By the time Mira Halker started high school, hardly a day passed that she wasn’t either getting a migraine attack or recovering from one. She missed volleyball team practice. She missed classes. She missed social events. And few people understood. After all, she looked healthy.
“A lot of times, people think I’m faking it,” said Mira, now 16, who lives in Phoenix. Friends called her flaky; her volleyball coaches questioned her dedication to the team. “I’m like, ‘I’m not trying to get out of this. This is not what this is about,’ ” she said.
Her mother, Rashmi B. Halker Singh, MD, is a neurologist at Mayo Clinic who happens to specialize in migraine. Even so, finding a solution was not easy. Neither ibuprofen nor triptans, nor various preventive measures such as a daily prescription for topiramate controlled the pain and associated symptoms. Mira was barely making it through her school day and had to quit volleyball. Then, in the spring of 10th grade, Mira told her mother that she couldn’t go to prom because the loud noises and lights could give her a migraine attack.
Mother and daughter decided it was time to get even more aggressive. “There are these key moments in life that you can’t get back,” Singh said. “Migraine steals so much from you.
Diagnosis
One of the challenges Mira’s physicians faced was deciding which medications and other therapies to prescribe to a teenager. Drug companies have been releasing a steady stream of new treatments for migraine headaches, and researchers promise more are on the way soon. Here’s what works for children, what hasn’t yet been approved for use with minors, and how to diagnose migraines in the first place, from experts at some of the nation’s leading pediatric headache centers.
Migraine affects about 10% of children, according to the American Migraine Foundation. The headaches can strike children as early as age 3 or 4 years, said Robert Little, MD, a pediatric neurologist at Phoenix Children’s Hospital.
Before puberty, boys report more migraine attacks than girls, according to the American Academy of Pediatrics. But that reverses in adolescence: By age 17, as many as 8% of boys and 23% of girls have had migraine. To diagnose migraine, Juliana H. VanderPluym, MD, associate professor of neurology at Mayo Clinic in Phoenix, said she uses the criteria published in the latest edition of the International Classification of Headache Disorders (ICHD): A patient must have had at least five attacks in their life; and in children and adolescents, the attacks must last no less than 2 hours.
In addition, the headaches should exhibit at least two out of four features:
1. Occur more on one side of the head than the other (although VanderPluym said in children and adolescents headaches often are bilateral).
2. Be of moderate to severe intensity.
3. Have a pounding or throbbing quality.
4. Grow worse with activity or cause an avoidance of activity.
If the attacks meet those criteria, clinicians should check to see if they meet at least one out of the two following:
1. Are sensitive to light and sounds.
2. Are associated with nausea and/or vomiting.
A clinician should consider whether the headaches are not better accounted for by another diagnosis, according to the ICHD criteria. But, VanderPluym warned that does not necessarily mean running a slew of tests.
“In the absence of red flag features, it is more than likely going to be migraine headache,” she said. That’s especially true if a child has a family history of migraine, as the condition is often passed down from parent to child.
Ultimately, the diagnosis is fairly simple and can be made in a minute or less, said Jack Gladstein, MD, a pediatrician at the University of Maryland whose research focuses on the clinical care of children and adolescents with headache.
“Migraine is acute,” Gladstein said. “It’s really bad. And it’s recurrent.”
First Line of Treatment
Whatever a patient takes to treat a migraine, they should hit it early and hard, Gladstein said.
“The first thing you say, as a primary care physician, is treat your migraine at first twinge, whatever you use. Don’t wait, don’t wish it away,” he said. “The longer you wait, the less chance anything will work.”
The second piece of advice, Gladstein said, is that whatever drug a patient is taking, they should be on the highest feasible dose. “Work as fast as you can to treat them. You want the brain to reset as quickly as you can,” he said.
Patients should begin with over-the-counter pain relievers, Little said. If those prove insufficient, they can try a triptan. Rizatriptan is the only such agent that the Food and Drug Administration has approved for children aged 6-17 years. Other drugs in the class — sumatriptan/naproxen, almotriptan, and zolmitriptan — are approved for children 12 and older.
Another migraine therapy recently approved for children aged 12 and older is the use of neurostimulators. “It’s helpful to be aware of them,” VanderPluym said.
However, if neurostimulators and acute medications prove insufficient, clinicians should warn patients not to up their doses of triptans. Rebound headaches can occur if patients take triptans more than twice a week, or a maximum 10 days per month.
