TEACHERS
Exploding the myths
Contrary to popular belief, children do suffer from migraine and it has been reported in infants as young as four months. 10.6% of school age children suffer from migraine and up to the age of 12 it occurs equally in both sexes.
Although migraine is not a life threatening condition it can make you feel extremely unwell and unable to carry out normal daily activities.
It is another common misconception that migraine is just another word for a headache. In fact it is a complex neurological condition which affects people in a wide range of different ways.
Migraine in adults can differ from migraine in children and because there are sometimes no obvious external signs of an attack, children can be simply not believed when in fact they may be in considerable pain. Adult migraineurs often relate horror stories of their agonies with migraine as a child when adults thought that they were just trying to avoid doing something they didn't like or were trying to attract attention to themselves.
What is migraine?
Migraine is an episodic condition. The symptoms last for a finite period of time and the sufferer is perfectly well between attacks. Headaches which occur every day or which come and go over a period are not migraine ( this by no means implies that they should not be taken seriously but that they require different treatment) .
In adults, the predominant symptom is usually an intense, throbbing headache, usually on one side of the head only. Although this can be similar in children, the headache may be in the middle of the forehead or behind the eyes. This will be accompanied by an increased sensitivity to light, noise and smells. The pain is exacerbated by movement so the child will normally want to sit or lie down quietly. A child who complains of headache and then runs out to play, watches television or plays computer games does not have migraine.
The child will often feel nauseous, refuse food and may vomit (the vomit will often contain bile). He/she may also be drowsy. During an attack the child may look very pale with dark circles under the eyes. A few children initially appear flushed before later developing pallor.
As in adults, migraine is a disabling condition, which will prevent the child continuing with normal daily activities.
The International Headache Society defines migraine in children as lasting between 2 and 48 hours but some specialists believe that attacks can be shorter, possibly around one hour. However, a headache lasting less than an hour, or which comes and goes, is not migraine.
Although only 10-15% of adult migraine sufferers experience an aura, this is believed to be more common in children. This usually takes the form of visual disturbances, such as blurred vision, flashing lights, blind spots in the vision or zigzag patterns but can also include pins and needles or numbness in the limbs or the child may become clumsy or confused and may stagger or stutter. Younger children may not have the vocabulary to describe what is happening to them and may say things such as:
"I can't see."
"There are spiders crawling on the walls."
"There are snakes around me."
"It's like fire-works."
"Everything has gone dark."
"The sun/light is hurting my eyes."
Sometimes children can be encouraged to draw the things they see and the pictures can be very enlightening.
Sometimes, just before an attack, children may have "Alice in Wonderland" signs and feel they are becoming smaller and smaller
The aura phase of the attack can last up to 30 minutes and usually precedes the headache by 20-30 minutes.
Migraine equivalents:
Abdominal migraine: In around 4% of children, the predominant symptom is abdominal pain, possibly without headache, or the headache is only mentioned in response to questioning.
The child will experience episodic midline abdominal pain, possibly radiating through to the back, which cannot be attributed to any other cause (it is important to eliminate other possible diagnoses first).
As with migraine headaches, the abdominal pain occurs in defined episodes, does not come and go during the attack, disrupts normal activities and may be associated with the same symptoms, including: increased sensitivity to light and sound; flushing or pallor; dislike of food; nausea; vomiting; confusion; lack of co-ordination. The child will be completely normal between attacks.
Other migraine equivalents, which occur more rarely, are:
Cyclical vomiting: Some children experience bursts of vomiting of such severity at times that dehydration can occur, so that hospitalisation for intravenous therapy may be required. These attacks seem to occur at regular intervals of between four to six weeks. For more information, contact: Cyclical Vomiting Syndrome Association, 4 Pear Tree Close, Heswall, Wirral, Cheshire, CH60 1YD - tel. & fax: 0151 342 6620. Click link for Cyclical's website ... www.cvsa.org.uk
Paroxysmal vertigo is characterised by the sudden onset of vertigo (dizziness). This can be very frightening for the child and may be so severe that they fall over. They may also vomit. This migraine equivalent usually affects pre-school children and often spontaneously improves by school age but it is frequently replaced by the more usual migraine symptoms.
