Headaches in children

Survivors of terrorist attacks are four times more likely to suffer from migraines and three times more likely to suffer from tension-type headaches, according to a study just published in Neurology. The researchers evaluated 213 of 358 adolescent survivors of the 2011 massacre at a summer camp in Norway that resulted in deaths of 69 people. These survivors were compared to over 1,700 adolescents of the same sex and age who were not exposed to terrorism. The survivors were not only much more likely to suffer from migraines and tension-type headaches, but were also much more likely to have daily or weekly attacks.

Many previous studies have shown that physical, sexual, and emotional abuse in childhood and posttraumatic stress disorder (PTSD) are strong risk factors for the development of migraines and chronic pain in many previous studies. Having a family history of migraines further increases this risk, as does head trauma, and having other painful or psychological disorders. Headache is also one of the first symptoms reported by adolescent girls and women who were raped.

The authors of the current report cite evidence that “Childhood maltreatment during periods of high developmental plasticity seems to trigger modifications in genetic expression, neural circuits, immunologic functioning, and related physiologic stress responses. It is plausible that exposure to interpersonal violence could induce functional, neuroendoimmunologic alterations, affecting central sensitization and pain modulation and perception. Central sensitization, expressed as hypersensitivity to visual, auditory, olfactory, and somatosensory stimuli, has long been thought to play a key role in the pathogenesis and chronification of migraine.”

It is likely that early intervention after a traumatic event will result not only in better psychological outcomes, but also in fewer and milder headaches. One such intervention is cognitive-behavioral therapy. However, there are several different types of such therapy and a study just published in JAMA Psychiatry compared 12 sessions of cognitive processing therapy (CPT) with 5 sessions of written exposure therapy (WET) for the treatment of posttraumatic stress disorder. WET was shown to be at least as good as CPT with fewer treatment sessions required. This makes WET more efficient and affordable and patients are more likely to complete it.

My previous blog posts mention online self-administered courses of cognitive-behavioral therapy for PTSD, anxiety, depression, OCD, insomnia, chronic pain, and other conditions. The site is and the researchers behind it have published scientific data indicating that their approach is very effective. It is also very inexpensive – some courses are free and some cost about $50.

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Deficiency of coenzyme Q10 (CoQ10) is the second most common deficiency in migraine sufferers after magnesium. Fully one third of migraine sufferers are deficient in CoQ10, according to a study by Dr. Andrew Hershey and his colleagues published in the journal Headache. They tested 1,550 children and adolescents and a study in such a large population tends to be very reliable. Supplementing these children with 1 to 3 mg/kg of CoQ10 produced significant improvement not only in CoQ10 levels but also in the frequency of attacks (from 19 a month to 12) and the disability (the disability score dropped from 47 to 23).

This deficiency is present in adults as well, as was shown in another study by a Swiss neurologist, Dr. Peter Sandor and his colleagues. They gave 100 mg of CoQ10 three times a day or placebo to 42 adult migraine sufferers and discovered that a 50% drop in migraine attack frequency occurred in 48% of patients on CoQ10 and only 14% of patients on placebo.

The Hershey study was done in a more logical way – determine who is deficient and give them CoQ10. If you give CoQ10 to those who need it and those who don’t, the results of the study and in practice will not be as impressive. Although CoQ10 is not expensive ($7 a month for 200 mg a day) and is very safe, why supplement to someone who does not need it? Although the blood test for CoQ10 is fairly expensive ($158 at Labcorp), it is usually covered by most insurance plans. It is important to ask your doctor what the actual blood level was because the laboratories will report as normal values between 0.37 and 2.2 (Labcorp) or 0.44 and 1.64 (Quest Diagnostics), studies have shown that the level should be at least 0.7.

As far as side effects, a few of my patients developed insomnia, possibly because CoQ10 is involved in energy generation, so I always advise taking it in the morning. While Sandor gave his patients 100 mg three times a day, in Hershey’s study the benefit appeared at lower doses. I usually recommend 100 to 200 mg (depending on body weight and how low the level is), to be taken once, in the morning.

