Migraine Disability in Children
Migraine can change throughout any one individual’s lifetime. While approximately 25% percent of children who have migraine will be migraine-free by the age of 25, almost half will still have migraine symptoms at the age of 50. Another trend is that three times as many females develop migraine symptoms for the first time in late childhood.
It has been estimated that about 10% of children between 6 and 20 years of age have migraine. Attacks can begin at an early age and the prevalence increases with age:
- 3% in children ages two to seven
- 5% percent in ages seven to eleven
- 5% of boys and 10% of girls during puberty, ages eleven and older
Migraine is likely underdiagnosed in children. Headaches are a common complaint and are easy to dismiss, but migraine is one of the top five childhood diseases.
The majority of children with headache will also have at least one symptom of the ear, eye or nose. The most frequent complaints are a blocked ear sensation, watery eye, red conjunctiva, a drooping eyelid, dry eye, nasal blockage or runny nose.
When a child complains of a headache, the first step should be to take the complaint seriously.
Frequent headaches can cause significant disability. The negative impact of migraine disease on a child’s overall quality of life cannot be underestimated. Its impact has been comparable to that of pediatric cancer, heart disease, and rheumatic disease.
Clinical manifestations may vary depending on the age of the child: infants younger than twelve months may have episodes of “head banging” only.
Toddlers, aged one to five years, often look ill. They have abdominal pain, vomiting, and the urge to go to sleep in a dark room; they express their pain by being irritable, rocking or crying without having any apparent reason.
School-aged children (ages 5 to 10 years) have bifrontal, bitemporal, or retro-orbital headache; abdominal pains, nausea, vomiting, sound sensitivity, light sensitivity, dizziness, the need to sleep, tearing, swollen nasal passages, thirst, excessive sweating, increased urination, or diarrhea.
The diagnosis of migraine headache is based primarily on a thorough history. As with adults, it is helpful to tell a clinician about the intensity, duration and frequency of headaches.
Knowing if there are other family members with a history of migraine symptoms can be helpful in identifying this diagnosis. As many as 90% of people with migraine report having a family member who also experiences migraine.
Diagnostic criteria are similar to that of adults, but there are differences: the duration of attacks is often far shorter, the headaches are more frequently on both sides of the head, with fewer auras for those under 8 years old, and more frequent nausea and vomiting. Children often want to avoid light, noise, strong odors and movement.
There are other medical conditions that often coexist in children with migraine. These comorbidities include seasonal allergies, asthma and frequent ear infections.
Other medical problems associated with childhood headaches include anemia, obesity, abdominal illnesses, and early menses.
As with adults, children can have common psychiatric comorbid diseases, including depression, anxiety, ADHD, as well as epilepsy, sleep disorders, Tourette syndrome and cardiovascular disease.
In contrast to comorbid conditions, there are pediatric medical conditions that can potentially evolve into migraine.
The earliest of these potential migraine precursors is infantile colic. This common condition is defined as an infant who is irritable or cries for 3 or more hours a day, three or more days a week, for three or more weeks. Infantile colic is increasingly believed to be an age-specific form of migraine. This theory is based on the observations that children with migraine, between ages 6 and 18, often have a history of infantile colic – three times higher than normal. And mothers with a history of migraine were 2.6 times as likely to have a child with colic.
Benign paroxysmal torticollis
Benign paroxysmal torticollis is a rare condition of recurring episodes of abnormal head tilt or rotation, sometimes associated with vomiting and ataxia. During an episode it is possible to experience color loss, light sensitivity, ataxia, drowsiness and headache, which resemble migraine features.
Alternating hemiplegia of childhood
Alternating hemiplegia of childhood is marked by recurrent episodes of temporary muscle weakness, often affecting one side of the body. The paralysis lasts from minutes to days. During some episodes, the paralysis alternates from one side of the body to the other or affects both sides at the same time. This weakness can affect all the muscles on the affected side, not just those in the limbs. Other symptoms include difficulty swallowing and speaking. Alternating hemiplegia of childhood is a very rare condition. These episodes begin usually before 18 months of age.
Benign paroxysmal vertigo of childhood
Benign paroxysmal vertigo of childhood and vestibular migraine are the two most common diagnoses of dizziness in children. They are both related to other migraine symptoms later in life.
Benign paroxysmal vertigo of childhood is characterized by a sudden onset of a spinning sensation and headache without hearing loss. Episodes of benign paroxysmal vertigo of childhood typically last several minutes or even hours. They are not provoked by movement. These are characteristics that help differentiate it from canalithiasis where a sudden head movement precipitates the spinning sensation and resolves within one minute. Parents may notice unusual awkwardness, clumsiness or poor balance. Distinctive historical details are car sickness, headaches and a family history of migraine.
The estimated prevalence is about two percent in children between 3 and 6 years of age, but its prevalence remains uncertain because it is easily confused with canalithiasis.
There is little guidance in the literature for treatment. Vestibular rehabilitation is not effective, but this condition frequently responds well to cyproheptadine.
Managing children with headaches is a challenge because there are few well-established treatment options.
