Headaches in children | Headache NewsBlog

Antidepressant use during pregnancy

By: Dr. Mauskop

30-04-2023

Brain disorders, Chronic migraine, Headache medications, Headaches, Headaches in children, Migraine, Pain, Psychology of headaches

Antidepressants are commonly prescribed to treat migraines, tension-type headaches, and various types of chronic pain. Migraines primarily affect women of reproductive age, and those who suffer from migraines are more likely to develop anxiety and depression compared to those without migraines. This may be another reason why someone with migraines might be prescribed an antidepressant. Women who are pregnant or planning to become pregnant are understandably cautious about taking any medication.

Antidepressant use during pregnancy does not increase the risk of neurodevelopmental disorders in children, according to a new study published in JAMA Internal Medicine.

Antidepressant use during pregnancy has been associated with neurodevelopmental disorders in children in some studies. However, other factors such as the parent’s mental health status, genetics, and environmental factors may have influenced these results. The objective of this study was to evaluate the association between antidepressant use in pregnancy and neurodevelopmental outcomes in children.

The study looked at data from over 3 million pregnancies, tracking children from birth until outcome diagnosis, disenrollment, death, or the end of the study (maximum 14 years). There were 145,702 antidepressant-exposed pregnancies.

The study found no evidence to suggest that antidepressant use in pregnancy itself increases the risk of neurodevelopmental disorders such as autism spectrum disorder, attention-deficit/hyperactivity disorder, specific learning disorders, developmental speech/language disorders, developmental coordination disorders, intellectual disabilities, or behavioral disorders.

However, given the strong crude associations found in previous studies, antidepressant exposure during pregnancy may be an important marker for the need for early screening and intervention to modify factors that do increase such risk.

Intravenous magnesium prevents migraines in children

By: Dr. Mauskop

27-06-2022

Alternative Therapies, Headaches in children, Migraine

Regular intravenous infusions of magnesium prevented migraines in five children, according to a report presented at the annual meeting of the American Headache Society by A.J. Freed and S. Sahai-Srivastava. The children were between the ages of 11 and 16. Four of them had the diagnosis of chronic migraines and one, episodic. Two of them continued to have daily headaches but they were mild with the infusions. The other three also had a significant drop in the number of headache days.

Over the past 30 years, we’ve given monthly infusions to thousands of patients, including children as young as 6. Genetic factors play a role in some patients with magnesium deficiency. We’ve had three generations of a family coming for monthly infusions. Besides genetics, other reasons for magnesium deficiency include stress, alcohol, gastrointestinal disorders, poor diet, and others.

About half of migraine sufferers are deficient. They are likely to respond to oral magnesium supplementation. Many, however, do not absorb magnesium taken by mouth. If we know that a patient is deficient because they have other symptoms of magnesium deficiency (cold extremities, muscle cramping, PMS, palpitations, brain fog, and others) or because their blood level (RBC magnesium) is low or is at the bottom of the normal range, we give magnesium intravenously.

If you cannot find a doctor who gives infusions of magnesium, you may want to search for an infusion center or an urgent care facility that would do it. In many large cities, magnesium and vitamin infusions are done at some spas. There are also companies that offer home visits by a nurse.

Skipping breakfast, lack of greenery, and other factors that may predispose kids to headaches.

By: Dr. Mauskop

02-05-2021

Alternative Therapies, Chronic migraine, Headaches, Headaches in children, Science of Migraine

We know that physical emotional, and sexual abuse in childhood increases the risk of developing chronic pain and migraines later in life. Dutch researchers looked at several other potential predisposing factors. The results of their study were published in the May issue of the journal Pain.

This study was a part of the Dutch Prevention and Incidence of Asthma and Mite Allergy birth cohort study. It included 3,064 children who were evaluated at the ages of 11, 14, 17, and 20. The researchers assessed headache prevalence and incidence in girls and boys and explored associations with early life, environmental, lifestyle, health, and psychosocial factors.

From age 11 to 20 years, the prevalence of headaches increased from 9% to 20% in girls and remained in 6% to 8% range in boys. Eighty-eight percent of the girls and 76% of boys with headaches also reported at least one of the following at age 17: sleeping problems, asthma, hay fever, musculoskeletal complaints, fatigue, low mental health, or worrying. They also found that lower educational achievement, skipping breakfast on two or more days per week, and in boys, exposure to tobacco smoke in infancy, increased the risk of developing headaches. In girls, sleeping problems and musculoskeletal complaints were associated with a higher chance of having headaches. Interestingly, residential greenness reduced the chance of developing headaches.

