Consultants for Pediatricians – November 2007
In most children, migraine manifests with severe bilateral pain, nausea and/ or vomiting, and photophobia or phonophobia (Figure). While this presentation can be alarming–particularly for parents whose worst fear is that their child has a brain tumor–it is actually classic for pediatric migraine.
This article focuses on making the diagnosis, addressing stress and other trigger factors– and helping school staff understand the importance of early intervention when a migraine develops while a child is at school. For details on treating acute attacks and on preventing recurrences, the reader is referred to several excellent articles on this topic.
- If there are autonomic symptoms and the headache pattern is acute and recurrent, the diagnosis is migraine.
- A migraine attack may be preceded by such symptoms as sluggishness, hunger, difficulty with words, or a feeling of doom (similar to that experience by some patients with seizures).
- Pediatric migraine usually occurs without an aura.
- Migraine is often accompanied by dizziness, light-headedness, pallor, or purple “bags” around the eyes. (Parents may be able to make the diagnosis just by looking at the child.)
- Migraine duration is shorter in children than in adults (1 to 72 hours) and is more often bilateral
- During a migraine attack, a child or adolescent will typically want to retreat to a dark quiet place and lie down. Exercise exacerbates the headache.
A long list of migraine triggers has been implicated. These can be mitigated somewhat if the child eats, exercises, and sleeps regularly. School is a significant migraine trigger. School stressors include waking up very early, worrying about grades or social issues, undiagnosed learning disabilities, and parental pressure. For the “stressed-out kid” with a “full plate” of school and extracurricular activities, it may help to give permission to lighten up the child’s load a bit. In many children, migraines go into “remission” during the summer, and begin again once school is underway.
WHEN A MIGRAINE OCCURS AT SCHOOL
In the school setting, it is often difficult for a child to find a dark, quiet place in which to lie down. Triptan medications can be taken at school at the first signs of headache. These agents allow the child to resume school activities.
The lesson for the child and the school nurse is to aggressively treat headache at the first twinge. The worst strategy is to send the child back to class immediately without medicine because the headache is “not so bad.” For migraineurs, the prescribed medication should be taken even during milder attacks.
It is essential that teachers and the school nurse allow the child access to medication at
the first twinge of headache, and to rest for a short time before returning to class. A note from the clinician to the school staff can be particularly helpful in enlisting the school’s cooperation. The note should stress the importance of early intervention and the need for the youngster to take his medication immediately.
Dehydration is a headache trigger for many young migraineurs. It is important for teachers to understand the need for the child to drink at his desk–and to grant bathroom privileges as needed (despite the potential for classroom disruption).
Certain teachers drop student’s grades for attendance reasons. This must be discouraged for migraine patients. The stress of artificial grade dropping may exacerbate migraines. Rather, a liberal makeup policy for missed days gives the migraineur some control and assurance that he will not be punished for days when no work can be done. Help teachers and administrators understand that while a child is in the throes of a migraine, it is impossible to concentrate on school work.
The biggest mistake is to allow a pediatric migraineur to stop attending school because of headaches. Although school may be stressful, it is a child’s job. Once a child is out of school, it is extremely hard to get him back in school.
The doctor and school staff can develop a partial attendance program (eg, in which the school day starts a little later than usual and accommodations are made when a child is absent). Such a program is preferable to home school programs. Many children feel isolated
and defeated when told they cannot return to school. On the other hand, some youngsters with migraine relish the idea of staying home. Obviously, avoidance is not the answer.
- Use a maximum of 3 doses of analgesic medication per week to avoid medication overuse headache.
- Keep a headache calendar, documenting headache frequency and intensity (scale of 1-10), as well as abortive medications taken. Please bring the calendar to the next office visit.
- Maintain healthy habits recommended for headache prophylaxis including:
- Drink 4-5 cups of non-caffeinated fluids daily.
- Eat 4-5 small frequent meals containing green, leafy vegetables and fruit.
- Maintain a healthy sleep routine.
- Exercise regularly.
THE BOTTOM LINE
A pattern of headaches that are accompanied by autonomic symptoms, the need to rest during attacks, a family history of migraines, and benign physical findings are migraines until proved otherwise. When a migraine develops at school, a triptan should be taken at the first sign of headache.
Foods implicated as migraine triggers*
||Histamine, tyramine, sulfites
*Fasting can trigger release of stress hormones and hypoglycemia, leading to migraine