Recurrent limb pain (sometimes referred to as "growing pains"), which cannot be attributed to any other cause, may also be a migraine equivalent.
Complicated migraine such as hemiplegic migraine (temporary paralysis of parts of one side of the body), opthalmoplegic migraine (temporary loss of sight in one or both eyes) and basilar migraine (constriction of the basilar artery which can cause dizziness or loss of consciousness) very rarely occurs in children and requires specialist investigation. It may not necessarily be accompanied by headache.
If you suspect that a child may be suffering from migraine it is advisable to discuss this with the parents so that they can obtain medical advice. Sometimes parents fail to notice changes in their child or patterns of illness which may indicate an underlying condition.
If the problem persists you may wish to discuss with the parents the possibility of them requesting a referral for the child to visit a specialist migraine clinic.
What triggers an attack?
It is believed that a susceptibility to migraine may be inherited, so some children, especially those with one or more parent or grandparent who suffers, will have a lower threshold, beyond which an attack will occur.
As with adults, potential triggers are numerous and vary from individual to individual.
Many triggers are an integral part of school life and children should be encouraged to identify their own personal triggers and take sensible steps to avoid them. The school may in some instances have to make special arrangements for children with certain susceptibilities but it is important not to become too obsessive, as this can lead to the child having an unnecessarily restricted lifestyle.
Triggers can include:
Dehydration: Children should be encouraged to drink plenty of fluids, including at least 1 litre daily of water. Some children try to avoid drinking during school hours and this may be because they dislike using the school toilets or are embarrassed by the possibility that they may need to ask to be excused during lesson times. An easily accessible supply of fresh drinking water should be provided
Particular foods: There is a wide variety of foods which it has been suggested may trigger migraine although in fact food may not be implicated at all. It is a very individual condition and children should not be encouraged to give up certain foods because they or their parents have heard that it triggers migraine in someone else.
One trial at Great Ormond Street Hospital showed that children may be more intolerant to wheat.
Other suspected culprits are aspartame (found in many soft drinks, desserts and confectionery - some schools ban these items from their premises ) and monosodium glutamate (found in a huge variety of manufactured food).
If a particular food is the culprit, it is unlikely to have been eaten immediately prior to the attack; it is more probable that it was eaten 8-24 hours before (i.e. a sensitivity, not an allergy).
Long gaps between food: Often it is not what the child eats but how often that triggers an attack. The importance of eating sensibly and regularly should be impressed upon all children. As a general rule, children should not go longer than 3-4 hours without food during the day or 13 hours overnight.
Children who are susceptible to migraine should never skip breakfast
Children should always eat a well balanced lunch. However they may be embarrassed about eating in front of others or so busy playing with friends, going to lunchtime clubs etc that they may forget to eat their packed lunch.
The aim is to keep blood sugar levels stable, as dramatic peaks and troughs are believed to be implicated in triggering attacks. It is, therefore, a good idea to include slow release carbohydrate foods in the diet and avoid too many sugary snacks - some schools forbid such items.
Stress: Although this is generally regarded as affecting only adults, children often have worries or tensions. These may seem insignificant to adults but can cause problems for the susceptible child.
- Pressures of school work (even very young children can now feel under pressure to prove themselves academically), finding it too difficult or boring. A very bright child can sometimes be anxious about losing his/her place at the top of the class.
- Problems at home, for example, sibling rivalry or arguments between parents can also cause tension.
- Problems with schoolmates, such as bullying or being made to feel inferior because he/she doesn't have the latest "designer" clothes or toys.
Changes in sleep patterns, such as late nights or long lie ins.
