Migraine prevention in children and teenagers

Various factors can increase the likelihood of having a migraine. Finding out what those factors are and avoiding them could help prevent some migraine attacks. But it's often a combination of factors, not individual factors alone, that lead to migraines in children.

Possible triggers include noise and bright light. Certain foods and drinks may also trigger symptoms.

Changes in routines and habits can play a role too, for example due to a vacation or changes in the weather, changes in your daily routine and irregular mealtimes.

A number of studies suggest that lack of sleep and certain sleep habits can increase the likelihood of having migraines, and that "better" sleep habits may help prevent them. For instance, not drinking caffeinated soft drinks in the evening and avoiding loud music before bedtime.

Children and teenagers can try to find out what triggers their attacks, either on their own or with the help of their parents. Keeping a migraine diary for a while can help here. You can use the diary to make a note of things like

• what happened before the migraine attack started,
• the time the migraine started and when it was over,
• how severe the pain was,
• whether you took medication and – if so – what kind of medication and how much.

If you avoid a specific potential trigger for a while in order to see whether it makes a difference, you can write that down in the diary too.

It's important to keep the diary for several weeks or months and remember to write down everything. Otherwise you may easily overlook a trigger, or suspect that something is a trigger although it actually has nothing to do with your migraines.

Tension and stress are considered to be potential migraine triggers. Psychological stress caused by things like your parents splitting up, problems at school or the changes associated with a move can make migraines more likely too. If you're often affected by stress, it can be worth learning a relaxation technique to help you cope better with it. This also helps to prevents migraine attacks, or at least make them milder, in some children and teenagers. Young people who tend to get headaches or migraines when they feel stressed should also generally make sure that they have enough breaks during the day. Exercise and sports can help to manage stress too – as long as the child enjoys it and is not under pressure to perform.

There are various relaxation techniques. The most common techniques are known as progressive muscle relaxation and autogenic training. Both of these techniques have to be learned and practiced – either in classes or by teaching yourself. Progressive muscle relaxation involves repeatedly tensing and relaxing different muscles in your body. This is meant to relax and calm your body and mind. Autogenic training aims to help people enter a state of "self-hypnosis." You sit or lie in various positions and focus on being aware of different parts of your body and feelings of calmness, heaviness, warmth or cold. The aim is to feel deeply relaxed and get rid of negative feelings.

Biofeedback involves trying to become consciously aware of certain body functions and then influence them. During biofeedback sessions, sensors are placed on your skin where they measure things like your brain activity or your skin temperature. The readings can be seen on a screen. After enough practice, it's usually possible to deliberately change things like your skin temperature by consciously focusing on doing so. The readings displayed on the screen show you if it's working. By learning how to control their own body functions, people are meant to be able to keep headaches under control if they notice one coming on. This technique must be learned, though, and health insurers generally don't cover the costs.

Behavioral therapy is a psychological treatment approach that teaches people methods and strategies to help them prevent migraine attacks. It is based on the theory that certain behaviors and attitudes make migraines more likely to occur. These may include things like bad sleep habits or problems coping with stress. In behavioral therapy to prevent migraines, children might learn how to distract themselves from the pain or from the fear of having a migraine. They also become aware of how their thoughts and feelings can influence migraines. This can make the pain feel less intense and help them cope with it better. Behavioral therapy often also includes other approaches such as relaxation techniques or biofeedback.

Many of the approaches described above have not yet been tested in scientific studies with children and teenagers. But several studies have looked into more comprehensive treatment packages. The biggest study, carried out in the U.S., involved a total of 135 children and teenagers between the ages of 10 and 17 who had chronic migraine. People are considered to have chronic migraine if they have migraine symptoms on more than 15 days per month.

In this study, cognitive behavioral therapy combined with biofeedback was compared with simple patient education. The cognitive behavioral therapy consisted of ten one-hour-long group sessions in which the children and teenagers learned things like

• how their behavior and feelings affect pain,
• how to distract themselves from the pain,
• how they can organize and adapt their activities to make them more manageable,
• how to recognize harmful (overly negative) thoughts and replace them with more useful positive thoughts, and
• how to relax using biofeedback.

The parents attended a few of the sessions so they could help their children apply what they had learned.

The children and teenagers who simply had patient education classes learned about the causes and possible triggers of migraines and the treatment options. But they weren't given any advice on how to cope better with the pain. As well as having cognitive behavioral therapy or attending simple patient education classes, all of the children in the study took the medication amitriptyline for preventive purposes.

The study showed that cognitive behavioral therapy can help a lot of children and teenagers cope better with the pain. This approach also reduced the number of days on which they had severe pain: In the four weeks following the therapy, the children and teenagers had an average of five "headache days" less than before.

Specialists recommend using medication to prevent migraines if

• you have more than three migraine attacks per month,
• the attacks are especially painful or last a long time,
• migraine medication for acute attacks doesn't help enough or can't be used, for instance because of side effects.

When deciding whether or not to take medication to prevent migraines, personal factors will play a role too: For example, how debilitating the child perceives the migraines to be or whether he or she can imagine taking medication every day.

The drugs flunarizine, propranolol and topiramate are used for the prevention of migraines. But hardly any studies have looked into the preventive effect of these medications in young people. They have been approved for the prevention of migraine attacks in adults. When children take migraine medications like topiramate, it is considered to be off-label use. This is when a medication is used in a group of people or for a medical condition that it has not been approved for.

It isn’t clear whether topiramate can prevent migraine attacks in children and teenagers. Some studies found that it reduced the number of "migraine days" from about three days per month to about two per month. But the children and teenagers in those studies only had occasional (episodic) migraines.

The potential side effects of topiramate include tiredness, weight loss, an altered sense of taste, and abnormal skin sensations such as tingling and numbness. It is estimated that about 25 out of 100 children who take this medication will have such side effects.

It is not clear whether flunarizine and propranolol effectively prevent migraines in young people. They can have various side effects too. Propranolol can cause tiredness, dizziness and sleep problems, and isn't suitable for children who have asthma. The possible side effects of flunarizine include tiredness, weight gain, gastrointestinal (stomach and bowel) problems and mood swings.

People who take medication to prevent migraines have to be patient: It usually takes about two to three months to start working.

Various herbal products and dietary supplements are available for the prevention of migraines too, including coenzyme Q10, feverfew, riboflavin (vitamin B2) and butterbur. There's not enough conclusive evidence to be able to say whether these products actually prevent migraines.

There has been more research on the effect of medication for migraine prevention in adults. But just because a drug works in adults, it doesn't necessarily mean it will work in children too: Drugs can affect children's bodies differently, and children's migraines are different from the migraines adults get. They may need to use lower doses too.

If a child or teenager takes preventive medication, it is important to review the situation every few months. This is because young people often "grow out of" migraines, so they may no longer need treatment.