December 1, 2004
Migraines Not Just An Adult Problem
The words "migraine headache" and "children" do not seem to fit together, however children can experience migraine headaches. In fact, the disorder is much more common in children than previously thought. While complaints of headache are common in almost 70% of children, studies have shown 5% to 15% of children between the ages of 7 and 14 suffer from migraine headaches and 28% of the adolescent population exhibit chronic headache symptoms.'"4 These are large numbers, compared to how infrequently the diagnosis of pediatrie migraine is made.
Migraine headaches in children are often unrecognized and misdiagnosed. Not only is the diagnosis of migraine in children uncommon in the primary care environment, research data related to diagnosis, especially the treatment and prophylaxis of migraines in children, is also scarce. Guidelines for the management of adult migraines are well established, while the treatment of pediatrie migraines remains ambiguous and surrounded with uncertainty.5 It is possible that limited research findings of the disorder in children can be attributed to inadequate treatment. Therefore, it is necessary to discuss the evidence related to epidemiology, diagnosis, and treatment of children with migraine headaches.
Migraines show no sex discrimination in the prepubescent age groups. In children under the age of 12 years, the female to male ratio of migraine occurrences is 1:1. However, the numbers increase after age 12 with the onset of puberty. Girls are twice as likely to suffer from migraines as boys beyond the age of 12 years. This strongly implicates the roles of estrogen and progesterone in the cause and sometimes relief of migraines. While the intensity and length of individual migraine headaches are the same for both sexes, boys suffer from them more frequently.6 Approximately one-half of children with migraines will be plagued with them as adults.6
Recurrent headaches in children often cause fear of a brain tumor. Although the vast majority of headaches, including migraines, are benign, the seriousness of very few has given headaches a dreaded reputation. The possibility of migraine is typically not considered by parents, even in the presence of a family history. The problem continues at the clinician's office. Often, the primary care provider does not include migraine in the list of differential diagnoses when the child is brought for diagnosis and treatment of headache pain.
The actual cause of migraine headaches is unknown and the pathophysiology is uncertain. An older theory suggests that the aura of migraines is actually a loss of neurologic function resulting from vasoconstriction of vessels that supply specific areas of the brain. This explained the symptoms of hemiplegia, blindness, photophobia, and gastrointestinal disturbances. Current research has been unable to show any correlation between the location and severity of pain and cerebral blood flow.2
A newer theory suggests that the vascular changes associated with migraines are a secondary phenomenon, and that the true genesis lies within the central nervous system (CNS). One of the more widely accepted theories to support this idea suggests that the cephalgia of migraine is the result of activation of reticular diencephalic neurons that, for reasons unknown, activate the efferent fibers of the trigeminal nerve, resulting in the dilation of the vessels in the meninges outside the brain. The domino effect subsequently continues with the release of inflammatory and pain mediating peptides. The sensory fibers of the trigeminal nerve then transmit the sensation of pain back to the brain producing a migraine headache.2"4
Serotonin is believed to play a major role in migraine pain as well. Evidence to support this theory is demonstrated by falling levels of serum serotonin during a migraine headache. At the same time, levels of 5-hydroxyindoleacetic acid, a metabolite of serotonin, rise in the urine. To further support this theory, the triptans (a class of drug approved and indicated by the Food and Drug Administration [PDA] for the abortive treatment of migraines in adults) are agonists for 5-hydroxytryptamine (5-HT) receptors and have become a mainstay of treatment for these headaches.2
* Symptoms and Triggers
Clinical manifestations of childhood migraines include the rapid development of a headache in less than 1 hour, and lasting approximately 1 to 48 hours.4 The pain is severe and throbbing, and the child often looks ill and pale.8 Cephalgia of migraine in children is usually bilateral as opposed to unilateral in adults. Fatigue, crying, and irrilability often occur along with nausea and vomiting, photophobia (sensitivity to light), phonophobia (sensitivity to loud noises), and osmophobia (sensitivity to smells). Abdominal pain and complaints of motion sickness are common in children. Children also endure a higher rate of headache recurrence than adults.6
An important factor in the diagnosis, prevention, and treatment of pediatric migraine is the identification of triggers. The notoriously poor diet habits of teens are often the culprit. Some of the many triggers that may precipitate a headache are dairy products (buttermilk, sour cream, aged cheese), chocolate, and citrus fruits. Some people are especially sensitive to monoamines such as tyramine and phenylethylamine because of a deficiency of certain chemicals in the body. These foods are believed to cause vasodilation in these individuals. Aspartame, as well as caffeine found in tea and soda, have also been triggers for some individuals.6 Excessive intake as well as withdrawal from these substances can rouse a migraine. Skipping meals can also serve as a trigger. Other food triggers include monosodium glutamate (MSG), a flavor enhancer found in many processed foods, and nitrates and nitrites, which are vasodilating agents found in most processed meats like sausage, hot dogs, and bacon. Checking labels closely and avoiding processed foods are practical ways to avoid a migraine.8 Some nondiet-related triggers include getting too much or too little sleep, a change in barometric pressure, stress, and fatigue. Activities such as swinging, hanging upside down, or spinning in circular motions have also been shown to trigger headaches.
