Childhood Migraine Disorders Revisited
There are several reasons we are re-visiting this subject, the focus of a newsletter 8 months ago. First, recent tweets on this subject have shown an enormous interest in this oft misunderstood area of the migraine spectrum. Second, a recent study on medications for childhood migraine called into question their efficacy. Specifically, placebo was shown to be as effective as amitriptyline or topiramate in children, with no adverse side effects. Given the current level of interest and recent research results, this area deserves a second look. However, a comprehensive look at this subject is well beyond the scope of this newsletter. We are looking to (hopefully) answer a few questions and spark interest. As with many areas of medicine, you are your own best advocate. Or, your child’s best hope.
We know that migraine presents differently in children and adolescents. There is no FDA approved medication for migraine prevention in children under the age of 12 years. What does migraine look like in children? Here are some possible clinical scenarios:
- Preschoolers with migraine may look sick, experiencing abdominal pain and vomiting that resolves itself with sleep.
- Preschoolers also exhibit pain with behavioral changes such as irritability, crying, and seeking a dark room.
- Children aged 5-10 experience bilateral pain accompanied by abdominal cramps and vomiting. These children often fall asleep within an hour of onset.
- A family history of migraine is common.
- As the child ages, the intensity and duration of the headache worsens. The headache may become more unilateral.
- Early in age more boys suffer from migraines, later it reverses to girls.
- Children may also experience photophobia (sensitivity to light), phonophobia (sensitivity to sounds), odd smells, vertigo, GI disturbances, and fatigue.
- Most children who experience migraine do not have an accompanying aura. Those that do experience aura find it difficult to describe. The aura in children is usually more frightening than the headache itself. Children who experience migraine with aura often present earlier than those who experience migraine without aura.
- Infants with colic are associated with migraine disease in later life, suggesting a developmental process at work.
- Other less common migraine variants in childhood include aura without headache, basilar migraine, and hemiplegic migraine. Again, a family history is usually found and referral to a specialist is indicated.
Just how big is this problem? Current research suggests 5% of seven year olds, and 15% of fifteen year olds suffer from migraines. Migraines also rank third among illness related causes of school absence. As with adult sufferers, migraine disease can hijack a young person’s childhood. Friendships, sports, all manner of normal, healthy activities are compromised.
Another theme that is prevalent throughout the literature concerning treatment of childhood migraine is that need for engagement of the entire family. In other words this is not a condition that will be cured by a simple course of medication. In some cases no approved medications exist. No specific diagnostic test is available. Diagnosis is made by history and examination. This does not imply that childhood migraine is not treatable: it most certainly can be treated. It will require a family effort.
This condition responds best to a combination of approaches, invariably involving the entire family. A blend of cognitive behavioral therapy (CBT) and carefully chosen medications for the prevention and treatment of migraine attacks, age approved and appropriate, has been proven to be useful. Identification and avoidance of migraine triggers is essential. Diet and lifestyle will need to change. The keystone to this approach may be a childhood migraine literate physician who can oversee the entire treatment plan. Hopefully, this will result in much needed relief for the younger migraineur and the family.