Posted tagged ‘migraine’

Headaches every single day

August 28, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Jenny wrote in about her son, who has a lot of headaches: “My 12 year old son gets them pretty much every day, and this has been going on for six months. He missed a lot of school, and now is starting to get them again in the summer. The doctor ordered a CT scan which didn’t show anything. What can this be? Could it be sinuses?”

Headaches are common in children. They’re usually “primary” headaches—meaning they’re not caused by anything specific, and they’re not associated with any specific medical condition. They’re just headaches.

Kinds of “primary” headaches in children include:

Migraine – maybe the most common of the more-severe headaches. In children they’re often bilateral and fairly brief. Sometimes they’re accompanied by vomiting, or are worsened by lights or sound; often the best “cure” is to go to sleep. Migraines often run in families.

Tension – These create a band-like, or squeezy feeling in the head, and aren’t usually severe. Yes, kids of all ages get tense.

Chronic daily headache – This sounds like Jenny’s son. They often occur on top of occasional more-severe headaches, like migraines.

The general principles of chronic daily headache:

  • AVOID daily Advil or Tylenol– if you use those more than 3 days a week, you will perpetuate the headaches. I know this sounds odd, but I promise it is true.
  • Try to maximize healthy lifestyle things: good regular sleep, diet, avoiding a lot of preservatives and chemicals, getting regular exercise. Again, I know this sounds odd, but it does help.
  • Try NOT to missschool– that inevitably makes headaches worse.
  • Consider massage/yoga/relaxation therapy.
  • If there is an overlay of depression/anxiety/mood issues, deal with that. There is often a psychological component, either contributing to the headaches, or being caused by the headaches and missing school and activities.
  • Consider a daily medicine to control the headaches– not painkillers, but other kinds of medicines that prevent headaches. You will need a physician’s guidance if daily medication is needed.

About CT scans and headaches: they’re almost never necessary for chronic, ongoing, stable headaches (or headaches that come and go in a stable pattern.) Imaging is really only useful for acute, worse-in-a-lifetime headaches, headaches associated with other symptoms (like seizures or neurologic problems), or progressive headaches that are getting worse and worse. CTs (or MRIs) are completely unnecessary in the workup of most children with headaches, and will sometimes give misleading results that lead to wild goose chases and misery.

Another headache myth: Most people out there who think they’ve got sinus headaches have been misdiagnosed.  Recurrent “sinus” headaches are genuinely uncommon. When they do occur, they’re associated with persistent nasal congestion and cough that precede the headache. Migraines themselves, which are far more common than recurrent headaches from sinusitis, can cause nasal or sinus symptoms that begin about the same time as the headache. It’s unlikely that Jenny’s son has headaches from sinus disease without other obvious persistent sinus symptoms, especially with a normal CT scan.

Yet another headache myth to dispel: vision problems rarely cause recurrent headaches in kids. Some people who are nearsighted will squint, and by the end of the day will develop tension-like pain from tightening up the muscles of their face and scalp, but that really is uncommon.

Headaches in children are common, and most commonly are caused by a minor infection, dehydration, hunger, or stress. If they’re recurrent, they’re likely to be one of the common primary headaches, like tension headaches or migraine or chronic daily headache. Headaches that are progressive (worsening), or associated with other prominent or worsening symptoms, need an urgent medical evaluation, but those are fortunately rare. More typically, headaches just need to be treated like, well, headaches. Don’t forget the simple stuff: rest, a kiss on the forehead, a cool compress, something to help relax. In the long run, those are probably better headache remedy for children than any medication.

Darwin’s illness explained

February 4, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

What Charles Darwin did was really quite extraordinary. Evolution, per se, had been thought about for centuries—his own grandfather, Erasmus, had the idea of species sharing a common ancestor pretty well worked out. What Darwin did was introduce a mechanism, natural selection, that fit and explained his precise observations of the variability of species across different environments. If you’ve got some time (and maybe a few cups of coffee), read through his On the Origin of Species. It painstakingly, slowly, and very thoroughly walks though the mechanism of evolution, stopping at every step to ensure that observations from the natural world support his idea.

Darwin spent most of his life ill, starting with his voyage on The Beagle. In a Christmas, 2009 article from the British Medical Journal, professor John Hayman commemorated Darwin’s 200th birthday by trying to figure out just what malady caused his suffering. The article is behind a paywall, which is too bad. It’s pretty cool. Luckily, you’ve got me to summarize it for you:

Darwin suffered from what had been assumed to be severe sea-sickness during his journey, with episodes of nausea, vomiting, abdominal pain, weakness, and lethargy. He also complained of disabling visual disturbances, palpitations, dizziness, and “inordinate flatulence.” These symptoms occurred in spells or attacks throughout the rest of his life, though it appears that in between spells he felt fairly well—well enough to father 10 children. He also lived to the age of 73. Whatever caused these symptoms, it probably wasn’t something progressive that killed him.

A number of historians have suggested psychological diagnoses, including hypochondria and panic attacks; others have speculated that his symptoms stemmed from guilt related to issues in his relationships with his father and wife, or misgivings about how his theories fit in with his theological beliefs. Others have proposed a number of different medical diagnoses, including Meniere’s Disease, arsenic poisoning, and Chagas Disease.