Another possibility is to add a preventive therapy. One mild, first option is nutraceuticals, like riboflavin (vitamin B2) or magnesium, said Anisa F. Kelley, MD, a neurologist and associate director of the headache program at the Ann and Robert H. Lurie Children’s Hospital of Chicago.
“We don’t have definitive evidence, but they’re probably doing more benefit than they are harm,” Kelley said of these therapies. “In patients who have anywhere from 4 to 8 migraine days a month, where you’re in that in-between period where you don’t necessarily need a [prescription] prophylactic, I will often start with a nutraceutical,” Kelley said.
For those patients who don’t respond to nutraceuticals, or who need more support, clinicians can prescribe amitriptyline or topiramate. VanderPluym said.
A 2017 study found such prophylactics to be no more effective than placebo in pediatric migraine patients, but experts caution the results should not be considered definitive.
For one thing, the study enrolled a highly selective group of participants, with milder forms of migraine who may have improved anyway, VanderPluym said. All participants also received lifestyle counseling.
Every time participants came in for a follow-up, they were asked questions such as how much water were they drinking and how much sleep were they getting, Kelley noted. The takeaway, she said: “Pediatric and adolescent migraine [management] is very, very much reliant on lifestyle factors.”
Lifestyle Triggers
Clinicians should counsel their migraine patients about lifestyle changes, experts said. Getting adequate sleep, staying hydrated, and managing stress can help reduce the intensity and frequency of attacks.
Migraine patients should also be mindful of their screen time, Kelley added.
“I’ve had lots and lots of patients who find excessive screen time will trigger or worsen migraine,” she said.
As for other potential triggers of attacks, the evidence is mixed.
“There’s clearly an association with disrupted sleep and migraine, and that has been very well established,” Little said. “And there is some modest amount of evidence that regular exercise can be helpful.” But for reported food triggers, he said, there have been very inconclusive results.
Commonly reported triggers include MSG, red wine, chocolate, and aged cheese. When Little’s patients keep headache diaries, tracking their meals alongside when they got migraine attacks, they often discover individualized triggers — strawberries, for instance, in one case, he said.
Scientists believe migraines result from the inappropriate activation of the trigeminal ganglion. “The question is, what causes it to get triggered? And how does it get triggered?” Gladstein said. “And that’s where there’s a lot of difference of opinion and no conclusive evidence.” Clinicians also should make sure that something else — usually depression, anxiety, insomnia, and dizziness — is not hindering effective migraine management. “If someone has terrible insomnia, until you treat the insomnia, the headaches aren’t going to get better,” he said.
As for Mira, her migraine attacks did not significantly improve, despite trying triptans, prophylactics, lifestyle changes, and shots to block nerve pain. When the headaches threatened Mira’s chance to go to her prom, her neurologist suggested trying something different. The physician persuaded the family’s insurance to cover a calcitonin gene-related peptide antagonist, an injectable monoclonal antibody treatment for migraine that the FDA has currently approved only for use in adults.
The difference for Mira has been extraordinary.
“I can do so much more than I was able to do,” said Mira, who attended the dance migraine free. “I feel liberated.”
It’s Only Migraine
One of the greatest challenges in diagnosing migraine can be reassuring the patient, the parents, even clinicians themselves that migraine really is the cause of all this pain and discomfort, experts said.
“A lot of migraine treatment actually comes down to migraine education,” VanderPluym said.
Patients and their parents often wonder how they can be sure that this pain is not resulting from something more dangerous than migraine, Little said. In these cases, he cites practice guidelines published by the American Academy of Neurology.
“The gist of those guidelines is that most pediatric patients do not need further workup,” he said. “But I think that there’s always a fear that you’re missing something because we don’t have a test that we can do” for migraine.
Some warning signs that further tests might be warranted, Kelley said, include:
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Headaches that wake a patient up in the middle of the night.
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Headaches that start first thing in the morning, especially those that include vomiting.
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A headache pattern that suddenly gets much worse.
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Certain symptoms that accompany the headache, such as tingling, numbness or double vision.
Although all of these signs can still stem from migraines — tingling or numbness, for instance, can be signs of migraine aura — running additional tests can rule out more serious concerns, she said.
This story originally appeared on MDedge.com, part of the Medscape Professional Network.
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