migraines and 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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Excessive consumption of marijuana can lead to bouts of severe nausea and vomiting, which in medicalese is called cannabinoid hyperemesis syndrome (CHS). With many states legalizing medical and recreational marijuana, there has been an increase in ER visits and admissions to the hospital for severe vomiting. This is often misdiagnosed as cyclic vomiting syndrome (CVS), a condition which is more common in children than adults and is related to migraines. CVS, which is mentioned in a previous post, is often relieved by sumatriptan (Imitrex).

Unfortunately, people who overindulge in pot, do not realize that it is responsible for their symptoms and end up undergoing endoscopies, MRI scans and other procedures. Taking a hot shower is known to relieve pot-related vomiting, but hot shower also works for some patients with CVS, so this does not help in differentiating the two conditions. German researchers tried to find a reliable way to differentiate CHS and CVS and concluded that the only way to tell these apart is to completely stop marijuana. They do note that CHS can develop after years of using marijuana and that after marijuana use is stopped, it may take several days and up to a couple of months for symptoms to subside.

So far, we’ve prescribed medical marijuana to a couple of hundred patients with headaches, migraines, and nerve pain and have not seen such a problem. It is possible that the amount used for medicinal purposes is too small to cause CHS. The cost of medical marijuana is relatively high and could be preventing its overuse.

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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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The field of marijuana research is starting to take off due to the wider acceptance of medicinal marijuana. The other night I attended a lecture in NYC by the “father of cannabis”, Raphael Mechoulam.

According to Wikipedia, “Dr. Mechoulam is an Israeli organic chemist and professor of Medicinal Chemistry at the Hebrew University of Jerusalem in Israel. Mechoulam is best known for his work (together with Y. Gaoni) in the isolation, structure elucidation and total synthesis of THC (?9-tetrahydrocannabinol), the main active ingredient of cannabis and for the isolation and the identification of the endogenous cannabinoids anandamide from the brain and 2-arachidonoyl glycerol (2-AG) from peripheral organs together with his students, postdocs and collaborators.”

Dr. Mechoulam identified THC in 1964 and in his lecture he lamented the paucity of research into the many potential healing properties of cannabis in the past 50 years. He strongly feels that the two main active ingredients in marijuana, THC and CBD should be tested rigorously in large double-blind studies just like any other prescription drug. This will allow doctors to prescribe a proven medicine, rather than rely on anecdotal reports and go through trial and error, as we are doing now. His research suggests that cannabis ingredients could possibly help a wide variety of conditions, from diabetes and cancer to pain and nausea.

Prescribing medical marijuana is at least possible in New York and 20 other states, so that we do not have to wait, possibly up to 10 years, for a cannabis-based drug to be approved by the FDA (one CBD-containing drug might be approved soon for a rare form of epilepsy).

At this time we have to go through trials of various ratios of THC and CBD and various modes of delivery (inhaled, sublingual or oral) to determine the best treatment for each patients. Another obstacle is the fact that no insurance company pays for medical marijuana. After a year of prescribing medical marijuana for patients with migraine and other painful conditions it is clear that it works for a minority of my patients. However, I prescribe it only after more traditional methods fail, so my results may not be as good as if I used medical marijuana earlier. Our standard approach involves lifestyle changes, regular exercise, dietary changes, magnesium, CoQ10, and other supplements, followed by drugs and Botox injections. These are mostly well-studied treatments and with the possible exception of drugs, should precede the use of medical marijuana. Having said that, For a few of my patients medical marijuana dramatically improved their quality of life and I am very glad that we have this treatment option available.

Dr. Rafael Mechoulam and Dr. Alexander Mauskop
May 4, 2017, NYC

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