Paul Winner, DO, FAHS
Be prepared for these four simple but critical steps:
Step 1: Describe in detail what your child experiences, how often and for how long.
Step 2: Ask for a specific diagnosis, such as migraine, not just headache.
Step 3: Get in writing a treatment plan you agree with, understand and can follow.
Step 4: Request a follow-up visit and what to do if the treatment is not working.
Headaches can occur at any age, from two to three years of age and older—but headache symptoms in children do not exactly mirror those in adults. As a result, children often remain without a correct headache diagnosis for many years until the episodes take on an adult pattern. Adults who experience migraine often describe the headache as lasting for one to three days, with nausea and/or vomiting, and sensitivity to light and sound.
Since children and adolescents can experience severe headaches and not be able to describe what they are feeling, it’s important for parents to provide detailed information. With a little background, careful observation, and creative questioning, you can get an idea about your child’s headaches and obtain the right diagnosis.
How Headache Differs in Young People
Many children get headaches, and many actually have migraine with or without aura. There are some noticeable differences in migraine when comparing clinical symptoms between children and adults.
Specifically, in children:
- The headaches may be shorter, lasting only an hour or two. Frequently, they’re less than twelve hours.
- The episodes don’t occur as often. For example, they may happen only once a month, or every few months.
- The headaches may go away after a period of a few months to years.
- The pain tends to be more bi-frontal (across the forehead) than unilateral (on one side of the head). As children get older, the pain tends to be more unilateral.
- When they’re fairly young (two to eight years of age) and before they complain of headache, children may get other childhood migraine syndromes. The two most common are abdominal migraine and cyclic vomiting syndrome.
- Abdominal migraine seems like migraine except instead of headache, children complain of stomach aches. The pain is vague or cramping around the belly button or all over the stomach.
- Cyclic vomiting syndrome consists of episodes of vomiting with predictable repeat episodes weeks later. These can be very dramatic and can lead to dehydration.
- Since episodic abdominal pain or vomiting may be due to a gastroenterological problem, it’s a good idea to have a gastroenterologist assess your child before initiating migraine therapies.
- Children may not report symptoms normally associated with a migraine episode, such as sensitivity to light or sound (these symptoms may be inferred from their behavior).
Piecing the Puzzle Together
Might your child have migraine headaches? One challenge parents and doctors face is figuring out what the children experience when they have an episode. If you ask them direct questions such as, “Are you sensitive to light or sound?” they may not understand your question. Sometimes rephrasing the question or watching their behavior may help get a better understanding of potential headache symptoms. For example, a child with light sensitivity may not want to play outside or watch TV because “the light is so bright.”
Nausea is another symptom that’s difficult for a younger person to identify or explain. Ask your child, “are you nauseated?” and there’s a good chance they won’t understand your question. Even if you say, “are you sick to your stomach?” they might not know what you mean. You may notice, however, that they simply do not want to eat or they may say that their stomach feels bad.
By watching your child’s behavior, you also can help identify what your child may be experiencing when they have a migraine attack. For instance:
- Watch to see if they go into a quiet place to rest or even nap.
- Notice if they talk to you less than usual or have a mood swing.
- Watch for a change in their daily routine. They may not engage in their usual reading or television activities because their eyes hurt or focusing is more challenging.
- Be aware of when they resume their normal activities.
What to Expect When You Visit Your Medical Provider
When a young person is diagnosed with migraine, it’s important to understand that you are dealing with a benign (not dangerous) disorder. Migraine certainly is a serious problem, but there is usually nothing to fear. In nearly all instances, it is an episodic disorder that can be treated. When you visit your medical provider try to remember the following:
- Step 1: Be prepared to describe in detail what your child experiences, how often these episodes occur, and how long they last.
- Step 2: Ask for a specific diagnosis, such as migraine, cyclic vomiting syndrome, or tension-type headache, etc. You can then start working with the school nurse, teachers, coaches and other family members who spend time with your child.
- Step 3: Ask for a clear treatment plan with which you agree and obtain it in writing because you and the school will need to understand it completely.
- Step 4: Ask, even insist on a follow-up visit and what to do if treatment is not working.
