S5:Ep7 – Understanding and Managing Migraine in Kids and Teens



Voice-over: Welcome to Spotlight on Migraine hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.

Thank you to our 2023 education sponsors.

Migraine affects about 11% of children and adolescents, but it can look different from migraine in adults. Dr. Michael Oshinsky, from the National Institute of Neurological Disorders and Stroke, discusses the signs and symptoms of pediatric migraine as well as ways to support children at school and with their personal lives. He also talks about treatment options and how the NINDS Migraine Trainer App can help with management of the disease.

Molly O’Brien: Hello and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. We know that migraine can affect people at any age. So, today, we’re looking at how migraine impacts young people. We’re talking about kids and teens. To help us learn more, I’m pleased to introduce our guest, Dr. Michael Oshinsky. Dr. Oshinsky is the Director of Preclinical Pain Research at the National Institute of Neurological Disorders and Stroke. Dr. Oshinsky, thank you so much for joining us today.

Michael Oshinsky, PhD: Molly, thank you so much for having me. I’m really excited to speak to you about pediatric migraine, headache, in kids and teens. I think it’s a really important topic.

O’Brien: It is an important topic and a hot topic among the migraine community right now. I think more people are really interested in finding out, hey, what resources are out there for my kids? What do symptoms look like? All that. So we’re going to dive in. But before we do that can you tell us, just briefly, a little bit about your background?

Oshinsky: Sure, Molly. I got my PhD at Cornell studying computational neuroscience, sound localization of small arthropods, if you can believe that. And did my postdoc at University of Pennsylvania studying circadian rhythm and drugs of abuse.

And then, I joined the faculty at Thomas Jefferson University and Jefferson Headache Center. And for 14 years, I studied headache in a clinical population and in rats in order to develop better platforms for developing treatments for migraine.

So with the caveat that I’m a basic scientist, but I spent a lot of time around migraine patients and some of the best clinicians in the world who treat headache at the Jefferson Headache Center.

O’Brien: I love that your background is so interesting, and that you’re a basic scientist. Here, at the Association of Migraine Disorders, we love research, we love advancing research. So excited to talk to someone who’s out there getting it done.

All right so let’s jump into our conversation all about pediatric migraine. We know that migraine is the most common headache disorder in children. Roughly how many young people have migraine?

Oshinsky: So it’s pretty surprising for some people to hear that between 7 and 8% of all children have migraine. Wow. That’s almost 1 in 10. Now, when a child has a headache, sometimes it’s difficult for them to communicate that they have that headache. And sometimes they focus more on the GI symptoms, and they’ll complain more about a stomachache or being nauseous, which is an associated symptom with migraine. But a good physician knows the questions to ask to really get at the root cause of all those associated symptoms.

O’Brien: Absolutely. And because migraine can look different at different ages – we’re talking about infants, toddlers, and teens – the symptoms can look different, and it doesn’t always come with headache. So you mentioned nausea, GI symptoms, but walk us through what migraine can look like at these different age groups of young people.

Oshinsky: For those of your listeners who have experience with adult migraine, may be familiar with the adult criteria for diagnosing migraine. A headache that lasts 4 to 72 hours. So if it lasts less than 4 hours, it doesn’t necessarily fall into the strict criteria for diagnosing migraine in adults.

But in a pediatric population, it’s actually pretty common for those headaches to be shorter lasting than four hours. And then, some of these associated symptoms, which I mentioned earlier, that nausea, which is actually pretty uncommon for adults with migraine to actually vomit. But in children, it’s very common. And then, the headache will even resolve after they vomit, which doesn’t typically happen in adults either.

Some of the GI symptoms are more exaggerated in a pediatric population than adults. And then, a migraine lasting only two hours long is okay to diagnose it as a migraine in the pediatric patient, whereas in an adult they wouldn’t.

Now, we’re talking about children that are very young teens or younger than that. Once you get into the later teens after either boys or girls have reached puberty, then their symptoms kind of start to line up with what we see in the adult population. And that’s a really important point, since I brought up boys and girls.

In the adult population, we know there’s a three to one ratio of more women experiencing migraine than men. But if you look in very young children, let’s say under 10-years-old, the ratio is pretty much the same, and it doesn’t change until the girls reach menarche. That means they start their menses. That’s when you start to see more girls experiencing migraine than men. And that’s probably due to a hormonal trigger for those attacks.

