Childhood Migraines: An Interview with Dr. Pascal Saremsky

Migraine is the 3rd most prevalent illness in the world, with 1 in 7 adults afflicted. However, most undiagnosed sufferers of migraine attacks are children. While research and treatment of migraine in adults has increased over time, migraine remains an underdiagnosed condition in children, with an estimated 10% of school-age children experiencing migraine episodes. About half of them will have their first attack before the age of 12. 

In addition to being painful and uncomfortable, migraines can impede a child’s development and academic performance, particularly when a child also has Attention Deficit Hyperactivity Disorder, Autism Spectrum Disorder, or a learning or developmental disorder. Safe and effective options for migraine prevention and the treatment of the symptoms are available and it is important to consult with a medical specialist to determine which options are optimal for you child. In this article, pediatric neurologist and epileptologist Dr. Pascal Saremsky answers questions about migraines in children and treatment options.

What is migraine and how does it differ from other headaches?

Dr. Saremsky: Headaches come in many forms, including tension headaches, cluster headaches, nummular headaches, exertional headaches, and others. Clinically speaking, migraine is not just a headache, although the condition can present with headaches as a symptom. Patients with migraine can exhibit the following symptoms:

• A headache on one side of the head (occuring in 50% of cases), although headaches can be absent and in children can often occur on both sides of the head.
• The presence of an aura (in 15% of cases) which includes visual disturbances, numbness or tingling, and sensitivity to external stimuli.
• Visual disturbances such as zigzagging lines, flashing lights, and visual impairment.
• Numbness and tingling in the face, lips, tongue, or extremities.
• Nausea, vomiting, and other abdominal symptoms.
• Sensitivity to light (photophobia) and sound (phonophobia).
• They can be frequent and long-lasting (3-72 hours).
• They can include what is called a prodrome and postdrome (symptoms occurring before and after the main episode).
• Migraine pain may get better when lying down.

There also exist different forms of migraine, each with its own particularities and treatment options. These include:

• Migraines with aura (classic migraines) versus migraines without aura (common migraine)
• Episodic migraines versus chronic migraines
• Abdominal migraines (more common in children), ocular migraines, and basilar migraines

Image Source: The American Migraine Foundation (https://americanmigrainefoundation.org/)

How is migraine in children diagnosed?

Dr. Saremsky: It is important to first look for red flags that might indicate a more serious underlying condition, such as stroke or tumors. This may include the sudden onset of intense headaches, cognitive impairment, or the dropping of held items. If such red flags are present, an MRI or CT scan may be ordered. In the absence of more worrisome symptoms, diagnostic procedures should be minimally-invasive and appropriate to the child and situation, as the potential risks and complications of invasive diagnostic techniques may be unnecessary. A thorough medical evaluation is recommended, including screening for cardiological issues, infectious diseases, autoimmune and metabolic disorders, ophthalmological and vision issues, and a possible ENT evaluation for possible allergies and sinus issues. Once underlying conditions are ruled out, a diagnosis is made based on a criteria match for migraine symptoms and a course of treatment can be prescribed. 

What are the causes of migraine?

Dr. Saremsky: There is not yet a scientific consensus as to the ultimate cause of migraines. A prevailing theory is that migraines are caused by rapid waves of brain cell activity crossing the cortex, the thin outer layer of brain tissue, followed by a period of inactivity called cortical spreading depression (CSD). However, there are other contributing factors that are known:

• Genetic predisposition and family history - At least 70% of children with migraine have a close family member that also suffers from migraines. Children are more likely to experience migraines if one or both parents are sufferers.
• Trauma & illness such as concussions and fevers.
• Emotional factors such as stress associated with school, family, and social life.
• Dehydration (recent studies have shown that more than half of school-age children do not maintain adequate levels of hydration due to overconsumption of sodas and juices and underconsumption of water).
• Dietary triggers such as nitrates, caffeine, high levels of sodium, MSG, and other compounds.
• Poor sleep hygiene - stimulants like caffeine, stress, playing video games or using social media late into the night, and taking naps during the day can prevent adequate restful sleep at night.
• Medication side effects and overuse. NSAIDs, headache abortives, and some nasal sprays shouldn’t be used continuously for long periods of time as they can cause rebound headaches. Always speak to your doctor about potential side effects and the effects of long term use.
• Adult women are 3 times more likely to suffer from migraines than men, but in childhood, more boys suffer from migraines than girls. This trend reverses in adolescence as hormonal changes associated with puberty and menstrual cycle may exacerbate or trigger migraine episodes.
• Environmental triggers (some are controllable and some are not)
• Loud or ongoing noises
• Bright or flickering lights
• Weather and temperature changes and extremes

How is migraine treated in children?

