Migraines in Children and Adolescents
What is a migraine headache?
Migraine is a moderate-to-severe headache that lasts from 2 to 48 hours and usually occurs two to four times per month.
Migraine, also called an acute recurrent headache, occurs in about 3% of children of preschool children, 4% to 11% of elementary school-aged children, and 8% to 15% of high school-aged children. In early childhood and before puberty, migraine is more commonly seen in boys than girls. In adolescence, migraine affects young women more than young men. As adults, women are three times more likely to have a migraine than men.
What types of migraine occur in children and adolescents?
There are two main types. A migraine without an aura (called common migraine) occurs in 60% to 85% of children and adolescents who get a migraine. A migraine with an aura (called classic migraine) occurs in 15% to 30%. In young children, migraine often begins in the late afternoon. As the child gets older, migraine often begins in the early morning.
What is an aura?
An aura is a warning sign that a migraine is about to begin. An aura usually occurs about 30 minutes before a migraine starts. 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 changes in ability to speak, move, hear, smell, taste, or touch. Auras last about 20 minutes.
Are there other types of migraine that occur in children and adolescents?
Yes, other types are grouped as either complicated migraine or migraine variants.
Complicated migraines are migraines with neurological symptoms, including:
- Paralysis or weakness of the eye muscles that keep the eye in its normal position and control its movement. This was previously called an ophthalmoplegic migraine.
- Weakness on one side of the body. This is called a hemiplegic migraine.
- Pain at the base of the skull as well as numbness, tingling, visual changes and balance difficulties (such as a spinning sensation [vertigo]). This is called basilar migraine.
- Confusion and speech and language problems. This is called confusional migraine and may also occur after a minor head injury.
- Migraine variants are disorders in which the symptoms appear and disappear from time to time. Headache pain may be absent. Migraine variants are more common in children who have a family history of migraine or who will develop migraine later in life. Migraine variants include:
- Paroxysmal vertigo – dizziness and vertigo (spinning) that is brief, sudden, intense, and recurs.
- Paroxysmal torticollis – sudden contraction of the neck muscles on one side of the head that causes the head to “tilt” to one side.
- Cyclic vomiting – uncontrolled vomiting that lasts about 24 hours and occurs every 60 to 90 days.
- Abdominal migraine – pain in the belly, usually near the belly button (navel). Pain usually lasts 1 to 2 hours.
Migraine variants can sometimes be confused with other neurological disorders. A key difference is that migraine variants recur from time to time. There is complete recovery and no symptoms between attacks.
Symptoms and Causes
What causes a migraine?
Until recently, migraine was thought to be caused by the changing size of blood vessels in the brain. These changes either increase or decrease blood flow, which then trigger other changes. Today, migraine is thought to be a brain malfunction – a disorder that mainly affects the brain and nerves but also affects blood vessels. The “malfunction” is caused, in part, by the release of chemicals in the brain. One of these chemicals is serotonin. This cycle of changes cause inflammation and the pain of the migraine.
Migraine is genetic, meaning it tends to run in families. Some 60% to 70% of people who have migraine headaches also have an immediate family member (mother, father, sister, or brother) who have or may have had a migraine.
A migraine can cause great discomfort, disability, and interfere with activities. However, they do not usually cause damage to the body. Migraine headaches are not related to brain tumors or strokes.
What are the symptoms of migraine?
Although symptoms can vary from person to person, general symptoms include:
- Pounding or throbbing head pain. In children, the pain usually affects the front or both sides of the head. In adolescents and adults, the pain may affect one side of the head.
- Pale skin color
- Irritable, moody
- Sensitivity to sound
- Sensitivity to light
- Loss of appetite
- Nausea and/or vomiting
What are some migraine triggers?
Things that trigger migraine differ for each person. However, some common migraine triggers in children and adolescents include:
- Stress – especially related to school (after school activities, friends, bullying) and family problems. Carefully reviewing what causes stress can help determine what stress factors to avoid. In some cases, a counselor may be needed to determine the cause of the stress. Stress management includes regular exercise, adequate rest and diet, and enjoying pleasant activities and hobbies.
- Lack of sleep – results in less energy for coping with stress. Aim for 8 hours of sleep nightly.
- Menstruation – normal hormonal changes caused by the menstrual cycle can trigger migraine.
- Changes in normal eating patterns – skipping meals can cause migraine. Eating three regular meals and not skipping breakfast can help.
