Pediatric migraine is unique, and it requires an individualized treatment plan with the aid of specialists who understand and have expertise in the diagnosis and treatment of migraine. But while professionally crafted strategies are the cornerstone of effective migraine treatment in children, don’t underestimate the relief that you, the parent, can provide your child by offering reassurance and understanding.
In that spirit, it’s essential to understand what your child is going through and what their treatment entails. Knowing how to assist your child will go a long way in helping them lead a fulfilling life.
Mild- vs. severe-migraine treatment
The approach to migraine treatment depends on the level of disability a child or adolescent experiences. If the person experiences mild disability—for instance, they miss just an hour of class, do not experience severe pain or have only minimal associated symptoms—then the treatment can be as easy as taking a break and resting until the symptoms have passed. Creating a calm, quiet and safe environment while soothing your child for the duration of his or her migraine can provide tremendous comfort during what may be a painful and scary experience.
However, if the migraine attacks cause a moderate-to-severe disability—pain that lasts for two to six hours—and prevents the child from staying in school or participating in his or her usual activities, your provider should recommend an abortive (also referred to as acute or rescue) medication. Abortive medications are intended to reduce or terminate migraine. These medications are typically most effective if administered at the onset of symptoms when the pain is still relatively mild.
How to treat migraine in children
Migraine appears to result from a genetically “sensitive” brain, wherein the pathways that normally conduct head pain are activated too easily. It is thought to be a “neuro-inflammatory” disorder, as the activation of the head pain pathways is accompanied by inflammation around the blood vessels within the lining of the brain.
Two of the most effective classes of medications available for acute migraine treatment are:
- Non-steroidal anti-inflammatory medications (NSAIDs): Examples are ibuprofen and naproxen sodium. These medications decrease the inflammatory process, and their effectiveness may be enhanced by taking them in conjunction with caffeine.
- Triptans/ergots: These medications interrupt the chain of physiologic events that generate and sustain a migraine attack. They are designed to alleviate migraine within two to four hours, preferably in as little as one to two hours. The triptan group includes tablets and nasal sprays, as well as injectable forms. Dihydroergotamine is available in nasal spray or injectable formats; when necessary, compounding pharmacies can make other formulations.
It’s important to remember that children and adolescents should limit acute pain treatment to two days a week. If your child needs abortive medication more frequently, notify their provider. Just as adults can transition from frequent episodic to chronic daily headache, so can children. This is why it is important to monitor your child’s frequency of migraine, use of acute medication, and the response to treatment.
It should also be noted that opiates or narcotics are discouraged for use in pediatric migraine treatment. They may cause sedation or even dependence if used too often, and can make chronic daily headache harder to treat in the long run.
Infrequently, children or adolescents who are experiencing migraine attacks more than twice a week may benefit from additional treatment with preventive therapy. Preventive medications are taken daily to prevent migraine attacks and to stabilize patients when headache frequency has risen to an unacceptable level. Many patients will only require preventive therapy for a few months; once their headache frequency has declined and remains at a low level, they may be tapered off the preventive medication and be able to maintain a lower headache frequency with lifestyle modifications alone.
Effective preventive medication may also improve the patient’s response to abortive therapy. Often, medications are used when a patient might benefit from a potential side effect (e.g., promoting sleep or decreasing appetite). Your child’s healthcare provider will review their headache history, identify any comorbidities (other disorders that coexist with migraine, e.g., depression) and discuss which preventive medication is likely to be the best option.
Additionally, there are neuromodulation devices that may be used for the prevention of migraine, such as the supraorbital nerve stimulator, vagus nerve stimulator, and the transcranial magnetic stimulator.
Cognitive behavioral therapy
In addition to medication, cognitive behavioral therapy is often effective in reducing migraine frequency. Children with migraine are very sensitive to stress, and sudden changes in the level of stress may trigger an acute attack. Chronic stress may also reinforce chronic migraine. Biobehavioral management helps patients understand how better to control stress, and understand when to utilize additional therapies during headache attacks.
Children experiencing an increase in headache frequency may benefit from lifestyle modifications aimed at increasing hydration and sleep, eating regular meals, reducing stress, taking regular breaks in a busy schedule, being more active, and reducing frequent rescue medication use.
Here are some general guidelines:
- Hydration: eight to 12 glasses of a non-caffeinated beverage per day.
- Sleep hygiene: eight to 10 hours of sleep at night, going to bed and waking up at the same time every day.
- Exercise: 30-60 minutes/day most days of the week (preferably aerobic conditioning—e.g., jogging, lap swimming and cycling).
- Nutrition: Three meals daily at regular intervals, focusing on foods that are low in fats and sugars while emphasizing vegetables and protein.
Working with a trusted professional
Finally, it is important to follow the recommendations from your child’s healthcare provider carefully and 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 treatment, a child experiencing uncontrolled migraine attacks can typically anticipate significant improvement and, consequently, improved quality of life.
This blog was updated in March 2020.