O’Brien: More evidence pointing to those hormones being involved.

Oshinsky: Involved, but not the only issue because we do have those boys and those adult men that do suffer from migraine, and they do suffer.

O’Brien: So, we’re talking a little bit about that teenage group. Teenagers really seem to have it tough sometimes. So many physical changes going on in the body. Can you tell us what are some of the common symptoms that teens live with or that parents might be able to recognize if they don’t really understand migraine?

Oshinsky: For those of us who have teenagers – or teenagers with migraine – know that irritability is a big symptom, especially during or immediately post a headache, what we call the postdrome. Don’t look at pain as the only symptom of migraine pain. Migraine is a neurological disorder that has lots of neurological manifestations. And those neurological manifestations are not only in personality or mood changes, or in pain, but they’re also in other organ systems, like we mentioned earlier, the GI system. It’s flowing down the GI and anorexia means stopping eating, during the attack, is also really common and really common in adolescents during their migraine attack.

Now, having trouble sleeping or getting those eight hours a night, which are recommended by all of the professional societies on the physician side, is really difficult in this population. And not keeping a set of sleep and wake time even on the weekends can be difficult, make it difficult to manage migraine in the adolescent population.

So that’s the Saturday morning headache when you sleep in, until noon. Or the Monday morning headache when you’ve got to get up early again for school. So sleep changes are associated with migraine. There’s the eye issues, irritability, just being a difficult teenager. Hard to separate that from migraine but it can really be exacerbated.

So, the parents understanding what their children are going through, not just associated with their hormonal changes, but also, really not stigmatizing this pain they’re experiencing that’s absent of any organic or tissue damage.

So, you just look at your child, they look young, they look healthy, they’re active with their friends, but they might have a test due, so this have this stress trigger and then all of a sudden they start complaining about their head and their stomach and they can’t go to school. No, I can’t do the test, I can’t even think straight. So the cognitive symptoms. And the cognitive slowing and fogging that’s associated with migraine, is real. Let’s not stigmatize them for that. It’s really important.

O’Brien: I think that’s so valuable to talk about not stigmatizing or just think your child is trying to get out of a test or a big assignment. Because that often can happen. It still happens with adults. We still face that stigma, you know, I can’t go to work today because you’re too stressed, you’re too overwhelmed. I think that’s really, really valuable information to share. And yeah, you start seeing a pattern of this happening around every big stressful event, so that can help too.

Let’s talk about keeping a routine, having some consistency with sleep, with eating, like you said, kids don’t always have that, whether it’s on the weekend, or even the summertime when our kids have the opportunity to have free time or go to camp or all of the other fun, cool stuff you can do as a child.

When there are scheduled changes, what are some good things that parents and kids can do to kind of help stay consistent to reduce the risk of attack or prevent attacks?

Oshinsky: Let’s talk about changing from school to camp. We’re at the beginning of the summer, ending school recently. This is happening with lots of families, or maybe even going on vacation. There’s going to be a change in routine. So, try to minimize which changes you have. Whereas there might be a change in sleep schedule but keeping that feeding schedule consistent. Right. Or the types of food consistent.

We know that when we’re traveling, we know that when we’re no longer eating those school lunches which has a pretty set routine that we can gravitate to foods and maybe to the foods that are more comfort foods which in some individuals can trigger headache. And I don’t want to say that headache is only triggered from external factors like food, etc. There are internal triggers and changes in physiology that can lead to them.

But an individual, knowing themselves could be really careful about what they eat if they have migraine associated with triggers. And there are also allergies. There’s allergies to particular foods and they can manifest as a trigger for a migraine also, which we see in pediatric populations.

This is really important. If you give a pretty good headache history, and when a physician or when a parent is trying to get the information together in order to compile it to give it over to their physician, or when the parent joins a child in discussing their headaches with their physician, is to let the kid talk. Because they can give subtleties in answering those questions from the physician that the parents, they can just be really surprised about those answers.

