Adolescents and Headache

Key points:

• adolescents experiencebiological, social, psychological, educational changes simultaneously
• when female adolescents turn 17, as many as 23% of females experience migraine
• migraine triggers include: lifestyle, environmental, dietary, hormonal
• Headache Neurologists Doctors Christine Lay and Ana Marissa Lagman-Bartolome discuss the traffic light method for controlling headaches with medicines
• a new class of preventative medicines is coming, or is available
• proven non-drug complimentary therapies - specific to treating migraines
• lifestyle adjustments include proper sleep habits, regular exercise, meal regularity

Introduction

Adolescence is a difficult time. Adolescents experience multiple biological, social, psychological, and educational changes simultaneously. The addition of illness to this complex developmental process can be a small burden or have a large impact, depending on individual circumstances. When the illness is head pain, pain management becomes dependent on a therapeutic alliance between the patient, parents, and healthcare professionals. ¹

Research suggests that prior to puberty, boys tend to suffer from migraine more often than girls, but as adolescence approaches the incidence increases more rapidly in girls than boys.

A proper diagnosis is a step that many parents and adolescents tend to skip. A proper diagnosis is made through a physician carefully analyzing a completed detailed patient history and performing a physical exam if necessary, that rules out other explanations or factors for the symptoms being experienced. ²

 

We also know that Migraine tends to run in families, so having a parent that suffers from Migraine will significantly increases the risk of developing Migraine.

Migraine Prevalence

According to the Migraine Research Foundation, "Before puberty, boys suffer from migraine more often than girls. As adolescence approached, the incidence of migraine increases more rapidly in girls than boys. By the time they turn 17, as many as 8% of boys and 23% of girls have experienced a migraine." ³

Table 1Adolescent migraine prevalence according to:

Age Prevalence (%)

• Teenager Prevalence (%)

According to Dr Stewart Tepper, Professor and renowned Headache Neurologist from Cleveland, Ohio, he suggests teenage males experience migraine is at a percentage of 4.1%; Females - 17% ⁴

Migraine Triggers

A trigger doesn’t cause the migraine, it sets it off at any given time. Different things trigger migraines in different people. And the same trigger doesn’t always provoke a migraine in the same person. To complicate things, everyone is different – what triggers a migraine in one person probably won't be a trigger for someone else. ⁵

Everyone's migraine trigger is different. And individual triggers may fluctuate slightly. For example enjoying Chinese food that contains monosodium glutamate (MSG) might be one powerful trigger for some that "may" induce a bad migraine one night - whereas that same adolescent may ingest the same Chinese food containing MSG another night, and have virtually no reaction.

The following is a short list of potential triggers:

Lifestyle - skipping meals, fasting, alcohol consumption, irregular sleep habits, over exertion, stress.

Environmental - barometric pressure changes, storm fronts, humidity, sudden weather-related fluctuations, glaring or bright lights.

Dietary - red wine, monosodium glutamate (MSG) a flavor- enhancer found in some Chinese food and others foods, nitrates (cured meats), aspartame (an artificial sweetener) , aged cheeses, others.

Hormonal (females) - menstruation, pregnancy, hormone replacement therapy, oral contraceptives. (see Women's Issues and Migraine)

Medicines for Controlling Headaches

• The Traffic Light Method for Controlling Headaches

According to Dr. Christine Lay and Dr. Ana Marissa Lagman of the Women’s College Hospital Centre for Headache, in Toronto, Canada it can be difficult to judge which drug to take for which headache. Using the Traffic Light of Headache method can make it easier. (Journal: Headache January 2018).

A Green level headache is mild and you are able to “Go”, while a Yellow level headache is moderate and it is necessary to “Slow Down” and a Red level headache is severe and one needs to “Stop”.

Mild or Green level headaches can sometimes be left untreated if they are short-lived. For longer lasting mild headaches, simple over the counter medications such as the anti-inflammatory, naproxen sodium (brand name Aleve) can be helpful. It is generally well tolerated and is not addictive. In some instances, this is longer lasting and more effective than the other over the counter medications, acetaminophen and ibuprofen. Caution must be taken and always discussed with a doctor first. These medicines should not be taken more than 2 times a week, as this could contribute to medication overuse, and more frequent, disabling headaches.

Moderate or Yellow level headaches which slow someone down or prevent someone from staying in class or having fun with friends might respond to an over the counter medication like Aleve, but often a triptan, or a migraine specific medicine is needed. Triptans were specifically developed to turn off a migraine attack, not prevent it. Migraines are strong headaches with light or sound intolerance, often with a loss of appetite or nausea, that prevent someone from doing their routine activities. The triptan, almotriptan is approved for use in adolescents age 12 and older. There are two doses, 6.25mg and 15.5mg. Almotriptan is well tolerated and side effects are not serious (fatigue, dizziness, nausea). There are other triptans available and they can be used in adolescents, but they are not specifically approved for anyone under 17 years. These medications should not be used more than 10 days a month to avoid medication overuse and worsening migraines.