- Caffeine – caffeine is a habit-forming substance and headache is a major symptom of caffeine ingestion and withdrawal. If you are trying to cut back on caffeine, do so gradually. The goal is not to consume any caffeine at all.
- Weather changes – storm fronts or changes in barometric pressure can trigger migraine in some people.
- Medications – some medications such as oral contraceptives (birth control pills), asthma treatments, and stimulants (including many of the drugs used to treat attention-deficit hyperactivity disorder [ADHD]), may occasionally trigger a migraine. If you think medicines are causing the headache, ask your doctor about other options.
- Alcohol – may cause the brain’s arteries to expand, resulting in a migraine.
- Travel – the motion sickness sometimes caused by travel in a car or boat can trigger a migraine.
- Diet – certain foods or food additives can trigger a migraine. These foods include aged cheeses; pizza; luncheon meats; sausage or hot dogs (which contain nitrates); caffeine-containing foods and beverages including chocolate, teas, coffee, colas; and monosodium glutamate (MSG)-containing foods such as Doritos® and Ramen® noodles. Remembering what foods were eaten before the migraine attack may help identify potential food triggers so they can be avoided. It's a good idea to check food labels for things like nitrates or MSG.
- Changes in regular routine – such as lack of sleep, travel, or illness can trigger a migraine.
Diagnosis and Tests
How is a migraine diagnosed?
Gathering details about the headaches is the key to making the diagnosis. The headache history should be obtained from both the patient and his or her parents.
The history includes a description of current and previous headaches – specifically, how the patient feels before, during, and after the headache. Information on how often the headaches occur, how long they last, and any other symptoms are also collected. The names of medications taken in the past, current medications, and names of medications that have worked the best are also gathered.
After taking the medical history, your doctor will perform a physical and neurological examination. The exam is usually normal. Sometimes additional tests are needed, such as additional lab work, CT or MRI scan. In typical patients with migraine, no additional tests are needed. Based on all the information collected, your doctor can determine the type and cause of the headaches.
Patients with complicated migraine with neurological symptoms require a more thorough neurological exam, more laboratory tests, and imaging scans. MRI (magnetic resonance imaging) and MRA (magnetic resonance imaging of the arteries) scans allow the tissues and arteries within the brain to be seen and evaluated. Most patients with complicated migraine recover completely. A structural problem, such as a brain tumor, is rarely found.
Management and Treatment
How are migraine headaches treated in children and adolescents?
Basic lifestyle changes can help control a migraine. Whenever possible, avoiding the known triggers can help reduce the frequency and severity of migraine attacks.
Biofeedback and stress reduction. Biofeedback helps a person learn stress-reducing skills by providing information about muscle tension, heart rate, and other vital signs as a person attempts to relax. It is used to gain control over certain bodily functions that cause tension and physical pain.
Biofeedback can be used to help patients learn how their body responds in stressful situations, and how to better cope. Some people choose biofeedback instead of medications.
Other stress reduction options include counseling, exercising, and yoga.
Vitamins, minerals, and herbal products. These products have shown some effectiveness in migraine. They include magnesium, riboflavin, and coenzyme Q10.
Medications. 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. These medicines are used to relieve symptoms associated with headaches, including the pain of a headache or the nausea and vomiting associated with migraine. These medications include simple analgesics (ibuprofen or acetaminophen), anti-emetics (for nausea/vomiting), or sedatives (to help sleep; sleep relieves migraine). Some of these medications may require a prescription; others are available over-the-counter without the need for a prescription, but should only be taken on the advice or recommendation of a physician.
Important: If symptomatic relief medications are used more than twice a week, see your doctor. Overuse of symptomatic medications can actually cause more frequent headaches or worsen headache symptoms. This is called rebound or medication overuse headache.
Abortive therapy. These medications help stop the headache process and prevent migraine symptoms including pain, nausea, and light sensitivity. They are taken at the first sign of a migraine.
Abortive medications include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs; such as ibuprofen, naproxen)
- The triptan medications sumatriptan succinate (Imitrex®), zolmitriptan (Zomig®), rizatriptan (Maxalt®), almotriptan (Axert®), eletriptan (Relpax®), and the longer-acting triptans frovatriptan (Frova®) and naratriptan (Amerge®)
- Antiemetics (medications that relieve nausea and vomiting) are often used together with the medications listed above.