It may be best to start with some conservative, supportive suggestions, such as
- Lying down in a cool, dark, quiet room and sleeping
- Applying ice or pressure to the site of discomfort
- and using relaxation and self-hypnosis techniques
Many of the same interventional medications used in adults can be used in children. For children aged six and older, early treatment of migraine with acetaminophen and ibuprofen has proven to be safe and effective. Anti-nausea medications that have a secondary blocking effect on dopamine, such as metoclopramide and prochlorperazine, can be helpful in patients with associated symptoms of nausea and vomiting.
And, if these fail, triptans could be considered as an acute treatment option for children and adolescents with migraines, although their use is mostly 'off-label'. They must be used in low doses.
Rizatriptan has FDA approval for children as young as 6 years of age.
Almotriptan, sumatriptan-naproxen sodium combination tab and zolmitriptan nasal spray, (which is helpful when a child has nausea or vomiting with the headache) are approved for the use in children aged 12-17.
At this time, there is insufficient data to recommend frovatriptan, naratriptan and eletriptan for use in pediatric patients with migraines.
Nerve blocks, usually with lidocaine and preferably occipital nerve blocks, are an effective alternative intervention.
The neuromodulation device, Nerivio, is also FDA approved for use in children 12 years and older.
When childhood migraine becomes chronic and is not effectively treated by acute medications, there are few FDA-approved preventive options.
It’s important to determine whether or not it is appropriate to recommend any preventive migraine medication for children. The effectiveness and side effects of preventive medication in children need further study.
Topiramate, an anti-seizure medication used to prevent migraine in adults, is the only FDA-approved medication for prevention in children.
Other preventive options that can be prescribed off-label for children:
- divalproex sodium
- flunarizine (not available in the U.S.)
- CGRP blockers
A large 2018 review of pediatric preventive medications use concluded that topiramate had the best reduction of headaches at the rate at 67%. Although topiramate is the single FDA-approved preventive medication for ages 12-17 years, it has the potential side effects of memory loss, decreased appetite and increased moodiness. In contrast, the 2017 CHAMP study found amitriptyline and topiramate were no better than placebo and have more side effects.
Lifestyle Changes and Natural Approaches
Before starting any preventive medications, working on behavioral modifications is the preferred treatment option. In one study, nearly 20% of children reduced their headache frequency by at least 50% with good headache hygiene.
These behavioral changes may require parents to impose new strict routines in eating, sleeping and exercise, as well as a healthy diet and avoiding overscheduling of daily activities, before starting medications.
Regarding dietary restrictions, the American Headache Society only recommends limiting caffeine intake and does not restrict any type of food unless a very specific food trigger is identified.
A balanced diet appears to be important and skipping meals is often identified as a trigger. Dehydration is also commonly identified as a headache trigger. Recommend that your student carry an extra protein snack or bar to maintain more steady blood glucose levels and a water bottle. Make sure that the school understands the value of these routines.
Increasing physical exercise as a weight-loss tool and maintenance strategy must be recommended with caveats. Exercise can also be a trigger for some patients with migraine. There is some evidence that yoga and tai chi may be particularly helpful for patients with migraine.
Cognitive behavioral therapy
Vitamins & Supplements
Riboflavin - About 70% of children using either 240 milligrams of vitamin B2, or riboflavin, had a fifty percent or greater reduction in frequency of attacks and twenty-one percent reduction in intensity. There were no significant side effects.
Coenzyme Q-10 - A large open-label trial of coenzyme Q10 on pediatric migraine patients showed that the majority had at least mildly deficient coenzyme Q10 levels. Adverse effects were rare and included nausea, anorexia, dyspepsia, diarrhea, and rash, especially at high doses.
Melatonin - In one study of a single daily dose of .3 milligrams per kilogram melatonin for three months, monthly frequency, severity and duration of headache reduced by about fifty percent.
Magnesium - Studies of magnesium as a preventive medication for pediatric migraine are limited and small. The efficacy of this micronutrient is still unknown. Dosing for magnesium for pediatric migraine is also unclear and is limited by the side effect of diarrhea.
Butterbur - Should be avoided in children because of concern for hepatotoxicity in its unpurified forms.
Management At School
With 60% of children complaining of headaches, school nurses are on the front lines of headache management.
There are a number of strategies that school nurses should consider with children who complain of headaches and stomach aches. Various stressors, such as family and peer problems, especially bullying, are regarded as important causes of recurrent headaches.
These complaints are easy to dismiss as an excuse but, given the currently known high prevalence of migraine and tension headaches, school nurses need to be advocates for children with headaches who may not be properly diagnosed.
It can be very helpful for clinicians to provide school nurses with personalized treatment recommendations, or a Migraine Action Plan, on each child with migraine. This written document is a set of guidelines for the school’s medical personnel, who may not know as much about a child’s history of symptoms and medications.
Presenting this migraine action plan is an opportunity to educate the school nurse and other school personnel about triggers, to modify the school environment, to recognize the onset of an episode and to initiate early pharmaceutical interventions. A better understanding of migraine among school and college officials may reduce misperceptions and increase empathy for class absence or poor performance.
The Migraine Action Plan should include the recommendation of a low trigger environment, specifically a room that is quiet and dark, perhaps with a bed, and available ice pack and hydration. There should be an assessment of pain periodically and an individualized choice of medication available depending on the child’s reported pain level. This would include a preferred analgesic for mild to moderate pain and triptan for more moderate to severe pain. If the pain does not fall below a certain level within a specific length of time, the child may need to be transferred to an Emergency Department.