stop the process that causes the headache pain. By stopping the headache process, abortive medications help prevent the symptoms of migraines including pain, nausea, light-sensitivity, etc. Abortive medications include: ergotamine tartrate and caffeine (Cafergot), dihydro-ergotamine mesylate (DHE-45), a combination medication (Midrin), sumatriptan succinate (Imitrex), zolmitriptan (Zomig), and others.
Preventive Therapy (prophylactics)
Prophylactic medications are used to treat very frequent tension headaches and migraines. Preventive therapy is aimed at reducing both the frequency and severity of the headaches and includes nonsteroidal anti-inflammatory (NSAID) medications, antidepressants, antihistamines, beta blockers, calcium channel blockers and anticonvulsant medications as recommended by your doctor. Most of these medications require a prescription.
How is migraine treatment administered to young children?
To treat infrequent migraine attacks in young children, these symptomatic medications are useful:
- Simple analgesics — pain reliever medications such as acetaminophen or ibuprofen, but not aspirin
- Antiemetics — medications that relieve nausea and vomiting
- Sedatives — medications that help a child rest
To treat very frequent attacks in young children, these preventive medications may be prescribed:
- Cyproheptadine, propranolol, tricyclics or calcium-channel blockers
- Anticonvulsants are not generally recommended
How are migraines treated in adolescents?
To treat infrequent migraine attacks in adolescents (with or without aura), the following abortive and symptomatic medications can be useful:
- Analgesics — pain reliever medications
- Antiemetics — medications that relieve nausea and vomiting
- Sedatives — medication that helps a patient rest
To treat infrequent migraine attacks in adolescents (if an aura is not present), the following abortive medications can be prescribed:
- Ergotamine tartrate and caffeine (Cafergot)
- A combination medication (Midrin)
- Triptans (Imitrex, Zomig, Amerge and Maxalt)
To treat severe migraine attacks in adolescents, the following abortive medications can be prescribed:
- Triptans nasally, orally or by injection
In adolescents with frequent attacks and when the above medications have been unsuccessful, preventive medications such as propranolol, tricyclic antidepressants or calcium-channel blockers or anticonvulsants may be prescribed.
Please note: many of the medications listed previously have not been approved by the FDA for use in children and adolescents with headaches.
How can migraines be prevented?
Identifying and then avoiding migraine triggers should reduce the frequency of your migraine attacks.
Recalling what was eaten prior to an attack may help you identify chemical triggers and make the necessary dietary changes to avoid these triggers in the future.
Young women who get migraines during their menstrual periods should become aware of the menstrual cycle patterns as they relate to the onset of the headaches to help them take preventive action against the headaches. Hormonal treatment of migraines has not been satisfactory, however.
Stress management and coping techniques, along with relaxation training, can help prevent or reduce the severity of the migraine attacks.
Migraine sufferers also seem to have fewer attacks when they eat on a regular schedule and get adequate rest.
Regular exercise – in moderation – can also help prevent migraines.
What is the outlook for children and adolescents with migraine?
Migraines can go away as soon as a year after they first appear, or they may remain for life. Treatment helps the majority of children and adolescents with migraines. Fifty percent of children and adolescents report migraine improvement within 6 months after treatment. About 60 percent of adolescent-onset migraines continue off and on for many years.