Excitement, either as a result of looking forward to a special event (often these can be ruined because the child experiences a migraine) or over-stimulation (e.g. frightening or exciting films or books).
Television, computers, video games: It is advisable for the susceptible child to avoid these for at least an hour before bedtime. Their use at other times should also be monitored.
Exercise: It is, of course, important for children to participate in physical activities such as sports, games, dancing etc but it should be remembered that this will deplete blood sugar levels more quickly. Attention should, therefore, be given to ensuring that their diet is adequate to provide the extra energy required. Sometimes a glucose tablet taken before a sporting activity and another immediately afterwards can prevent migraines that are provoked by exercise.
Stuffy atmosphere: Many children are now ferried around by car and spend their leisure time in physically inactive pursuits. It is important to ensure that they have the opportunity to walk or play in the fresh air every day.
Light: Bright, flashing or flickering lights can cause problems. These can be natural, such as bright sunlight, reflected glare from water, plain white walls or computer screens; patterns of dark and shade, such as dappled shade in a leafy lane or travelling along a road bordered by palings or poles; or artificial, such as fluorescent lighting, strobe lighting at discos or theatres and film/television techniques which cut quickly from frame to frame.
Dental (e.g. tooth grinding, misalignment of bite) or eyesight problems may also be migraine triggers. Sometimes teachers can notice these things more readily than parents.
This is by no means a comprehensive list and triggers vary from person to person. Migraine is a complex condition and the combination of symptoms and triggers is almost peculiar to each individual. Keeping a migraine dairy can help to understand an individual's migraine and identify their personal triggers. Click here for a migraine diary for children.
Very often it is not just one trigger which causes an attack but an accumulation or combination of several factors, which can be tolerated if they occur individually but, together, can push a child over their personal migraine threshold, beyond which an attack will occur.
Avoiding attacks
In addition to preventing pain and suffering for the child it is clearly in everyone's interests to avoid the disruption to the class that a sick child can cause by taking sensible precautions. This should be done with a minimum of fuss and without singling the child out for special attention. Any measures should only be applied once they have been established as helpful for the individual child and agreed with the child and his/her parents or guardians.
Things that may be considered are:
- allowing the child to move from direct sunlight or glare from artificial lighting;
- ensuring that the classroom is kept well ventilated;
- allowing the child to move away from a radiator or heater;
- recognition of a sensitivity to noise e.g. banging drums, piercing whistles or sirens;
- providing alternatives to art, craft or science activities which involve strong smelling chemicals (e.g. paints, glues etc.);
- ensuring that the child always has time and opportunity to eat and drink at break times;
- providing access to clean drinking water;
- confidential discussion of any concerns or problems that the child may have and taking steps to alleviate them.
Treatment
If a child has been diagnosed with migraine it is important for the school to agree an action plan with their parents in case an attack occurs during school hours. All members of staff, including lunchtime supervisors, classroom assistants etc., should be made aware of this plan, especially those who are in regular contact with the child.
It is important for the child to report to their teacher (or other supervisor) as soon as the attack starts as this avoids unnecessary suffering and provides a much greater chance of treating it effectively. Provision should be made for this immediate reporting so that the child is not afraid to interrupt a lesson etc. The teacher should be willing and able to promptly implement the agreed action plan.
Many children require no medication to treat their migraine. Children will often recover well with a short sleep in a dark, quiet place. This may not be possible within the school environment so often it will be necessary for the parents to be contacted to take the child home. If possible the child should be allowed to wait in as quiet a place as possible - not, for example, a busy corridor. The child should have some supervision during this period.
In some children, vomiting will resolve the attack.
If medication is prescribed it will be most effective if administered early in the attack. During a migraine attack, the digestive system can "shut down", a condition known as gastric stasis, and medication taken later in the attack may not be quickly absorbed into the bloodstream and thus bring relief. The action plan should include the quickest way of administering the medication in accordance with the school's policy.