It is important to note that children with migraines will have symptom-free intervals. Serious conditions associated with increased intracranial pressure rarely occur in children who have completely normal exams. When headache symptoms are atypical for migraine or tension headache, or if the neurological exam is abnormal, magnetic resonance imaging (MRI) should be considered.1
* Epidemiology and Diagnosis
In 1988, the Headache Classification Committee of the International Headache Society (IHS) proposed criteria for the diagnosis of headache disorders. In 1997, the Pediatrie Headache Committee of the American Association for the Study of Headache proposed a revision to the IHS criteria for pediatrie migraines. The revisions include criteria for headaches with and without aura (see Tables: "Diagnostic Criteria for Migraine Without Aura in Children Younger Than 15 Years of Age" and "Diagnostic Criteria for Migraine With Aura in Children Younger Than 15 Years of Age"). These findings help differentiate migraine from a progressive, organic disorder, which requires further diagnostic assessment.9
Since there is no test that can definitively diagnose migraine, diagnosis is based largely on history of symptoms and comparing these symptoms to the criteria listed above. A complete and careful history, coupled with a thorough physical and neurological exam including occasional diagnostic tests to rule out more serious or unusual disorders, is the most effective way to arrive at an accurate diagnosis (see Table: "Differential Diagnoses for Migraine"). An accurate history, although crucial, can be difficult to obtain from a young child. For this reason, including the parents in the history taking process is important.
There is a positive family history of vascular, migrainous headaches in three-quarters of children with migraine. ' According to Alfven, twin studies indicate that one-half of migraines can be explained by heredity.7 These statistics emphasize the need for a complete and accurate history, including family history, in the assessment of children with headaches.
Use of the PedMIDAS, a questionnaire developed by researchers to aid in the assessment of the disability caused by headaches in school-age children, is also a helpfui tool.10 This six-question assessment is a sensitive, reliable, and valid assessment of the disability of childhood headaches. The PedMIDAS can also be used to monitor response to treatment (see Table: "PedMIDAS").8
Recent studies indicate that having children draw a picture of what their headache feels like is effective in helping the provider to accurately differentiate among headache types. This is especially useful in children who have trouble expressing their symptoms verbally. In one study, children described their headaches as "pounding" and "throbbing" pain, and drew pictures of hammers, rocks, bricks, firecrackers, and jackhammers to illustrate their pain."
