The management of pediatricmigraine incorporates lifestyle strategieswith acute therapy and preventivemeasures. Lifestyle changes that candiminish the frequency and intensity ofmigraines include maintaining regularsleeping, eating, and exercise habits;staying well hydrated; dealing withstress; and avoiding dietary triggers ofmigraine. Acute treatment represents arace against the clock: the longer aheadache continues to smolder, the harderit is to treat. An over-the-counteragent may help in the very early stagesof headache: if it does not, however,it must be followed within an hour by atriptan. Patients with significantmigraine disability may need preventionmedications or alternative therapies.
The diagnosis of pediatric migraine- the focus of the first article in this 2-part series-is based on the presence of severe headache that occurs in an acute, intermittent pattern and is accompanied by autonomic symptoms (Table 1).1 Once the diagnosis of migraine has been made, the approach to treating the youngster with migraine can be divided into 3 phases: lifestyle strategies, acute treatment, and preventive measures.
I explain to parents that children with migraines have a lower threshold for pain when a stimulus is presented than do children without migraines. Something that bothers a migraine sufferer does not necessarily bother someone who does not have headaches. For example, migraineurs are more sensitive to hunger; to changes in light in a room; and to repetitive visual stimuli, such as flickering lights, or watching telephone poles while riding in a car.
A number of lifestyle measures can help reduce the frequency and severity of migraines (Table 2).
Eat regularly. Not all patients have the same migraine triggers, but in many affected children, the threshold for developing headaches is reduced when they are hungry, thirsty, tired, or stressed. At our headache clinic, we encourage migraine sufferers to avoid missing meals. Working with the school to allow a youngster a morning snack can be an effective preventive measure.
Stay well hydrated. Children with migraine should err on the side of over-hydration. Try to have the child drink enough fluids so that he or she needs to urinate every 2 to 3 hours. Children in whom inadequate fluid intake is a migraine trigger must be allowed to keep a water bottle at their desk at school.
Sleep consistently. Sleep patterns should remain constant-even on weekends. Wild fluctuations in weekend sleep schedule can lead to more headaches. Most teens like to stay up late on weekend nights and then sleep in the next day. For adolescents with migraines, one solution is to wake up at the same time every day-even for a few minutes-grab a bite to eat, go to the bathroom, and then go back to sleep. Of course, lack of sleep can be a migraine trigger as well.
Deal with the stress. Stress is a major trigger for many migraineurs. Recognition of stress is a key step. This is often a family matter for kids who are over scheduled. Some youngsters internalize their stress, while others acknowledge it openly. Along with worries about good grades and social acceptance, children can be stressed out if they are being bullied or are having a hard time learning because of an undiagnosed learning disability. Asking about family discord, trauma, and about relatives who are sick may help you elicit additional sources of a stress in a youngster.
Exercise regularly. Exercise helps with migraine prevention. For kids debilitated by their headaches, an exercise regimen should start slowly. Aerobic exercise for 20 to 30 minutes 5 times a week has been shown to decrease headache frequency.2
Avoid dietary triggers. The role of diet in headache is controversial. Multiple foods can be migrainogenic- the list is gigantic. The easiest approach is to have the child eliminate one food at a time and see whether it affects the headache pattern. Most kids figure out what foods get them into trouble and avoid them. It is a good idea to avoid excess caffeine as well.
ACUTE TREATMENT Once a migraine has started, treatment becomes a race against the clock. A migraine is much easier to treat when it first starts: it becomes more refractory to therapy the longer it continues to smolder. Mediators of inflammation act peripherally early in the development of a migraine: these mediators can be "turned off" readily by drugs such as triptans. As the headache progresses, the entire brain can become inflamed and drugs that act peripherally will not be effective. Allodynia is the external manifestation of a headache that has become a central event. Patients report that their scalp is tender; that they cannot wear their hair in braids, or put glasses on their nose, or wear a sweater on their shoulders. Rule #1 of migraine treatment: treat early to prevent allodynia.'
The choice of therapy is based on how long the headache has been present and whether nausea is prominent. When a headache wakes a child from sleep, the headache has already been brewing for a few hours. Often such headaches are accompanied by nausea or allodynia. It is unlikely that an over-the-counter (OTC) medication will be effective in this setting. Parents need permission to give their child "strong medicine"-either a nasal spray or subcutaneous injection (see treatment options below).
