Headache: Migraine

What is it?

Although many people commonly use the term "migraine" to mean any severe headache, it really refers only to a specific category of headaches. The exact cause of migraines is still unclear. It seems to be a combination of factors. Sudden release of a brain chemical called "serotonin" is one factor. Another is the expansion and contraction of arteries in the covering layers of the brain. This causes the throbbing, severe pain of a classic migraine. Migraines appear to run in families, although doctors do not fully understand the pattern. As many as 5% to 10% of children suffer from migraines.

There are many different kinds of migraine headaches. The most common kind, and the one we’ll talk about here, has certain typical characteristics. Most patients with classical migraines develop an "aura," or warning of an upcoming attack. Auras can take many different forms. They can be unusual sounds, or changes in vision, smell, or taste. Some patients say they see "halos" around objects, or shooting lights. Others report a "metallic" smell or taste just before a headache. In rare cases, patients have the "Alice-in-Wonderland" syndrome, in which things suddenly look much bigger or much smaller than they really are. Following the aura, the person goes on to develop a severe headache within a few minutes to an hour. Knowing about the aura is important, because many of the medicines for migraines work best if we use them as early as possible in the attack.

Once the headache starts, a person with a migraine has severe, pounding or throbbing pain in the head. The pain is not usually easy to locate to one part of the head. Many migraine sufferers have vision changes during the headache, such as black spots (doughnut vision) or narrowing of their vision (tunnel vision). Some have sections of their normal visual field that go black (field cuts). Many people complain of nausea and may even vomit. On rare occasions, people with migraines develop a temporary paralysis of part of the face or body. They may have tingling or numbness in one area. These signs often make the person or the doctor worry about a stroke.

Migraines almost always get better with sleep – in fact one important part of the diagnosis is learning if sleeping helps the headache go away. While it can happen, most people with migraines do not wake up with a new migraine headache.

Relief of pain is always the first concern. After that we need to make sure we have the correct diagnosis, especially if this is the first time a child has had such a headache. Other, more dangerous conditions can sometimes act like migraines. Many doctors are comfortable doing this with a careful history-taking and a thorough physical examination. Next, they may suggest a trial of migraine medication. If the symptoms and history are classical, and the migraine medicine works, no further tests may be needed. If the findings are not typical for migraine, doctors often look at CT or MRI scans or other tests before making a migraine diagnosis.

Once the doctor is certain of the diagnosis of migraine, the biggest concern is treating the pain for the duration of the attack. Your doctor will then work with you and your child or teen to help recognize symptoms. In this way, we can prevent future attacks, or at least cut them short with medication. Finally, as with other diseases that come and go (such as asthma and allergies), it is very important for both the child and the family to learn to identify "triggers" that can set off an attack. In many cases, the child can learn to avoid these triggers and control the condition.

The first few times a child or teen has a migraine, many doctors recommend basic pain medications like acetaminophen (Tylenol® and others) or ibuprofen (Advil® or Motrin®). These medicines often work, and are worth a try because they are so safe and have few side effects. Many children and teens with migraines find that they need more powerful medication during the worst of the attack, however. Mild narcotic pain medicines like codeine, hydrocodone (Lortab® and others), or mixtures such as Tylenol 3®, Tylenol® with Codeine, or Vicodin® and others can be very helpful. In some cases the pain is severe enough to require a potent narcotic like morphine or dilaudid by injection. Some patients may require a few days’ supply of these medicines to take by mouth at home. Please know that these medications are extremely safe when used as directed and under a doctor’s careful observation. If one uses them only to treat pain, the risk of addiction is quite low. Most doctors have learned to get their patients’ pain under control quickly with strong medications. Then they can actually use less powerful medicines for shorter periods of time later on. All of the narcotics cause some degree of constipation in most people. It is a good idea to have a supply of stool softener such as docusate (Colace® and others) or a bulk laxative such as psyllium (Metamucil® and others).

Once the diagnosis of migraine is reasonably certain, most doctors and patients prefer to switch to a different medication to try to treat attacks early. The most effective drug for this purpose so far is one called "sumatriptan" (sue-mah-trip-tan) (Imitrex® and others). It is available in oral and self-injectable forms, but most children prefer to use the nasal spray version. Sumatriptan works very quickly, with relief within a few minutes to half an hour. Some children do not get relief from sumatriptan. These children may have to rely on the pain relievers we discussed above, until some of the promising newer drugs are available.

Other medications that doctors sometimes use instead of or in addition to sumatriptan include ergotamine (err-got-ah-meen) (Migranal®, Cafergot®, and others). These medications tend to have more side effects than sumatriptan, but in some cases they are necessary. Some anti-nausea or anti-vomiting drugs, such as prochlorperazine (Compazine® and others) and metaclopromide (Reglan®) sometimes work as well, with relatively few side effects. Certain anti-depressant medications sometimes are helpful at preventing painful attacks, though doctors prefer to avoid these.

If your child has very frequent migraines, your doctor may recommend a preventative medication for him or her to try. Unfortunately, no medicine has turned out to be effective at preventing migraine attacks reliably. This means that the migraine patient must learn to identify his or her own "triggers," and how to avoid them. A good way to do that is to start keeping a diary each day of foods and activities. Then, when a migraine happens, you and your child can look back and see what things might be associated with the headache. You may want to start by avoiding certain food categories that are well-known to trigger or worsen migraines. These include:

• Foods containing a chemical called "tyramine" (for example, aged cheeses, sour cream, and yogurt)
• Chocolate
• Dairy products
• Foods with additives such as nitrites, MSG, or aspartame.

A change in caffeine intake, either up or down, can also trigger migraine. Please remember that there’s caffeine in many drinks other than coffee, such as colas and other soft drinks. Young adults with migraines should avoid alcohol, especially red wine.

Relaxation techniques and biofeedback can also be useful in children who are old enough to participate.

Migraines can be excruciatingly painful, but they are not dangerous. In most cases, the main thing to worry about is getting the pain under control quickly and effectively. Migraine headaches change in children as they get older, and children grow larger. This can mean that the dose of medicine that worked the last time may not be effective this time. Please check with your doctor if your child does not get prompt relief from pain, or at least fall asleep, after taking the correct medicaition. In most cases, pain can be relieved, and there’s no good reason for a child to suffer in pain.

Please remember that children who get migraines can also get other kinds of headaches for the same reasons that other children get them. Sometimes there are other conditions or complications going on. Here are a few things to watch out for:

• Fever with a headache
• Stiff neck
• Any major change in the type of headache or a difference in the aura
• Paralysis, numbness, weakness or tingling that is new or not common in your child’s "normal" migraines
• Difficulty speaking
• Mental confusion
• Abnormal gait (walking)
• Vision changes that don’t go away when the pain clears up
• Persistent vomiting
• Lethargy (sleepiness) or unconsciousness

If any of these occur, please be sure to call your doctor’s office right away. If your child is difficult to awaken or seems unconscious, go directly to the emergency room.

Migraines can be severe enough to cause reduction in a child’s or family’s quality of life and emotional health. Their treatment can be frustrating, although eventually most sufferers find a combination of diet, lifestyle, and medication that works. Talking to others who have migraines, or whose children do, can be very helpful. If you would like more information about migraines, diet, or other facts about migraines, two good on-line sources are the Migraine Awareness Group and the U.S. Food and Drug Administration’s migraine site.

Once a child has had the same kind of headache more than a few times, it is usually pretty clear if s/he has migraines. The first few times, though, we always have to keep in mind other possibilities. You can read our Aftercare Instructions on Non-Migraine Headaches.  Causes for these include:

• Tension headache – usually in older children and teens, this kind of headache feels like a tight "band" around the head, and is often worse at both temples. It is related to muscle tension in the neck and shoulders. Tension headaches are usually easy to relieve with acetaminophen (Tylenol® and others) or ibuprofen (Motrin® or Advil® or others). A warm bath or shower, and/or a shoulder and neck massage can help a great deal.
• Sinus headache – in children over 5 to 6 years old, sinus headaches cause pain in the forehead and cheeks. Some people describe this pain as a "heaviness" in the face. Other people have tooth pain with it. Children and teens with sinus headaches often suffer from allergies or asthma as well. Sinusitis is an infection of the sinuses that can cause severe pain, fever, and tenderness over the areas. People with sinusitis often have cloudy yellow or green drainage from one or both sides of the nose. Bad breath is another symptom of sinusitis.
• Vision problems – if your child complains of headaches near the end of school every day, or seems to sit too close to the TV to watch it, s/he may have a vision problem. Please ask your doctor about whether a vision test is a good idea. This is a cause of headache that is easy to fix.
• Anxiety or depression – teens who are feeling depressed, anxious, or worried, or who are having turmoil in their lives, may complain of a headache even when we cannot find a physical cause. This does not mean that the teen is lying or making up the headache. It does mean that most medications won’t work, and that some sensitive talking and gentle exploration of his or her issues by a trusted parent or counselor would be a good idea.

Having a sick child at home can be tiring and frustrating. As badly as you feel for your child, you yourself may feel out of control, inadequate, or even angry – these are normal feelings. Children who are sick are often fussy and irritable, and parents often feel stressed to the breaking point, especially when there are other children or adults to take care of. One of the best things you can do for your child is to be sure you take care of yourself. If possible, try to have other adults take care of your child for an hour or two each day so you can get some rest or just some quiet time. If you get so stressed that you are worried about your baby’s safety, call your local Parents’ Anonymous Hotline or visit the Parents Anonymous website to find a group near you.