A complete history and physical with special attention to a neurological exam iswarranted with each new headache complaint to successfully diagnose the type of headache. Sinus headaches are usually frontal, surrounding the eyes, with a constant pain as opposed to a throbbing pain. Often, there are other symptoms such as stuffy nose, fever, or purulent drainage if infection is present. Tension-type headache, which is probably the most common headache in children as well as adolescents, is often described as a vice or strap around the head. It is almost always bilateral. When children complain of daily headaches, the tension-type headache is often the culprit. Central nervous system infections such as meningitis cause severe unrelenting headaches that can be unilateral or bilateral, with throbbing pain. Nuchal rigidity and high fevers often accompany the headache. Lumbar puncture is mandatory when CNS infection is suspected.12 A brain tumor will usually result in an abnormal neurological exam. A stumbling gait, history of falls, confusion, and mood lability and vomiting without nausea can be ominous signs. A migraine attack with aura can also exhibit abnormal neurologic signs, which is when diagnostic imaging is indicated. Computed tomography scan, MRI, or magnetic resonance angiography (MRA) of the brain is indicated anytime the neurological exam is abnormal or when the headaches change in pattern, frequency, or intensity. Even when the neurological exam is normal, neuroimaging is indicated if the child is less than 6 years old with onset of headache less than 6 months. Computed tomography scan is preferred in most emergency situations, but MRI and/or MRA are best in elective situations.12 Other indications for neuroimaging studies include coexisting seizures, the absence of family history of migraine, a change in the headache characteristics, and recent onset of a severe headache.13
Management of migraines in children is centered on the avoidance of headaches. Avoiding triggers is of obvious importance. Patient and parent education regarding triggers is imperative. Some helpful remedies include sleep during an attack and ice packs to the head, although some children prefer warm packs-whichever is most comforting is appropriate.5,14 The United States Headache Consortium determined that some behavioral treatments such as relaxation, thermal biofeedback training, electromyogram biofeedback therapy, and cognitive/behavioral therapy are effective for some patients. On the other hand, physical treatments like acupuncture, transcutaneous electrical nerve stimulation (TENS), and cervical manipulation have shown no proof of effectiveness.14 Nonpharmacological treatment works best when combined with drug therapy; however, safety issues often limit the use of drugs in young children.
Next, a plan for abortive therapy must be addressed. Simple analgesics such as ibuprofen or acetaminophen are the mainstay of therapy in the pharmacological treatment of pediatrie migraine. These medications should be given as soon as possible after the headache pain begins.1 Early intervention is essential in children since the duration of pain and the time it takes to reach peak intensity is less than in adults.14 For acetaminophen, a dose of 10 to 15 mg/kg PO every 4 to 6 hours as needed (not to exceed 2.6 g/ day) is indicated; for ibuprofen, the dosage should be 10 to 20 mg/ kg PO every 6 to 8 hours as needed.
Opioids are rarely warranted in children. Nonoral routes of administration and antiemetics such as metoclopramide and domperidone 10 to 20 minutes before administration of oral analgesics are often helpful if the child is experiencing nausea and/ or vomiting. Ergot derivatives are sometimes used for severe attacks in adolescents, but their safety has not been established for use in younger children.5 The addition of isometheptene (Midrin) is a less- than-mediocre treatment for migraines and can predispose patients to have paroxysmal pain evolve into a chronic daily headache, according to one pediatrie neurologist at the University of South Alabama School of Medicine.
Prophylactic therapy options, both pharmacological and nonpharmacological, should always be discussed with parents when a child's headaches: are recurring more than twice a month; are prolonged, disabling, or disruptive; cause missed school and activities; and when acute therapies are ineffective or cause significant side effects. Prophylactics are taken daily over a prolonged period to reduce the frequency and severity of occurrences. They are not a perfect treatment, however. A 50% reduction in migraines is considered a favorable response.8 Although it is an older drug and is used less, cyproheptadine (Periactin), an antihistamine and antiserotonergic agent, maybe given prophylactically to children younger than 10 years of age. Appropriate dosage is 0.25 mg to 1.5 mg/kg (2 to 8 mg daily).19 Common side effects of cyproheptadine are increased appetite and drowsiness. These side effects are sometimes a relief if the child has been unable to sleep, and can be minimized by reducing the dose.12 Nonselective beta-blockers such as propranolol (Inderal) are often a first choice when pharmacologie prophylaxis is needed because of their proven efficacy. Seventy percent of migraine sufferers report a reduction in frequency and intensity. A beginning dose of 1 mg/kg/day, increased to 3 mg/kg/day in two divided doses if needed is effective prophylaxis for some children. Beta-blockers are 5-HT2 antagonists, and decrease the frequency and severity of headaches by affecting the central catecholaminergic system and seratonin receptors in the brain.8 History and physical exam should assure that there are no contraindications such as asthma, diabetes, atrioventricular conduction defect, or congestive heart failure before beta-blocker therapy is prescribed. Anticonvulsants such as valproic acid (Depakote), tricyclic antidepressants such as amitriptyline (Elavil), calcium channel blockers such as verapamil and cyproheptadine are available for prophylaxis in adolescents.