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A new report by doctors at UC Irvine describes successful treatment of 9 children aged 8 to 17 with migraine headaches using Botox injections. It may sound surprising, but unfortunately children also suffer from chronic migraines. Chronic migraine is defined as headaches that occur on 15 or more days each month and on at least 8 of those days headaches have migraine features. In children with episodic and chronic migraines, migraine features, such as throbbing, unilateral location, sensitivity to light and noise are less common than in adults.

There are only 5 treatments that are approved by the FDA for the prevention of migraine attacks. Four are drugs – 2 blood pressure medications, propranolol (Inderal) and timolol (Blocadren) and 2 epilepsy drugs, topiramate (Topamax) and divalproex sodium (Depakote). The fifth treatment is Botox injections. While Botox is not approved for kids with migraines, it is approved to treat eye conditions in children 12 years of age and older. Botox is also widely used to treat younger children with cerebral palsy (CP), although there is no official FDA clearance for such use. For a child with CP, Botox injections can make a difference between being wheelchair-bound and walking unassisted. However, very young children with CP are at the highest risk of serious complications and even death because they have small bodies and very stiff muscles, which require relatively large doses of Botox.

The dose to treat migraines is much smaller and therefore a lot safer. My youngest child with chronic migraines was a boy of 8 who weighed 50 lbs. He had excellent relief of his migraines after receiving 15 units of Botox into his forehead. He underwent a total of five treatments over a period of two years and for the last treatment, I gave him 50 units (forehead and temples). By then his weight was 65 lbs. The standard adult dose for migraines is 155 units. The dose for cerebral palsy in an adult goes up to 400 units.

The main difficulty in using Botox in children with migraines is that insurance companies often deny coverage, which they justify by the lack of FDA approval. However, Botox injections at low doses used to treat migraines in children are safer than drugs for epilepsy, high blood pressure, or depression.

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Anxiety is at least twice as common in both children and adults with migraine headaches compared to people without migraines. A new study presented at the recent American Headache Society meeting examined the impact of anxiety on functioning in pediatric migraine population. The researchers analyzed records of 530 kids with migraine and 371 with tension-type headache seen in the pediatric neurology clinic of the Boston Children’s Hospital.

Dr. Lebel and her colleagues discovered that physiological anxiety was associated with more severe functional disability in kids with both migraines and tension-type headaches. Physiological anxiety often manifests itself by sleep difficulties, racing heart, shortness of breath, feeling shaky, fatigue, and other. The other two types of anxiety, worry and social anxiety did not seem to lead to more disability.

This study confirms the importance of cognitive and behavioral treatments, such as progressive relaxation, biofeedback, meditation, and cognitive therapy. Kids are very good at these techniques and they are particularly receptive to smartphone-based apps. For meditation, I recommend 10% Happier and Headspace. offers free podcasts for meditation and provides very inexpensive and scientifically proven cognitive-behavioral therapy.

At the NY Headache Center we always try to avoid drugs, especially in children. In addition to cognitive and behavioral techniques, we address sleep, exercise, diet and supplements such as magnesium, CoQ10, and other. If medication is needed, this study suggests that a beta blocker, such as propranolol (Inderal) may be a good choice because in addition to preventing migraines, it reduces physiological symptoms of anxiety (it is also used for performance anxiety). Potential side effects of beta blockers are mostly due to its pressure lowering effect and include fatigue, dizziness, and lightheadedness.

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Most children who complain of headaches report pain in the forehead and/or temples. Doctors and parents tend to get more alarmed when a child complains of a headache in the back of the head and such children are more likely to have an MRI scan of the brain. According to a new study published in Neurology, there is no reason for concern.

The researchers examined records of 308 children under 18 (median age was 12) seen at a pediatric neurology clinic and found that 7% of them had pain only in the occipital area, while another 14% had pain in the occipital and another part of the head. The majority of children had migraine headaches. Not surprisingly, more kids with pain in the back of the head had an MRI scan. However, they did not have any more abnormal MRI findings than children with pain in other parts of the head. In fact none of the 4 children in this group who had a serious problem (2 had tumors and 2 had increased pressure) had occipital pain.

Considering that migraine headaches are common in children (4-11% of all kids) there is no need to do MRI scans in all kids with recurrent headaches. The American Academy of Neurology and Child Neurology Society do not recommend a CAT or MRI scan in children with recurrent headaches and a normal neurologic examination. However, 45% of children do get neuroimaging. Imaging is particularly unnecessary if other members of the family suffer from similar headaches.

