How Can Neurologists Manage Pediatric Migraine?

OJAI, CA—Migraine headaches can be debilitating in children and adolescents and result in more missed days of school and poorer performance in the classroom, compared with children without migraine, according to an overview presented at the 10th Annual Winter Conference of the Headache Cooperative of the Pacific.

Amy Gelfand, MD

Understanding Pediatric Migraine

Pediatric migraine is defined as at least five attacks that fulfill the following criteria: headache attack lasting for two to 72 hours (untreated or unsuccessfully treated), headache with at least two of four characteristics (ie, unilateral location [though in children it is often bilateral], pulsating quality, moderate or severe intensity, and aggravation by or causing avoidance of routine physical activity), and headache accompanied by either nausea and vomiting or phonophobia and photophobia. It affects approximately 5% of children by age 10, making migraine five to 10 times more common than epilepsy in children. Chronic migraine, which entails headache on at least 15 days per month for at least three months, affects 0.6% of children between ages 5 and 12.

Pediatric migraine can have a different phenotype than adult migraine. The shortest duration for untreated or unsuccessfully treated attacks in adults is four hours, compared with two hours in children. In addition, migraines in children and adolescents tend to be bilateral.

Following puberty, there is a higher prevalence of migraine among young women and girls than among boys and young men, said Dr. Gelfand. Also, children with low socioeconomic status are nearly fourfold more likely to have chronic migraine than children from affluent backgrounds.

How to Take a Pediatric Headache History

A systematic approach to taking a headache history can be helpful, said Dr. Gelfand. When neurologists take a headache history, seating the child or adolescent in a central position near the clinican can help signal that the patient is going to be the primary person to provide the history. In addition, neurologists should set expectations for pediatric patients by explaining the questions they are going to ask about the child’s headaches.

Children are encouraged to share additional information about their headaches and to ask parents for help when necessary. Also, neurologists should hesitate to consider “not really” an answer to questions about the presence of symptoms such as nausea or movement sensitivity, because it often means “yes, but it is mild, and I can handle it and do not want to complain.”

Finally, when querying for sensitivity to light or sound, neurologists are advised to ask the following questions: During your headaches, do lights ever bother you? Do lights ever seem brighter than usual? Do lights ever make the headache worse? “For younger kids who might not be able to articulate sensitivity to light or sensitivity to sound, we may be able to infer those sensitivity symptoms from their behavior. Are they pulling the blankets up over their head or are they asking for the TV to be turned off? These are behaviors that their caregivers can report,” said Dr. Gelfand.

Acute Migraine Treatment

Acetaminophen and ibuprofen have been examined in randomized controlled trials that included children as young as 4. These drugs appear to be efficacious. In addition, the FDA has approved four triptans for acute treatment of pediatric migraine. Almotriptan was approved in 2009 for adolescents ages 12 to 17. In 2012, the FDA approved rizatriptan for children and adolescents ages 6 to 17. Finally, in 2015, zolmitriptan, a nasal spray, was approved for adolescents ages 12 to 17, as was a combination including naproxen and sumatriptan. Children with a history of peripheral vascular disease, stroke, and uncontrolled hypertension should not use triptans for the treatment of pediatric migraine.

In addition, Powers et al observed that amitriptyline and topiramate were no different from placebo for reducing headache frequency; approximately 60% of participants in all three study arms improved. The 361 children and adolescents involved in the study received a lot of headache education and counseling about medication overuse, and also received optimally dosed acute migraine medications, which may have contributed to the high rate of excellent outcomes, said Dr. Gelfand.

Preventative Strategies and Diet

A key component to preventive care in pediatric migraine is maintaining a healthy lifestyle. Neurologists should encourage patients to eat regular meals, get regular exercise and sleep, and stay consistently hydrated. Additionally, daily preventive treatment may include medications or supplements that are well tolerated. Cognitive behavioral therapy can also be beneficial.

Children and adolescents with migraine should avoid fasting, alcohol, or nitrate-containing meats such as hot dogs, some lunch meats, salami, and beef jerky. Chocolate, cheese, citrus, gluten, sugar, or dairy might not need to be avoided. Also, proper hydration can help control or prevent migraines. Pilot studies have shown that increased water intake decreases headache hours and severity. Spigt et al found that greater water intake resulted in a statically significant improvement in quality of life.

The Future of Pediatric Migraine Research

Sixty percent of patients will improve following treatment, but 40% of patients do not get better. In addition, “children who have continous headache and medication overuse have not been well studied, so we do not know what treatments might be most effective for them,” said Dr. Gelfand. “These are the kids that our future trials should be focusing on. That is where we need to spend our time, money, and attention.”

—Erica Tricarico

Suggested Reading

Qubty W, Gelfand AA. Psychological and behavioral issues in the management of migraine in children and adolescents. Curr Pain Headache Rep. 2016;20(12):69.

Spigt MG, Kuijper EC, Schayck CP, et al. Increasing the daily water intake for the prophylactic treatment of headache: a pilot trial. Eur J Neurol. 2005;12(9):715-718.