Biology 202
2002 Third Paper
On Serendip

What is a migraine headache?

Many people are surprised to find that children get migraines. It is one of those illnesses that are associated with adults only. A migraine is an intense, pounding headache with nausea that occurs infrequently. The headache starts around the eyes, the forehead, or the sides of the head. Bright lights and loud noises also make the headache worse, and any movements make this headache worse. Migraines last from a few hours to a few days in serious cases (1).

Over 8 million children get migraines a year, which results in over 1 million lost schooldays cumulatively. 20% of adolescents in high school suffer from migraines as well. Pediatric migraines commonly stop when a child becomes an adult. Migraines occurring prior to puberty are about evenly split between boys and girls, and after puberty many more girls than boys experience them. Older children experience migraine pain typically on only one side of the head. Younger children, however, experience pain on both sides of the head. Some people also see a "warning aura," which is a pattern of lines or shadows in front of their eyes as the headache starts (2). Types of migraines are therefore classified as either common (no aura warning) or classic (with aura warning). Aura symptoms usually occur 30 to 60 minutes before the acute headache and generally are resolved by that time (3).

Why are pediatric and adult migraines different?

There are many different stimulants that trigger a migraine headache. Certain foods, like cheese, processed meats, chocolate, caffeine, MSG, nuts, or pickles are common triggers. Stress and too much exercise can also trigger an attack (1).

Most children with migraines have a family history of the illness. If both parents suffer from migraine, there IS A 70% risk that the child will also develop migraines. If only one parent suffers from migraine, the child has only a 45% risk of developing migraine (3).

Does pediatric migraine display both physiological and psychosocial symptoms?

Yes, children with migraines as well as their parents have noted the existence of both social and psychological symptoms of migraine, in addition to the physiological symptoms of migraine.

Physiological Symptoms:

Physicians look for slightly different symptoms when diagnosing a pediatric migraine. These symptoms include recurrent conditions such as vomiting, abdominal pain, or dizzy spells. Other symptoms include appetite loss, diarrhea, constipation, hot flashes and cold hands and feet. Unlike adults, children's migraines can wake them up from sleep, or are present upon waking (4). It is often not the child who is sick, but those around the child (typically parents), who notice that about 24-28 hours before the headache begins, the child is irritable, fatigued, pale, or depressed. Sometime children and adults both experience periods of elation, restlessness, and wakefulness. Many children, as opposed to adults, feel relief after sleeping for a few hours (3).

Psychosocial:

A controlled study by Aromaa et al from 2000 is the most recent study to report the pain experience of children with headaches and their families (5). Researchers followed 1143 families expecting their first child for over seven years. A questionnaire inquiring about the children's headaches was sent 6 years after their birth to 1132 of the original families followed. The results of the study indicate that children with headaches were more often very sensitive to pain, were more excited about physical examinations, cried more often during blood sampling or vaccination, avoided playing games for fear of getting hurt, and had recurring abdominal and growing pains. Researchers were able to conclude that migraine was recorded as being more intensive pain than tension-type headaches. They also concluded that although migraine has a large hereditary component, the child's pain-coping mechanisms could be influenced by parents' information.

Another study by Christiane Hermann and E.B. Blanchard tested the hypothesis that physiological responses of migraine patients are symptom–specific (6). Researchers applied both laboratory and parental conflict stressors to children and measured six of the autonomous, physiological responses of 26 children with migraine history and 10 control children. The two stressors were specifically chosen because the most frequently cited migraine triggers in children, this article claims, are achievement situations and emotional stress. The purpose of the study was to examine the psychophysiological response of children with migraine in comparison to control children (non-headache). The main theory behind the hypothesis was that children suffering from migraine usually show more cranial vasodilatation and peripheral vasoconstriction in response to stress. Like previous migraine studies with adults, results showed that children with migraine had similar heart rate (HR), finger temperature, and skin conductance level (SCL). The study also concluded that, despite opposite results from Aromaa et al's study, the children suffering from migraine did not subjectively experience more intense stressors than the control children. Blood Volume Pulse Amplitude (BVP) was expected to be greater for migraine children, but was insignificantly different than the rate for the control group. This suggests that the temporal artery may be the only extracranial blood vessel that contributes significantly to migraine pathogenesis. Hermann and Blanchard finished their study by saying that it is possible that factors other than psychophysiological reactivity may be most relevant for onset of migraine disorder.

