“My wife gets migraines—really bad ones—and now my daughter seems to be getting them too. She’s only 7! Is she just copying what her mom does? Can a child really start getting migraines?”
Oh, yes they can. Migraine is very much a childhood disorder. About 5% of adults have migraines, and half of them started having their migraines as kids.
As in adults, migraines in children can be severe and debilitating. However, there are some differences. Fewer children than adults report auras—those strange visual or other neurologic manifestations that often precede and accompany migraines. Also, children are more likely to have headaches that feel like they’re all over their head, or on both sides. Children may not report the “throbbing” nature as adults do, and their migraines may be quite a bit shorter.
The most characteristic features of migraines are the same in adults and children. Migraines will almost always be followed by deep sleep (which usually ends the headache). And in between migraines, there are no symptoms at all.
There are a couple of odd associations with pediatric migraine. Kids with migraines often have a history of getting carsick, and sometimes have a history of sleepwalking. Sometimes, when migraines start in early childhood, the attacks are not mainly headaches, but other sorts of symptoms like vomiting or abdominal pain or hallucinations or trouble with balance and walking. Later, many of these children will start to have more-ordinary, adult-like migraine headaches.
In most cases, migraine is diagnosed clinically, based on the history and a careful physical exam. No imaging by CT nor MRI is needed unless there are “red flags” that indicate a different diagnosis is likely.
Which children need to have advanced imaging? The most important clue is how the headaches are progressing. Headaches that are getting worse and worse indicate a need for rapid imaging, as opposed to headaches that have been episodic and have been going on for several months.
Also, a sudden single very severe headache, sometimes called “the worst headache of my life,” should prompt consideration of a brain scan (however, recurrent “worst headaches” that go away and come back later are not of as much concern—those are very likely migraines.)
Other “red flags” that increase the need for imaging in a child include any persistent abnormalities on the neurologic exam, or headaches beginning in a child who for other health reasons is at risk for serious intracranial problems (like a child who has had brain surgery or has cancer.)
The most important part of treating childhood migraine is prevention. Many, but not all, kids with migraine will have identifiable triggers that can be avoided. These might include disrupted sleep or hunger, or bright light, or stress. Regular healthy lifestyle habits including good eating, sleep, exercise, and stress-reducing hobbies can go a long way towards preventing many migraines.
After prevention strategies, all migraine sufferers need an action plan: what to do when a migraine begins. Whatever treatment is chosen, it will work best if started soon, as soon as possible after a migraine begins, before the headache becomes severe. Some over-the-counter medicines work well, like ibuprofen. There are also prescription migraine-stoppers, some of which are FDA approved in children. Migraine treatment, after medicine, should also include encouraging the child to rest in a quiet, dark place.
It’s important that migraine-stopping medicines not be overused. Frequent use of any of these, including OTC products like ibuprofen or acetaminophen, will lead to rebound headaches that can get very bad, and can become a daily problem. Migraine stopping medicine shouldn’t be used more than two or three times a week.
There are also medical strategies to prevent migraines, including prescriptions that can be taken every single day. Some vitamins (like riboflavin) or herbs (butterburr), have been studied in adults and can be effective migraine preventers—but their use in children hasn’t been studied, and since these products are poorly regulated there are important questions about purity and dosing. Still, I often prescribe these alternatives. They may be worth trying prior to prescription medications.
It’s also important to be realistic when dealing with children who are having migraines. It may not be possible to prevent all of them, and treatment once a migraine begins may only be partially effective. Still, we can usually help children with migraine headaches feel better most of the time.
Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.