The risk factors are usually divided into modifiable and non-modifiable. Sex, age, and genetic factors are some of the non-modifiable ones. The factors mentioned in the study, except for sex, are all theoretically modifiable. In practice, however, they are very difficult to fix. Eating breakfast every morning is probably the easiest to achieve for most families. But even that can be difficult for the very poor. Moving to suburbs for greener surroundings, improving educational opportunities, and avoiding second-hand smoke in infancy are even harder to achieve.

Cyclic vomiting, a migraine variant

By: Dr. Mauskop

25-02-2021

Chronic migraine, Headaches, Headaches in children, Migraine, Science of Migraine

Cyclic vomiting is considered to be a form of migraine. It is most common in children. Surveys indicate that 2% to 3% of children may be suffering from this condition. These children often develop typical migraines as they get older. Cyclic vomiting can also occur in adults. The main and usually the only symptom is intense vomiting. Vomiting occurs several times an hour with bouts lasting anywhere from an hour to several days. It is different from abdominal migraines which manifest themselves mostly by stomach pains. Nausea and vomiting can also occur, but abdominal pain is the predominant symptom. Some children progress from cyclic vomiting to abdominal migraines and then, to typical migraine headaches. Many children and adults have a family history of migraines.

To diagnose cyclic vomiting we need to consider and rule out all other possible causes of vomiting. These include gastrointestinal disorders, genetic conditions, brain tumors, and infections. An endoscopy, abdominal ultrasound, MRI scan of the brain, and blood tests are some of the usual tests.

Physical and emotional stress can trigger an attack of cyclic vomiting. Treatment is very similar to the treatment of migraines. It begins with regular sleep, exercise, relaxation training or meditation, magnesium and COq10 supplements. If attacks are frequent, preventive medications such as tricyclic antidepressants and epilepsy drugs can be useful. For acute attacks, sumatriptan nasal spray (Imitrex NS, Tosymra) and zolmitriptan nasal spray (Zomig NS) or sumatriptan injections can be effective. Antinausea drugs such as ondansetron (Zofran), metoclopramide (Reglan) and aprepitant (Emend) can be given by injection. Prochlorperazine (Compazine) and promethazine (Phenergan) are available in rectal suppositories.

This post was prompted by a review of this topic in the last issue of the journal Headache by Dr. Kovacic and Li of the Medical College of Wisconsin. It is an open-access article – you can read the entire article for free.

Nerivio relieves migraine in adolescents

By: Dr. Mauskop

03-01-2021

Alternative Therapies, Headaches in children, Migraine

Nerivio device is approved by the FDA for the acute treatment of migraine attacks in adults. A study just published in the journal Headache indicates that it may be effective in the treatment of migraine in adolescents, aged 12 to 17.

This study was open-label, which means that it was not as rigorous as the one done to get FDA approval in adults. There was no placebo arm and it was not blinded.

Forty-five participants, out of 60 who were enrolled, performed at least one treatment. There was one device-related adverse event in which a temporary feeling of pain in the arm was felt. Pain relief and pain-free status were achieved by 71% (28/39) and 35% (14/39) of participants, respectively. At 2 hours, 69% (23/33) of participants had improvement in functional ability.

Nerivio is a remote electrical neuromodulation, or REN device. It is applied to the upper arm and the current is turned up to produce a strong sensation below the pain level. It works by stimulating endogenous pain-relieving mechanisms. A recent review of various neurostimulation methods found REN to be the only one clearly proven to be effective.

Nerivio requires a prescription from a health care provider. If you don’t have one, you can consult one at a telemedicine startup, Cove (I am a consultant for Cove). It is a disposable device that costs $99 for 12 treatments. Some insurance companies pay for it.

New daily persistent headache (NDPH) is an unhelpful myth

By: Dr. Mauskop

26-12-2020

Chronic migraine, Headaches, Headaches in children, Science of Migraine

Researchers in Cincinnati, OH led by Dr. Andrew Hershey reviewed information about the diagnosis, headache features, medication overuse, functional disability in a group of 1,170 children and adolescents with continuous headaches. They compared patients given the diagnosis of chronic migraine with those who were diagnosed as having new daily persistent headache.