In this review, the author makes a compelling case for a different diagnosis: migraine. Though most migraines in adults are dominated by headaches, in children (and some adults) the primary symptoms can be in the gut: abdominal pain, nausea, and vomiting. Terms such as “cyclic vomiting syndrome” and “abdominal migraine” are now being used to describe these atypical migraines. They’re not terribly uncommon, and they can truly be disabling. As with other migraine conditions, there are no symptoms between attacks. We don’t know for sure, but it seems likely that migraine was the cause of Darwin’s illness.

Darwin had no knowledge of genes or mutations or chromosomes—these concepts and discoveries developed later, and have provided molecular confirmation of Darwin’s theory. Archeology has also progressed exponentially since Darwin’s time, and the accumulated evidence from bench science, anthropology, archeology, and molecular genetics has reinforced the usefulness and basic truth of Darwin’s theory. I wonder how much further he could have gone with a few basic tools to treat his migraines.

Acupuncture doesn’t work, and the media blows it again

October 8, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

This blog is here to provide solid, reliable, science-based information. And by science based, I mean I read the actual studies in the actual science literature—sometimes requiring great quantities of coffee, yes, but that’s the price one has to pay. Then I tell you honestly what’s been figured out. Sometimes it’s something new, sometimes it’s something old, and often it’s something that disagrees with what you’re reading in the newspaper. Such is the nature of science: it is not a static body of knowledge, but rather a method of observing and testing the natural world. Progress. Science!

Media reporters are supposed to read and interpret, too. After all, most people don’t have the time/patience/wherewithal/serum caffeine concentration to wade through the arcana of the scientific literature. So the “science media” developed, to interpret what the big-brained eggheads were up to, to explain things so we could all become more knowledgeable.

To my dismay, science reporting is often just… deplorable. Journalists seem to parrot whatever the “message” is supposed to be, whether or not it’s supported by the research. No one talks about who did the study, who influenced the study, what the study’s shortcomings are, or what the study really showed. You get a snappy headline that’s akin to a nearsighted monkey throwing a water balloon at a pile of porcupines. I suppose wherever it pops, that’s the truth. Take the recent reporting of the AAP’s new opinion on circumcision. What the AAP actually said was that the benefits of circumcision are small, but that they outweigh the risks; so insurance should pay for the procedure for parents who choose it for their babies. The AAP did not endorse circumcision for all babies, despite what the headlines proclaimed.

And now, a new example. The headlines: “Acupuncture provides true pain relief in study” (New York Times), “Acupuncture works, one way or the other” (CNN). Even the National Library of Medicine joined the bandwagon: “More Evidence Acupuncture Can Ease Chronic Pain.”

Wow. One might think from these unequivocal headlines that some kind of new study has really proved that acupuncture works. Unfortunately that’s not what the “study” showed.

The paper itself was published last month in The Archives of Internal Medicine. The authors, all members of the Acupuncture Trialists’ Collaboration, re-reviewed data from 29 of the 31 previously published, randomized trials of acupuncture for any of 4 chronic pain conditions, mashing up the aggregate patient sets into one big study. This is called a “meta-analysis”—it’s not new research, per se, but a way of seeing an overview of a number of studies. Of course, if the studies collected were biased or of questionable quality, a meta won’t make them any more reliable; still, a re-publication seems to attract media eyeballs.

So what did the authors say that they found? There are a lot of statistics to wade through, but I’ll simplify: assume that your back hurts, and on a scale of 1-100 you rate the pain a “100”. On average, the included studies found that your pain would be reduced to a score of 60 with no intervention at all—that’s the reduction for people who had no change in anything the were doing for the pain. The people who had sham acupuncture, using fake needles, had a reduction down to 35. And the people who underwent true acupuncture had their pain reduced all the way down to… 30.

Got that? Doing nothing improves your pain by 40 points. Getting fake acupuncture reduces your pain by a total of 65 points, or 25 points more than doing nothing. And real live genuine pointy acupuncture will get your pain down by another whopping 5 points.

Do you think anyone could tell the difference between a pain score of 30 or 35 on a scale of 100? And: do you think these studies, many of whom the authors themselves admit could not be free from bias or well-blinded, could possibly accurately measure or confirm a 5 point difference?

Even more compelling: if you really focus in on the few best recent studies of acupuncture, using fake needles or other tricks to effectively blind both the patients and the acupuncturists so that no one knew whether real acupuncture was being performed, you find one consistent result: Acupuncture is no better than fake acupuncture. It doesn’t matter where you stick the needles, or whether they even puncture the skin. Acupuncture doesn’t do anything beyond what imagination, expectations, and natural healing would have done anyway.

So: a reasonable, truthful headline on this study would have been “Acupuncture no better than fake,” or “Once again, acupuncture fails to prove its worth.” And the media blows it again.

For more detailed reviews of this study, placebo effects, meta-analyses, and the sorry state of science news reporting, visit Science Based Medicine blogs here, here, and here.