November 11, 2015

For Young Migraine Sufferers, Treatment Can Be Hard To Find

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Bridget Araldi’s headaches started after a concussion on the soccer field, and they became so debilitating that the Wilton girl missed 70 days of her sophomore year at high school. She spent much of that time lying in her darkened bedroom, her head covered with cold cloths.

A succession of doctors Araldi’s mother took her to did not offer any relief—an experience that is not unusual, according to a new study. The study shows that most children do not get proper treatment for migraines. Many doctors who specialize in headaches say this is because children’s pain is too often dismissed.

“Only a small percentage … are getting the right diagnosis,” said Robert Nicholson, director of behavioral medicine at the Mercy Clinic Headache Center in St. Louis, and lead investigator of the study.

Severe headaches caused Bridget Araldi to give up soccer.

Photo Courtesy of Bridget Araldi

Severe headaches forced Bridget Araldi to give up soccer.

Slightly more than 10 percent of children and adolescents get migraines, a condition that can include visual disturbances and nausea, in addition to throbbing pain. The 2015 study, which looked at 40,000 young sufferers, ages 6 to 17, showed that 46 percent were prescribed nothing; 84 percent were not prescribed a recommended, evidence-based medication; and one in six were prescribed an opioid, which has the risk of dependency and can also cause migraines to become chronic.

Dr. William Zempsky, head of the Division of Pain and Palliative Medicine at Children’s Medical Center in Hartford, said that medicine only recently recognized the urgency of treating children’s pain. “Certainly for a long time we didn’t think that children had pain. And if we felt they had pain, we weren’t very good at evaluating it or treating it. … Over the past 20 years, there’s been an evolving recognition that children, even the youngest children, premature infants, have pain, and we need to be aggressive about managing that pain,” he said.

Dr. Jennifer Werely, assistant medical director at the New England Institute of Neurology and Headache in Stamford, has treated 10 and 11 year olds who have suffered since they were toddlers. “I think kids with headaches aren’t taken seriously,” said Werely.

With no outward symptoms, a child’s complaint about feeling ill is often met with frustration from a parent or teacher who thinks they are just making excuses, Werely said.

Headaches can also be wrongly diagnosed as a psychiatric illness.

In Araldi’s case, she said she did feel depressed and anxious as her headaches caused intense pain and made her unable to function. She was prescribed an anti-depressant and an anti-anxiety medicine before she was finally given the right medication to address her migraines.

“Many of the [migraine] treatments that we use for adults are not approved by the Food and Drug Administration for children. And that can be a little problematic for physicians who don’t want to treat … off label,” said Dr. Peter McAllister, medical director of the New England Institute for Neurology and Headache.

There are a variety of drugs to relieve migraine symptoms for people of all ages. But only one drug is FDA-approved to actually prevent migraines in children, Topiramate, and it is only approved for kids 12 and older.

McAllister said that migraine is a combination of biology, genetics and lifestyle, and often using biofeedback is effective.

“We have to get these kids to sleep. We have to get them to eat good, healthy food. We have to get them to drink lots of water, because dehydration is a trigger for migraines,” he said.

“We also screen for anxiety and depression,” which frequently co-occur with migraine. “Sometimes we get these kids better without even using medicine,” McAllister said.

Dr. William Zempsky

CMC Photo.

Dr. William Zempsky

For a child with a severe headache, opioids may be appropriate rather than hospitalization, said Zempsky, but they are not a long-term solution.

Like McAllister, he said that lifestyle changes are crucial to relieving serious headaches.

Stress, Zempsky said, is often the No. 1 headache trigger.

McAllister has advised parents that their children should cutback on extracurriculars and even drop Advanced Placement classes. He wants kids to refrain from hours of Internet connectivity and smart phone use.

Student athletes are at-risk of head injuries that can result in concussions, with long-term consequences. Werely said that she treats athletes with head injuries almost every day, which she says is the result of rougher play on the field.

A May study in the Journal of the American Medical Association (JAMA), that followed youth, high school and college players reported that 10 percent of them suffer an on-field concussion in a given season. High school players accounted for the majority of those injuries, most often during practices rather than games.

Soccer players are at risk, too. Araldi suffered two on-field concussions and a third at home from a simple bump, because her head was already injured. A study published in JAMA Pediatrics found that high school soccer players experience concussion at about half the rate of football players. However, the risk is higher for girls. For every 10,000 times a player takes the field, 4.5 girls will get a concussion, compared with 2.8 boys.

Headaches forced the Wilton girl to give up soccer, which she said was like losing “a second family.” Now a senior, she is still worried that not being an athletic recruit and a drop in grades would hurt her academically. But at 17, she’s back on the honor roll, and taking medication that controls, though doesn’t eliminate, her headaches.

Araldi said that even she used to dismiss on-field concussions. “I thought: Come on. I saw you fall. I’m sure it’s not that bad,” she said.

She agreed to be interviewed in hopes that people would learn about concussions and headaches and then treat those affected by them with more understanding, she said, “and just more compassion.”

For more on Bridget’s story and how doctors search for the right treatment for young migraine suffers listen to C-HIT’s podcast.

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