The mean age was 14 and 79% of the group were girls. The authors reported that “The overwhelming majority of these youth had headaches with migrainous features, regardless of their clinical diagnosis. Most youth with continuous headache experienced severe migraine-related functional disability, regardless of diagnostic subgroup.”

They concluded that “Overall, youth with continuous chronic migraine and new daily persistent headache did not have clinically meaningful differences in headache features and associated disability. Findings suggest that chronic migraine and new daily persistent headache may be variants of the same underlying disease.”

Here is my take on NDPH adapted from the soon-to-be-released book, The End of Migraine: 150 Ways to Stop Your Pain:

New daily persistent headache (NDPH) is one of the dozens of types of headaches listed in the classification of headaches. This particular listing causes more harm than good. NDPH is defined by the single fact that the headache begins on a certain day and persists without a break. The classification says that NDPH may have features suggestive of either migraine or tension-type headache.

There are no parallels to NDPH in medicine. There is no new daily persistent asthma, or new daily persistent colitis, or any other “new daily” disease.

There does not appear to be any justification for having NDPH as a distinct condition. It does not have a typical clinical presentation and it has not led to any research or treatment. When you search for this condition on the internet, you will not find any effective treatment for it. The suffering of many patients is magnified by the loss of hope, worsening depression, and flagging will to live.

Most importantly, some patients with NDPH do respond to treatment. According to anecdotal reports and in my experience, Botox injections, intravenous magnesium, preventive drugs for migraines, and other treatments can be effective.

Botox for migraines in children

By: Dr. Mauskop

27-08-2018

Botox, Headaches in children, Migraine

Injections of onabotulinumtoxinA (Botox) are approved for the treatment of chronic migraine headaches in adults. Botox is also widely used off-label (not an FDA-approved use) for the treatment of migraines in children. We know that botulinum toxin is safe in children because another very similar form of botulinum toxin, abobotulinumtoxinA (Dysport) is approved for the treatment of cerebral palsy in children as young as 2. The youngest child with chronic migraines whom I treated with Botox was 8 years old.

Two groups of physicians presented results of their treatment of migraines in children with Botox at the recent annual scientific meeting of the American Headache Society held in San Francisco.

The first report, whose lead author was Ilya Bragin of St. Luke’s University Health Network describes positive results of Botox injections in 30 adolescents with chronic migraines. All 30 had to fail amitriptyline (Elavil) and topiramate (Topamax) to be eligible to receive Botox. Seven of of them had a history of a head trauma. The adult injection protocol of 155 units injected into 31 sites was followed. Both migraine frequency and severity improved with no reported side effects.

The second report from doctors in Delaware describes 44 children aged 11 to 20, who were treated with Botox for their chronic migraines. The dose ranged from 35 to 155 units, depending on pain location and child’s tolerance of injections. About 70% of children had at least a 50% improvement in their migraine frequency and severity. No child developed any side effects.

We tend to use the Delaware group’s approach in that we tailor the dose and the injection sites to each child, depending on pain location and weight of the child. And we also find that about 70% respond, which is the rate of improvement in our adult patients.

Terrorism and headaches

By: Dr. Mauskop

22-01-2018

Chronic migraine, Headaches, Headaches in children, Psychology of headaches

Survivors of terrorist attacks are four times more likely to suffer from migraines and three times more likely to suffer from tension-type headaches, according to a study just published in Neurology. The researchers evaluated 213 of 358 adolescent survivors of the 2011 massacre at a summer camp in Norway that resulted in deaths of 69 people. These survivors were compared to over 1,700 adolescents of the same sex and age who were not exposed to terrorism. The survivors were not only much more likely to suffer from migraines and tension-type headaches, but were also much more likely to have daily or weekly attacks.

Many previous studies have shown that physical, sexual, and emotional abuse in childhood and posttraumatic stress disorder (PTSD) are strong risk factors for the development of migraines and chronic pain in many previous studies. Having a family history of migraines further increases this risk, as does head trauma, and having other painful or psychological disorders. Headache is also one of the first symptoms reported by adolescent girls and women who were raped.

