Preventing and treating pediatric migraines

The Pediatric Insider

© 2016 Roy Benaroch, MD

Parents are sometimes surprised to find out that migraines are the most common cause of recurrent headaches in children. Yes, kids get migraines – and many adults who get them started getting them as children, even if they weren’t diagnosed correctly.

(And: many adults who get migraines are still not being diagnosed correctly. Do you get “sinus” headaches? They’re almost certainly migraines. Yes, I know you feel congested with them. Yes, I know you know they’re “sinus.” But they’re not. They’re migraines, and have nothing to do with your sinuses. But I’m getting off topic here, and I’m not your doctor, and feel free to just disregard this paragraph.)

Dealing with pediatric migraines starts with making the right diagnosis – which is usually easy, if you listen to the patient and ask a few of the right questions. A brief physical exam can confirm that there’s nothing else to worry about, and advanced imaging like CTs or MRIs is almost never needed. Once there’s a history of over a few months of recurrent headaches, a clinical exam will tell you everything you need to know.

Prevention is the key. Migraines are really uncomfortable and disruptive, and an ounce of prevention is worth much more than a pound of cure. Many pediatric migraines are triggered by things like hunger, lack of sleep, disrupted schedules, dehydration, and many other lifestyle habits. Stress is almost always another contributor. Remember: stress to a child includes not just worry, but even excitement and strong positive emotions. Stress isn’t just things a child doesn’t like. Families and kids can learn to identify and avoid some of their own triggers, leading to far fewer migraines.

In adults, daily medications are commonly used as preventives. A recent study from the New England Journal looked at two common migraine preventers in children – topiramate (AKA Topamax) and amitriptyline.  The good news is that both medications did decrease the frequency of headaches – but the bad news is, neither was any better than the placebo group. That’s right, whether the study participants (all children and teens) took either of the drugs or a placebo pill, they all reported a decrease in headaches. Score one for sugar pills! Both the amitriptyline and topiramate groups experienced side effects, so the study was stopped early.

There’s some evidence for the effectiveness of a few less-traditional agents to prevent migraines in adults. These might help in children, too. Vitamin B2, taken daily, seemed to work better than placebo, and at least small trials of a few other generally-safe agents like magnesium and butterbur show promise. Even if they’re not much better than placebo, they’re safer than most medications.

We do have very good “abortive” agents to treat migraines once they begin. These include non-steroidal OTC meds like ibuprofen or naproxen, or prescription medications called “triptans”. All of these work best if taken very soon after any migraine symptoms start. But all of these are also prone to causing “rebound headaches” if taken too frequently. So, again, prevention is better than cure. (Still, a cure is nice to have if you need one!) By the way, narcotic medications should never be used to treat migraines, especially in children—they increase the sensitivity of the pain system, and can increase pain episodes
after even short-term use.

If your child has recurrent headaches, start by keeping a log to track potential triggers and causes. Don’t discount the role of stress, even if your child “doesn’t seem stressed”. And try to encourage good, regular sleep and eating habits. Still having headaches? It’s time to see the doctor. Even if daily medications don’t show much promise, we’ve got other good options to both prevent and treat migraines in children.

How old is he now, anyway?

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4 Comments on “Preventing and treating pediatric migraines”

  1. wzrd1 Says:

    I was fortunate in that I never had migraines as a child. Those started intermittently once I was in my mid 20’s and seem to have stopped occurring around 7 years ago.
    Now, the migraine still occurs, but it’s painless, with exclusively visual and visual processing symptoms (I do get the post nasal drip feeling that’s associated with my previous migraines).
    https://en.wikipedia.org/wiki/Scintillating_scotoma
    These resolve in around 30 – 45 minutes.
    I do know that I can’t use amitriptyline for prevention, as I was taking that some years ago for neurological pain and while it was highly effective at relieving pain, I went into anaphylactic shock.
    As for triptans, I’m a huge fan of them. They halted my last three classic migraines.

    That is one thing that’s infrequently mentioned, that the characteristics of a patient’s migraines can change over time.

    Perhaps in the future, a timely article on epistaxis, specifically seasonal/winter related? I used to have the worst nosebleeds in the winter as a child, literally filling bath towels with blood.
    I’m sure that you’d have excellent insight into the worthiness of cautery in severe cases.

    Like

  2. Dr. Roy Says:

    “That is one thing that’s infrequently mentioned, that the characteristics of a patient’s migraines can change over time.”

    True, but these are gradual changes — a migraine over years can morph, and have more GI symptoms. But I’d always be cautious if a person with migraines has a headache that’s very different from their usual headache. Having a history of migraine doesn’t prevent something new or different or scary from causing a different kind of headache.

    Epistaxis coming up!

    Like

  3. wzrd1 Says:

    I’ll be bringing that up soon with doctor, as my hypertension needed addressing ASAP and the hyperthyroidism that was feeding it.
    Hypertension severe enough to cause a 2.2 cm aortic dilation, so it would be prudent to see if anything upstairs didn’t also begin to fail.

    Like

  4. genepedia Says:

    You don’t mention hormones. At least for postpubescent girls these can definitely be a trigger. It’s been a trigger for mine since I started getting them around age 13 and understanding that has helped me make birth control decisions and make sure I always had abortive meds on hand when they are most likely to strike. It’s also important for girls to know if they get migraines when making birth control decisions because of the way it affects the risk of hormonal birth control in terms of stroke.

    I’m glad to see you raising this though. Even though both my parents get migraines mine went undiagnosed for more than 10 years because I didn’t get aura like my sister did (for that matter, my mom didn’t understand hers were migraines until mine were diagnosed). My youngest brother went undiagnosed for about 8 years after his started at age 6 or 7. We didn’t realize the pattern of him complaining about his head and then puking 10 min later was a migraine despite how many others in the family got them! Getting them diagnosed results in such a huge quality of life improvement. It’s good to see this getting attention.

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