Kids Korner Archive - #162

My doctor has diagnosed my child with migraine. How is migraine treated in children?

Calming the Migraine Brain

Migraine occurs when a genetically-predisposed nervous system meets an environment that surpasses the system’s ability to adapt to it. Psychologists and other trained healthcare providers can help identify triggering environments and teach children tools that will help them adapt.
Another way to think of it is that a child with migraine has a highly excitable brain that responds to change more readily than a person without migraine. An interview with the child and his parent(s) will uncover recent changes, but speaking to the child alone will provide insight into his perception of those changes. Often the child feels responsible or judges his performance as being below unspoken expectations. At night, instead of sleeping, the child may ruminate over what he fears he did wrong during the day and anticipate difficult situations the next day.

Children need a tool that enables them to turn off the critical voice inside. One effective tool is thermal biofeedback. By taping a finger thermometer to the index finger, the child can gauge for himself the amount of tension he is carrying. The average finger temperature is 85 degrees; those with migraine often have a finger temperature in the 70s. By visualizing a relaxing setting, the child can raise his finger temperature (the goal is 96 degrees). Children usually have few preconceived notions and learn the technique very quickly. By doing it daily, the child can shed built-up tension before it reaches migraine-producing intensity. Conversely, when his finger temperature drops, he’s able to recognize
that his nervous system is vulnerable to a migraine attack and prevent it through exercise, fun activities or more biofeedback.

Because of their vulnerability to changes, children with migraine need routine, as described in the following 10 tips to prevent children’s headaches:

• Eat breakfast and keep predictable mealtimes.
• Wake up at the same time each morning.
• Exercise at least three times a week.
• Do biofeedback daily to balance internal physiology.
• No caffeine. No aspartame.
• Listen to your body. Relax when you’re overloaded.
• Take time out. Set aside time for doing whatever you want.
• Talk about what you’re thinking.
• Accept imperfection. You don’t have to be the best all the time.
• Play is as important as homework and organized sports.

— Kathleen Farmer, PsyD, Headache Care Center, Springfield, Missouri

A Rational Approach to Medications

The cornerstone of migraine treatment is get to the headache before it becomes untreatable. A migraine is very easy to treat at first twinge, but very difficult to treat once your child is nauseous. Migraine responds to over-the-counter (OTC) as well as prescription drugs when treated early. So both your child and his teachers need to react to the first twinge of pain as if it were a medical emergency that can’t wait. The school nurse must understand that your child should get pushed to the front of the line and get his or her medication right away.

The second principle in acute migraine management is to use high doses of medicine, since the stomach is not emptying properly. Part of a migraine is a kind of stomach paralysis, which is why nausea is part of migraine for a lot of kids. To absorb a good amount of the medication in the bloodstream, aim for the higher dose given on the bottle of pain relievers (but do not exceed package directions).

The third principle is don’t waste time with oral medications once nauseated. A lot of youngsters have a very short window from first twinge to onset of nausea. Once nauseous, use nasal sprays or shots as they will be absorbed more reliably and consistently. (Nasal spray formulations and injections are by prescription only.) Don’t waste time with oral medications for children who wake with a migraine, as hours have likely gone by already since the attack began.

The fourth principle is get to know one medication at a time. Since each migraine may be a little different in severity, give a migraine medication a chance with at least three attacks before trying a new one.

The fifth principle is triptans are your friends. Although these medications don’t have an FDA-approved pediatric indication, the drugs are safe and effective for children. There is a technical reason for the lack of an FDA-seal of approval related to the design of the drug trials. There was a high placebo rate in these studies because the children received their study drug or placebo only when they got home from school. For many, the headache was already on the way to getting better whether they got a placebo or triptan. Nevertheless, all the studies showed the drugs to be safe.

Before there were triptans, we had little to offer the headache sufferer in the throes of a migraine, so we prescribed medications that would act preventively when taken on a daily basis. Now, we start with the 10 prevention principles mentioned earlier and stress the early use of triptans. In this way, a lot of youngsters have been able to avoid chronic use of medication.

Nevertheless, there are some children whose burden of migraine still interferes with their success at school and at home and, in these cases, a preventive medication may be necessary. The choice of which medication to use is often related to other health issues a child may have. For example, if a youngster has an obesity problem, using topiramate may help shed some pounds. Conversely, a youngster fighting anorexia might benefit from either amitriptyline or cyproheptadine, whose main side effect is weight gain.

Since preventive drugs are taken every day, it is best to start with a very low dose and gradually increase it until the drug works or side effects ensue. It may take a few months to decide if a drug has worked or not.

Lastly, many youngsters with migraine are sick and tired of being sick and tired. The unhappiness, depression and anxiety that often accompany migraine must be anticipated and addressed. Combining a good medication regimen with counseling will achieve the best outcome.

—Jack Gladstein, MD, Director, Pediatric Headache Clinic, University of Maryland