Some children may be prescribed preventative medication to try to eliminate attacks or reduce their frequency and severity. The school should be advised of this as such medication can have side effects such as drowsiness, increased appetite and weight gain.
Very often, the best preventative treatment is the removal of the anxieties or pressures that the child is feeling. If they know that they will be sympathetically and quickly treated if a migraine strikes whilst they are at school this will be a huge relief and may actually prevent attacks.
Any changes to the normal routine should be prepared for and explained to avoid any additional anxieties.
After an Attack
Children usually regain their health and vigor quickly after an attack and will usually want to return to their normal activities. However, some children may feel "washed out" and listless for a few hours after the attack has passed.
What about my migraine?
We know that many teachers are migraineurs. Teaching can be an extremely stressful career and the school environment and the demands of the job provide numerous triggers for attacks.
Coping with 30 lively children is always challenging but trying to do it when you can suddenly only see half of them or whilst your head is pounding is even more difficult and, of course, you can't just abandon your class to retire to a quiet, dark room when an attack strikes; few schools now have the luxury of additional staff on hand for emergencies; cover, if it exists, takes time to arrange so more often than not you just have to carry on. Employers and other members of staff may be not be supportive or understanding.
Fortunately there are now many effective treatments available. Visit our main website at www.migraine.org.uk for more information.
PARENTS
What triggers an attack?
It is believed that a susceptibility to migraine may be inherited, so some children, especially those with one or more parent or grandparent who suffers, will have a lower threshold, beyond which an attack will occur. 
As with adults, potential triggers are numerous and vary from individual to individual. It may help to keep a migraine diary to try to identify (and thus avoid) triggers but it is important not to become too obsessive, as this can lead to the child having an unnecessarily restricted lifestyle snacks.
Stress: Although this is generally regarded as affecting only adults, children often have worries or tensions. These may seem insignificant to adults but can cause problems for the susceptible child. It can be helpful for the parent gently and discreetly to investigate any possible causes for stress, such as:
- Pressures of school work (even very young children can now feel under pressure to prove themselves academically), finding it too difficult or boring. A very bright child can sometimes be anxious about losing his/her place at the top of the class.
- Problems at home, for example, sibling rivalry or arguments between parents can also cause tension.
- Problems with schoolmates, such as bullying or being made to feel inferior because he/she doesn't have the latest "designer" clothes or toys.
Changes in sleep patterns, such as late nights or long lie ins.
Excitement, either as a result of looking forward to a special event (often these can be ruined because the child experiences a migraine) or over-stimulation (e.g. frightening or exciting films or books).
Television, computers, video games: It is advisable for the susceptible child to avoid these for at least an hour before bedtime. Their use at other times should also be monitored.
Exercise: It is, of course, important for children to participate in physical activities such as sports, games, dancing etc but it should be remembered that this will deplete blood sugar levels more quickly.
If attacks are infrequent, it may be more appropriate to treat them if and when they occur than to disrupt the child's life and to draw further attention to his condition by trying to avoid trigger factors. If triggers are identified and changes are made to a child's diet or lifestyle, it is important to explain why these are necessary and not make it seem that they are being punished for being ill, for example by being denied favourite foods etc. Try to find interesting, acceptable substitutes such as taking the time to play a quiet game with or to read to a child for whom television immediately before bed is a problem.
Action
- Record the frequency and pattern of attacks, using a diary such as the one of page x.
- If appropriate try to identify any trigger factors, perhaps by completing charts such as the one on the take action page.
- If any suspected triggers are identified, avoid or eliminate them one at a time for a period of at least one month. If no difference is noted, reintroduce them and try eliminating another suspect.
Treatment
Many children require no medication to treat their migraine. Children will often recover well with a short sleep in a dark, quiet place. Some children like to be left alone, whereas others need the reassurance of the presence of a parent or carer (we all like a cuddle when we're feeling ill). Younger children may like to sleep on their mother's lap.
In some children, vomiting will resolve the attack.
