What to Know About Treating Pediatric Migraine
Here’s what you need to know about special treatment considerations for your pediatric migraine patients
About one in 11 children experience migraine, but it can be hard to diagnose migraine in the pediatric population. Children can have different symptoms and duration of attacks compared to adults. They also have difficulties describing their pain and expressing their symptoms to parents and caregivers. As a result, pediatric migraine often goes undiagnosed and untreated.
Just like children can have unique migraine symptoms, there are also some unique considerations for treatment and referring. Learn more about treatment options, lifestyle goals, signs of when to image and the red flags for pediatric migraine to help you provide proper treatment to your pediatric patients. Read more about pediatric migraine treatment and evaluation.
There are many migraine treatment options available for children. Acute headache treatment taken at the onset of migraine can help reduce the severity and duration of migraine attacks. There are three steps for using acute therapy to treat pediatric patients. The first step is to apply a simple analgesic (Acetaminophen, NSAID) and/or electrolyte fluid to eliminate pain. These medications are helpful for mild pain and minimal disability associated with migraine. If children also experience nausea and/or vomiting with migraine, primary care providers may consider giving patients simple analgesic and/or an anti-emetic to relieve the symptoms as the second step. The third step in acute therapy is for moderate to severe migraine that doesn’t respond to treatment in the previous two steps. Caregivers should offer triptans to pediatric patients in this case.
To successfully manage and treat pediatric migraine, it is important to start the treatment early. Parents and primary care providers should ask children what symptoms they have to make the right diagnosis and better address them. Caregivers should also educate the family on Medication Overuse Headache and avoid more than two treatment days per week. Headache log including date, time, situation and treatment is beneficial for families and clinicians to keep track of children’s migraine pattern and symptoms and identify triggers and reactions to medications.
In terms of dosing, primary care providers should keep in mind the “Rule of Twos.” If needed, re-dose in two hours. In general, pediatric migraine patients should limit medications to two doses per day and two treatment days per week.
Patients and caregivers need to be aware of possible side effects and contraindications for migraine medications, including flu-like symptoms and tightness in the chest, throat and/or jaw. Patients with uncontrolled hypertension, arrhythmia, transient ischemic attacks, history of stroke, ischemic heart disease, coronary vasospasm (including Prinzmetal’s), multiple risk factors for coronary artery disease and hemiplegic migraine should refrain from taking the medications above.
In addition to acute headache treatment, children with migraine should maintain a healthy lifestyle to reduce attacks. For pediatric patients who have more than four attacks per month and do not receive enough relief from acute therapy, they can also take daily preventive medications (i.e., propranolol, topiramate) to assist treatment.
A healthy lifestyle can also treat and prevent migraine. Pediatric patients should apply lifestyle changes together with medical treatment. Lifestyle goals include staying hydrated by drinking water (in ounces) that equals the weight (in pounds) of a child per day with a maximum of 100 ounces of water per day. It is also important to keep adequate and regular sleep. Children should have 10-12 hours of sleep (within 2 hours variability) during the week and on the weekends. Exercising and avoiding extensive naps are also necessary.
You can also educate parents on food that might make sense for their children to avoid. Pediatric patients should avoid possible food triggers such as caffeine, cheese, chocolate, dairy, smoked foods, sausage, hotdogs, bacon, vinegar, red meat, pepperoni, bologna, deli meats and food with MSG (nuts, soy sauce). It is also beneficial for children to avoid skipping meals, especially breakfast. Parents and caregivers should also pay attention to other possible triggers of migraine like stress, intense emotions, weather changes, strong odors/fumes, loud noise, over-exertion, travel, medications and hormone changes (menstrual cycles).
Red Flags and When to Image or Refer
When diagnosing and treating a child who might have migraine, primary care providers should look out for potential red flags in disease history and neurological exams. They should be aware if children experience the worst headache of their life, positional headache, head pain during sleep or early morning especially with emesis, atypical or change in headache pattern, headache intensified by exertion, headache associated with neurological deficit, acute vision loss or diplopia, sudden decline in school performance, seizure and/or personality change.
Usually, pediatric migraine does not require imaging, but if you observe signs of increased intracranial pressure, abnormal neurological assessment, severe/abrupt headache (thunderclap), change in headache pattern (increasing frequency or severity), deviation from criteria for migraine or tension headache, lack of responding to daily or acute medications, infection and/or trauma in patients, imaging can be necessary.
Red flags in neurological exams include meningeal signs, fever, rigors, signs of increased intracranial pressure, neurocutaneous findings, altered mental status, focal neurological findings, papilledema, nystagmus, cranial nerve abnormality, hemiplegia and/or ataxia.
If caregivers see the above red flags in history and/or exam, they should refer to pediatric neurologists for further evaluation. Besides, a referral may be necessary if imaging points to significant abnormality, if patients are not responding to daily or acute medications, and if children are younger than five years old.
Primary care practitioners are essential to identifying and treating headache disorders. The American Headache Society’s First Contact – Headache in Primary Care program provides educational resources to empower healthcare professionals and improve headache and migraine care. Learn more about the program here.