An OTC medication is more likely to be effective if taken at the first "twinge" of a migraine. Many patients do not respond to OTC migraine drugs, however, even if the medication is taken early. If OTC therapy is not effective, it must be followed within an hour by a triptan.
There are currently 7 oral triptans available (Table 3). Two come in an intranasal formulation. One comes in an injectable form with 2 fixed doses.
Triptan trials in children uniformly show good efficacy.3-8 However, they also show a strong placebo effect. For this reason, there has yet to be an FDA-approved triptan for children. Study design issues probably account for this "lack of spread" between placebo and drug efficacy.
Children's headaches are relatively short-lived. If a child waits to get home from school before taking either a triptan or placebo, the headache may already be waning. Also, children aim to please their parents and doctor, and may not understand that it is okay to not get better. They may overrate the effectiveness of a medication-even when given a placebo. 3-9 The good news is that studies that focus on triptan safety have been positive. Therefore, pediatric headache experts routinely incorporate triptans as a vital part of the armamentarium for acute treatment of migraine. In fact, most health insurance plans allow a youngster to receive a triptan without prior approval.
As noted, when a headache is accompanied by allodynia, it becomes more difficult to treat. Oral triptans may not work in this setting, and adverse effects of the triptan may be more pronounced. For example, patients with allodynia may have more chest pain, arm tingling, and jaw pain. Options at that point may include an injectable triptan or intranasal dihydroergotamine (DHE).
If these measures do not "cure" the headache, or if the headache is worse, the child is considered to have status migrainosus-the headache equivalent of status asthmaticus or status epilepticus. More intensive treatment is needed. The emergency department can offer treatments with various intravenous therapies, including fluids, magnesium, corticosteroids, DHE with metoclopromide, and/or valproate. If such therapy fails to afford relief, the youngster may need to be admitted for around-theclock intravenous DHE and metoclopromide administration.
The use of narcotics in the management of children and adolescents with recurrent headache should be discouraged, because frequent use can lead to dependence. Nevertheless, when all else fails, narcotic agents have a role in rescue for the patient with infrequent yet debilitating headaches.
After teaching patients about lifestyle strategies, recommending acute migraine management-stressing early intervention-and offering a rescue plan when a migraine has gotten out of control, preventive therapy can be considered. Patients with significant disability may need prevention medications or alternative therapies in an attempt to decrease headache frequency. In youngsters, disability is measured crudely in days of school missed; it is also measured more subtly using the concept of "presenteeism." Presenteeism is a state in which a child goes to work or school but does not function despite being present. A drop in grades can be an indication of this condition.
A child or teen who is either missing many days of school or who is attending school but whose grades are dropping may need daily preventive medications. There are many pharmacological options. All have potential adverse effects, so the decision to start migraine prophylaxis must be made cooperatively with the youngster and his family.
Because it is generally held that no drug is any better than any other, one goal is to chose an agent that treats a coexisting condition while not exacerbating other comorbidities. For example, for migraineurs who have seizures, therapy with topiramate, valproate, or gabapentin is suggested. For obese migraineurs, topiramate is the best choice. Conversely, for patients who have an eating disorder, ciproheptadine, or amitriptyline may induce some increased appetite. For patients with conduct disorder, valproate may help. Patients with insomnia and migraines may benefit from either amitriptyline or ciproheptadine. Athletes should avoid propranolol, which may cause exercise intolerance. For those people who prefer neutraceuticals, magnesium, feverfew, riboflavin, or coenzyme Q10 can be used.
For those who prefer to avoid medication altogether, relaxation exercises, biofeedback, yoga, and acupuncture are options.
The clinician's role in caring for the headache patient often extends beyond the office. It frequently means being an advocate for the patient at school. Often, anxiety about having to make up work and frequent school absence combines with anxiety about being "held back" because of lateness and absence. The easy way out is to offer home schooling or a home tutor. This approach is not advisable, however, because it perpetuates the sick model rather than stressing wellness. Working with the school to allow a flexible make up schedule, and allowing students to go to the nurse to get medications quickly may help the youngster get through school successfully.
TAKE HOME POINTS
The management of pediatric migraine combines enforcing healthy behaviors, early treatment, allowing for rescue, pharmacological and nonpharmacological prevention treatments, and advocating for the patient at his school. Because migraine is a recurrent condition, empowering patients and families helps to offer the best outcome in helping to transform a "migraineur" to just a normal kid with manageable headaches.
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