Ryan is a healthy 11 year old boy that I have cared for since his birth. Other than an occasional sore throat, he comes in for his yearly physical and is the picture of health. He is quite an athlete too. He has played against my son in flag football, basketball and baseball. He strikes me as the All-American boy.
As I grab his chart, I assume that he is coming in today for the once a year sore throat. I am surprised however, to find him laying motionless on the examining table with a wet wash cloth on his forehead and a plastic bucket by his side...the make-shift emesis basin. That is always an ominous sign.
According to mom, Ryan was fine this morning while he was getting ready for school. But in the car, he complained of not feeling right, and his mom said he was quiet and almost "distant". He said that he was seeing spots or "floaters" before his eyes and he would blink to try to make them go away. He assured mom that he was all right, and said there was no way he could miss school because he had a big English test. At 10:15, mom got the call from the school nurse to come and pick him up. He had vomited and complained of a severe headache. From school she came directly to the office.
After getting a thorough history, it turns out that Ryan has had four such episodes over the past 5 months, but never quite this badly. Further questioning revealed that there is a strong family history of migraine headaches--mom herself suffers from them. But could Ryan, at 11 years of age and in such good health, have migraines?
Most parents are surprised to know that children have migraines. In fact, around 5% of all children under the age of 15 years suffer from them. The hallmark of migraines is recurrent headaches separated by pain-free periods during which the child is completely normal. The headache is usually abrupt in onset and builds in intensity over time. The frequency and severity of the headaches varies tremendously from child to child. Before puberty, migraines occur as commonly in males as they do in females. After puberty however, they are much more common in females.
There are certain factors that may precipitate migraines and these include: stress, fatigue, over-exertion, menstruation, alcohol, caffeine, certain antibiotics, diet and birth control pills. In evaluating a child with migraines, a strong family history can be obtained in over 75% of the cases.
The exact cause of these headaches is unclear. One theory suggests that it has to do with constriction of blood vessels in the brain, followed by a dilating of these vessels. Another more recent model points to alterations in certain brain neurotransmitters, particularly serotonin.
There are two major types of childhood migraines, namely common and classic. Common migraines as the name suggests, is the most common type seen in children. There is no preceding focal disturbance (aura), but the child may be reported to be irritable and pale. Shortly thereafter, the headache starts abruptly. It is described as a throbbing, bilateral headache that is most intense over the forehead. This may be accompanied by abdominal pain, nausea, loss of appetite and vomiting. This headache is often relieved by sleep if the child is able to do so.
Classic migraines occur in about a third of these children. These are preceded by an "aura" which can take on many forms. The child may complain of blurred vision, seeing spots before their eyes, seeing flickering or flashing lights, or even the loss of a part of the field of their vision. The aura is replaced by the headache which is usually one-sided and is frequently accompanied by nausea and vomiting. Classic migraines will also abate if the child can fall asleep. This is best accomplished in a dark and quiet room.
There are a number of complex migraine disorders, and migraine variants that do occur, however, these are less common in children and a discussion of these entities is far beyond the scope of this article.
I carefully examined Ryan and could determine that his physical, with particular attention to his neurological status, was completely normal. Other than appearing a bit pale, he was fine. Further questioning revealed that each time Ryan got one of these headaches in the past, he was in the middle of a sport and was overly tired. I sensed that mom's biggest fear was that he could have a brain tumor. I assured her that children whose headaches are due to a brain tumor should have obvious neurological abnormalities on their physical exam within 6 months of the onset of headaches.
Ryan's mom then asked the next obvious question, "Are there any tests that can be done to prove that these are migraines?" I again assured her that in childhood migraines, if the history is typical, and the physical and neurological exams are normal, no lab tests or neurodiagnostic studies are necessary. This would include a CT scan, a MRI, or an EEG. In fact, they are a waste of time and resources. One paper states that lab tests have been helpful in identifying an organic cause in less than 5% of ALL children with headaches.
The treatment of childhood migraine requires an individualized approach that will vary with each child. First and foremost, it is essential to try and identify any of the precipitating factors. In Ryan's case, fatigue and over-exertion played a key role in triggering his headaches. We determined that these occurred during intense sports activities. Ryan is a highly motivated and competitive athlete, and curtailing his participation in sports was not even an option. His mother at least knew what to watch for and could insure that Ryan had appropriate "down time" and rested when things became too hectic.
Medications play an important role in the treatment of migraines. The therapy can be divided into three main categories. 1) acute symptomatic treatment--medications are given to relieve the symptoms once the headache has started. These include pain medications, anti-inflammatory drugs or certain combination drugs. In addition to these, it is often necessary to give something for the vomiting. 2) acute abortive treatment--there are a number of medications that can be given at the earliest sign of a headache starting, usually during the aura. If taken at the right time, the headache can be averted. 3) prophylactic treatment--this is reserved for the child whose migraines have sufficiently altered their life style. There are a number of different medications that can be used for this, and the children usually take these daily for a number of months. If successful in preventing the migraines, they can be tapered off over a short time period. Fewer than half of these children require a second course of prophylactic medication.
Some people feel that biofeedback and relaxation training may play a role in the treatment and prevention of migraines although, there is not a great deal of experience with this in children.
In Ryan's case, his mom was anxious to do something to prevent his migraines. Sports were important to him and today's headache scared both mom and Ryan. He did NOT want to have to go through anything like this again. I put him on cyproheptidine (periactin), which is an anti-histamine, three times a day for a 3 month period. During this time, he did not have a single headache. The dose was then reduced to once at bedtime for one month after which he was tapered off completely. This was 6 months ago, and he has been headache free ever since.