Migraine headaches in children are often underdiagnosed, because it may present in a different manner compared to adults. Many parents also are surprised when this diagnosis is made at a very young age, thinking that migraines tend to occur only later in life. (Approximately 25 per cent of childhood migraine has its onset prior to age five.)
The history of a unilateral headache, throbbing or pulsatile in nature and frequently associated with nausea and vomiting, lasting mostly a few hours and relieved by a dark room or sleeping would fit a typical presentation. Sometimes there is an association with Red Ear Syndrome.
Migraine variants, or conditions which can be confused with migraine, are cyclical vomiting, opthalmoplegic headaches, abdominal migraines, cluster headaches, and transient weaknesses on one side. (For more details on how these conditions overlap with migraines, see a comprehensive resource at http://www.headaches.org)
This condition so often is a matter of lifestyle and geographic locations. For example, with the increased prevalence of obesity and its associated sleep apnea, we are seeing more migraines; people who reside at higher latitudes and altitudes also tend to more prone to migraine; excessive screen time is associated with a higher risk; stress and anxiety are setups for migraine; dehydration is a risk factor; running low in Vit D has been linked with migraine; and a diet low in Riboflavin predisposes some children to migraine.
Migraine headaches are also worse in girls. When they experience puberty and the associated hormonal swings, it may impact the quality of life greatly in that school classes become impossible to attend and athletic events are missed.
There is a score to assess the severity of migraines: the PedMIDAS score, also known as the Migraine Disability Assessment Score. There are apps which serve as a log or diary to track headaches, although some experts question the use of electronic devices during a time of headaches. The main goal of diaries is to document how frequently headaches occur and if triggers can be identified. This data may influence the type and timing of future treatments.
A Canadian study published in Pediatrics in 2010 involved the Pediatric Emergency Research Canada organization, comprising of a number of ERs scattered all over Canada. The study looked at how patients seeking help in the ER for migraines were treated as outpatients prior to presenting in the ER. It concluded that many ER visits could have been prevented had patients received better treatment.
The majority of experts will tell us to use painkillers with anti-inflammatory effects (Ibuprophen for example); to use them early in the onset; and if that fails to use second line treatment in the form of triptans delivered via a melt format or nasal spray.
The acute treatment is not always effective—thus raising the matter of preventive modalities. Proactive treatments include propranolol, valproate and amitriptyline. They all have various side-effects which led researchers to explore non-pharmaceutical modalities.
In the August 2016 edition of Pediatrics, Norwegian authors suggest that biofeedback in children work very well for prophylaxis. These authors claim their study was the first of its kind to look at pooled data — specifically in children. The conclusion is that biofeedback indeed reduced the frequency and duration of migraines. It works well in conjunction with cognitive behavioural therapy and hypnosis.
One reason migraines seem to be more prevalent at higher latitudes may be lower levels of Vitamin D. The link between low Vit D levels and migraines has been well documented by the American Headache Society.
Riboflavin, or Vitamin B, is another vitamin used in the treatment of migraine. Foods such as asparagus, broccoli, spinach and poultry contain riboflavin, but higher amounts in supplement form are used effectively in teens and adults.
A popular nutraceutical is the herb Butterbur. It works by providing anti-inflammatory effects and although it is over the counter and natural, there are concerns that some Butterbur products contain alkaloids, which if used over the long term, may cause liver damage. Butterbur made in Germany, where it is quite popular, may be less likely to contain alkaloids. Patients with ragweed allergies should avoid butterbur.
The role of Ginkgo and magnesium, frequently mentioned as potential alternative treatment modalities, is still unclear
Gluten as a cause of migraines is a relatively new field of research. According to Dr. Babineau, a migraine expert based at the Mount Sinai Hospital in New York City, avoiding gluten as a way to treat migraines may only work for patients with Celiac Disease and not for those with a gluten sensitivity.
The role of fatty fish in the prevention of migraines requires more research. (My own opinion is that if it fails, then there are still many other health benefits associated with the anti-inflammatory benefits associated with omega 3’s)
For patients interested in getting weekly newsletters, updating them on new research, see http://www.migraine.com
Dr. Nieman is a community-based paediatrician and the president of the Alberta Chapter of the American Academy of Pediatrics. He contributes bi-weekly to CTV Morning Live as a life coach, author and marathon runner, having completed 101 marathons.