While some kids seem to suffer from headaches or stomach aches at all-too-convenient times in hopes of avoiding school or their piano lesson, some children suffer from migraine headaches or abdominal migraines that really do leave them feeling like they just need to lie down and sleep until the pain passes.
Although migraine headaches aren't that difficult for pediatricians to diagnose, certain childhood syndromes that are considered a type of migraine are more challenging to pick up because they don't actually involve a headache. Symptoms such as unexplained nausea, vomiting and abdominal pain can be wrongly attributed to a flu bug, a bad tuna fish sandwich or a nervous stomach. But these symptoms can also indicate migraines in children. Below, Mary Anne Whelan, MD, PhD, a pediatric neurologist who is affiliated with Community Health and Behavioral Services in Utica, NY, talks about how migraines appear in children and teenagers, and how parents can help their children prevent migraines, or make them as comfortable as possible when migraines hit.
How common are migraines in children and teenagers?
Most of the good data we have about the prevalence of migraine in children comes from studies in Scandinavian countries, especially Denmark. The figures that come out of those prospective studies suggest that up to 3 percent of children 3 to 7 years of age have migraine. And up to 11 percent of 7- to 11-year-olds have migraine. Between 11 and 15 years on up, migraine affects over 8 percent of children. During adolescence it becomes more frequent in girls than in boys.
What is a migraine?
There has to be at least five attacks that fulfill certain criteria. The criteria are headaches lasting anywhere from four to 72 hours that have at least two of the following characteristics: Being located on one side of the head, having a pulsing quality, being moderately or severely painful in intensity, and being aggravated by physical activity so that all the patient wants to do is to lie down. During the headache, the patient often has either nausea and/or vomiting and is sensitive to light and sound. And the headache mustn't be attributable to some other underlying disorder.
What are the different types of migraine?
Migraine is divided into different subsets, several of which are more frequent in children than others. Migraine with and without aura are more common in children. The aura is often visual in nature, so that the patient sees flashing, flickering light in the visual field. There are often pins and needles around the mouth or sometimes in one hand or elsewhere.
There is also a group of symptoms that actually aren't associated with a headache. These syndromes—called childhood periodic syndromes—can evolve into more typical migraine around puberty.
What are the different types of childhood periodic syndromes?
One type is cyclic vomiting, which is characterized by recurrent episodes of unexplained nausea and vomiting sometimes lasting several days. This is nausea and vomiting that isn't associated with a fever or diarrhea or some transmissible illness or gastrointestinal problem. Abdominal migraine is another type and is characterized by recurrent attacks of abdominal pain with loss of appetite, nausea and sometimes vomiting, but the major symptom here is the abdominal pain, which can dull, sore or intense. It's usually in the middle of the abdomen, localized around the navel.
Another syndrome that we see in children is benign paroxysmal vertigo, in which children get attacks of severe dizziness, again, not due to anything else identifiable. Sometimes children have an acute confusional syndrome whereby they just aren't making sense for a period of time; the confusion can last from minutes to hours.
How are migraines in children diagnosed?
For an experienced clinician, it's a pretty easy diagnosis to make since the symptoms are characteristic. In children, the family history is particularly important. If you really take a good family history, it would be quite unusual not to be able to turn up a positive family history of migraine in either the parents or the aunts or uncles, or multiple family members.
The general physical examination and the neurologic examination should be normal. There really are not specific tests for migraine. In fact, the Child Neurology Society does not recommend routinely obtaining an MRI or CT scan of the brain in children whose neurologic exam is normal. Other tests such as brain wave tests and lumbar punctures, or spinal taps, are also not recommended unless there is a specific aspect of the history or the examination that makes that appropriate.
It's more difficult to make the diagnosis in some of the childhood periodic syndromes. Children with the abdominal migraine or cyclic vomiting may be sent to a gastrointestinal (GI) specialist. The children with dizziness may go to an ENT (ear, nose and throat) doctor. Children with prominent visual symptoms may go to the eye doctor.
How can you tell if a child is experiencing a migraine?
Children at very early ages will often hold their head and say, "Ow!" or indicate head pain in some specific way. Children with migraine headaches are irritable and want to be left alone. They are bothered by light or sound or they don't want to go out and run around and play. They just want to lie down. So it's pretty easy to tell when a child is having a headache and they usually have other accompanying symptoms that point you toward migraine.
Are triggers for migraines in children similar to those for adults?
A prominent trigger in children is food. Common among those is chocolate, which children hate to hear, of course. Others are foods preserved with nitrites or nitrates, which are cold cuts, ham, bacon, sausage and smoked meats like beef jerky. There is even something known as hot-dog headache.
Another common trigger is the overuse of caffeine. Children get tremendous amounts of caffeine in sodas. Caffeine constricts blood vessels, and it's actually a part of a number of medications that are used to treat migraines. But if you drink a lot of it you constrict the blood flow to the head. The caffeine wears off and you get a reflex vasodilatation and that can precipitate a migraine. Alcohol use, which we never like to think of in connection with children but which happens as children get into adolescence, is a potent trigger.
Psychological stress is a trigger for migraines. It doesn't usually occur in the acutely stressful period. The headache often shows up in the letdown period. And sometimes cigarette smoke and unusual strong smells can also be triggers.
How are migraines, including the childhood syndromes, treated?
Avoidance of identifiable triggers is recommended. When the headache does happen, the first line of defense in children is usually age-appropriate doses of common over-the-counter pain relievers such as acetaminophen or ibuprofen, and occasionally prescription medications. When pain relievers are not sufficient, there are a number of prescription drugs available that can be used on a routine daily basis to try to prevent the headache from coming in the first place. These are recommended when the headaches are resulting in a significant amount of time lost from school or other activities; usually the cutoff point is once a week or more frequently. This is pretty rare in childhood.
What medications are used to prevent migraine?
Two classes of drugs we use are beta blockers and calcium channel blockers, which also treat high blood pressure primarily. Some of the anticonvulsants used to treat epilepsy are good prophylactic drugs against migraine.
Do children usually respond well to the therapies?
They do. But I think if you have a tendency toward migraine, some episodes are inevitable. Some people will have a lot more trouble than others.
Are there any other lifestyle changes that are recommended?
There are good general principles of health, such as getting enough sleep, eating regular meals, and eating a reasonable diet. People with migraine often tend to be sensitive to head bumps, as well as active physical activity. So when a person who doesn't have migraine falls off a bike and gets a head bump, they may not have much of a headache. Another person who is vulnerable to migraine might have quite a headache from what one would judge to be roughly the same amount of trauma. However, one cannot live in cork-lined room, so parents should just use common sense based on what bothers their child.
What is your overall advice to the parents of children with migraines?
I think it's reasonable to check with a qualified medical person to be sure that that's the diagnosis. Thereafter, the commonsense principles of avoiding triggers and making a child comfortable when migraine does occur apply. If ordinary measures don't result in satisfactory management, then one can see whether there needs to be a step-up in level of medication or other management techniques.
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