Naproxen sodium maybe used for prevention of menstrual-related migraines.5 Daily dosing is started the week before menses and continued for a week after.19 Aspirin products are contraindicated in children less than 15 years of age because of the risk of Reye's syndrome.
* The Triptan Controversy
Triptans are a class of drugs specifically indicated and approved by the FDA for abortive treatment of migraine headaches in adults .18 years and older. However, pediatrie neurologists report that triptans are usually safe and well-tolerated in children, and some children may benefit from their use. Examples of triptans include: rizatriptan, (Maxalt) sumatriptan (Imitrex), zolmitriptan (Zornig), naratriptan (Amerge), almotriptan (Axert), eletriptan (Relpax), and frovatriptan ( Frova). These medications are available in regular tablets, oral disintegrating tablets, injection, and nasal spray; the latter two have the fastest onset of action.
A review of several trials, both randomized and openlabel, looked at the safety and efficacy of the triptans in populations between the ages of 6 and 18. The findings in these trials indicated that oral rizatriptan was well-tolerated but did not prove to be clearly beneficial, and nasal sumatriptan use in an acute migraine attack when other medications failed was supported.15 The results have been successful in other trials in 40% to 57% of the study group-in one study, subjects become pain-free within 2 hours. However, migraines in children are often of a much shorter duration-2 hours or less-so the placebo arm achieved many of the same results as the test group, concluding that triptans are a safe and effective option for second- line treatment when acetaminophen and ibuprofen fail.16 Some pediatrie neurologists use triptans as first-line abortive treatment, especially in populations 12 years and older, but this is an off-label use.
Although not currently approved for use in children, triptans are being studied in clinical trials. Results have been positive, showing that triptans decrease the symptoms of migraines in younger populations. However, these response rates must be interpreted in the context of high placebo response rates.18 Treatments that provide relief to adults should be adjusted for use in adolescents and children. They are selective agonists for serotonin 5-HT1 receptors in cranial arteries. They suppress inflammation associated with migraine headaches.8 It is anticipated that as new triptans are developed and new dosage formulations are approved, the abortive treatment of childhood migraine will significantly change in years to come.17
* Follow-Up and Referral
Follow-up is always indicated for children with migraine headaches. It is important to track the efficacy of treatment to detect worsening or persistence of symptoms. Followup care is also indicated anytime the diagnosis is uncertain. It is also necessary to monitor the child; many neurological disorders are only apparent when observed over time. The duration and frequency of follow-up evaluations is based on the judgment of the clinician. The parent and the child or adolescent should understand that there are numerous therapies available. They should not give up when one or two treatments fail. Headache diaries are often helpful in the diagnosis and the follow-up phases to track response to therapy.
Referral to a pediatrie neurologist is indicated when the neurological exam or diagnostic imaging is abnormal. Otherwise, neurologist referral is only warranted when the headaches are refractory to treatment (for a period of at least 6 months), continue to worsen, become more frequent, or are severely disabling.8 In addition, a psychiatric consultation and psychological counseling for the child may be appropriate, especially if the complaint is chronic daily headaches in the absence of any objective findings.12
Migraines are among the most frequent, acute,and recurrent causes of headaches in children. They can lead to inability to concentrate, learning disabilities, and psychological conflicts.4 To prevent these sequelae and to insure adequate pain control, primary care providers must consider the inclusion of migraine headache in the list of differential diagnoses when children present with headache. Children and adolescents have enough growing pains to deal with already; unrecognized or misdiagnosed migraines do not have to be one of them.
Migraines Not Just An Adult Problem
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An important factor in the diagnosis, prevention, and treatment of pediatrie migraine is the identification of triggers.
Diagnostic Criteria for Migraine Without Aura in Children Younger Than 15 Years of Age
1. At least five attacks fulfilling criteria 2 through 4
2. Headache lasts 2 to 48 hours
3. Headache has at least two of the following characteristics:
a. unilateral location
b. pulsating quality
c. moderate to severe intensity
d. aggravated by routine physical activity
4. During headache, at least one of the following is present:
a. nausea and/or vomiting
b. photophobia and/or phonophobia
Adapted from Headache Classification Committee of International Headache Society.