Neuroimaging is indicated in patients with recurrent headaches and abnormal neurologic examination, seizures, those with recent onset of severe headaches or recent changes in the character of headaches. Changes in the character of headaches may include shift in location, increase in frequency or severity, new associated symptoms such as blurred vision, dizziness, fever, and other.

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With 13 million participants, soccer is the third most popular sport in the US after basketball and baseball. Worldwide, 250 million people play soccer. Unfortunately, a number of studies have linked playing soccer with neurological symptoms. The latest study from the Albert Einstein College of Medicine published in Neurology evaluated 222 amateur soccer players aged 18 and older (mostly in their 20s and 30s) over a two-week period.

The study suggests that playing soccer even without heading the ball is associated with symptoms of a concussion. Those who did not report heading the ball often had unintentional head impacts (head to head, elbow or knee to head, head kicked, etc) and were much more likely to have concussion-related symptoms which were rated as moderate or severe. These symptoms included headache, dizziness, feeling dazed, and other. Unintentional head impacts were experienced by 37% of men and 43% of women, while heading-related symptoms were reported by 20%.

Not all symptoms necessarily represent a concussion and some pain and dizziness could be neck-related, so additional large studies are needed. Some studies have detected brain changes in soccer players who frequently head the ball, but these findings are considered to be preliminary and not conclusive.

According to the US Soccer Federation children under the age of 10 should not be allowed to head the ball in practice or in games. Children aged 11 to 13 are allowed to head the ball only during practice. However, this new study suggests that soccer players of any age may be risking brain injury, mostly from heading and unintentional head injuries.

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About 6% of young children suffer from migraine headaches. After puberty, this number triples to 18% in girls and remains at 6% in boys. Several abortive drugs (drugs taken as needed), such as rizatriptan (Maxalt) and zolmitriptan (Zomig) are approved for migraines in children. Only topiramate (Topamax) is approved for children (over the age of 12) for the prevention of migraines. We do use preventive drugs approved for adults in children as well. These are divalproex sodium (Depakote), propranolol (Inderal), and botulinum toxin (Botox). Many other drugs, such as amitriptyline (Elavil), gabapentin (Neurontin), candesartan (Atacand) are used “off label”, meaning that they are not FDA-approved for migraines in adults or children. One of the reasons that more drugs are not approved specifically for children is the difficulty in conducting research in kids. Their are migraines are usually shorter in duration and often stop occurring for long periods of time without treatment.

A large multi-center 24-week study just published in the New England Journal of Medicine examined the efficacy of topiramate, amitriptyline and placebo in children between the ages of 8 and 17. It was a double-blind study with neither the children and their parents nor the doctors being aware of who was getting which drug or placebo. The study showed no statistically significant difference among the three groups. The main outcome measure was a 50% or higher reduction of headache days. Placebo achieved this result in 61% of children, while this number was 52% for those on amitriptyline and 55% on topiramate. Not surprisingly, side effects were much more common in children taking medications than placebo. Fatigue and dry mouth were the most common side effects from amitriptyline, while topiramate caused mostly tingling and weight loss. Serious side effects occurred in four – three kids on amitriptyline had a serious mood disorder and one on topiramate attempted suicide.

This study did not prove that amitriptyline and topiramate are ineffective since they did help half of the children they were given to, however the placebo worked at least as well. These findings are not surprising since placebo has a powerful effect, which is often more pronounced in children and because children’s migraines often stop on their own. Even in adults, placebo effect has often made clinical trials, particularly in migraines, very difficult. It took a couple of attempts to prove that Botox prevents migraines better than placebo, again not because Botox was ineffective, but because placebo also worked well.

The initial approach to treating migraines in children and adults should always involve looking for modifiable triggers, such as sleep schedule, regular meals with healthy food, elimination of caffeine and sugar, regular exercise, sleep hygiene, meditation or biofeedback, and so on. Our second step is trying supplements such as magnesium (which sometimes is given intravenously because of poor absorption of pills) and CoQ10, which have been proven to be effective both in children and adults. Other, less proven supplements, such as riboflavin, feverfew, and boswellia are also worth trying before starting a daily preventive medication. At the same time, since migraine often causes severe pain, we often prescribe abortive migraine medications, such as sumatriptan or rizatriptan, which are often more effective than ibuprofen and acetaminophen.

