Migraines are surprisingly common during childhood, and can be distressing as the headache can be severe in intensity and result in missed schooldays and withdrawing from activities. They can start at any age and parents will naturally be concerned there is some ‘awful cause’ . This article discusses migraines to help parents understand this distressing condition
What are migraines ?
Recurrent episodes of severe headache, for which there is no obvious cause. Theories about headache generally focus on the changing diameter of blood vessels which supply the head, and their relationship to the nerves surrounding these blood vessels. Treatment in adults focus on changing the ‘blood pressure’ in these brain blood vessels, which has had the most success. Some of these medications are acceptable in the older child who is suffering severe frequent migraines.
How do they Present ?
They can occur at any age but generally middle to late childhood, and into adolescence. They generally occur late in the day, and sometimes there is a premonition, or a pale appearance, or vomiting which will herald the onset of the headache. The child will retreat to the bedroom, and eliminate light and noise as much as possible. If sleep occurs this will relieve the headache in most cases. The frequency is usually once per month but may be as often as twice to three times per week. The headaches will last a few hours, less than the standard adult migraine. Between the episodes the child will be entirely normal.
Migraines can occasionally result some localised weakness in an arm or leg which improves after the migraine has resolved. Obviously this needs to be diagnosed by a specialist after investigations to ensure there are no medical reasons.
What causes them ?
Migraines can run in families, and in fact there have been several genes that have been found to play a significant role in migraines, so genetic susceptibility followed by an environmental ‘trigger’ is the current thinking. However in children there are often no identifiable triggers. (This is different in adults where specific foods will be the trigger such as cheese, redwine etc). Sometimes exercise on a hot day will trigger a headache which can lead to a migraine. Sometimes they occur on a particular period of a week such as Saturday morning, or after a stressful school event or exam. One of the most consistent triggers for headaches and migraines is sleep deprivation – such as the migraine that occurs after a sleep over.
How can they be treated or prevented ?
Treatment is divided into pharmacological management and lifestyle adjustment. There is no cure to prevent migraines and triggers are usually not obvious or do not exist. This is very frustrating for parents. What is most important is keeping a diary and seeing if a trigger is found, such as lack of sleep, too much caffeine (soft drinks) or exercise in the sun.
- Acute treatment – the simplest, safest medication is ibuprofen at an adequate dose given as soon as possible. This ‘rescue’ treatment should be administered at the earliest sign. Make sure the dose is 8 – 10 mg per kg. If vomiting is a feature a wafer of ondasetron should be considered. More complex medications are available for the older child and adolescent including a group of medications called ‘Tryptans’ which have been very effective in adults.
- Preventative treatment – When the headaches are frequent and debilitating it is worth considering preventative treatment. There are a number of medications that have been used in the past including antihistamines, anti hypertensives and epilepsy medications, which have been found to lessen frequency when compared to placebo.
General measures to improve a child’s lifestyle will lessen the frequency and intensity of migraines. This includes adequate sleep, removing caffeine and additives from the diet, exercise and maintaining optimal weight. None of this will ‘cure’ the migraine which some parents are hoping will happen but it will help to make them manageable. Many parents feel ‘stress’ is a trigger but this is probably related to sleep disturbance than anything else.
In the acute setting, at the onset of headache, ensuring the child is placed in a dark quiet cool room to try and fall asleep is probably the most important treatment.
What is the outcome ?
The good news is that childhood migraines usually ‘burn out’ and do not necessarily mean that the child will have headaches as an adult.
Myths tales and tips.
- There is no evidence that alternative therapy such as chiropractic treatment has any affect. There are some small studies that suggest adults with low coenzyme Q10 or riboflavin can be helped but this has not been found in paediatrics. Unfortunately migraines belong to that group of illnesses where there is no obvious cure. This means they are a target for alternative practitioners who prey on desperate parents, offering expensive treatments which unfortunately are not backed up by any evidence.
- Keeping a diary will accurately determine whether there is a need for more aggressive treatment and is important way of monitoring how treatments are working
- A ‘brain scan’ is nearly always normal with typical migraines. It is sometimes done to allay parental anxiety and this should be in the form of an MRI to avoid unnecessary radiation.
- There is little evidence that they are due to ‘allergies’. Wish they were, as it would make treatment easier.