Diagnostic Criteria for Migraine With Aura in Children Younger Than 15 Years of Age
1. At least two attacks fulfilling criterion 2
2. At least three of the following:
a. one or more fully reversible aura symptoms indicating focal, cortical, and/or brainstem dysfunction
b. at least one aura symptom that develops gradually over >4 minutes or two or more symptoms that occur in succession
c. no aura symptoms lasting >60 minutes
d. headache follows aura within 60 minutes
Adapted from Headache Classification Committee of International Headache Society.
Differential Diagnoses for Migraine
Central nervous system infection (meningitis, encephalitis)
Temporomandibular joint condition
Chronic daily headache
The following questions assess how headaches are affecting day- to-day activity. Your answers should be based on the last 3 months. There are no right or wrong answers.
1. How many full days of school were missed in the last 3 months due to headaches?
2. How many partial days of school were missed in the last 3 months due to headaches (do not include full days counted in the first question)?
3. How many days in the last 3 months did you function at less than half your ability in school because of a headache (do not include days counted in the first two questions)?
4. How many days were you not able to do things at home (i.e., chores, homework, etc.) due to a headache?
5. How many days did you not participate in other activities due to headaches (i.e., play, go out, sports, etc.)?
6. How many days did you participate in these activities, but functioned at less than half your ability (do not include days counted in question 5).
Total PedMIDAS Score
2001, Children's Hospital Medical Center
All Rights Reserved. Reprinted with permission.
A migraine attack with aura can also exhibit abnormal neurologic signs, which is when diagnostic imaging is indicated.
Simple analgesics such as ibuprofen or acetatninophen are the mainstay of therapy in the pharmacological treatment of pediatrie migraine.
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6. Bral EE: Migraine in children: American Journal of Nursing, 1999;! 1, pp35-41.
7. AlfVen, G. Understanding the nature of multiple pains in children. Ped, (2001)138(2)156-8.
8. Mack KJ, Mack P: Migraine Headache: Pediatrie perspective. 2003
9. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8 Suppl 7:1-96.
10. Hershey AD: PedMidas: Development of a questionnaire to assess disability of migraines in children. Neurology 2001;57(ll):2034-9.
11. Stafstrom C, Rostasy K, Minster A: The usefulness of children's drawings in the diagnosis of headache. Pediatrics 2002;109(3):460-72.
12. Silvcrboard G: Childhood Migraine: A practical review. Medscape Neurology and Neurosurgery 2001;3(1).
13. Schor NF: Brain imaging and prophylactic therapy in children with migraine recommendations versus reality. The Journal of Pediatrics 2003;143(6):776-9.
14. Landy S: Migraine throughout the life cycle: treatment throughout the ages. Neurology 2004;62(2):S2-S8.
15. Major PW, Grubisa HS, Thie NM: Triptans for treatment of acute pdiatrie migraine: a systemic literature review. Pediatrie Neurology 2003;29(5):425-9.
16. Winner PK: Advances in the treatment of migraine in kids. Headache, The Newsletter of the American Council for Headache Education 2001;12(1).
17. Turk WR: Childhood Migraine. Advanced Pediatrics 2000;47:161- 97.
18. Jamieson DG: The safety of triptans in the treatment of patients with migraine. The American Journal of Medicine 2002, Feb. 1, vol 112. 135-40.
19. Wynne ALW, Millard TM: Pharmacotherapeutics for Nurse Practitioner Prescribers. Philadelphia, Pa.: F.A.Davis Company. 2002: 992.
Virginia Seay Fleener, MSN, ARNP, BC
Brenda Holloway, MSN, ARNP, BC
The authors have disclosed they have no significant relationship or financial interest in any commercial companies that pertain to this education activity.
ABOUT THE AUTHOR
Virginia Fleener is a Certified Advanced Nurse Practitioner at The Doctors' Office, P.A., Marianna, Fla. Brenda Holloway is a Certified Advanced Registered Nurse Practitioner and Director of the Family Nurse Practitioner Program at the University of South Alabama, Mobile.
Copyright Springhouse Corporation Nov 2004