It is considered unethical for doctors to prescribe placebo, although we do sometimes prescribe very mild drugs in a small dose (cyproheptadine is one such drug), which is almost the same as prescribing a placebo.

An interesting study of placebo in patients with low back pain was just published in the journal Pain . One group was given the usual treatment and the other received the usual treatment as well as a placebo pill, but they were told that they are being given a placebo. The group that knowingly took placebo had a significant reduction in pain and disability. After three weeks of this trial, the first group was also given a placebo pill and they also had a significant drop in pain and disability. It is possible that the effect is just due to the act of taking a pill, which subconsciously sends a message to the brain that something is being done to fix the problem.

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Zolmitriptan is one of seven triptans available in the US and it comes in tablets (Zomig), orally disintegrating tablets, that is tablets that melt in your mouth (Zomig ZMT), and nasal spray (Zomig NS). The nasal spray was just approved for children 12 and older. It is available in 2.5 mg and 5 mg strength and the 2.5 mg is the starting dose, but kids are allowed to take 5 mg dose up to twice a day.

My previous post mentioned the approval of Treximet, a combination of sumatriptan (Imitrex) and naproxen (Aleve) in adolescents. However, Zomig is the only triptan in a nasal spray form (the second triptan available in a nasal spray is sumatriptan or Imitrex) approved in the US for children. The advantages of this form of drug delivery is that it tends to have faster onset of action and it can be taken when severe nausea or vomiting precludes the use of oral medications. Sumatriptan nasal spray is approved in kids in Europe, so there is no reason not to use it as well, however Zomig spray seems to be better than Imitrex spray. The amount of fluid in a single dose of Zomig is less than that in Imitrex and the spray droplets are of smaller size, leading to better retention of fluid in nasal passages and better absorption. Also, many patients complain of a very unpleasant taste with Imitrex spray, although this can be avoided by sucking on a hard candy while spraying. This will carry the saliva out of the mouth down the throat and the drug will not reach the mouth. When using nasal sprays it is important not to sniff them up your nose because this will carry the medicine into the throat rather than having it stay in the nose where it gets absorbed faster.

Since we are on the topic of nasal sprays, I should mention three other nasal sprays that can be used to treat headaches. Migranal nasal spray contains dihydroergotamine, which is one of the strongest injectable migraine medications. However it is a lot less effective in a nasal spray form. Sprix is a nasal spray of ketorolac (Toradol), a nonsteroidal anti-inflammatory drug, which is also much stronger when injected. It is also available in a tablet, but the tablet is not any stronger than aspirin or ibuprofen. The third nasal spray is Stadol NS and it contains butorphanol, a strong narcotic pain killer. It should be avoided because it is very addictive.

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A combination pill containing 10 mg of sumatriptan with 60 mg of naproxen sodium was just approved by the FDA for children aged 12 to 17. This combination in a higher dose (85 mg of sumatriptan and 500 mg of naproxen) has been available for adults for the past 7 years. This recent FDA approval allows children to take up to one adult strength tablet a day. It is good to have a smaller size tablet for kids. However, there is a big issue of cost. We don’t yet know what the pediatric strength tablet will cost, but a single tablet of the adult strength Treximet is $75. Yes, $75 for one tablet, even with a coupon you can get at and $80 or more without a coupon. Very few insurance companies will pay for Treximet because you can get a generic tablet of sumatriptan (Imitrex), 100 mg for $1.50 and a tablet of naproxen, 500 mg for 7 cents. So, make-your-own Treximet will cost you $1.57. A very rare patient will tell me that they get better relief from the branded pill, which is possible because of the inactive ingredients, speed of onset and occasionally poor quality generics (I wrote about this problem in a previous post). However, such patients are very few.

