DIAGNOSING ADOLESCENT MIGRAINES CAN BE DIFFICULT
Many physicians do not know criteria to determine this all-too-common ailment
A recent headline in one of the pediatric journals I subscribe to caught my eyes: “Kids with migraine not receiving optimal treatment.”
Migraines are one of the most common reasons for referrals to a pediatric neurology clinic.
Worldwide, the prevalence is 7.7 per cent. About 10 per cent of school-aged children suffer from migraines and boys are affected more frequently before puberty. Girls are affected more commonly after puberty.
Migraine headaches have a huge impact on quality of life. Children with migraines miss on average eight school days yearly, versus four days of school missed by children without migraines. Many of these children grow up without a resolution to their issue. Among adults globally, migraine headaches rank seventh among specific causes of disability.
In a recent article in Contemporary Pediatrics (June 2018), Dr. Christopher Oakley, assistant professor of Neurology at Johns Hopkins School of Medicine, laments the fact that not all physicians understand the diagnostic criteria for pediatric migraine and its variants.
The International Classification of Headache Disorders (ICHD -3) established criteria to classify migraines. The reality is the ICHD -3 classification is extremely complex — making it hard for many doctors in primary care to sort through the problem properly, thus creating a huge number of referrals to specialists.
What stands out, in terms of the complexity in the ICHD -3 criteria, is the listing of migraine variants. The latter includes conditions such as: chronic migraine, familial hemiplegic migraine, cyclical vomiting syndrome and abdominal migraine.
In addition, there are patients who get migraines without an aura. They suffer from what is called a prodromal complex where symptoms are rather nonspecific (fatigue, nausea, stiffness, difficulty concentrating, blurred vision, yawning and turning pale).
The typical migraine headache patients experience is a throbbing and pounding pain; they describe a feeling of being pressured or feeling a stabbing pain in the head. The pain can be located on one side but in children it may also be bi-frontally (Both sides of the forehead).
The elephant in many exam rooms is the often undeclared concern of “Can this be a headache due to a brain tumour?” The good news is, in 98 per cent of children with brain tumours who present with headaches, there is at least one or two neurological findings.
Many primary care doctors struggle with when to run an MRI. For this reason, neurologists have established a list of red flags which include: Early morning wakening by a headache associated with nausea and vomiting; worsening headaches while straining; changes in mood, mental status or school performance; an increasing sense of light-headedness; numbness around the mouth or by the hand associated with a weakness and an explosive pain in the back of the head.
The majority of migraine headaches respond to ibuprofen (10 mg per kg every six hours). This medication is the most widely studied analgesic for pediatric headaches. Children who suffer from Gastro-intestinal bleeding, renal impairment or kids who also use anticoagulants should be treated with acetaminophen, which is considered second-line treatment.
The study mentioned earlier which questioned the appropriate treatment of migraine suggested only one in six patients got the proper evidence-based treatment; that some kids in an ER setting were prescribed opiates too easily and that almost half the kids in the study (presented at a recent American Headache Society Scientific Meeting) at one point did not receive any treatment.
A specific class of migraine medications known as triptans have helped a great number of patients. What strikes me is the vast number of products in this class, which complicates the choice of best-overall.
According to Dr. Oakley, a new medication is on the horizon. This particular medication works by blocking the concentration of a substance called calcitonin gene related peptide (CGRP), a potent vasodilator found in the external jugular vein at the time of an attack.
Recently, more clinicians are interested in using nutraceuticals for the treatment of migraines, such as magnesium and Vitamin B2 (riboflavin).
Migraine prevention is considered when patients experience at least three to four migraines monthly. Consensus is slim at this time and the American Migraine Prevalence and Prevention trial recommends considering prophylaxis to patients 12 years and older.
Botox injections have been tried in adults with variable success. Clearly young children will not be a fan of injections or acupuncture! Older teens who experience a poor quality of life may be open to this modality.
Lifestyle Medicine has become increasingly popular as a subspecialty for some doctors. At a time when many patients are interested in avoiding pharmaceutical products, a change in lifestyle has attracted attention. Proper sleep, fresh air, avoiding excessive amounts of technology/screen time and staying well hydrated have been shown to help in some cases.
For more information on lifestyle medicine see the Canadian Academy of Lifestyle Medicine (www.calmlifestylemedicine.ca) or the American College of Lifestyle Medicine (www.lifestylemediciane.org)
Migraines are one of the most common reasons for referrals to a pediatric neurology clinic.