Headache disorders, such as migraine, can drastically disrupt daily life. Still, they are underestimated, underrecognized, and undertreated. Migraine is among the top three causes of disability in individuals aged 10 to 24, with 10 per cent of children experiencing it before reaching puberty. Migraine is associated with school absenteeism, disengagement from extracurricular activities, and decreased social life. It is classified by the World Health Organization as one of the neurological conditions with the highest burden, including impaired quality of life and financial costs. To mark Migraine Awareness Month, we’re taking this opportunity to highlight recent developments that can benefit patients.
You’re not alone. Migraine attacks are common and can be very impactful, but they’re treatable.
– Dr. Garth Meckler
“The latest evidence points to emerging options, including the expansion of emergency department (ED)-based treatments and medication,” says Dr. Garth Meckler, an investigator at BC Children’s Hospital Research Institute (BCCHR) and associate professor in the Department of Pediatrics at the University of British Columbia. His team reviewed published studies to identify trends, and found less invasive ways of caring for pediatric patients in EDs.
When the treatment with medications that are widely available, such as ibuprofen and acetaminophen, is not effective and families feel they have run out of options, they visit the emergency department. “In the past, ED teams relied exclusively on intravenous therapy — which is highly effective but requires a needle — an alternative that is distressing to most children,” says Dr. Meckler. “Now, there are an increasing number of emerging treatment options that can be given as nasal sprays.”
Research shows a number of emerging options to treat pediatric migraine and better support families.
As part of the recent evidence, a range of medications could expand care for pediatric patients with migraine: from monoclonal antibodies — lab-made proteins in the form of injections to prevent headaches — to oral dissolving pills used to treat acute migraine. “These pills are gepants, a new class of drugs that has significantly improved prevention and treatment of migraine,” says Dr. Meckler. Gepants are part of a targeted therapy that works on the neurochemical pathways that lead to migraine, and research shows they’re more effective than painkillers.
While the new medications are quite expensive, they show promise. Gepants have been approved by both the United States Food and Drug Administration (FDA) and Health Canada. “These medications seem to be effective and family doctors can prescribe them, so parents should be hopeful that the prices will come down or they will be covered by PharmaCare eventually,” says Dr. Meckler. “While it may be difficult to be optimistic and encouraging when emerging treatment options aren’t readily available to everyone, it’s important to know that scientists are working to find solutions that can better support patients and families.”
The guidelines for migraine treatment and management have been updated to provide the latest evidence to health-care providers and patients.
To ensure health-care professionals — particularly emergency department teams — are aware of the recent developments, the guidelines for migraine treatment and management have been updated nationally by the Canadian Pediatric Society, in BC, and within Translating Emergency Knowledge for Kids (TREKK) — a knowledge mobilization network focused on addressing critical knowledge gaps and improving pediatric emergency care by co-designing and sharing resources with families and providers.
To help create awareness of the latest evidence, Dr. Meckler — who is also a member of the TREKK Steering Committee and head of their critical care resources — has started giving presentations to broad audiences of general practitioners and emergency physicians in BC. “I’ve been talking about assessment and prescription of lifestyle changes, behavioural modification, and medication for patients experiencing migraine attacks,” he says.
While it may be difficult to be optimistic and encouraging when emerging treatment options aren’t readily available to everyone, it’s important to know that scientists are working to find solutions that can better support patients and families.
– Dr. Garth Meckler
These developments could help many patients. Migraine is a neurological condition and one of several headache disorders. The exact cause of migraine is not fully understood, but it is thought to result from the release of pain-producing inflammatory substances around the nerves and blood vessels of the head. “Families with children experiencing painful or frequent symptoms such as headaches are advised to discuss them with their family doctor or pediatrician,” says Dr. Meckler.
Migraine pain can happen on one side or part of the head, and spread to become more global. In addition to severe pain, symptoms often include sensitivity to light, sound, smell, and movement; nausea and vomiting; dizziness; brain fog and greater difficulty concentrating; and fatigue. Some children with migraine may experience an aura, marked by temporary changes in vision — e.g., flashing lights or colourful patterns — or in sensation — e.g., tingling or numbness on one side of the face. Aura often occurs before the headache, and lasts around 20 minutes. Migraines can be triggered by a number of factors, including lack of sleep, altitude, exercise, dehydration, skipped meals, or stress.
Migraine symptoms are usually different before and after puberty, and migraine becomes more common in females than males during adolescence.
Before puberty, migraine is usually bilateral (both sides of the head), shorter in duration than in adults, and accompanied by gastrointestinal symptoms. It presents in female and male children at equal rates. Later, during adolescence, migraine symptoms may be more similar to adults’, with unilateral pain, aura, and longer episodes. Migraine also becomes more common in females during adolescence, partly due to hormonal changes.
Some individuals are predisposed to migraine due to genetic differences that can influence brain chemistry. For them, circumstances such as stress and changes in hormones can trigger a chemical imbalance and, consequently, migraine attacks. “We can’t change our predisposition to something, but we can control the triggers by adopting a lifestyle that supports our health,” says Dr. Meckler.
Younger children have more difficulty to convey headache pain, so caregivers need to look for signs and infer the symptoms from their facial expressions and behaviours.
Headache pain can be difficult for younger children to convey. Families need to pay attention to some signs and infer the symptoms from the child’s facial expressions and behaviours, such as holding their heads, wanting to lie down, and staying in a dark and quiet room, which may indicate sensitivity to light and sound. “Seeing a physician is important to identify any early life expressions of migraine,” says Dr. Meckler.
To help track and assess migraine attacks, patients and families can use Migraine Canada’s diary, tracker, and Traffic Light System — a straightforward, colour-coded tool recommended by pediatric neurologists to help determine the severity of symptoms and how to respond. Patients should visit the emergency department if experiencing symptoms such as a sudden, explosive head pain that peaks in intensity within a minute; weakness, numbness, or slurred speech; fever with stiff neck; persistent vomiting; and confusion or behavioural changes.
Important resources can be accessed by families to manage pediatric migraines at home, but stress management and mental health balance are key.
Families can take several steps at home to better understand and manage migraine:
- Keep a symptom diary for your child to identify patterns, triggers, and responses to different treatments.
- Track how often your child takes medication to help avoid overuse.
- Treat acute headaches as early as possible because a delay can make symptoms much harder to resolve.
- Make lifestyle modifications — including in the areas of sleep, hydration, nutrition, exercise, and stress management — because they’re the most important changes you can make to keep migraine attacks under control.
- Take advantage of all the resources available on Migraine Canada’s website.
Stress management and mental health balance are key to long-term migraine management. This condition can cause stress, depression, and anxiety, which in turn can trigger and aggravate migraine. “Keep in mind that you’re not alone,” Dr. Meckler says. “Migraine attacks are common and can be very impactful, but they’re treatable and we’re doing everything we can to provide the best care to children and their families in BC.”