Now clearly, when it comes to family history or when it comes to the perception of how the lifestyle has changed with regards to the headache, the parents are absolutely essential there. But we could also learn a lot from our kids about what their suffering by just listening and not assuming it’s like our disorder if we have migraine and projecting on them.

O’Brien: Oh my gosh that’s such a valuable piece of advice to actually, if your child can talk, you know, some kids who experience migraine are not speaking yet.

Oshinsky: Oh that’s a good point. Let’s talk about migraine in infants. So, there are some associated symptoms that we’re finding in the research in this population and one of them is torticollis. And that’s a tilting of the head and it’s actually pretty common and it’s something you should discuss with your pediatrician.

But if you’re also seeing feeding changes associated, is that sometimes the child leans their head to the side and sometimes doesn’t. That could be associated with head pain or episodic migraine in that patient. And then that can help the pediatrician or the pediatric neurologist read that, treat that pain in the child and then they can straighten up their head and then they can get back onto a regular feeding schedule also.

So, one of the things that they found is that if you look at young children when they start to being able to communicate whether or not they have a headache, and you look at their history, torticollis is actually pretty common.

O’Brien: Wow, that’s fascinating. And always interesting to think back, too, like, why is my child acting like this. There could be some explanation.

Oshinsky: Also, in a lot of parents’ experience, they say, well my older child didn’t do this. They try to project with one child onto another. And for those of us who have multiple children, they’re all different. Even though it’s just so natural to project what the expectations are from one to another, you have to look at them as individuals.

O’Brien: That is great advice. Parenting is hard. I’m learning that. It is hard. It’s rewarding, but it’s hard. Let’s talk a little bit about some treatment options among various age groups. Again, always good to talk to your doctor, your pediatrician, your healthcare provider. But, there are treatment options out there for young people as well as lifestyle changes, medications, nonmedicated devices that are cleared.

Let’s talk about what options that young people with migraine have.

Oshinsky: First of all, many of the treatments, not all of them, but many of the treatments are used off-label. That means they don’t necessarily have an indication or approval from the FDA for this particular population. Some of them do. And then there’s contradictory clinical trials, which is also really difficult. So one of the things that’s really important to do is to find a physician who has experience treating headache in your child’s age group.

And then they’re going to be the best resources to trying to figure out what’s appropriate for the child and then how to balance side effects or off-target effects associated with that treatment that your child may have the potential to experience in the context of the benefits that we’ll get in relation to their headaches etc.

There’s a whole slew of options and you should know there are lots of choices. And I’m going to start with behavioral interventions first. Right, lifestyle things. That’s what we discussed earlier. But there’s also behavioral interventions for having the child deal with the pain. And then gaining that mastery over understanding what their suffering, understanding their disorder, and being able to manage it from that perspective standpoint, their headaches become better and less frequent.

So, cognitive behavioral therapy is one example, CBT. ACT is another one, acceptance and commitment therapy. So that’s another one that’s associated and that has some pretty good evidence in migraine also.

And then we have trigger point injections have been…seem successful in some adolescent patients. Those are either lidocaine and sometimes they use lidocaine with a steroid that treat the trigger points and some sore points on the neck, some sore points on the head, so those muscle contractions can be a sign of over excitability in the trigeminal system. That means the sensory system that processes from the head and the neck.

And then there are medications that a child can take acutely. One of the things we found is that if you treat the individual attacks, meaning, really commit yourself to getting those attacks or those experiences of an episodic migraine, and treating those individual attacks, that they’ll become less frequent over time. And then if we let them become full-blown or fully experienced by the patient, then the headaches may become more frequent. So, headache begets headache. But if we treat it well, then we can prevent that also.

So there’s over-the-counter medications such as acetaminophen which we have to be careful how often we use that because of the potential liver toxicity. And then there’s drugs that are nonsteroidal anti-inflammatory drugs. And an example of that is like Advil. And then those can be used in combination with prescription medications like the triptans and there’s a whole slew of different types of triptans that are used to treat individual headaches.

And what’s important is, is because the gut does slow down, so sometimes a pill isn’t the best way to treat a headache and it might be through a nasal spray or through an injection. There are autoinjectors that can be used from these triptans or these medications or a dissolving tablet. Really, you have to speak to your physician. You have to talk about all of the different symptoms the patient is experiencing in order to find the right combination of treatments.