If painkillers are required they should be administered according to the dosage instructions on the pack. Special children's analgesics, such as Calpol or Junifen, may be considered. Aspirin should not be given to children under 12. Medication prescribed for an adult migraineur should not be given to children. If in any doubt about the suitability of any medication for a child, please consult your pharmacist, especially if the child has other medical conditions or is taking other medication, either over the counter or prescribed.
If medication purchased over the counter does not help, your doctor may prescribe other medication. This may include an anti-sickness drug, such as domperidone, which will not only address nausea and vomiting but help the body to absorb the painkillers better.
Many migraine treatments are not normally recommended for children under 18 but they can be prescribed "off licence" at the discretion of your child's doctor. A decision will be taken based on your child's condition, his medical history and that of the family.
If attacks occur very frequently (more than 4-6 times a month), your doctor may prescribe preventative drugs for your child to take every day, irrespective of whether s/he has a migraine. If these are to be effective, they need to be taken at a regular time every day, usually for a period of several weeks or months.
Pizotifen (sanomigran) can be a very effective treatment for children but side effects can include drowsiness, increased appetite and weight gain.
Low doses of beta blockers (medication originally developed to treat high blood pressure) may also be considered.
Very often, the best preventative treatment is the removal of the anxieties or pressures that the child is feeling. It may be necessary for the whole family to review their life-style and the impact that this is having on the child.
It can be tremendously helpful to keep your child's environment as stable as possible, with regular nutritious meals and regular times for going to bed and getting up. Any changes to the normal routine should be prepared for and/or explained to avoid any additional anxieties. For example: "We are going to Granny's today; because it is a long journey and we may not be able to have our lunch until about 2 o'clock, I am taking some sandwiches to keep us going on the journey." "I have to go to a meeting today. I hope to be back in time to meet you from school as usual but, if I am delayed, I will telephone Matthew's mummy, who will take you home with them and give you some tea. I will come and fetch you as soon as I can."
Tell your child's school about their migraine to ensure that they are taken seriously if an attack strikes. Agree with them a plan of action so that your child does not have to suffer unnecessarily. This may be to telephone you immediately so that the child can be brought home, to allow the child to sit quietly or to administer medication promptly (many schools are now reluctant to do this).
Adults who supervise your child at other times should also be informed, e.g. Scout or Brownie leaders, football coaches, child minders, after school clubs etc.
Older children might prefer to be trusted to keep their medication with them at all times, so that it can be taken quickly and discreetly at the onset of the attack without the need to draw attention to themselves.
Specialist Treatment:
If your child's migraine is particularly frequent or severe and/or proves resistant to the treatments your GP suggests, you may wish to ask for a referral to one of the specialist migraine clinics (please contact us for a list).
After an Attack
Children usually regain their health and vigour quickly after an attack and will usually want to return to their normal activities. However, some children may feel "washed out" and listless for a few hours after the attack has passed.
A Family Affliction
There is believed to be a genetic predisposition to migraine, so the majority of child sufferers will have a parent or other close family member with the condition, who will, therefore, recognise it in the child. However, if migraine is suspected, it is always wise to consult a doctor for confirmation of the diagnosis and to discuss management.
Light at the End of the Tunnel
Fortunately, there is a great deal of research continuing world wide into the causes and treatment of migraine. Computerised scanning techniques have enabled us to find out much more about what is occurring in the brain in the time leading up to and during a migraine attack. Advances in genetics have also increased our understanding and the gene implicated in the very rare familial hemiplegic migraine was identified in 1999. However, it is believed that more than one gene is implicated in the more prevalent forms of migraine.
Although the "miracle cure" may still be years away, we now have a wide range of very effective treatment options available and doctors with a special interest in, and understanding of, all types of headache disorders. Therefore, the impact that migraine will have on the lives of our young sufferers will, hopefully, be much less than that of their parents and grandparents.
Others who can help
You may find the following organisations useful:
