John, a healthy sixth-grader, came to the office for his sports physical.. Strong and well-developed, this young man not only excelled in the classroom but was an outstanding athlete in three different sports. He was in such good health the only time we have seen him was for his yearly physical.
Going through the review of systems I was surprised when asking about headaches. His mom nodded as to affirm that I had hit on something. I directed my question to John. He calmly answered, “Oh yeah, I get headaches all the time.”
Questioning further I was to learn that he gets significant headaches once or twice a month. At times they are severe enough to even cause him to be sent home from school. The headaches are painful and throbbing, located in his forehead. On a few occasions he has even vomited. None of the over-the-counter preparations give much relief. The only thing that seems to break the cycle is being in a dark room and falling asleep.
According to mom they weren’t as frequent in the past. But going through puberty, John seems to get them more often now. She added, “I have migraines and my mother had them also, but I didn’t think that children could get them.”
Migraines are actually quite common in childhood. The mean age of onset in boys is 7 years; in girls it is 11 years. For children between the ages of 3-to-7 years they are more common in boys; from 7-to-11 years the incidence between boys and girls is equal; after that they are more common in girls.
The cause of migraines is felt to be due to a genetically determined process involving the neurons of the brain, whereby the cerebral cortex is triggered into a hyper-excitable state. As a result, the blood vessels to the area become dilated. Some of the proteins “leak” into the surrounding tissue causing inflammation of the area which has now become hyper-sensitive. In this state, any stimulation--mechanical, thermal or chemical--can be perceived as pain.
There is an international classification of headaches and migraines which is beyond the scope of this article. But for discussion purposes we will look at migraines with an aura, migraines without an aura and Basilar Type migraines.
An aura is an event that occurs before the onset of the headache. This may be a visual disturbance such as flashes of lights, seeing spots or “floaters”, tunnel vision, loss of fields of vision, distortion of perception (Alice in Wonderland syndrome where little objects seem large, or vice versa) or actual hallucinations. These precede the headache, usually by minutes, and are completely reversible. The aura may also present as sensory symptoms such as a feeling of needles and pins, numbness, ringing in the ears or trouble speaking. These, too, are completely reversible. Around 15-to-30 percent of children with migraines will have an aura.
In childhood migraines, 60-to-85 percent DO NOT have an aura. To meet the criteria for having migraines a child needs to have had at least five such headaches. They last from 1-to-72 hours. The pain is in the front or side of the head (not in the back), is usually throbbing or pulsating, and is aggravated by normal physical activity such as climbing stairs or walking. There may be nausea and vomiting; however this is not always the case.
Approximately 3-to-15 percent of children with migraines have the Basilar Type (BM) which is actually a migraine variant. These start with symptoms of ringing in the ears, dizziness, trouble with speech, double vision, decreased hearing, numbness, and distortion of the fields of vision. These early transient features may last for minutes or up to one hour. They are then followed by the headache. Unlike the migraines described above, the BM headaches are usually located in the occipital area of the head; in the lower back portion. They, too, may be throbbing or pulsating.
When evaluating a child for possible migraines, a thorough and detailed history is critical. This also includes a good family history. Each child must have a complete physical exam including vision and blood pressure. A detailed neurological exam is imperative. If it is normal the chances of the headaches being due to a more serious and concerning diagnosis are much less likely. Nonetheless, the need for any imaging (CT or MRI of the head) must be made on an entirely individual basis.
The treatment must also be determined on an individual basis. If a person with migraines has an aura that precedes the actual headache, he can often take medicine at the first sign of the aura and “abort”, or prevent, the headache from starting. There are numerous drugs that are successful in doing this. However, most are not approved for persons under the age of 18 years. In the pediatric patient, one can try Ibuprofen or Acetaminophen at the onset of the aura with the hope of preventing the headache. It is important that the proper dosage is used as these medications are dosed per the patient’s weight.
If one is having migraines more frequently than 2-to-3 each month, most experts would agree that these are bothersome enough to consider a daily regimen to prevent the migraines altogether. One of the more successfully used medications in the pediatric patient with migraines is a well-known and safe antihistamine called cyproheptadine, or Periactin. This is given every day for 2-to-3 months as a preventive medication. Since it is an antihistamine, it may cause some drowsiness, but it can be given one a day, or divided into three times a day. The only potential side effect is that it can be an appetite stimulant. However, this is rarely problematic. If the Periactin is successful in preventing the migraines the patient is kept on this for 2-to-3 months. Thereafter they can be tapered off the medicine over the next 2-to-3 months. If the headaches do not recur the patient has a very good chance of being headache free from then on.
If the Periactin is NOT successful in preventing the migraines, there is a whole arsenal of various medications available which include: anticonvulsants (Topamax, Valproic acid, Gabapentin), tricyclic anti-depressants (Nortryptilin and Amitriptilin), calcium channel blockers (Verapimil) and beta blockers (Inderal). Which of these medications is to be used must be determined by the prescriber’s experience and comfort level. If I have a patient that has failed the Periactin trial, they will be referred to a pediatric neurologist for further treatment. Let them decide which medicine would serve the patent best.
In John’s case it was clear that he did suffer from migraines. With the long standing history of these headaches, classic family history, and completely normal exam I felt comfortable in not doing a CT or MRI of the head. He was started on Periactin, given twice a day, and tolerated this very well, having no side effects.
Once this program was started his migraines stopped completely. He was headache-free for the three months he took the Periactin. He was tapered to once a day dose for two months, and he did just fine. He has been off the Periactin for the past four months and has not had a single migraine since.