Not just a bad headache: migraines

One day when my son, Cole, was six, he suddenly dropped to the floor, pale and trembling, small hands clutching his forehead. While my husband and I didn't doubt he was in pain, we never imagined Cole might be in the throes of his first migraine. It simply didn't cross our minds that a six-year-old could suffer from them.

Turns out we weren't alone in that misconception.

"People tend to think it's an adult condition, but it's very common in children," says Shanna Lindsay, a paediatric neurologist at St. Joseph's Health Centre in Toronto. While migraines are more pervasive among teens, four to five percent of school-aged children suffer from them, compared with 30 percent of adults. (These estimates include those who have had one or two migraines in their lives, as well as those who suffer daily.) "Even tiny babies can have migraines. Those are very rare, but it happens," says Daune MacGregor, a paediatric neurologist with the Headache Clinic at SickKids in Toronto. "Small babies will bang their heads against their crib. Two- and three-year-olds could be unsteady and walk around like a tiny drunk."

The medical definition of a migraine is a headache with moderate to severe pounding, usually on one side of the head, and often associated with nausea, vomiting and sensitivity to light and noise. A complex pain response, which includes inflammation of the walls of blood vessels in the brain, results in the pounding sensation. Anyone who has had a migraine will tell you it's not the same as a tension headache, which feels like being squeezed by a cap or band around the head and usually doesn't cause nausea.

Some people, including children, sense an aura that warns them a migraine is on its way. They may see jagged bright lights that shimmer like the northern lights. Others temporarily lose their vision in one eye about 10 to 15 minutes before the migraine starts. But for most people there's no aura, no warning. The pain simply begins.

While most migraine symptoms are the same whether you're a child or an adult, the big difference is how long they last and where the pain occurs. With children, a migraine lasts for one hour or longer; in adults they are longer than four hours. And while adults describe the pain as one-sided, children often say their pain is all over their head, though that's partly perception. Children are unable to pinpoint the source of their pain, MacGregor explains. "They may have pain on one side, but because they can't localize it, they say it's all over. Some of them are quite dramatic in describing it. We get them to draw their headaches, and I have some pictures that show a big knife going through the head."

The majority of those drawings are done by boys. Until adolescence, boys suffer migraines slightly more frequently than girls. But once their bodies start to change, girls' monthly hormonal fluctuations put them at greater risk. While boys may outgrow their migraines by their teens, girls are rarely so lucky.

If your child is suffering from migraine-like symptoms, the first step is to get a diagnosis from a paediatrician or paediatric neurologist. "There is no blood test, X-ray, MRI or any kind of medical test that says this is a migraine," says MacGregor. "It really is a diagnosis by exclusion." After ruling out other possibilities, such as sinus infections, vision problems or (in very rare cases) brain tumours, a paediatrician or neurologist will make a diagnosis based on a combination of symptoms and family history (migraines are often inherited).
Migraines have a bewilderingly wide range of triggers. The most common food triggers are caffeine, chocolate, cheese and — especially in kids — processed meats. "You know, hot dogs, salami, pepperoni," says Lindsay. "Skipping meals is another big one, especially for teens who skip breakfast so they can sleep in."

Changes in weather, bright lights, dehydration and lack of sleep can also bring on migraines. So can stress, even the good kind of excited stress associated with a birthday party. Of course, there are other kinds of tension or worry in a child's life. "As adults, we think, 'How can our kids be stressed? They're six,'" says Lindsay. "But it could be that somebody said something in the playground a month ago and they're still thinking about it. I think we forget as adults what can be stressful for a little kid." She recalls treating an eight-year-old girl who suffered daily migraines at school. "She had incredibly hairy forearms and all the boys were making fun of her. She had the hair removed and the migraines disappeared."

If your child is diagnosed with migraines, the best way to manage them is to avoid the triggers. Keep a daily diary of what your child eats and drinks, how much she sleeps and what kind of stresses she might be experiencing. MacGregor tells her young patients they must take charge when it comes to avoiding their triggers. "I say, 'Whose head hurts? Is it Mommy's head? Is it Daddy's head? No, it's yours, and you have to take some responsibility.'"

When a child does get a migraine, MacGregor recommends putting her in a quiet, darkened room — no TV or iPods! Some children find relief from either a cool or warm cloth on the head or neck. Pain therapists, such as those at the Headache Clinic, can also help children to use relaxation techniques to control the pounding.

In the case of a severe migraine, both MacGregor and Lindsay recommend non-prescription drugs such as ibuprofen (sold as Motrin and Advil) or acetaminophen (Tylenol and Tempra). "Most children do quite well with over-the-counter medications, as long as they're given a good dose," says Lindsay. She says that because drug manufacturers err on the side of caution when suggesting doses, kids should get the OK from their doctor for a higher dose. "The key is, they need one good dose as soon as they get the headache. If you wait, you've missed the boat and [the] is bad."

If you've tried Motrin and that doesn't do the trick, you can also try giving your child Tylenol, or vice versa. Lindsay says that since these drugs act on different pathways in the brain, you can use both at the same time. Lindsay and MacGregor caution, however, against using non-prescription drugs more than three times a week. "You can get a rebound headache," says Lindsay. "Your body is saying, 'Where is my Tylenol?' In this situation, we need to consider a preventive medication." (See Can Migraines Be Prevented?)

With migraines that hit once every couple weeks, Cole is lucky enough not to require preventive drugs, but we do often resort to over-the-counter medication. And having discovered that lack of sleep is his major trigger, we've become, much to his dismay, militant about bedtime.
Can migraines be prevented?
Doctors are reluctant to prescribe preventive medication — drugs taken daily to ward off migraines — to children. They have side effects such as weight gain, kidney damage and drowsiness, and none has been properly tested on children. In severe cases, though, after all other options have failed, doctors will consider prescribing drugs such as amitriptyline, pizotyline and gabapentin.

As a last resort for young patients, Daune MacGregor, a paediatric neuro-logist at Toronto's SickKids, will even use Botox (yes, the treatment best known for temporarily removing wrinkles when injected into the face). The botulinum toxin blocks nerve impulses and temporarily relaxes muscles when used in high doses for cosmetic purposes. In smaller doses, used for migraines, it blocks pain pathways in the brain. "It has to be redone every three months, but some of these kids haven't been to school in a year," says MacGregor.