If someone is having a more severe or Red level headache that prevents them from going to school or confines them to bed, a triptan is usually the first line of defence, possibly with an additional dose of Aleve. Again, triptans should not be used more than 10 days a month. it is important to treat migraines early and to keep track of how many someone has to determine if they need a prevention medication. ⁶

View our article on Medicines for Migraine, that is coming soon.

Having a headache is like having a terrible sun-burn all the time. As hard as you try to explain your pain, many seen unsympathetic.

Dr. Joel Saper, Michigan Headache & Neurological Institute, Ann Arbor, Michigan

Chronic Migraine

 

When people with migraine have headache on more than 14 days a month, they are diagnosed with chronic migraine. Chronic Migraine is one cause of very frequent headache, with some patients having headache almost every day or even every day. A treatment approved by Health Canada, is onabotulinum toxinA (brand name Botox injections. You can also visit www.mychronicmigraine.ca. ⁷

According to the Migraine Research Foundation, roughly 85% of Chromic Migraine sufferers are female. ⁸

Our organization has a special page devoted to Chronic Migraine that discusses: How to Identify CMs, How to Manage your CMs, and Medication Overuse (this headache type is often a complicating factor)

View our page on Chronic Migraine at www.headache-help.org/chronic-migraine

New Class of Preventative Medicines Available, or Coming

Much excitement exists surrounding the recent discovery of a class of medicines know as Anti Calcitonin Gene-Related Peptide (CGRP) migraine medicines.

CGRP is a small protein that acts as a neurotransmitter (a chemical messenger) that is found throughout the brain and body and is highly prevalent in the trigeminal system, the sensory nerves that supply the head and neck. Researchers discovered CGRP is found in high levels in migraine sufferers during an attack providing a new target for pharmaceutical drugs to focus on. ⁹

The first anti CGRP medicine that has been approved is now available is called erenumab (brand name Aimovig). Learn about Aimovig at www.aimovig.com There will likely be other Anti CGRP drugs approved at a future date.

Please see our newly created page on these Anti CGRP migraine treatments by visiting:

www.headache-help.org/Anti-CGRP-Treatments-for-Migraine

Periodic updates will appear on this page.

Non-Drug Treatments

Non-drug Treatments are often well suited for

• those who experience side-effects with medications
• sufferers that are having an inadequate response to medication
• the patient has other medical conditions that prohibit/alter medication use
• the sufferer is simply interested in exploring non-drug approaches

Some people have a preference for a non-drug treatments which includes women who are pregnant, planning pregnancy, or breastfeeding. According to research, patients should limit or avoid prescription medication use.

Migraine sufferers with medication overuse or high stress levels also benefit from non-drug approaches that emphasize lifestyle and behaviour changes. When discussing non-drug treatments, the term complementary therapies is often used. Non-drug therapies can be used alone to treat headaches or they can be used in conjunction with medicinal treatments. ¹⁰

Due to space limitations I will list provide a point-form list of proven non-drug approaches to treating migraines. These treatments can be discussed with a physician.

• Behavioural Approaches
• Relaxation Techniques
• Deep Breathing
• Progressive Muscle Relaxation
• Autogenic Training
• Mindfulness Meditation
• Biofeedback
• Cognitive Behavioural Therapy (CBT)

 

• Physical Approaches
• Acupuncture
• Massage
• Physiotherapy
• Chiropractic (Cervical Manipulation)
• Dental Appliances

• Vitamins and Herbs
• Magnesium
• Riboflavin (vitamin B2)
• Coenzyme Q10 (CoQ10)
• Feverfew (tanacetum parthenium)

Feverfew is a plant sometimes used in migraine treatment. Studies on feverfew are sparse and of low quality, which make it difficult to assess its role as a migraine preventative supplement.

• Butterbur (Petasites Hybridus)

Note: ONLY use Petadolex® with the advice of your physician. This herbal therapy extract contains pyrrolizidine alkaloids (PAs), which can be damaging to the liver and have also been shown to be carcinogenic in animal studies.14 It is therefore critical that a manufactured version be used, that has had PA’s removed. The only brand that has shown complete safety is Petadolex ®

• Neuromodulation Devices
• gammaCore
• Cefaly
• Occipital Nerve Stimulation (ONS) - implantable - available at some specialty headache centres
• SphenoCath (an SPG block)

• Injections
• onabotulinum toxinA Botox - Treatment for Chronic Migraine
• Trigger-Point Injections for Migraine
• Nerve Blocks for Headache

For an in-depth description of these various non-drug approaches, please access our non-drug treatments page HERE (Chad: put "coming")

The American Migraine Foundation also has listed "Complementary Therapies" that you can do at home. They include:

• cold therapy
• managing nausea
• shielding from the sun and light
• minimizing noise
• controlling the temperature
• aromatherapy
• hydration and nutrition

Access the full article at https://americanmigrainefoundation.org/resource-library/complementary-therapies-and-coping-tools ¹¹

Lifestyle Adjustments

Lifestyle Adjustments for Adolescents and Headache include:

• Proper Sleep Cycles

Waking and retiring at roughly the same time is a very good way to manage migraines. Research has shown that adolescent migraine patients with an irregular sleep cycle tend to suffer more frequently from migraines.