After the above study was published, another study further attempted to determine the relationships between neurophysiological and psychosocial factors within the pathogenesis of migraine (9). Researchers investigated the contingent negative variation (CNV), parent-child interactions, and the relation between the two using an experimental group composed of 30 families with a migraine child and a control group of 20 families. The results showed that both groups showed the same results according to CNV measurements. The study also demonstrated that parents from migraine families exerted a lot more control over migraine children than over healthy siblings. Furthermore, the relation between CNV and parent-child interactions was shown to be strong only for very young children with migraine. Researchers were able to conclude that there's a strong influence of family interactions on the development and management of the neurophysiological aspects of the migraine disorder.

The most important tool for diagnosing migraines in children is the detailed history, which hopefully elicits a particular headache profile or pattern. Certain therapies are also specifically better for children. Biofeedback and relaxation techniques work better with children simply because they are more enthusiastic about these types of therapy. Some physicians recommend that parents maintain a regular sleep pattern and meal schedule, and that the child avoid doing an overload of activities. Like adults, many children can decrease the pain of a migraine by identifying certain migraine triggers. If drug treatment is needed for a child, the physician will prescribe simple analgesics (pain relievers). Depending on whether or not painkillers are enough, the physician might add preventive medicines to the child's regimen. Drugs that work for adults also work for children; the most commonly prescribed drug for children is an antihistamine, cyproheptadine. This drug is taken in both syrup and tablet form every 8-12 hours, and possible side effects include drowsiness and weight gain (2).

Sartory et al conducted a study that compared the efficacy of psychological vs. pharmacological treatments for children with migraine (7). The psychological treatment entailed either progressive relaxation or cephalic vasomotor feedback (CVF), both with stress management training via ten sessions for six weeks; pharmacological treatment entailed taking metoprolol (8), an oral beta-blocker for ten weeks. Results showed two main differences in correlation with treatment variation: the first is that relaxation and stress management training reduced the frequency and intensity of headaches more effectively than metoprolol with CVF and stress management in between. The other is that when compared to pre- and post-treatment data, children treated with relaxation training improved significantly in headache frequency and intensity; those treated with CVF improved significantly in headache frequency and duration, and mood. The medication had little effect on children's headache activity in this study. Researchers suggest that a calcium-channel blocker may have been more effective. Also, metoprolol is regarded as having a preventive effect and therefore acted as a psychological treatment instead of a pharmacological treatment.

Conclusions:

Pediatric and adult migraines do seem to be slightly different from one another, although not enough to categorize either as unique. The fact of the matter is, migraine research still has a long way to go because researchers have done few studies that are comprised of large sample sizes, or that can comprehensively separate psychosocial and physiological influences as well as therapies. It is, in fact, not yet clear whether genetic factors (the accepted physiological "cause" of migraine) or societal/psychological factors exert more influence over the other in determining the specific pathogenesis of migraine.

References

1) American Academy of Family Physicians. "Migraine Headaches in Children and Adolescents." American Family Physician 65:4 (2002): 635."

2)Migraine homepage for the Journal of the American Medical Association, a comprehensive review of diagnostic and therapeutic aspects of migraine

2)Diamond, Seymour. "Migraine in Children: how to recognize-how to treat." Consultant 39:7 (1999): 2045-2050.

4)Private Information Page, basic generalities about migraine

5) Aromaa, M. et al. "Pain Experience of Children With Headache and their Families: A Controlled Study." Pediatrics 106 (2000): 270-275
.
6) Hermann, C. and Blanchard, E.B. "Psychophysiological Reactivity in Pediatric Migraine Patients and Healthy Controls." Journal of Psychosomatic Research44:2 (1998): 229-240.

7)Sartory, G. et al. "A comparison of psychological and pharmacological treatment of pediatric migraine." Behaviour Research and Therapy 36 (1998): 1155-1170.

8) Pivate Pharmacological Information site, greeat online pharmacist answers to questions about metoprolol medication.

9) Gerber, Wolf-Dieter et al. "Slow cortical potentials in migraine families are associated with psychosocial factors." Journal of Psychosomatic Research
52 (2002): 215-222.


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