How to help children with migraines

This article looks into how parents can help their children who have migraine headaches, and discusses the benefits of cognitive behavioral therapy.

Nearly 2% of the pediatric population suffer from chronic migraine. Yet, the Food and Drug Administration (FDA) has not approved a therapy for treatment of chronic migraine in children or adolescents. So, how does your child's neurologist or headache specialist treat your precious one's head pain?

One study in JAMA suggests a combination treatment regimen of both medical and behavioral therapy. Before reviewing this study, let's understand the basics of what a chronic migraine is.

What is a chronic migraine?

According to the second edition of the International Classification of Headache Disorders (ICHD-II), chronic migraine is defined as a migraine headache that occurs at least 15 days a month for more than 3 months. Additionally, the headaches of chronic migraineurs must have at least two of the following features:

• One-sided location
• Pulsating
• Moderate or severe intensity of pain
• Head pain is exacerbated by daily physical activity (i.e. walking around your home)

During a migraine attack, an individual must have at least one of the following:

• nausea and/or vomiting
• photophobia AND phonophobia

Study Overview

Purpose: To compare two regimens for treating children and adolescents with chronic migraines.

• Cognitive-Behavioral Therapy (CBT) + amitriptyline
• Health education + amitriptyline

Amitriptyline (Elavil)  is an tricyclic antidepressant that works by blocking the re-uptake of two neurotransmitters in the brain, serotonin and norepinephrine.  It is a sedating medication and typically taken at bedtime. It is FDA approved as a migraine preventive medication for adults.Cognitive-behavioral therapy entails learning how to identify headache triggers and cope with them in a more adaptive, less stressful manner.

Methods: 135 children and adolescents, between the ages of 10 and 17, who suffered from chronic migraine and scored greater than 20 on the Pediatric Migraine Disability Assessment Score (PedMIDAS) participated in the study.

The participants were randomly assigned to either the CBT + amitriptyline group or the health education + amitriptyline group. Each participant underwent 8 weekly therapy sessions that were one-hour in duration. The participants and their parents were blinded as to whether they were receiving CBT versus health education during these sessions. All of the participants were given a dose of amitriptyline of 1mg/kg/day at dinner time. The children and adolescents were allowed to take medication for acute migraine abortion, like NSAIDs and triptans. They were not allowed to use them for more than 3 times per week. Finally, the participants maintained a headache diary to record various headache measures such as headache occurrence, duration, and associated symptoms.

Results: The two main outcomes measured were number of days per month of headache occurrence and headache disability. By 20 weeks, participants in the CBT + amitriptyline group achieved a ≥50%percent reduction in days with headache when compared to the health education + amitriptyline group (66% versus 36%). This also held true at the 12 month follow-up, with 86% in the CBT + amitriptyline group having a ≥50% reduction in headache frequency versus 69% of the health education + amitriptyline group.

In terms of migraine disability, by the 12 month follow-up, 88% of the CBT + amitriptyline participants had a PedMIDAS of less than 20 points versus 76% of the headache education + amitriptyline group.

What Does This Mean?

The use of cognitive-behavioral therapy with amitriptyline in children and adolescents with chronic migraine reduced migraine frequency and disability, when compared to health education with amitriptyline. This suggests that CBT be considered as a reasonable and effective treatment for chronic migraine in the pediatric population.

If your child suffers from chronic migraine, discuss the use of a behavioral intervention, like CBT, with his or her healthcare provider so you can be an informed parent and remain proactive in your child's health.

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Is it migraine or occipital epilepsy? Panayiotopoulos syndrome (PS) can cause vomiting and headache!

What are the key differences between occipital seizures and migraine? 

Sometimes its hard to tell...JR 
Panayiotopoulos syndrome (PS) 

Benign childhood focal epilepsies: assessment of established and newly recognized syndromes

1. Chrysostomos P. Panayiotopoulos, 
2. Michael Michael, 
3. Sue Sanders, 
4. Thalia Valeta and
5. Michael Koutroumanidis

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1. Department of Clinical Neurophysiology and Epilepsies, St Thomas’ Hospital, Guy's and St Thomas NHS Foundation Trust, London, UK

1. Correspondence to: Michael Koutroumanidis, MD, Department of Clinical Neurophysiology and Epilepsies, St Thomas’ Hospital, London SE1 7EH, UK E-mail:michael.koutroumanidis@gstt.nhs.uk

• Received April 14, 2008.
• Revision received June 30, 2008.
• Accepted July 1, 2008.

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Summary

A big advance in epileptology has been the recognition of syndromes with distinct etiology, clinical and EEG features, treatment and prognosis. A prime and common example of this is Rolandic epilepsy that is well known by the general pediatricians for over 50 years, thus allowing a precise diagnosis that predicts an excellent prognosis.

However, rolandic is not the only benign childhood epileptic syndrome.

Converging evidence from multiple and independent clinical, EEG and magnetoencephalographic studies has documented Panayiotopoulos syndrome (PS) as a model of childhood autonomic epilepsy, which is also common and benign. Despite high prevalence, lengthy and dramatic features, PS as well as autonomic status epilepticus had eluded recognition because emetic and other ictal autonomic manifestations were dismissed as non-epileptic events of other diseases.

Furthermore, PS because of frequent EEG occipital spikes has been erroneously considered as occipital epilepsy and thus confused with the idiopathic childhood occipital epilepsy of Gastaut (ICOE-G), which is another age-related but rarer and of unpredictable prognosis syndrome. Encephalitis is a common misdiagnosis for PS and migraine with visual aura for ICOE-G. Pathophysiologically, the symptomatogenic zone appears to correspond to the epileptogenic zone in rolandic epilepsy (sensory-motor symptomatology of the rolandic cortex) and the ICOE-G (occipital lobe symptomatology), while the autonomic clinical manifestations of PS are likely to be generated by variable and widely spread epileptogenic foci acting upon a temporarily hyperexcitable central autonomic network.

Rolandic epilepsy, PS, ICOE-G and other possible clinical phenotypes of benign childhood focal seizures are likely to be linked together by a genetically determined, functional derangement of the systemic brain maturation that is age related (benign childhood seizure susceptibility syndrome). This is usually mild but exceptionally it may diverge to serious epileptic disorders such as epileptic encephalopathy with continuous spike and wave during sleep.

Links with other benign and age-related seizures in early life such as febrile seizures, benign focal neonatal and infantile seizures is possible. Overlap with idiopathic generalized epilepsies is limited and of uncertain genetic significance.

Taking all these into account, benign childhood focal seizures and related epileptic syndromes would need proper multi-disciplinary re-assessment in an evidence-based manner.


Full article here....