New guidelines for therapies for children and adolescents can reduce or eliminate attacks of migraine and greatly shorten their duration.
My grandson Stefan was about 8 years old when he began to get migraine headaches. As soon as he could after getting home from school, he would lie down and go to sleep, awakening an hour or two later, usually with the headache gone. But before the pain abated, he sometimes vomited, prompting him and his relatives to keep barf bags handy at all times.
Then as Stefan approached puberty, these debilitating headaches stopped as mysteriously as they had begun.
Though Stefan’s headaches were disruptive and disabling, he was luckier than his grandma. My migraine attacks (misdiagnosed as sinus headaches) began around puberty, usually occurred three times a month, each lasting for three days, and didn’t end until menopause. Even though sleep can often terminate a migraine attack, nothing I tried brought relief, and there were no prescription medications at the time to treat or prevent them.
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Migraine is a disease with a genetic component and often runs in families. The pounding, nauseating headache is a symptom of that disease. Before puberty, the disorder affects boys and girls equally, but after puberty, when testosterone kicks in to suppress migraine attacks in boys, the incidence among girls becomes very much higher.
Happily, for the more than six million children who suffer frequently from migraine headaches, the prospects for relief are now very much better than when I was a teen and premenopausal adult. In August, the American Academy of Neurology and the American Headache Society issued new guidelines for therapies for children and adolescents that can both reduce, if not eliminate, attacks of migraine and greatly shorten their duration.
Since 2004, when the organizations published the first set of guidelines, “a lot more studies have been done of acute and preventive therapies that have been approved for children and adolescents by the Food and Drug Administration,” said Dr. Andrew Hershey, professor of pediatrics and neurology and director of the Headache Center at Cincinnati Children’s Hospital Medical Center.
For youngsters with chronic migraine who have headaches for about 15 or more days a month, there is now at least one effective preventive: a combination of cognitive behavioral therapy and an antidepressant called amitriptyline (Elavil), Dr. Hershey said. Treatment options for an acute headache run the gamut from an over-the-counter NSAID (nonsteroidal anti-inflammatory drug like ibuprofen) to a prescribed triptan like Imitrex, Maxalt or Zomig that are safe and effective for young sufferers, he said.
Interestingly, with respect to preventives, the main randomized study of 361 young patients, called CHAMP, found that a reduction of 50 percent or more in the number of headache days occurred in both groups taking either the drug amitriptyline or topiramate (Topamax, an anti-seizure drug), as well as those in the placebo group, and the active drugs caused more side effects.
The findings suggest to Dr. Hershey, “It’s not so much what we do but how we do it. We offer options: ‘Do headaches bother you enough to take a preventive medication every day?’ We give patients the choice, and the expectation of a response drives a clinically positive result.
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Attention parents, teachers, coaches, doctors and anyone else who interacts with children and teens: Too often, adults tell them to “suck it up, it’s just a headache.” A migraine is not “just a headache,” nor is it something they can ignore. A migraine makes you feel sick all over, often acutely sensitive to light and noise, nauseated and unable to concentrate on anything but the desire for relief. Very young children with migraine may be spared the head pain and instead get only gastrointestinal symptoms like vomiting and stomach pain.
“We can use that expectation clinically, telling patients they don’t have to be on medication very long. When the frequency of headaches declines to two or three times a month and the headaches go away in an hour, they can stop preventive medication and use an acute therapy to treat the headache when it occurs.”
Based on the results of the CHAMP trial, Dr. Christina L. Szperka, pediatric neurologist and director of the pediatric headache program at Children’s Hospital of Philadelphia, suggests that clinicians first try a nutraceutical like magnesium or riboflavin (vitamin B2) to reduce headache frequency, along with lifestyle measures like staying well hydrated, eating regular meals, not skipping breakfast, getting enough sleep and getting some exercise.
She told NeurologyLive: “If the act of taking something like a pill every day and believing it is likely to help you and is part of what triggers the body’s response to heal itself, then we feel like it makes sense to think about using something that’s pretty harmless to start the process. If they don’t respond to those nutraceuticals, then that’s when we bring in the other prescription medications.”
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Dr. Amy Gelfand, director of the child and adolescent headache program at the University of California, San Francisco, has found that taking melatonin along with riboflavin can also help to reduce the frequency of migraine attacks. Melatonin is the body’s natural sleep-inducing hormone and is available in pharmacies without a prescription.
“Too often kids and families are told nothing can be done about migraine,” Dr. Gelfand said. “That’s the wrong message. The kids who are being treated are doing really well.”
One often overlooked contributor to attacks of migraine is stress. Dr. Szperka told me, “Stress is a huge factor in migraine. Kids have told us, ‘If I’m worried about something, that’s when I have my headache.’ Kids today are under so much pressure to do well in school and in sports if they want to get into a good college. They push themselves and suffer. Sometimes the best suggestion to them is to ease up academically.”
Although it has long been thought that certain foods — like chocolate, aged cheese, processed meats, citrus fruits and artificial sweeteners — can act as triggers for a migraine headache, experts say this has yet to be proven. The chocolate myth may have arisen, Dr. Gelfand suggested, because the premonitory phase before a migraine attack often induces a craving for sweets.
Still, for those who suspect a particular substance or circumstance may be acting as a migraine trigger, it can help to keep a diary, recording under what conditions the headaches seem to occur. A woman I know used a food diary to discover that her headaches followed consumption of corn in any form, even cornstarch as an ingredient.
If a child’s primary care doctor is unable to deal successfully with migraine, the experts urged parents to consult a pediatric neurologist or headache specialist.
By Jane E. Brody
Image by Gracia Lam