Migraines in Children and Adolescents

Migraine is a moderate-to-severe headache that lasts from 2 to 4 hours and usually occurs two to four times per month. (These episodic migraines are also called acute recurrent headaches.)

Migraines affect about 2% of children by age 7 and about 7 to 10% of children and adolescents by age 15. Disability from headaches -- anything that interferes with activities -- can be significant.

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 a migraine?

Migraines tend to run in families -- that is, they are hereditary. Approximately 70% of people who have migraines also have an immediate family member (mother, father, sister or brother) who suffers, or may have suffered, from migraines in their childhood. Migraines cause a person to experience significant discomfort and disability, but they do not usually cause damage to the body. Migraines are not related to brain tumors or strokes.

Until recently, the cause of migraine was thought to be vascular -- caused by the constriction and expansion of blood vessels in the brain. Today, migraine is thought to be an episodic brain malfunction --"a central nervous system (CNS) disorder" of primarily the brain and nerves, and secondarily of the blood vessels. The "malfunction" is caused, in part, by changes in the level of circulating neurotransmitters (chemicals in the CNS), and involving serotonin in particular.

What are the types of migraine in children and adolescents?

• Common migraine or migraine without aura* — is the most frequent type in children and adolescents, accounting for 70 to 85% of all migraines.
• Classic migraine or migraine with aura* — is less frequent than common migraine, accounting for about 15 to 30% of all migraines. In young children, migraine often begins in the late afternoon. As the child gets older, the onset of migraine may change to early morning.

* An 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. 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 about 20 minutes.

Complicated migraine syndromes are associated with neurological symptoms, including:

• Ophthalmoplegic migraine, which causes abnormal paralysis of the motor nerves of the eye and a dilated pupil
• Hemiplegic migraine, which causes weakness on one side of the body
• Basilar artery migraine, which causes pain at the base of the skull as well as numbness, tingling, visual changes and balance difficulties (such as vertigo, a spinning sensation)
• Confusional migraine, which causes a temporary period of confusion and speech and language problems, and is often initiated by minor head injury

Patients with complicated migraine syndromes require a complete neurological evaluation, which may require laboratory tests and two types of imaging tests, MRI (magnetic resonance imaging) and MRA (magnetic resonance imaging of the arteries) scans. These tests allow the tissues and arteries within the brain to be seen and evaluated. Most patients with complicated migraine recover completely, and a structural abnormality is rarely found.

Migraine variants are disorders in which the symptoms appear and disappear from time to time. Headache may be absent. Migraine variants, which are more common in children, include:

• Paroxysmal vertigo — dizziness and vertigo (spinning) that is brief, sudden, and intense
• Paroxysmal torticollis — sudden contraction of one side of the neck muscles that causes the head to "tilt" to one side
• Cyclic vomiting — uncontrolled vomiting that lasts about 24 hours and occurs every 30 to 60 days. Many have a family history of and/or develop migraine later in life.

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 between attacks. Patients with migraine variants may also have a positive family history of migraine, and have a history of or develop migraine headaches.

What are the symptoms of migraine?

Although symptoms can vary from person to person, the general symptoms of common and classic migraine are:

• 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 usually affects one side of the head.
• Pallor, or paleness of the skin
• Irritability
• Phonophobia or sensitivity to sound
• Photophobia or sensitivity to light
• Loss of appetite
• Nausea and/or vomiting, abdominal pain

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:

• Stress — especially resulting from school and family problems. Carefully reviewing what causes stress can help determine what stress factors to avoid. Stress management includes regular exercise, adequate rest and diet, and promoting pleasant activities such as enjoyable hobbies.
• Lack of sleep — results in less energy for coping with stress.
• Menstruation — normal hormonal changes caused by the menstrual cycle 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.
• 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.
• Weather changes — volatile weather, such as storm fronts or changes in barometric pressure, trigger migraines 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 trigger a migraine. Ask your doctor if there are alternatives to these medications.
• 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 — some migraine sufferers find that certain foods or food additives trigger a migraine. These foods include aged cheeses, pizza, luncheon meats, sausage or hot dogs (which contain nitrates), chocolate, caffeine, Doritos®, Ramen® noodles, monosodium glutamate or MSG (a seasoning used in Oriental foods). Recalling what was eaten prior to a migraine attack may help identify certain foods that are potential triggers so you can avoid them in the future.
• Changes in regular routine — such as lack of sleep, travel, or illness can trigger a migraine. Exercising regularly and getting adequate rest can decrease the number of migraine attacks.

By identifying your migraine triggers, you can take steps to avoid the trigger to decrease the frequency and severity of your migraines and make life more enjoyable.

How are migraines diagnosed?

The correct headache diagnosis is needed to develop an effective treatment plan. The most important aspect of the headache evaluation is the headache history, which should be obtained from both the headache 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 as well as headache frequency, duration, and associated symptoms. The history includes what medications have been taken in the past, what medications are currently being taken, and which medications have worked best.

Important: The results of previously conducted studies or tests should be brought with you and given to your doctor.

After completing the medical history part of the evaluation, your doctor will perform physical and neurological examinations. After evaluating the head-ache history, physical examination and neurological examination, your doctor should be able to determine what type of headache the patient has, whether or not a serious health problem might be the cause of the headache, and if additional tests are needed -- such as additional lab work, EEG, or scan. In typical patients with migraine, no additional tests or evaluations are needed as no neurological abnormalities will be found.

How are migraines treated?

Basic lifestyle changes can help control migraines. Because migraines are often triggered by external factors, avoiding the known triggers whenever possible can help reduce the frequency of migraine attacks.