The authors of the current report cite evidence that “Childhood maltreatment during periods of high developmental plasticity seems to trigger modifications in genetic expression, neural circuits, immunologic functioning, and related physiologic stress responses. It is plausible that exposure to interpersonal violence could induce functional, neuroendoimmunologic alterations, affecting central sensitization and pain modulation and perception. Central sensitization, expressed as hypersensitivity to visual, auditory, olfactory, and somatosensory stimuli, has long been thought to play a key role in the pathogenesis and chronification of migraine.”

It is likely that early intervention after a traumatic event will result not only in better psychological outcomes, but also in fewer and milder headaches. One such intervention is cognitive-behavioral therapy. However, there are several different types of such therapy and a study just published in JAMA Psychiatry compared 12 sessions of cognitive processing therapy (CPT) with 5 sessions of written exposure therapy (WET) for the treatment of posttraumatic stress disorder. WET was shown to be at least as good as CPT with fewer treatment sessions required. This makes WET more efficient and affordable and patients are more likely to complete it.

My previous blog posts mention online self-administered courses of cognitive-behavioral therapy for PTSD, anxiety, depression, OCD, insomnia, chronic pain, and other conditions. The site is ThisWayUp.org.au and the researchers behind it have published scientific data indicating that their approach is very effective. It is also very inexpensive – some courses are free and some cost about $50.

Migraines can be prevented with CoQ10 supplementation

By: Dr. Mauskop

08-01-2018

Alternative Therapies, Headaches in children, Migraine

Deficiency of coenzyme Q10 (CoQ10) is the second most common deficiency in migraine sufferers after magnesium. Fully one third of migraine sufferers are deficient in CoQ10, according to a study by Dr. Andrew Hershey and his colleagues published in the journal Headache. They tested 1,550 children and adolescents and a study in such a large population tends to be very reliable. Supplementing these children with 1 to 3 mg/kg of CoQ10 produced significant improvement not only in CoQ10 levels but also in the frequency of attacks (from 19 a month to 12) and the disability (the disability score dropped from 47 to 23).

This deficiency is present in adults as well, as was shown in another study by a Swiss neurologist, Dr. Peter Sandor and his colleagues. They gave 100 mg of CoQ10 three times a day or placebo to 42 adult migraine sufferers and discovered that a 50% drop in migraine attack frequency occurred in 48% of patients on CoQ10 and only 14% of patients on placebo.

The Hershey study was done in a more logical way – determine who is deficient and give them CoQ10. If you give CoQ10 to those who need it and those who don’t, the results of the study and in practice will not be as impressive. Although CoQ10 is not expensive ($7 a month for 200 mg a day) and is very safe, why supplement to someone who does not need it? Although the blood test for CoQ10 is fairly expensive ($158 at Labcorp), it is usually covered by most insurance plans. It is important to ask your doctor what the actual blood level was because the laboratories will report as normal values between 0.37 and 2.2 (Labcorp) or 0.44 and 1.64 (Quest Diagnostics), studies have shown that the level should be at least 0.7.

As far as side effects, a few of my patients developed insomnia, possibly because CoQ10 is involved in energy generation, so I always advise taking it in the morning. While Sandor gave his patients 100 mg three times a day, in Hershey’s study the benefit appeared at lower doses. I usually recommend 100 to 200 mg (depending on body weight and how low the level is), to be taken once, in the morning.

Botox for kids with chronic migraines

By: Dr. Mauskop

27-12-2017

Botox, Chronic migraine, Headaches in children

A new report by doctors at UC Irvine describes successful treatment of 9 children aged 8 to 17 with migraine headaches using Botox injections. It may sound surprising, but unfortunately children also suffer from chronic migraines. Chronic migraine is defined as headaches that occur on 15 or more days each month and on at least 8 of those days headaches have migraine features. In children with episodic and chronic migraines, migraine features, such as throbbing, unilateral location, sensitivity to light and noise are less common than in adults.

There are only 5 treatments that are approved by the FDA for the prevention of migraine attacks. Four are drugs – 2 blood pressure medications, propranolol (Inderal) and timolol (Blocadren) and 2 epilepsy drugs, topiramate (Topamax) and divalproex sodium (Depakote). The fifth treatment is Botox injections. While Botox is not approved for kids with migraines, it is approved to treat eye conditions in children 12 years of age and older. Botox is also widely used to treat younger children with cerebral palsy (CP), although there is no official FDA clearance for such use. For a child with CP, Botox injections can make a difference between being wheelchair-bound and walking unassisted. However, very young children with CP are at the highest risk of serious complications and even death because they have small bodies and very stiff muscles, which require relatively large doses of Botox.

The dose to treat migraines is much smaller and therefore a lot safer. My youngest child with chronic migraines was a boy of 8 who weighed 50 lbs. He had excellent relief of his migraines after receiving 15 units of Botox into his forehead. He underwent a total of five treatments over a period of two years and for the last treatment, I gave him 50 units (forehead and temples). By then his weight was 65 lbs. The standard adult dose for migraines is 155 units. The dose for cerebral palsy in an adult goes up to 400 units.

The main difficulty in using Botox in children with migraines is that insurance companies often deny coverage, which they justify by the lack of FDA approval. However, Botox injections at low doses used to treat migraines in children are safer than drugs for epilepsy, high blood pressure, or depression.

Anxiety contributes to disability in kids with headaches

By: Dr. Mauskop

07-08-2017

Alternative Therapies, Headaches in children, Psychology of headaches

Anxiety is at least twice as common in both children and adults with migraine headaches compared to people without migraines. A new study presented at the recent American Headache Society meeting examined the impact of anxiety on functioning in pediatric migraine population. The researchers analyzed records of 530 kids with migraine and 371 with tension-type headache seen in the pediatric neurology clinic of the Boston Children’s Hospital.

Dr. Lebel and her colleagues discovered that physiological anxiety was associated with more severe functional disability in kids with both migraines and tension-type headaches. Physiological anxiety often manifests itself by sleep difficulties, racing heart, shortness of breath, feeling shaky, fatigue, and other. The other two types of anxiety, worry and social anxiety did not seem to lead to more disability.

This study confirms the importance of cognitive and behavioral treatments, such as progressive relaxation, biofeedback, meditation, and cognitive therapy. Kids are very good at these techniques and they are particularly receptive to smartphone-based apps. For meditation, I recommend 10% Happier and Headspace. TaraBrach.com offers free podcasts for meditation and ThisWayUp.org.au provides very inexpensive and scientifically proven cognitive-behavioral therapy.

At the NY Headache Center we always try to avoid drugs, especially in children. In addition to cognitive and behavioral techniques, we address sleep, exercise, diet and supplements such as magnesium, CoQ10, and other. If medication is needed, this study suggests that a beta blocker, such as propranolol (Inderal) may be a good choice because in addition to preventing migraines, it reduces physiological symptoms of anxiety (it is also used for performance anxiety). Potential side effects of beta blockers are mostly due to its pressure lowering effect and include fatigue, dizziness, and lightheadedness.

Occipital (back of the head) headaches in children

By: Dr. Mauskop

05-08-2017

Headaches in children

Most children who complain of headaches report pain in the forehead and/or temples. Doctors and parents tend to get more alarmed when a child complains of a headache in the back of the head and such children are more likely to have an MRI scan of the brain. According to a new study published in Neurology, there is no reason for concern.

The researchers examined records of 308 children under 18 (median age was 12) seen at a pediatric neurology clinic and found that 7% of them had pain only in the occipital area, while another 14% had pain in the occipital and another part of the head. The majority of children had migraine headaches. Not surprisingly, more kids with pain in the back of the head had an MRI scan. However, they did not have any more abnormal MRI findings than children with pain in other parts of the head. In fact none of the 4 children in this group who had a serious problem (2 had tumors and 2 had increased pressure) had occipital pain.

Considering that migraine headaches are common in children (4-11% of all kids) there is no need to do MRI scans in all kids with recurrent headaches. The American Academy of Neurology and Child Neurology Society do not recommend a CAT or MRI scan in children with recurrent headaches and a normal neurologic examination. However, 45% of children do get neuroimaging. Imaging is particularly unnecessary if other members of the family suffer from similar headaches.

Neuroimaging is indicated in patients with recurrent headaches and abnormal neurologic examination, seizures, those with recent onset of severe headaches or recent changes in the character of headaches. Changes in the character of headaches may include shift in location, increase in frequency or severity, new associated symptoms such as blurred vision, dizziness, fever, and other.