• Regular Exercise

Moderate regular exercise has been shown to reduce the frequency and severity of Migraines. The key is to exercise in moderation. An article on Migraines Brought on by Exercise is coming.

• Regular Meals

Adolescents tend to skip meals or have irregular eating patterns. ¹² Research has also shown that skipping a meal can be a very potent Migraine trigger.

If you have an interest in managing migraines through various dietary methods, please check back for an article on Diet and Migraine, that will discuss various special diets that was published in the Journal Cephalagia in 2015.

 

Experts recommend Parents should take an Interest

Possible Headache Causes

It is important to ask the patient and parents what they believe might be causing the headache. Their answer might shed light into overlooked factors such as head trauma. It also allows the parents to express their concerns and discuss the child’s symptoms. This will allow the practitioner to address these concerns and provide confident reassurance once the evaluation has been completed. ¹³

Record Keeping

Migraine Canada suggests that the best way to identify food triggers that one suspects are triggering migraines, is to keep a headache diary and make note of the relationship between certain foods and migraine onset. ¹⁴

 

A headache diary is the easiest way to identify a potential trigger, and then use trigger-avoidance when possible.

Studying, Exams and Impact on School

Remember to plan for time to get some rest and relaxation. If planning to do studying after school, make sure the student has breaks are part of the plan. Listening to music, getting some fresh air, or just getting away from the computer for 15 minutes, can all help. Choose the beast options that apply. ¹⁵

Headache can affect how well a child does in school. About 37% of children with migraine note poor school performance during headache. Most identify difficulty concentrating in class and on homework. One pediatric practice identified school problems in 46% of their adolescent headache patients. Another recent study found that young headache patients rank "school" among their most potent headache triggers - ahead of "parents" and other common triggers such as weather, lack of sleep, or missed meals. School-related noise and bright lights emerge as a consistent problem for the headache-prone student. Peer problems such as frequent bullying or harassment are also associated with more frequent and severe headaches. ¹⁶

Tension-Type Headaches (TTH)

Tension-type Headaches are often miss-labelled as "stress headaches" and we know that adolescents are subjected to multiple stress demands.

A typical TTH consists of a band-like pressing or squeezing pain that is very often found on both sides of the head. It is mild to moderate in severity and is usually not worsened by activity. Experts also state that it is a featureless headache - meaning that it is not accompanied by nausea, vomiting, etc.

When a TTH occurs on more than 14 days a month the diagnosis of a Chronic Tension Type Headache is made. Consult a physician to consider a preventative medication treatment.

Typical over-the-counter treatments for TTH include acetaminophen, ibuprofen

For more on Tension Headaches refer to the Headache Categories tab.

List of Headaches Teenagers Experience

The following list is a brief listing of some of more common headaches adolescents have been known to suffer from:

Common Headaches

• Migraine with Aura
• Migraine without Aura
• Tension-Type Headache
• Medication Overuse Headache
• Cluster Headache

Chronic Headaches (short list)

• Chronic Migraine
• Post Traumatic Headache
• New Daily Persistent headache
• Hypnic Headache

 

Note: See Headache and Migraine categories button, for a more complete listing that discusses Associated Symptoms, Features, etc,.

Conclusion

For many adolescents sleep alone may be an effective treatment.

In conclusion, adolescent headache can be a simple or extremely complicated problem, which, in either case, should be taken seriously by parents and medical professionals, as well as the adolescents themselves. Head pain is a condition that may evolve over time from intermittent to chronic, and early treatment to prevent medication overuse headache and even disability status as an adult are good reasons for early intervention. Education becomes the focus of treatment in adolescents as migraine and other primary headache disorders are not susceptible to cure and often require a lifetime of treatment strategy. ¹⁷

REFERENCES

1. Hamel, R Physicians Assistant, Michigan Headache & Neurological Institute, Ann Arbor, Michigan, Adolescents & Headache
2. Migraine Research Foundation, Adolescents and Headache
3. Migraine Research Foundation, Migraine Prevalence in Adolescents, Migraine in Kids is not just a bad headache
4. Migraine Research Foundation, Migraine Triggers
5. Lay, Christine, and Lagman-Bartolome, Ana Marissa, Women's College Hospital for Headache, Toronto, Canada
6. Becker, Werner, Canadian Headache Society, Chronic Migraine, 2016
7. Migraine Research Foundation, Percentage of Chronic Migraine Sufferers
8. Migraine.com - Calcitonin Gene-Related Peptide (CGRP) definition
9. Non-Drug Treatments for Headache, 2016
10. American Migraine Foundation, Complimentary Therapies
11. Michigan Headache & Neurological Institute, Ann Arbor, Michigan, What non-medication therapies or techniques have been helpful in treating adolescent headache sufferers?
12. Cleveland Clinic Manual, Adolescents, Page 118, 2011
13. Migraine Canada, Record Keeping
14. Migraine Trust, Advice for Teens
15. Michigan Headache & Neurological Institute, Ann Arbor, Michigan, How common are Headaches in School Aged Children?
16. Hamel, RL Adolescents and Headache, Michigan Headache & Neurological Institute, Ann Arbor, Michigan