Ten-year-old Brett was brought to the office with a chief complaint of “headache”. Naturally this perked my interest.This could mean so many different things.

 

When I entered the room he was sitting with mom and looked to be very healthy. I asked him how his summer had been, how he was faring with the quarantine because of Covid-19, and how he liked the virtual school as a result. He shrugged his shoulders and said it was alright.But he missed his friends and missed playing baseball. He seemed very appropriate and “all boy”.  

When I asked about his headaches he said that he had been having them for over a year. They happen every couple of months but he didn’t feel they were getting worse. Mom said that since school was shut during the Spring because of Covid and he was now home with her, she actually observed two of these headaches. She thought they seemed to be migraines which she herself gets as well as her mother.
 

In describing the headaches he said they are always the same.

 

First comes a tingling in his cheeks.Then his vision gets funny, sort of blurred.Half an hour later he gets the pain which is in his forehead and pounding. He feels nauseated but doesn’t vomit. If he lies down in a dark room, it eventually goes away. Mom gives him Motrin and it seems to help a little. They usually last an hour or two.
 

His blood pressure was normal as was his vision, 20/20 in both eyes.

 

My completed exam included a detailed neurological exam which was normal. His tempero-mandibular joints were checked to be sure there was no TMJ disease,also a known cause of headaches.The blood vessels of the retina appeared normal. After finishing his exam and commented how healthy he was, mom asked if we could do an MRI or a CT scan. Clearly she was worried and concerned. I reassured her that he did not need any imaging based on the fact that his neurological exam was normal.The headaches had been there for over a year and were not getting worse, and his history was classic for migraine.  

The red flags for doing imaging in children with migraines included those younger thanthree years of age who had recent onsets less than six months with progressive worsening of headaches or seizures. Also early morning occurrence of headaches with vomiting, double vision or worsening of headaches with straining or any irregularity with a neurological exam. Brett did not meet any of these criteria.
 

Migraine headaches are not uncommon in children and usually there is a strong family history of them.

 

Up to 60% will endorse a close family member with migraines. In children the incidence is 9.1%. They occur in 1.2% of young children and in as many as 23% of adolescence. Before the age of puberty migraines are more common in boys than in girls, but in the teen years they are two-three times more likely in females. Over 50% of children with migraines will have had their first headache before the age of 12 years and they are one of the main causes for a referral to a pediatric neurologist.
 

When discussing these headaches, they can be divided into those with an aura or those without an aura.

 

Twenty percent of childhood migraines will be associated with an aura or a preceding event that occurs before the headache actually starts. In children, the most common aura is a visual one.It can present as blurred vision, a hole in the center of the field of vision, a curtain drawn over part of their field of vision, or they may report floaters or flashes of light. There may also be numbness or tingling of the face or extremities. Weakness may occur or speech problems or problems with coordination. The aura precedes the headache by anywhere from 5-60 minutes. After the aura, the headache starts.in children it is usually a frontal headache in the forehead and it may be one-sided or on both sides. It is described as a pulsating or throbbing pain. There is often nauseaor vomiting, and photophobia (sensitivity light), or phono-phobia (sensitivity to sound). Increased activity usually makes it worse and the sufferer tends to want to be alone in a dark and quiet room. The headache can last for a few hours up to a day or even longer.
 

The treatment for migraines encompasses many different facets. Certain behaviors can contribute such as poor sleep hygiene.

 

Teenagers should get 8-10 hours of good quality sleep, not poor sleep from snoring or sleep apnea. Using electronic devices late into the night can interfere with good sleep so all electronics should be turned off at least an hour before bedtime. If a child has trouble transitioning into sleep melatonin may help. Many teenage females with migraines report that they are much worse when having their periods, and this should be addressed. Teens who do not drink enough fluids during the day are more likely to have a flare up of their migraines. They should be encouraged to drink enough fluids that they void at least six times a day. Other predisposing causes of migraines are stress, anxiety and depression. These too should be addressed. Certain foods have been implicated in triggering migraines including caffeine, MSG, soy, chocolate, nitrites, beer and wine.
 

Medications used to treat migraines can be divided into those that are abortive and those that are preventative (taken every day for months or even longer if needed).

 

The abortive medications are to be taken at the first sign of an aura or as soon as the headache starts. These should prevent or greatly modify the pain. These include the non-steroidal anti inflammatories such as acetaminophen (Tylenol) and ibuprofen (Motrin and Advil). Another group of abortive medications are the triptans that include Imitrex. If a migraine sufferer is having to use these more than once a month it would be time to discuss starting a preventive medication.
 

Preventive medications used for migraines can be divided into four main groups: antihistamines (Periactin), antidepressants (Elavil), anti-seizure medications (Topamax, Zonagram, Gabapentin), and anti-hypertensives (Inderol).

 

Personally, I am comfortable prescribing Periactin as a first line preventive medication for my younger patients.But if it comes to using the other preventive medication I would refer to a neurologist. Periactin doesn’t seem to be as effective in older migraine patients (high school age and older).
 

In addition to the medications described above, many neurologists will also use Riboflavin (Vitamin B-2), Co enzyme Q, or Magnesium.

 

Depending on the individual case, some may recommend biofeedback, cognitive behavioral therapy, or acupuncture. Botox, which is used with success in adults with migraines, has NOT been shown to be helpful in children.
 

In Brett’s case, he had relatively few migraines and all had a distinct aura preceding them. I asked Brett and mom to keep a headache log about activities and diet surrounding each one. I wanted him to take Ibuprofen (Advil or Motrin) at the VERY FIRST SIGN OF AN AURA to see if we could abort the headache. Ideally he could take this before it actually starts. When school returns back to the classroom I wrote a note to his teacher stating that he should be allowed to take the Ibuprofen as soon as possible which may mean going to the school nurse.I filled out a form for the school nurse to administer this. I wanted to see Brett back in one month unless things changed in any way. Brett looked at me with a very serious look and said, “ I think that another triggering event for me is Math.Could you write me a note excusing me from Math?” Then he giggled. We all got a laugh out of that and as I gave him a high five I said, “…Well played Brett!”