Besides Treximet, we have two other triptans approved for migraines in children. Rizatriptan (Maxalt, Maxalt MLT) is approved by the FDA for children and adolescents 6 to 17 years of age and it is available in a generic form. Almotriptan (Axert) is approved in adolescents, 12 – 17 years of age, but it is available only as a branded drug ($40 a pill). In the UK, 10 mg sumatriptan nasal spray (Imitrex in the US, Imigran in the UK) was approved for adolescents, ages 12-17, who suffer from migraine and cluster headaches. In the US, we have only 5 and 20 mg nasal sprays of sumatriptan, and both are available in a generic form. Sumatriptan and zolmitriptan (Zomig, Zomig ZMT – orally disintegrating tablet, Zomig NS – nasal spray) were also tested in kids. The reason these two drugs were not approved is because the placebo response in kids tends to be very high and the active treatment was not distinguishable from placebo. This is mostly because headaches in children tend to be shorter in duration and the headache goes away on their own in a couple of hours, making it difficult to separate the active drug from placebo. However, they are probably as effective and as safe as the triptans approved in pediatric patients.

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Doctors in St. Louis, MO examined how well headaches are treated in children. There has been little research about how well doctors in the US care for children and teens with migraine and if the treatment is consistent with evidence-based guidelines. They also assessed how often opioids (narcotics) are prescribed for children with migraines. The study used Electronic Health Record data to look at how almost 40,000 children and teens with migraine who presented to primary care providers, specialty care, or Emergency Room or Urgent Care (ER/UC) across four states in metropolitan and non-metropolitan areas were treated from 2009-2014.

The results showed that among children and teens presenting for care for migraine or likely migraine, nearly half (46%) were not prescribed or recommended any medication. Only one in six (16%) were prescribed or recommended an evidence-based medication. Among those who received medication, nearly one in six (16%) were prescribed an opiod (narcotic), and these numbers are even higher among teens 15-17.

The findings also revealed that the odds of getting an evidence-based medication were significantly higher if migraine was diagnosed, and the odds of getting any medication (evidence-based or not) were higher in non-metropolitan areas. Children and teens treated in a specialty care setting or the ER/UC were twice as likely to be prescribed an opioid than if treated in primary care.

The authors concluded that “Too many children who present for migraine or likely migraine are not getting any medication for their pain. Too few are receiving care consistent with evidence-based guidelines. And far too many are being prescribed an opiod. Five out of six children and teens are receiving suboptimal migraine care. A significant need exists to increase doctor awareness of the benefits of optimal migraine care and the potential dangers of prescribing opioids for children and teens with migraine.”

Guidelines issued by many medical organizations call for the use of ibuprofen as the first line treatment, however most children with severe migraines need to take a triptan. Triptans include sumatriptan (Imitrex), rizatriptan (Maxalt), zolmitriptan (Zomig), and four other similar drugs. Rizatriptan has been shown to be effective in children as young as 6, while other triptans have been approved for children older than 12. It is very likely that, just like in adults, some children respond better to one triptan and several triptans may need to be tried to find the best one. Just because the FDA approved one triptan for children above the age of 6 and another above the age of 12, it does not mean that there is a significant difference among the seven available triptans. These are safe drugs that have been in use for over 20 years and several of them are available in Europe without a prescription.

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Placebo effect is a well-documented phenomenon, which is particularly pronounced when treating migraine headaches. Intravenous (IV) infusion of saline water is a placebo commonly used in studies where placebo is compared to a medication also given IV.

It is baffling why a group of Canadian physicians decided to test the effect of (IV) fluids on migraines in children and adolescents seen in an emergency room (the study was just published in Headache). They compared a group of children who were told that they will get only IV fluids with another group who was told that they might also get a medication with the IV fluids. The second group actually watched a nurse add something to the bag of IV fluid, but the children were not told that it was just more of the saline water. The researchers thought that the expectation of getting a medicine will help relieve their migraine headache. In fact neither group, the one who received IV fluids without expecting any medicine and the group who thought that they may be getting medicine had much relief. Strangely, the doctors concluded that additional studies using larger volumes of IV fluids are warranted. As if there is a chance that giving more fluids will stop a severe migraine. Sadly, intravenous fluids are often used in emergency rooms as a treatment for migraines in adults and children and we did not need this study to show that it is an ineffective approach. Doing more such studies seems unethical. Imagine a parent getting up in the middle of the night, taking a sick child to an emergency room where the child receives only intravenous fluids and is sent home with the child still in pain.