Biofeedback and Stress Reduction

Biofeedback helps a person learn stress-reduction 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, yoga, and other relaxation techniques.

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 — 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), antiemetics (for nausea/vomiting), or sedatives (to help sleep; sleep relieves migraines). Some of these medications may require a prescription; others are available over-the-counter without the need for a prescription.

Important: If symptomatic relief medications are used more than twice a week, see your doctor. Overuse of these symptomatic medications can actually cause more frequent headaches or worsen headache symptoms.

Abortive therapy — helps to stop the headache process and to 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)(eg, ibuprofen, naproxen); acetaminophen
• The triptan medications sumatriptan succinate (Imitrex^®), zolmitriptan (Zomig^®), rizatriptan (Maxalt^®), almotriptan (Axert^® [approved for use in adolescents]), eletriptan (Relpax^®), and the longer-acting triptans frovatriptan (Frova^®) and naratriptan (Amerge^®).
• Ergotamine tartrate and caffeine (Cafergot^®)
• Dihydroergotamine mesylate (DHE-45^®, Migranal^®)
• Sedatives
• Antiemetics -- medications that relieve nausea and vomiting

Preventive therapy — taken on a daily basis to reduce the frequency and severity of the migraines. Some commonly prescribed preventive medications include:

• Antidepressant medications, such as amitriptyline (Elavil®)
• Antihistamines, such as cyproheptadine (Periactin®)
• Beta blockers, such as propranolol (Inderal®)
• Calcium channel blockers, such as verapamil (Calan® and Isoptin®)
• Anticonvulsant medication, such as divalproex (Depakote®) and topiramate (Topamax®)

Up to 70% of migraines can be modified with the use of preventive medications. Often, however, a combination of symptomatic and preventive medications may be necessary. 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 is the outlook for children and adolescents with migraine?

Treatment helps most children and adolescents with migraines. 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 migraines continue off and on for many years.

Rehabilitation Program

Some hospitals and/or other health care facilities offer inpatient program for children and adolescents; ask your doctor if their facility offers such programs. Patients typically accepted into these programs are those who are missing school, overusing medications, and whose headache pain is controlling their lives.

Clinical Trials

Some children and adolescents with migraines 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.

Treatment approaches for migraines in children and adolescents*

Young children: Infrequent migraines

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
• Sedatives — medications that help a child sleep (sleep relieves migraine)

Young children: Frequent migraines

These preventive medications may be prescribed:

• Cyproheptadine, propranolol, tricyclics, calcium channel blockers, or anticonvulsants
• A combination of symptomatic (from list above) and preventive medications

Adolescents: Infrequent migraines (with or without aura)

These symptomatic medications can be useful:

• Analgesics — pain-relieving medications, such as acetaminophen and napoxen
• Antiemetics — medications that relieve nausea and vomiting
• Sedatives — medication, such as diphenhydramine, that helps a patient sleep (sleep relieves migraine)

These abortive medications can be useful:

• Triptans (Imitrex^®, Zomig^®, Amerge^®, Maxalt^®
• Axert^®, Frova^®, and Relpax^®)
• DHE — given nasally
• A combination of symptomatic and abortive medications

Adolescents: Frequent migraines

These preventive medications can be tried:

• Tricyclic antidepressants, antihistamines, anticonvulsants, propranolol, or calcium channel blockers may be prescribed (see previous page for the names of some of these drugs).
• A combination of abortive and symptomatic medications.

Adolescents: Severe migraines (unresponsive to other medications and lasting > 24 hours)

These abortive medications can be prescribed:

• Triptans — given by injection
• DHE-45 — given by injection or infusion
• Anticonvulsants — given by infusion
• Sedatives — given by infusion
• Antiemetics — given by infusion
• Others — such as magnesium or NSAIDs

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 administered. The intravenous drugs are usually able to end the migraine attack. Patients’ length of stay at the infusion suite can range from a several hours to all day.

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. When a doctor chooses to prescribe a drug for a medical condition or for a certain patient type (eg, children) for which it has not received FDA approval, this practice is called ‘off-label’ prescribing. This is a common practice in the field of medicine. It is one of the ways by which 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 other than what the drug was first approved for.

Headache ‘Checklist’ of Management Suggestions

• Educate yourself and your family. Read about your type of headache and its treatment.
• Maintain a headache diary.
• Ask your doctor for written instructions about what to do when you have a headache.
• Limit your use of over-the-counter (nonprescription) medications to no more than two days per week. Excessive use can actually increase headaches.
• Follow a regular schedule:

  • Don’t skip meals, especially breakfast
  • Get 8 hours of sleep nightly
  • Exercise 30 minutes/day
  • Drink 6 to 8 glasses of water/day
  • Learn to identify and avoid headache "triggers." Common triggers include caffeinated foods and beverages (chocolate, teas, colas, coffee), nitrates (luncheon meats, sausage/hot dogs, pepperoni), tyramine (aged cheeses, pizza), Doritos^®, Ramen^® noodles, other "junk" foods, and foods containing MSG
  • Minimize stress and other headache triggers

• Daily school attendance IS A MUST!
• Initiate non-drug measures at the earliest onset of your headache:
• Seek rest in a cool, dark, quiet, comfortable location
• Use relaxation strategies and other methods to reduce stress
• Apply a cold compress
• Don’t wait!! Take the maximum allowable dosage of recommended medication(s) at the first sign of a severe headache.
• Take prescribed medication regularly, as directed, and maintain regular follow-up visits.
• Call your doctor when problems arise.

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