Dr. Saremsky: Treatment of migraines in children is a team effort between doctor and the child’s family and caretakers. It is rare that medication alone will cure the patient, and so a number of treatment modalities may be used simultaneously. 

First, it is important to control comorbid conditions in children that commonly occur together with migraine:

• Depression
• Anxiety
• Asthma
• ADHD
• Sleep Disorders

But other less common conditions need to be controlled as well, such as:

• Bipolar Disorder
• Stroke
• Epilepsy
• IBS (irritable bowel syndrome)
• Chronic Pain
• PFO/ ASD (patent foramen ovale/ atrial septal defect)
• Coronary Heart Disease

The physician should work together with the child’s family to create a plan for making lifestyle changes to help control external and internal migraine triggers. Such lifestyle changes can include:

• A specialized diet that avoids common and individual migraine triggers.
• Maintaining adequate hydration.
• Cutting out stress triggers and potentially seeking out therapy, school counseling, and specialized accommodations for school testing. Medication may be used to manage psychogenic symptoms in certain cases.
• Getting adequate and quality sleep and rest.
• Ensuring a conducive sound, light, and temperature environment at home and at school, sometimes requiring specialized accommodations from the school.

Medication treatment may entail the use of abortive or preventive migraine medications as well as minimizing the negative side effects of any new or existing medications. Anti-inflammatory medications may be needed to control inflammatory symptoms and to prevent inflammatory response. Some medication side effects may actually be beneficial - for instance, if a medication causes drowsiness, it may help to improve sleep if given at bedtime. Medication treatment may last for six to twelve months, with the goal of eventually reducing the need for it and managing symptoms through other means. Medications for migraine can include:

• NSAIDs
• Steroidal medications for severe headaches that won’t break
• Triptan medications for some severe cases when indicated in older children
• Preventive medications (e.g. topamax) for frequent migraines

Natural supplement treatments may also help to control migraine symptoms. These include:

• Riboflavin (Vitamin B2)
• CoEnzyme Q10
• Butterbur
• Magnesium 

There exist other treatments for migraine in children as well, which can be explored on an individual basis during a consultation. Migraines can be controlled, improving a child’s academic performance, social life, physical health, and overall well-being. The earlier diagnosis and treatment begins, the less risk there is of a worsening condition, additional complications, or an undiagnosed underlying issue. Pediatric neurology involves caring for a child’s body and mind, and is always a team effort between the physician, the family, and the school.

Dr. Pascal Saremsky is a board-certified pediatric neurologist and pediatric epileptologist.  He completed a fellowship in pediatric neurology at the Albert Einstein College of Medicine and a fellowship in pediatric epilepsy and neurophysiology at New York Presbyterian Hospital. He specializes in treating patients from newborns to early adulthood with a personalized and friendly approach that helps his young patients and their parents feel comfortable under his care.

If you believe your child may suffer from migraines or headaches, schedule a consultation with a pediatric neurologist today by calling (646) 679-6609 or booking online below.

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See Also:

• Learn More About Pediatric Neurology at NYNA
• Interview with Dr. Pascal Saremsky on ADHD
• Interview with Dr. Pascal Saremsky on Autism Spectrum Disorders
• 12 Common Causes of the Average Headache
• Headaches: Types and Treatments

Author

Dr. Pascal Saremsky Pascal Saremsky, MD, is a board-certified pediatric neurologist, pediatric epileptologist, and a valuable member of the team at NY Neurology Associates in New York City. He specializes in treating patients from newborns to early adulthood with a personalized and friendly approach that helps his young patients and their parents feel comfortable under his care.