Preventive therapy. These medications are taken daily to reduce the frequency and severity of the migraine over time. Some commonly prescribed preventive medications include:
- Antidepressant medications, such as amitriptyline (Elavil®)
- Antihistamines, such as cyproheptadine (Periactin®)
- Anticonvulsant medication, such as topiramate (Topamax®). Divalproex should not be taken by women in child-bearing years.
- Beta blockers, such as propranolol (Inderal®)
- Calcium channel blockers, such as verapamil (Calan® and Isoptin®)
Often a combination of symptomatic and preventive medications may be needed. Patients should be started at a low dose, with the dose slowly increased over time. Medication works best when combined with lifestyle changes and patient education.
What treatment approaches can be tried in children and adolescents with migraine?
Young children: Infrequent migraine
These symptomatic medications are useful:
- Simple analgesics – pain-relieving medications, such as ibuprofen or acetaminophen, but not aspirin
- Antiemetics – medications that relieve nausea and vomiting, such as ondansetron (Zofran®)
- Sedatives—medications that help a child sleep (sleep relieves migraine)
Young children: Frequent migraine
These preventive medications may be prescribed:
- Cyproheptadine (Periactin®), amitriptyline (Elavil®), topiramate (Topamax®), or gabapentin (Neurontin®)
- A combination of symptomatic (from list above) and preventive medications
Adolescents: Infrequent migraine (with or without aura)
These symptomatic medications can be useful:
- Analgesics – pain-relieving medications, such as acetaminophen, ibuprofen, and naproxen
- Antiemetics – medications that relieve nausea and vomiting
- Sedatives – medication, such as diphenhydramine, that helps a patient sleep (sleep relieves migraine)
If symptomatic medications alone are unsuccessful, the following abortive medications can be added the symptomatic medication:
- Triptans (Imitrex®, Zomig®, Amerge®, Maxalt®, Axert®, Frova®, and Relpax®)
Adolescents: Frequent migraine
These preventive medications can be tried:
- Tricyclic antidepressants, antihistamines, anticonvulsants (especially topiramate [Topamax®]), propranolol, or calcium channel blockers may be prescribed (see names of some of these drugs under “preventive therapy of migraine” above).
- A combination of abortive and symptomatic medications.
Adolescents: Severe migraine (unresponsive to other medications and lasting > 24 hours)
Adolescents experiencing severe migraine should be seen by a headache specialist.
When headaches – and especially migraine headaches – last longer than 24 hours and other medications have been unsuccessful in managing the attacks, medication administered in an “infusion suite” can be considered. An infusion suite is a designated set of rooms at a hospital or clinic that are monitored by a nurse and where intravenous drugs are prescribed by a physician. The intravenous drugs are usually able to end the migraine attack. Patients’ length of stay at the infusion suite can range from several hours to all day.
Outlook / Prognosis
What is the outlook for children and adolescents with migraine?
Treatment helps most children and adolescents with migraine. Fifty percent of children and adolescents report migraine improvement within 6 months after treatment. However, in about 60% of adolescents who experience their first migraine as an adolescent, the migraine may continue off and on for many years.
It should be noted that many of the medications listed in this handout have not been approved by the by the Food and Drug Administration (FDA) for use in children and adolescents with headaches. This is a common practice in the field of medicine and is called ‘off-label’ prescribing. It is one of the ways new and important uses are found for already approved drugs. Many times, positive findings lead to formal clinical trials of the drug for new conditions and indications.
Rehabilitation program. Some hospitals and/or other health care facilities offer inpatient headache management programs for children and adolescents; ask your doctor if their facility offers such programs.
Patients typically accepted into these programs are those who have a chronic daily headache (greater than 15 days a month), missed an excessive amount of school, have overused over-the-counter medications, and have headache pain that is controlling their lives. The staff of such programs can include psychologists, pediatric rehabilitation specialists, occupational and physical therapists as well as access to a child psychiatrist. Stress factors are an important focus of this program; not rapid changes in medications.
Clinical trials. Some children and adolescents with migraine don’t experience headache relief despite trying many of the currently available medications. If this is the case for your child, ask your doctor about possible participation in a clinical trial. Clinical trials provide access to drugs not yet approved by the FDA. Such drugs are not available through “regular” doctors’ offices; they are only available through doctors and health care organizations that have agreed to participate in the clinical trials. Your doctor will help determine if your child is an appropriate candidate for this type of research study.
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