A toddler is having bouts of projectile vomiting, quite frequently but not every day. Fearing something is "terribly wrong" with her daughter's digestive system, her mother takes her to the doctor. Within 20 minutes, the pediatrician has traced the girl's symptoms to motion sickness -- she gets sick every time she rides in the car, or shortly after. Although she's never had a headache, by age 3 the girl is diagnosed with the neurological disorder called migraine.
What Is Migraine?
A simple definition is a "recurrent, episodic headache, or head pain, that typically lasts between two and 72 hours untreated," says Andrew Hershey, chair and a professor of neurology at Cincinnati Children's Hospital Medical Center . For some people, migraine comes with nausea or vomiting, while others experience light and sound sensitivity. Headaches are usually throbbing and partial (involving one side of the head) and moderately or severely intense. Migraine has a strong genetic component.
Hershey, director of the CCHMC Headache Center, says while most migraine episodes come and go, they can evolve into chronic migraine: "About a third of our patients get to the point that the headache just never leaves them."
At least 10 percent of kids have migraine, Hershey says. While the rate is about 4 percent in preschoolers, by late teens it affects up to 15 percent of boys and 20 to 25 percent of girls. The youngest patient Hershey ever treated started at 10 months old.
What Triggers Migraine?
"Migraine is more than a headache. It's a generalized disturbance of function that involves brain and body," says Joel Saper, a neurologist and director of the Michigan Head Pain and Neurological Institute in Ann Arbor.
Although many people believe stress "causes" migraine, researchers are still working to determine the complex causes for the condition. What's known is that children have a variety of migraine triggers that can set off an episode, including food sensitivities, fatigue, bright lights, loud noises and sleep changes.
In younger kids, non-headache signs or "migraine equivalents" can include stomach pain, episodes of dizziness, vertigo (spinning), visual disturbances and sudden mood changes, Saper says. Motion sickness is migraine equivalent, he notes, and it's been recently established that colic in babies is a forerunner to migraine.
Before starting any kind of treatment, it's crucial to pin down the diagnosis. Some 300 other medical conditions cause headache in kids, Saper says. Emotional causes also have to be ruled out -- like school avoidance in a kid who's anxious or being bullied.
For parents, Saper says it's key to find a knowledgeable health care provider, whether it's a specialist, family practice doctor, nurse practitioner or physician assistant.
Life With Migraine for Kids
Two decades ago, Cathy Glaser was concerned about her 3-year-old daughter Samantha, who was having cyclical bouts of vomiting and upset stomach. Through careful questioning, the pediatrician traced the episodes to motion sickness.
Glaser knows a lot about migraine. "We like to say my daughter was doomed since both parents have migraine. It runs through both of our families," says Glaser, who eventually started the Migraine Research Foundation in New York.
Although Samantha was stoic, Glaser could always tell when she had a migraine coming on. "I could look into my daughter's eyes and see she was getting a headache," she says. "I could look at her face -- she was ashen. All of a sudden those sparkly child's eyes were absolutely dead. And her whole affect changed."
Migraine invaded every aspect of Samantha's childhood, and she visited the emergency room several times a year. It hijacked family trips. On their way to a family reunion at Hersheypark in Pennsylvania, they were forced to pull off the New Jersey Turnpike, because Samantha was green with motion sickness.
School presents many challenges for kids with migraine. Glaser says that as a parent, you need to be your child's advocate. And you have to be proactive.
"I used to go to school every year at the beginning, or before, with a doctor's note about migraine and my own daughter's treatment explain when she raises her hand and says, 'I need to take my medication now,' they need to let her go," she recalls.
Samantha "didn't want to miss her life," Glaser says. Even as an 8-year-old, she would say "Mom, I can be alone and feeling horrible, or I can be at school with my friends feeling horrible. I choose school."
Every summer Samantha's parents sent her off to sleep-away camps, and every time they got calls in the middle of the night to come get her -- the camp couldn't handle it. "This is the life of a child who has regular headaches who insists on living the life of a kid," Glaser says.
Boys and girls get headaches equally until age 12 or 13 -- but when girls start their periods, the picture changes. Migraine is an "estrogen-vulnerable" disorder, Saper explains. Hormone cycling in girls and later women -- from menstruation, oral contraceptives and menopause -- can make migraines worse. Boys are more likely to grow out of migraines than girls.
As she entered her teens, Samantha developed menstrual migraine. (She also gets weather headaches, when there's a change in barometric pressure or a storm's coming on.)
With migraine, "Sameness helps," Saper says. Sleep is a big issue, and regular bedtimes and waking times are important. If kids have trouble sleeping, he says melatonin "is a particularly good medicine" to help.
Some children with migraine are food sensitive. "What they eat may make a difference, whether it be the gluten, cheese or dairy products -- there's a long list," Saper says. Kids shouldn't miss meals or skip breakfast.
Dehydration can also trigger migraines, and healthy habits include drinking plenty of water or other non-caffeine drinks. Exercise also helps, and so do relaxation and stress-management techniques.
Not Your Parents' Headache
For migraine that goes beyond a headache or two a month, research suggests the best approach combines medication and cognitive behavioral therapy. The two main drug categories are medications for treatment and for prevention.
NSAIDs such as Aleve and Ibuprofen are used to break acute headaches in kids, Hersey says -- aspirin should be avoided because of the risk of liver problems. And parents and patients should be alert to overuse. For prevention, the drugs amitriptyline and topiramate are most commonly prescribed.
At Cincinnati Children's Headache Center, after kids undergo a neurological and headache exam, the team comes up with a multipronged treatment plan, including medication choices and learning healthy habits. Kids with chronic headaches return for cognitive behavioral therapy, which takes about six weeks to absorb.
Part of the goal is getting kids to accept that they have a chronic illness and teaching them to manage their own care, Hershey says: "We often say to the kids, 'It's your headache -- it's not your mom and dad's."
Scott Powers, a pediatric psychologist at the center, is working with his team to fine-tune a migraine app that kids can use to track their episodes and symptoms electronically. The app also allows researchers to better connect the dots between triggers and headache timing.
College and Migraines
With the importance of regular sleep, healthy eating habits and keeping stress on an even keel -- what could possibly go wrong when kids with migraine leave for college?
But when the time came, Samantha insisted on going away to a big school, Glaser says. After much discussion they agreed that Samantha would go to a school within driving distance, near a hospital and with a well-staffed campus health center.
"Her view about college was 'I want to stop being 'Migraine Girl,'" Glaser recalls her daughter saying. "'I want to stop being defined by my disease.'"