Migraine headache is a ubiquitous disorder that is quite common in the pediatric and adolescent population. Especially during the teenage years, it occurs more frequently in girls than in boys, but prior to puberty the prevalence of migraine is roughly equal in the two sexes.
The disorder can significantly reduce the afflicted child’s quality of life, negatively impacting academic performance and socialization. Because chronic pain so often produces stress and adverse changes in mood and behavior, a child’s migraine often affects his/her entire family.
Relatively few scientific trials have addressed migraine in the pediatric and adolescent population, but some research data (and abundant clinical evidence) are available to assist in improving control of the disorder and reducing its negative impact.
WHEN TO SEE A SPECIALIST
If your child’s or teenager’s headaches are not well controlled and are affecting his/her quality of life (eg, missing school, missing social activities, and adverse mood changes), the first step is to seek the help of a health care provider (HCP) who specializes in the treatment of headache.
It is very important to keep a headache diary or headache calendar to help the HCP understand and treat the young patient. The calendar should document the following:
- Frequency of the headache episodes
- Severity and duration of each headache episode
- Number of days that pain medications (prescription or over the counter) are used to stop the headache
- Routine intake of caffeine
- Triggers (are there certain factors that seem consistently to “trigger” headache attacks? common migraine triggers include sleep deprivation or “oversleeping,” menses, and abrupt weather changes)
Most treatment plans will include 3 levels of therapy:
1. Abortive (acute) therapy: This typically involves the use of medications intended to reduce or (hopefully) terminate the headache as it is occurring. Such medications typically are most effective if administered at the onset of the headache when the pain is still relatively mild.
Migraine appears to result from a genetically “sensitive” brain, wherein the pathways that normally conduct head pain may activate spontaneously or in response to some “trigger” in the internal (eg, menses) or external (eg, weather change) environment. Migraine appears to be a “neuro-inflammatory” disorder, as the activation of head pain pathways is accompanied by the development of inflammation around the blood vessels that lie within the lining of the brain (the meninges). Two of the most effective classes of medications available for acute migraine treatment are the following:
- Non-steroidal anti-inflammatory medications – Examples are ibuprofen, naproxen sodium, and aspirin. These medications decrease the inflammatory process, and their effectiveness may be enhanced by taking them with a caffeine-containing beverage.
- The triptans – Via at least 2 mechanisms, these medications interrupt the chain of physiologic events that generates and sustains a migraine attack. Not all triptans are Food and Drug Administration (FDA) approved for children younger than 18, but HCPs frequently prescribe any and all of the triptans when the benefit of such therapy is felt to outweigh its risk.
2. Preventive medications: These medications are taken daily to prevent migraine attacks and so stabilize the patient whose headache frequency has risen to an unacceptable level. Many patients will require preventive therapy for only a few months; once their headache frequency has declined substantially and remained at that low level, they may be tapered off the preventive medication and will not then experience an immediate return to frequent migraine. Effective preventive medication may improve the patient’s response to abortive therapy. A variety of preventive medications is available, and the headache specialist will review the patient’s headache history, identify any “comorbidities” (other disorders that coexist with migraine, eg, depression), and decide with the patient which medication is the best “fit.”
These treatments include medications taken orally, but if the patient’s headaches are not responding to these medications, other therapies are available. These include the following:
- Nerve blocks: injections of anesthetic medication, steroid, or both
- Onabotulinum toxin A (“Botox”): although currently approved by the FDA only for patients 18 and older, injections of this neurotoxin into the muscles of the forehead, temples, posterior head, neck, and shoulders potentially may prove to be another approach for suppressing migraine in pediatric and adolescent migraine sufferers who are experiencing headache 15 or more days per month (ie, “chronic migraine”).
3. Biobehavioral therapy: Patients with migraine are very sensitive to stress. Sudden changes in the migraineur’s level of stress may trigger an acute attack, and chronic stress may reinforce chronic migraine. Biobehavioral management helps patients understand how better to control stress as well as understand when to seek additional therapy. It is very important that often very helpful for young patients with migraine to adopt certain components of a healthy lifestyle. These include the following:
- Hydration: 8-12 glasses of a noncaffeinated beverage per day
- Good sleep hygiene: 8 hours of sleep at night, going to bed and arising at the same times each day and evening
- Exercising: at least 1 hour at least 3 times a week (preferably aerobic conditioning – eg, jogging, lap swimming, and exercycle)
- Eating well and at regular intervals: 3 meals daily, low on fats and sugars and heavy on vegetables and protein
Finally, it is important to follow the HCP’s recommendations carefully and to report any side effects or lack of improvement rather than simply stop treatment. With some positive changes in lifestyle, an appropriate regimen for the treatment of acute headache, and a well-chosen preventive medication, the pediatric patient afflicted with uncontrolled migraine typically can anticipate significant improvement and, consequently, improved quality of life.
J. Ivan Lopez, MD, FAAN, FAHS
Associate Professor of Neurology and Pediatrics Director, Vascular Neurology Training Program Director,
Neurology Clerkship University of Alabama at Birmingham
Marielle Kabbouche, MD, FAHS
Associate Professor in Pediatrics and Neurology
Cincinnati Children’s Hospital Medical Center