Emergency rooms, even in the medical mecca of New York City, are notorious for using ineffective treatments for migraine headaches. If not intravenous fluids, patients often get narcotic (opioid) pain killers, tranquilizers, or antihistamines, such as Benadryl. Some patients are just given a tablet of ibuprofen and are sent home after waiting for hours to be seen and treated. Here is a previous post on what to ask for if you end up in an emergency room with a severe migraine. Obviously, some doctors will not comply with your request, but it is worth asking.

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Besides many other mental and physical problems, bullying in school causes headaches. This is the conclusion of a group of psychologists at the University of Padua in Italy who published their findings in the last issue of the journal Headache. They looked at 20 published studies on bullying, which included 173,775 children, and found that 14 of these studies recorded the presence of headaches. While 19% of kids who were not bullied suffered from headaches, this number was 33% in those who were. There was no difference in the incidence of headaches between kids in Europe compared to other countries.

This study confirms what has been reported for health problems in bullied kids in general. It is well known that psychological stress causes physical symptoms. Social pain is a term that psychologists use to describe the effect of peer rejection, ostracism, or loss. Recent studies have shown that physical and social pain share many physiological mechanisms in the brain. The authors also speculate that lack of coping skills, low self-esteem or lack of assertiveness may lead to more psychological and physical problems. They also call on pediatricians, school nurses and others to become more aware of the physical symptoms, such as headache, as a manifestation of bullying.

I have seen a number of children with severe persistent headaches, which required home schooling. In some of these kids bullying was a definite contributing factor, although many children are reluctant to admit this even to their parents.

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Children with migraine headaches are usually given acetaminophen (Tylenol) or ibuprofen (Advil). A group of Italian doctors compared responses to these two drugs in kids with migraines who took a daily magnesium supplement to those who did not. Results of their study were published in the latest issue of the journal Headache. One hundred sixty children (80 boys and 80 girls) aged 5-16 years were enrolled and assigned to four groups to receive a treatment with acetaminophen or ibuprofen without or with magnesium. The dose of each drug was adjusted according to the child’s weight. Those children who were in the magnesium arm were given 400 mg of magnesium (the article does not mention which salt of magnesium was given – oxide, glycinate, citrate, or another). Migraine pain severity and monthly frequency were similar in the four groups before the start of the study. Both acetaminophen and ibuprofen produced a significant decrease in pain intensity, but not surprisingly, did not change the frequency of attacks. Magnesium intake induced a significant decrease in pain intensity in both acetaminophen- and ibuprofen-treated children and also significantly reduced the time to pain relief with acetaminophen but not ibuprofen. In both acetaminophen and ibuprofen groups, magnesium supplementation significantly reduced the attack frequency after 3 and 18 months of supplementation.

This study was not the most rigorous because it did not include a placebo group as the authors felt that placing children on a placebo would be unethical. However, it was rigorous in other respects and still provides useful information. The first conclusion is that taking magnesium reduces the frequency of migraines in children. The second is that taking magnesium significantly improves the efficacy of acetaminophen and ibuprofen.

The bottom line is that every child (and adult for that matter) should be taking a magnesium supplement. I have written extensively on the importance of magnesium because our research and that of others, including the above study, has consistently shown the benefits of magnesium. Unfortunately, after dozens of publications, hundreds of lectures, and recommendations from medical societies, many doctors still do not recommend magnesium to their migraine patients. Some are not familiar with the research, others dismiss any supplements out of hand, and yet others do not believe the studies because they think that magnesium is too simple and too cheap to be effective. Most doctors are trained to prescribe drugs and they feel that patients expect prescription drugs, so giving them a supplement will disappoint the patient and will reduce doctor’s standing in patients’ eyes. This is clearly not the case since many people prefer more natural approaches and because recommending a supplement does not mean that a prescription drug cannot be also given. In fact, magnesium improves not only the efficacy of acetaminophen and ibuprofen, but also prescription drugs such as sumatriptan (Imitrex).

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White matter lesions that often seen on MRI scans of adult migraine sufferers were also found in children. A study by Washington University researchers inn St. Louis examined MRI scans of 926 children 2 to 17 years of age (mean age was 12.4 and 60% were girls) who were diagnosed with migraine headaches. They found white matter lesions (WMLs) in about 4% or 39 of these children, which is not much higher than in kids without migraines. Just like in the adults, these WMLs were slightly more common in kids with migraine with aura. None of these lesions were big enough to be called a mini-stroke or an infarct. There was no correlation between the number of lesions and the frequency or the duration of migraines. In conclusion, WMLs in children with migraines do not appear to be caused by migraines and are most likely benign in origin. The origin, however remains unknown, which often causes anxiety in parents of these children.

