Migraine Headaches in Children and Adults By Lisa Glickstein, Ph.D, Triplet Mom Originally printed in April 2004 We are a migraine family. My husband and I both suffer from occasional migraine headaches, and several of our parents and grandparents have or had a history of migraines. Nonetheless, we were surprised when one of our daughters was diagnosed with migraines at age four. During her diagnosis and evaluation, I learned a lot about this mysterious, and sometimes debilitating, headache syndrome. Forms of Migraine Headaches and Their Symptoms Migraines are a specific syndrome and are unlike tension headaches. They are classified as occurring with or without aura, the strange visual hallucinations that can precede headache onset. Both types typically include severe pain, most commonly limited to one side of the head (except in children) and frequently behind one eye, nausea and vomiting, and last between hours to days. Although migraine with aura (also called "classical migraine") is the most commonly described in literature and the popular press, this form occurs in only about 15% of children and 30% of adults diagnosed with migraine. The majority of people with migraine do not experience an aura, and this type is also called "common migraine." Patients with migraines describe sensitivity to light, sounds, and smells during their headaches. There are many variant types that occur more rarely, or possibly occasionally, in any migraine sufferer. Two of the more common (and often misdiagnosed) are post-coital migraine and abdominal migraine. Post-coital migraine generally affects men, and is the sudden onset of common migraine following orgasm. Abdominal migraine is generally diagnosed in children, is also called cyclic vomiting, and is typified by frequent vomiting (with or without headache) over a period of hours to days. Abdominal migraine in children can convert into migraine headaches over time. Some more rare types include neurological symptoms such as paralysis, blindness, or severe dizziness. Diagnosis Proper diagnosis is essential. New onset of severe headache could have an organic cause, such as fever or viral infection, sinus infection, or, of greater concern, concussion, meningitis (inflammation of the tissues surrounding the brain), or tumor. Occasional headache accompanied by flu-like or upper respiratory symptoms will not likely resemble migraine headache and will respond to over the counter remedies like acetaminophen (Tylenoltm) or ibu-profen (Adviltm or Motrintm). Headache accompanied by facial pain (or toothache) and green or cloudy nasal discharge could indicate sinus infection, which can be treated by antibiotics prescribed by a primary care physician or pediatrician. Headache accompanied by vomiting and depression could indicate concussion, which might be suspected from recent injury, or meningitis (or other brain infection, particularly in adults), which might be accompanied by fever. Patients with either of these groups of symptoms should be promptly referred to a doctor. Headaches that resemble migraines in terms of symptoms, occur at least once a month or more, are progressively getting worse, do not respond to over the counter remedies, or are accompanied by behavioral changes, should be referred to a neurologist without delay. In adults, one might suspect a stroke or swollen blood vessel in the brain. Less than 1% of headaches in children, and 5% in adults, are caused by benign and malignant brain tumors. Nonetheless, rapid diagnosis will be beneficial to outcome. Most of these patients will be diagnosed with migraine headaches. Treatment Migraine treatment involves three steps: 1) identifying triggers and reducing or eliminating them; 2) taking an "abortive" medication to stop symptoms as soon as they occur; and 3) in severe cases, taking a daily medication to prevent migraines. Of interest, although stress does not cause migraine headache, patients with migraine are more likely to have a highly anxious and creative personality. The headaches themselves can be triggered by specific foods (typically nitrates, a type of preservative found in wine, cheese, preserved meats like hot dogs or cold cuts, chocolate, and seafood), lack of sleep or fatigue, missed meals or low blood sugar, viral or bacterial infection (particularly Streptococcus sp. Infections - "strep throat"), motion sickness, and menstrual cycles or hormone supplements, including birth control pills and progesterone. Identifying one or more of these triggers can be helpful in reducing the frequency of headaches to a manageable number. For example, eliminating food triggers from the diet, getting enough sleep, or taking an over the counter remedy for motion sickness (such as Dramaminetm or Boninetm), may be part of your personal regimen. Keeping a headache diary can be an important item for self-help, as well as information that can help your doctor understand and treat your headaches. Over the counter drugs are the first line of treatment for migraine, and the majority of migraine sufferers are able to control headaches with these drugs. These medications must be taken at the first sign of aura or headache to be effective. Excedrin Migrainetm contains an extra-strength dose of both acetaminophen and ibuprofen, along with caffeine. With a doctor's approval, you can get the same effect from a full dose of generic ibuprofen and a half dose of generic acetaminophen, with a cup of regular coffee. Caffeine makes over the counter remedies relieve pain about 40% better in clinical studies. For a child, a pediatrician may approve the same regimen in appropriate child dose, without the coffee (a cola may provide some benefit). A second or further doses, 6-8 hours apart, may be needed until the migraine ends. It is important to get an official diagnosis of migraine for a child, to keep appropriate medication at school in the nurse's office (or backpack of a high-school age child), and to educate the school nurse and teacher about migraine. In order to avoid missed school, medication must be given without delay, and the child can often return to activity after 30-90 minutes of quiet rest in the nurse's office. It is particularly important to monitor the use of acetaminophen medications (Tylenoltm, and cold remedies containing this pain reliever), as it has been recognized in the past year that it is easy to overdose on this drug and cause liver damage and even rarely death. No over the counter remedy should be taken in greater than the labeled dosage or at the maximum recommended dose for longer than two days for headache, without discussion with a doctor. For more severe migraine that does not respond to these treatments, there are a variety of prescribed medications for both abortive and preventative care. Aside from steroids, the most effective abortive remedies are mostly related to sumatriptan (Imitrextm), the first prescription medication for migraine used in the U. S. These are formulated as nasal sprays or rapidly dissolving tablets, to give rapid relief. Many treatments are available for prevention of migraines, but all have mild to serious side effects and are usually reserved for patients with migraines that do not respond to any other treatment, occur weekly or more often, or are causing severe disability in school, work, or daily living. These include heart medications (beta blockers or calcium channel blockers), anti-epilepsy medications, and anti-depressants. For more information, consult the National Headache Foundation, at www.headaches.org. Migraines are extremely common: 1 in 10 people suffer from them, and in half of these they interfere with lifestyle. With treatment, 95% of migraines can be managed.