Guest: Dr. Bernard L. Maria - Pediatric Neurology
Host: Dr. Pamela B. Morris – Cardiology
Announcer: Welcome to an MUSC Health Podcast.
Dr. Pamela B. Morris: Hi, I am Dr. Pamela Morris and today, I am interviewing Dr. Bernard Maria, who is a Professor of Pediatric and Neurosciences at the Medical University of South Carolina. He is also the Executive Director of the Charles P. Darby Research Institute here at MUSC. We are talking today about headaches in children, which is such a frequent problem among children and certainly as a parent, one of my common excuses for my children to miss school, let’s talk about the causes of headaches in children.
Dr. Bernard L. Maria: Yes, headaches are very common and migraine headaches are very significantly under-recognized and under-diagnosed and what’s really bad about that is that children are missing school as a result of their migraine and we have specific treatments for migraine that can make a tremendous difference, alleviate their suffering, reduce the frequency of their episodes, keep them in school, and functioning and this in the context usually of a family history of migraine. Normally, children who have migraine headaches 9/10 will have a family member with migraine. It may have skip the generation and may be grandmother, who is having sick headaches often they weren’t called migraine, they were called sick headaches, so you have to ask that questions and primary care physicians, who see the children who are having headaches, tend to think of things like sinus headaches or stress headaches and don’t recognize that most migraine in children involves both sides of the forehead unlike adults, where the headaches tend to involve more on one side of the head. Migraine comes from the Greek word half a head, so its if you will a misnomer in children because their headaches involve the forehead on both sides equally and the key is that the pain is pounding, it’s pulsating, it’s throbbing, and it’s like a hammer hitting your head.
Dr. Pamela B. Morris: What are some of the other features that would help a parent or a primary care physician to recognize the headache as a migraine?
Dr. Bernard L. Maria: They look like they have a headache. They are pale, they got blue circles under the eyes, without saying a thing you can tell as a parent that something is up. They are washed out by it. They would rather sleep it off. It lasts hours and not minutes. It is associated with some nausea. You feel sick your stomach, but children often don’t throw up like adults might with migraine. They are also bothered by bright lights. If you have bright light on or loud sound and sometimes their sense of smell changes. We call that osmophobia. So, this is a child who really looks very sick, just wants to be quite, go into a dark room and go to sleep and these headaches can be very frequent and cause a lot of disruption.
Dr. Pamela B. Morris: What about warning sign, I have often heard that migraines have a prodrome even prior to the onset of pain?
Dr. Bernard L. Maria: Right, about 90% of children who have migraine, don’t have a classic aura or prodrome with flashing lights or black holes in the visions some may ? the more common scenario is they get moody and cranky. They are not too sure why they are feeling the way they are and then the headache will come on. The good news is that we can completely prevent these headaches today using medications that are very specific, very targeted for migraine.
Dr. Pamela B. Morris: What are some of the triggers for migraines in children?
Dr. Bernard L. Maria: There are a lot of myths about triggers. A lot of things out there that have been passed on generation to generation, like certain foods for example will trigger migraine. Well, individual patients and children can sometimes report certain triggers like a change in their routine and vague more eating at the same time or didn’t go to bed and wake up at the same time or started back at school. These are the kinds of changes in life that can trigger migraine, but if you begin to eliminate foods that might trigger migraine, pretty soon you are down to bread and water, so it sounds a very practical approach and just to give you an example about how tricky this is used to be said that chocolate what actually trigger migraine and it has been shown in recent years that the craving for chocolate is part of the migraine episode. So, your migraine is coming on, you want to get some chocolate. You take chocolate, you get a headache. Did the chocolate cause the headache? I don’t think so, it’s a part of the migraine phenomenon.
Dr. Pamela B. Morris: Well, that is interesting too because many of the medications over-the-counter for treating headaches actually have some caffeine in them, which is part of the chocolate itself?
Dr. Bernard L. Maria: Yes, so taking a lot of caffeine can be part of what trigger headaches in some people. In others, its caffeine withdrawal and in another case it’s treatment of migraine involves using caffeine. In children, we tend to use medications other than those that contain caffeine for control of the headaches, but really the art of it is not just having something that stops the episode, but really to be on something for a period of time that would prevent the episodes from happening from three, four, or five months then the brain resets if you will like rebooting your computer, you can come off of medication and often times don’t have headaches than that want daily treatment.
Dr. Pamela B. Morris: When a patient comes to you with headaches that sound as if they are likely migraine, are there any diagnostic tests that you need to order to confirm your diagnosis?
Dr. Bernard L. Maria: After taking a good a history and carefully examining the child for other causes of headache such as things that would increase pressure in the head by examining the eyes and doing a good neurologic exam overall of strength, balance, tone, etc. When, we normally doesn’t need additional diagnostic tests if the headaches have been there for a while. So, if the brain tumor was producing headache and there are a lot of patients that come to us feelings are like Woody Allen Phenomenon. I have got a headache, I must have a brain tumor. If they have had the headaches for two to four months or longer and have a normal exam, it’s very unlikely that they have an explanation for the headaches that would warrant any kind of surgery or additional diagnostic testing.
Dr. Pamela B. Morris: You have referred several times now to the fact that we have effective treatments for both preventing and treating migraines, let’s talk about some of those therapies.
Dr. Bernard L. Maria: Therapy can really be divided into three parts. One involves what we call abortive therapy, that is just stopping the episode when it begins and as a rule of thumb, the earlier you treat a migraine the easier it is to stop. Some children have migraines at last hours, others have migraines at last three days, and others have a headache for several hours, but then this washed out feeling that lasts two to three days. So, the best medications that have been studied to stop a migraine are what we call triptans. You have seen the commercials, ask your doctor about Imitrex. So, Imitrex, Maxalt, and other groups of medications that are in this class called triptans were actually the first medication designed to target a particular receptor in the brain that’s involved in the migraine process. So, it is very targeted and modern medication that is designed just for migraine, very effective in children.
Dr. Pamela B. Morris: And these medications are taken only after the onset of a migraine to interrupt the migraine.
Dr. Bernard L. Maria: Correct, to stop the episode and not just like I said that people not just stop the pain, which is so disabling, really stop the whole migraine phenomenon, which can wash you out. So, I have had colleagues with migraine who are researchers, who have pain for several hours, but then can’t write a paper, can’t do a 07:41 for several days afterwards because of the washed out phenomenon. So, migraine really affects your brain in a number of different ways and these medications unlike Tylenol or aspirin or Motrin; these medications can stop that whole episode not just the pain.
Dr. Pamela B. Morris: And these are called abortive therapies of which the examples you gave would be Imitrex or Maxalt?
Dr. Bernard L. Maria: Right.Dr. Pamela B. Morris:What are the other types of treatments that you may use?
Dr. Bernard L. Maria: So, the second left, if you will, of treatment is preventative therapy that is taking something everyday as lower doses as necessary to prevent the episodes from coming on in the first place. So, medications that can be effective there are in several groups, some are called beta-blockers, others are antiepileptic medications which should have been approved for the treatment and prevention of migraine in children and particularly in teenage girls who have a lot of sadness with their migraine and lot of feelings of depression with their migraine and medications like tricyclic antidepressant medications can be very effective in restoring a normal life and preventing the headaches from happening.
Dr. Pamela B. Morris: Does every patient with the migraine need to be on long-term preventive medication and how do you decide how frequently the headaches occur as to whether or not a medication chronically is necessary?
Dr. Bernard L. Maria: Some children have migraine headaches and this is true for adults also. Very infrequently, once a year or every other year or once every six months, in those cases taking something that’s designed for migraine at the time of the headache is ideal. With others, the headaches can be twice a week and then they can evolve into a daily headache, which is chronic daily headache. If your migraine is not treated as migraine and is treated as something else then what can often happen is migraine will transform itself into this chronic daily headache, which makes it much more difficult to treat and much more difficult to function. So, the decision on when to initiate a daily treatment depends very much on the frequency and severity of headaches. 70% of children have a spontaneous remission from their migraine by age 11. Most begin their migraine between the ages of 5 and 7 and parents can sometimes recall as infants they would have cyclical vomiting on an every-30-day or 40-day-type cycle, which then evolved into headache and migraine once they were able to describe their pain. So, migraine can be there from very early on, but typically begins with kindergarten and first grade that’s when it is usually diagnosed. Often times, it goes away on its own. So, what we try to do is we try to use as little medication as is necessary and for a shorter period of time as is necessary and we normally time the withdrawal of medication for breaks from schools, so that it’s not so disruptive. So, typically the 10:42 in the year with medication they may come of during Christmas break, but usually wait until the summer break when headaches are less frequent.
Dr. Pamela B. Morris: Are there any side effects that we need to be concerned about with these medications when using them in children?
Dr. Bernard L. Maria: Like with every medication, there are benefits and then there are risks and when we talk with families about a decision to use something, there always benefits and risks of not doing medications. So, we have to consider both sides of the coin. These medications, I have talked about, have been tested in children for their safety and efficacy and the great majority of children who take these medications are very thankful that they have something that was specifically designed for migraine. It really is life-transforming treatment.
Dr. Pamela B. Morris: Well Dr. Maria this has been a fascinating discussing and very helpful for parents, who have children who suffer from migraines, so thank you so much.
Dr. Bernard L. Maria: Thank you.
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