In general, your youngster won’t have to go through much testing to get the diagnosis of migraine. However, on a case-by-case basis, the practitioner may do further evaluation. For example, if you have an unusual history and/or the medical provider finds something when doing a physical examination on your child, the provider may want to obtain additional tests to rule out other possible causes of headache. These may include simple blood tests or Neuroimaging studies.
Treatment for Young People
The approach to treatment depends on the level of disability a child or adolescent experiences. If the person experiences mild disability—they miss just an hour of class, do not experience severe pain, or have only minimal associated symptoms—then the treatment can be as simple as reassuring them and making sure they get some rest. You can use mild analgesics, such as acetaminophen.
However, if the episodes cause moderate to severe disability, such as duration of pain for two or six hours, and prevent the child from staying in school or participating in his or her usual activities, your provider should recommend other medications or treatments. An over-the-counter, nonsteroidal option, such as ibuprofen, may suffice at this point.
If your child’s migraine is not relieved within one or two hours by analgesics or combination analgesics, then you may need to consider migraine-specific medications, such as triptans or dihydroergotamine. These medicines are designed to relieve a headache within two to four hours, preferably as little as one to two hours. The triptan group includes tablets, nasal sprays, and injectable forms. Dihydroergotamine is available in nasal spray or injectable formats, and when necessary, compounding pharmacies can make other formulations. There are clinical studies on the use of triptans and dihydroergotamine in children and adolescents. Currently several triptans: Almotriptan (table), Rizatriptan (table), Zolmitriptan (Nasal spray) are approved by the Food and Drug Administration (FDA) for use in adolescents (12 to17 years old) and Rizatriptan (table) is also approved in children six to 11 years old. The others are considered “off-label” when used.
Opiates or narcotics in children are not usually recommended because they cause sedation and may cause dependence if used too often.
A child or teen who is getting a migraine one or two times a week should use preventive therapy—medication taken daily to prevent the onset of a migraine or non-drug behavioral approaches or better yet both. It is best for parent and child or teen to review the subject with their practitioner who will be familiar with the medications available and assess which one might prove optimal.
It’s important to remember that children and adolescents should limit acute pain treatment to two days a week. If your child feels a need for frequent dosing with headache medications, it could be a hint that something else might be wrong. Just as adults can begin to have chronic daily headache, young people can as well. This is why it is important for all headache sufferers to monitor the frequency of headaches, the medications taken and the response to treatment.
Non-pharmacologic approaches can be used in all young patients and can be quite beneficial.
The following regular lifestyle routines or habits may prove very helpful in your child:
- Make sure they sleep at the same hours nightly, if possible.
- Make sure that they exercise regularly as this reduces stress, anxiety, mood swings and helps them keep their weight under control (all risks for increasing headaches).
- See to it that they eat on a regular schedule and don’t skip meals. Low blood sugar may cause headache. Encourage fresh and unprocessed foods whenever possible.
- Commonly used supplements (magnesium, riboflavin( Vitamin B 2 ), coenzyme Q10) may be helpful in migraine prevention.
- Decrease caffeine intake from soft drinks and iced tea to one dose a day or less.
- Check to be sure that they drink plenty of water, particularly during the summer.
- Consider more formalized therapy, including biofeedback and stress management techniques, if these simple lifestyle changes don’t produce positive results.
As a parent, one of the best solutions you can try is education—for yourself and your child. It’s important for young people to know that they may have a significant problem, but that they are normal. Almost one out of five women and one out of 20 men suffer from migraine. Doctors understand some of the science behind I and have excellent treatments available today. In addition, there is great hope because extensive research is taking place in this age group.
Finding the Right Medical Provider
If your child fails to control their headaches despite these steps, reassess each step and meet with your provider. Consider a second opinion to learn about possible alternative management. Often, going to see a Pediatric Neurologist or Headache Specialist comfortable in caring for children with headaches leads to effective treatment. Preventive treatment reduces frequency and acute therapy stops a headache or at least blunts the pain within an hour or two. For the most part, children and adolescents respond well to the right therapy and need not suffer excessively.
Paul Winner, DO, FAHS. Director, Palm Beach Headache Center, West Palm Beach, FL; Clinical Professor of Neurology, Nova Southeastern University, Fort Lauderdale, FL
Updated August 16, 2015, from:
Updated January 2009 from Headache, The Newsletter of ACHE. Spring 2004, vol. 15, no. 1.