Unlike in children, adults with migraines and especially those with migraines with aura, are much more likely to have WMLs than adults without migraines. But even in adults, these appear to be benign as I mentioned in my previous post.

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The previous post mentioned a study confirming that caffeine makes headaches worse in adults 20 years or older. A study by pediatric neurologists from the Cleveland Clinic, Chad Whyte and David Rothner showed that this is also true in adolescents. They looked at 50 children, who were between 12 and 17 years of age who presented to their headache clinic. The average age was 15 and 64% were girls. The mean consumption of caffeine was 109 mg per day. In kids with chronic migraines the intake was 166 mg, while in the rest it was 65 mg. The most popular form of caffeine was soda drinks. This study further confirms the role of caffeine in causing worsening of headaches and leading to chronic migraines.

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Half of the kids seen by pediatric headache specialists suffer from chronic migraines. Dr. Hershey and his colleagues at the Cincinnati Children’s Hospital presented results of a study that compared cognitive behavioral treatment combined with amitriptyline (an antidepressant used to treat migraine and other pains) with amitriptyline alone in children aged 10 to 17 who suffered from chronic migraines. This was a first randomized clinical trial in childred with chronic migraines. Combined psychological & pharmacological treatment has been reported to be effective in adults and children with chronic pain other than migraine. Psychological intervention was cognitive behavioral therapy (including biofeedback); pharmacological intervention was amitriptyline (goal dose of 1 mg/kg/day). The control group was taught attention control with equal to psychological intervention in terms of contact frequency and face-to-face time, and involved education and support. They enrolled 135 children with mean age of 14 years; 15% minority; 79% female. Mean baseline headache frequency was 21 days and mean baseline disability score was 68 (severe disability grade). There were no differences between groups at baseline.

For the combined group, a greater than 50% headache frequency reduction was seen in 66% at post-treatment (20 weeks later), 86% at 12-month follow-up. And most impressively, 71% no longer had chronic migraines at the end of treatment and 88% were not chronic at 12-month follow-up. The disability score dropped to below 20 (mild to no disability) in 75% at post-treatment and 88% at 12-month follow-up. These results were significantly better than in the control group of children. The authors concluded that the combined psychological and medication treatment in youth with chronic migraine shows clinically significant reductions in headache frequency and migraine-related disability. At 12-month follow-up, almost 9 out of 10 children no longer had chronic migraines and were mild to no disability grade. They also felt that the results of this study should immediately impact practice of headache medicine in children. However, they could be wrong speculating that based on the published studies in adults, cognitive-behavioral therapy with amitriptyline may be better than other medications and Botox injections. In order to prove this, they need to do a study directly comparing Botox injections with cognitive-behavioral therapy and amitriptyline. One other factor that is not mentioned by the authors is that chronic migraines often subside on their own, which was shown in a study of 122 Taiwanese adolescents.

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Infantile colic seems to be a precursor or an early manifestation of migraine headaches in children. A new European study published in the journal JAMA supports an earlier American study mentioned in one of my previous blogs. This European study involved 208 children who were diagnosed with migraine at emergency departments found that 73% of them had a history of colic in infancy, compared with 27% of a control group of children. History of being colicky was as common in children and teens who suffered from both migraine with and without aura.

This study suggests that many colicky babies whose colic does not respond to any treatment directed at their digestive system may be suffering from migraine headaches. Some of these children may develop cyclic vomiting as they get older and then go on to have typical migraine headaches.

The researchers at two Italian and one French hospital did a second study involving 120 children with tension-type headaches. Only 35% of these children had a history of infantile colic, confirming that it is not any headache, but specifically migraine that is associated with infantile colic. Migraines are very common in children. Before puberty, about 6% of boys and girls suffer from migraines. After puberty, boys remain at 6% and the incidence of migraines goes upt o 18% in girls.

One of the authors of the study suggested that migraine medications might be effective for colicky babies, although this would require a controlled study. Such studies in infants are difficult to perform because of the unknown potential side effects, which understandably will lead to parent anxiety. However, the colic is painful and we know that pain even in infancy leads to harmful changes in brain chemicals and brain structure. A colicky baby also causes high stress for the parents.