And then there are the new CGRP antagonists. The small molecule antagonists, or the antibodies that are on the market that don’t have approval in very, very young children, but in adolescents and in adults. They’ve really changed the landscape for treating headache in this population, and also the lives that they live have completely been transformed.

O’Brien: Absolutely. It’s really nice to hear you talking about the options that are out there. Looking back on the years when I was a kid, living with migraine, we just didn’t have as many options. And I was one of the lucky ones who my mom advocated for me, let me talk and knew that we had a history of migraine, so I got a diagnosis very early.

But looking back, thinking, I’m so glad that there are so many more options for young people and for adults, obviously. It’s a really exciting time.

Oshinsky: It’s also devices. Electrical devices for stimulating the arm, stimulating the ear, the vagus nerve, the forehead, the branches of the trigeminal nerve that innervate these areas of the face, neck and head. It’s just a really exciting time to be in the migraine field. Maybe not from the patient’s perspective – except for the fact that they have more options – but from a research perspective and the physician’s perspective, they just have lots of tools in the toolbox.

O’Brien: So we’ll say it’s exciting from the patient side as well, because more options means more tools. Let’s talk about a tool that you all have. It’s really cool because we can keep track of symptoms, we can keep track of triggers, and that can really be helpful for some. So, talk to us about the Migraine Trainer App. This could be so helpful for kids and teens and it’s cool and easy to use as well. I’ve looked at it.

But let’s talk a little bit about the Migraine Trainer App, what it is, who can use it, and how it can help.

Oshinsky: So let’s first identify that tweens and teens, these age group love their phones. They love interacting with their peers, and that’s actually the number one information source for them. Either their peers and social media, for getting information, which they’re getting through their phone.

The NIH was aware of that, and one of the gaps that we saw in all of the applications that were being produced in the different app stores – either on the Android side or the Apple side –  for helping migraineurs were really focused on the adult population. So we chose to fill that gap, at least a little bit, with something that could give information about headache from really good sources – which is important when you’re interacting with the Internet or social media, to look at the source – and then also give suggestions for interventions and lifestyle changes that can help the adolescent deal with their headache.

And then we put it in this package with these great little cartoon character that just have not a great attitude, you know, something that the pediatric patient or those experiencing migraine can really empathize with, right. So, the application is developed by really great professionals that do this for a living, and we partnered with them to take the scientific expertise and that research content of what can be helpful for patients with migraine who are adolescents and really help them to just manage their headaches.

So it’s for helping for managing it from a behavioral perspective and then also tracking it and tracking, and it’s something they can also communicate with it with their physician, like to schedule, their history of headaches, how often they’ve happened, and how they’ve treated them.

We hope it can benefit them.

O’Brien: Absolutely. It’s nice to be able to have all of that content and resources right in one place on a thing that many, many people have, their phone, look at all of the time. Well before we go, before we wrap up, I’m curious, Dr. Oshinsky, if you have anything else that you want to share, any information with our followers out there?

Oshinsky: What I wanted to say is, sometimes individuals experiencing migraine feel like there’s no options out there. Especially if they’ve been to their primary care physician, especially if they’ve been to a neurologist who doesn’t necessarily have a lot of experience treating pediatric patients with headaches.

But, rest assured that there are many, many different options. And there’s no reason to give up hope that you can decrease your headache frequency, that you can eliminate migraine as a barrier for being successful in school and successful interacting with your peers or that will prevent you from sports. You can get great treatment. There’s lot of different options like we mentioned, stimulators, injections, pills, behavioral changes, and then cognitive behavioral therapy, etc. A combination of them also might be helpful. So don’t be afraid of that either.

O’Brien: I love that. Don’t give up hope, there are options out there and you can access them. I’d like to thank you so much, Dr. Michael Oshinsky, for joining us. He is with the National Institute of Neurological Disorders and Stroke. Thanks again for all of your wealth of insight and knowledge.

Oshinsky: Molly, it’s been a pleasure. Thank you.

O’Brien: Thank you, again, and thanks to all of those out there watching and listening. We appreciate your support. That wraps up this episode of Spotlight on Migraine. I’m your host Molly O’Brien. See you next time.

Voice-over: Thank you for tuning into Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.


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