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Migraine Headaches

Migraine headaches are common in the pediatric age group. About 10% of children 5 to 15 years of age, occasionally even earlier, will develop migraine headaches. After adolescence, about 6% of men and 18% of women will develop migraines. About 75% of the visits to the pediatric neurologist due to "headaches" turn out to be migraines. The diagnosis of migraine headaches is clinical. The diagnostic criteria were most recently re-established by the International Headache Society (IHS) in 1988. These criteria state that migraines must be chronic headaches with recurrent episodic attacks (a constant headache is not a migraine). There may or may not be an aura (a visual change that occurs prior to the headache and may serve as a warning sign that the migraine is imminent). This distinguishes the two migraine types:

  1. Migraine with an aura (formally classic migraine)
  2. Migraine without an aura (formally common migraine)
The duration of a migraine must be over 4 hours, but in children may be shorter. Also migrainous characteristics must be present. These may include fatigue. Sleep may be helpful and the child must feel tired, yet in many children there may be some associated difficulties with sleeping despite the tiredness (due to the pain). Other migrainous features may include nausea, vomiting, sensitivity to light and noise (phonophotophobia), and some associated dizziness. The frequency of the migraines may be rare, 1 to 2 per year, or may be frequent, several times per week.

Triggers for the migraine attacks must be identified due to the ability to prevent attacks by changing some environmental exposures. Triggers may include certain foods, such as chocolate, caffeine, Chinese food (MSG), nitrates (hot dogs, bologna, ham), yellow cheeses (cheddar, dark, or hard cheeses), nuts and peanuts, strawberries, bananas, or orange juice and other citruses. Not all foods are responsible for the headaches but some may be. Other triggers may be stress, fatigue, over sleeping, noises, smells, minor head bumps, bright lights, or physical activity.

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Treatment for Migraine Headaches

The treatment of migraines must be divided into two main considerations.

  1. Treatment that stops acute attacks (abortive treatment)
  2. Treatment that prevents the headaches from happening in the first place (prophylactic)
The preventative treatment may be achieved by medical and nonmedical measures. The termination of an acute attack is achieved with the use of medications. Many different medications may be effective. Some may be given orally, intranasally, and by injections.

This is the list of medications used to terminate acute attacks:

  1. Triptans:
    • Naratriptan
    • Rizatriptan
    • Sumatriptan (Imitrex)
    • Zolmitriptan (Zomig)
    • Eletriptan
    • Frovatriptan

  2. DHE (dehhydoergotamine) with or without antiemetics

  3. Combination medications:
  • Furinol
  • Furicet
  • EsgicPlus
  • Midrin <
  • Aspirin
  • Butorphenol
  • Ibuprofen (Motrin)
  • Naproxen
  • Prochlorpemazine (Phenergan)
  • Metoclopramide
  • Excedrin
  • Tylenol number 2
  • Chlorpromazine
  • Diclofenac (Volteren)
  • Ketoralac (Toradol)
  • Ergotamine with or without caffeine
  • Lidocaine
  • Meperidine
  • Methadone
  • Acetaminophen (Tylenol)
  • Dexamethesone
  • Hydrocortisone

Preventative treatments should be considered if the migraines become frequent, causing a significant impairment in function or lifestyle or causing paralysis (this may lead to stroke).

Preventative treatments may include the following:

  • Hypoallergenic diet
      NO:
    • Chocolate
    • MSG: Chinese food
    • Caffeine
    • Nitrates (hot dogs, bologna)
    • Yellow cheeses, cheddar, macaroni and cheese
    • Nuts and peanuts
    • Strawberries
    • Bananas
    • Citrus (orange, lemon juice)
  • Elimination of triggers (if possible), vitamin B2, magnesium, relaxation, and biofeedback
  • Cognitive behavioral therapy

Other unproven nonmedical methods for the treatment of migraines include the following:

  • Acupuncture
  • Hypnosis
  • Electrical nerve stimulation
  • Hyperbaric oxygen
  • TENS (transcutaneous electrical stimulation)

Medications used for the prevention of migraine attacks (prophylaxis) include the following:

  1. Beta-blockers:
    • Propanelol (Inderol)
    • Timolal
    • Nadolal
    • Metoprolol
    • Atenolol

  2. Antidepressants (tricyclics):
    • Amitriptyline (Elavil)
    • Nortriptyline (Pamelor)
    • Doxepin
    • Imipramine
    • Protryptyline

  3. Antidepressants (SSRI):
    • Fluoxetine (Prozac)
    • Paroxetine (Paxil)
    • Sertraline (Zoloft)
    • Fluxaminie (Luvox)

  4. Monoannine oxidase inhibitors (Phenelzine)

  5. Other antidepressants:
    • Bupropion
    • Trazodone
    • Venlafaxine

  6. Antiepileptics:
    • Valporic acid (Depakote):
    • Carbamazepine (Tegretol)
    • Gabapentin (Neurontin)
    • Topiramate (Topamax)
    • Tiagabine (Gabitril)

  7. NSAIDs:
    • Aspirin
    • Ibuprofen
    • Naproxen
    • Other NSAIDs

  8. Serotonin antagonists:
    • Cyproheptadine (Periactin)
    • Methysergide

  9. Calcium channel blockers:
    • Nimodipine
    • Verapamil
    • Diltiazem

  10. Others:
    • Magnesium
    • Vitamin B2

  11. Other medications:
    Many other medications, including some not scientifically proven to have a benefit, have been tried with a various rate of success.

The choice of preventative medications is made based on other needs of the patient, including sleep or eating difficulties, depressed mood, difficulties concentrating at school, and other considerations. The best situation is to benefit the child in more than one way with the choice of the therapeutic agent.

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