In my practice, I’ve encountered many children with episodic and chronic migraines whose parents report infantile colic that gradually transformed into a typical migraine. So, unfortunately, migraine can start even before a child can begin to speak.

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Children suffering from migraine headaches are more likely to have difficulty performing well in school, according to a new report published in Neurology. The doctors studied 5,671 children between ages 5 and 12 from 87 Brazilian cities and found that episodic migraine was present in 9% of children (9.6% of girls and 8.4% of boys), probable migraine, in 17.6% (17.3% of girls and 17.8% of boys) while chronic migraine in 0.6% (equally in boys and girls). Headaches were more common between ages 9 and 12 than 5 to 9. Chronic migraine was more common in poor children. Poor performance at school was significantly more likely in children with migraine and chronic migraine, compared to probable migraine and tension-type headaches.
These are not very surprising results, although they cannot be generalized to all children with migraines. It is very common for me to see children who do exceptionally well in school despite having many migraine attacks and missing many days of school. It is possible that those hard-working and driven kids get headaches because of stress, but despite their severe headaches are able to perform well. Because they are high achievers and like doing everything well, they often excel at biofeedback, which helps them learn how to control their stress and reduce their headaches. Regular meals, exercise, and sleep are also very important. We try magnesium, COQ10 and other supplements next, and if headaches are very frequent, Botox injections followed by preventive medications.

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Infant colic appears to be more common in babies whose mothers suffers from migraines, according to a just published study by researchers at UCSF. This study looked at 154 infant-mother pairs and discovered that the risk of colic increases 2.6 times if mother suffers from migraines. Dr. Amy Gelfand, the pediatric neurologist who was the lead author concluded that infant colic could be the earliest manifestation of migraine headaches. We also know that some people who suffer from migraines report being told by their parents that as infants they had brief attacks of vomiting associated with paleness which seemingly were not related to food intake. This study confirms the old suspicion that migraines can begin from infancy. While we have many effective therapies, the true cure of migraines will come from genetic therapies, which unfortunately are decades away.

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Rizatriptan (Maxalt) is the only migraine drug approved by the FDA for children as young as 6. Almotriptan (Axert), another drug in the same family of triptans, is approved for children from age 12 and up. Rizatriptan also has an advantage over almotriptan in that it is available in a “melt” formulation (Maxalt MLT), which is a wafer that melts in the mouth. This is especially important for younger children who may have difficulty swallowing solid tablets, but is also useful for migraine sufferers of any age who have severe nausea that makes swallowing tablets difficult. The study that led to the FDA approval of rizatriptan included over 900 children. Obviously, it was a positive study, however, it showed what many previous studies have also shown – children respond to placebo at a much higher rate than adults. That is after two hours many children will have good relief from taking a sugar pill. This is partly due to the fact that pediatric migraines tend to be much shorter in duration, often only one or two hours. So, regardless of what a child takes, the headache will be gone in two hours. Nasal sprays work a little faster, so they may be a little more effective in children and sumatriptan nasal spray (Imirex NS) is approved for children in Europe. Nasal spray also avoids the need to swallow tablets. Another triptan in a nasal spray form is zolmitriptan (Zomig NS) and anecdotally it is more consistently effective than sumatriptan. Zolmitriptan also doesn’t have a very unpleasant taste of sumatriptan and the amount of fluid that is being sprayed into the nose is much smaller. There have been many studies of various triptans in children and they all showed that these drugs are safe in pediatric population. Cost can be an issue since branded triptans are very expensive. Fortunately, sumatriptan (Imitrex) is now available in a generic form and by the end of 2012 rizatriptan (Maxalt, Maxalt MLT) will also lose it patent protection and become available as a generic.
Despite their safety and efficacy, triptans should not be always the first choice for pediatric migraines. Some children may respond well to ibuprofen (Advil) or acetaminophen Tylenol. Younger children should be given these drugs in a liquid form for ease of swallowing and for faster onset of action. And prophylactic measures should also be never forgotten – regular meals and sleep schedule, avoidance of sugar, exercise, biofeedback, magnesium and CoQ10 supplements, and other.

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