The Reality of Treatment
Migraine and other headache disorders are often not respected as real and profoundly disruptive medical conditions in themselves. The feeling is that a headache is simple and therefore the solution should be simple. Sometimes it is, but more often it is not. Migraine, as a disease, should be respected in the same way that epilepsy, diabetes, asthma or juvenile rheumatoid arthritis are respected. Very few parents would expect to cure their child’s diabetes through simple measures as getting them a new pillow, or getting them glasses or telling them to relax more.
When we start treatments, there is another “opportunity” for distrust to develop between the patient, the patient’s family and the provider. No parent wants their child on medications and we understand that. We always start with the non-drug treatments first, however, they are helpful 30% of the time at best. Rather than having a child suffer more, there comes a time when good medications should be tried.
There are good medications that control or alter the root cause of the disease, and there are bad medications that only cover up symptoms. Some people promote the misinformation that all medicines are dangerous, only treat the symptoms, and any parent that allows their children to take them are bad parents. That is most unfortunate and makes it much more difficult to help them get well.
Non Drug Treatments to Prevent Migraine in Children
While the cause of migraine is a complex interaction between the genetics of neuron function and the environment, there can be simple triggers. These triggers, while not the “cause,” can aggravate the condition, making the attacks either more severe or more often. Step 1 is always looking for triggers and then trying to avoid them.
I. Avoiding Triggers:
a) Try to go to bed at the same time each night, get plenty of sleep but avoid sleeping in.
b) Avoid dehydration.
c) Look for a pattern of foods acting as a trigger. There is no clear diet list that works for everyone and most patients don’t have food triggers. Most diet lists available and passed around today, including migraine elimination diets and gluten-free diets, were developed in the 60s – 80s and were not based on headache research. When these diets have been put to the test of research, they usually show no benefit. However, the patient and their families are welcome to try any headache diet they wish.
d) Allergies are never the “cause” of disabling headaches. However, uncontrolled allergies can aggravate a pre-existing headache condition. It could be worthwhile to have allergy testing, especially if there are other allergy-type symptoms of congestion, runny nose, itchy eyes or digestive intolerance to certain foods.
e) Mitigate the effects of stress. Stress is never the cause for headaches either, but can make a headache sufferer’s headaches worse. Sometimes counseling is helpful, as is biofeedback. If a child or teenager is having headaches on most days, then counseling is often helpful to equip them to cope with the disease.
d) Make sure that there are no new medications or supplements that could be causing the headaches as a side effect.
II. Hands-on Treatments.
a) Acupuncture has been well studied for headache prevention and the results are mixed. However, it is worth trying. The problem is that many teens and children don’t want to try it due to the needles.
b) I wish everyone with a bad headache could get massages. While there is no proof that massage prevents headaches, it certainly gives the patient a sense of well-being.
b) Many patients report that chiropractic treatment helps. It is worth trying especially if there is neck pain as part of the headaches. There is no scientific evidence that neck or spine alignment has anything to do with headaches. There is one decent study that showed chiropractic treatments to have more lasting benefit for headaches than one headache prevention medication, amitriptyline.
We always start with supplements first. There are ONLY four that have any good scientific evidence of working to prevent headaches and those are: riboflavin 400 MG per day, Co Enzyme Q 10, Magnesium 400-600 MG per day and an herb called Butterbur. For reasons that I may never fully understand, many families don’t try the proven supplements but, instead, try a lot of vitamins and supplements that have no evidence of working but were recommended by friends, family or health food store clerks.
As a footnote, I will add that patients are often told by people who have not studied evidence-based medicine (AKA Western Medicine) that we are not interested in “natural” treatments. That is absolutely not true and I would question the motives of anyone spreading this kind of misinformation. The American Headache Society (The major scientific headache research society) has a whole section devoted to finding non-drug, “natural” treatments for headache. Each year at the American and Intentional headache scientific meeting there are many studies presented on the topic of looking for non-drug ways to treat headache. The problems is that most simply don’t work and we would be dishonest to claim that they do. When they do work, we don’t hesitate to embrace them.
As the name suggest, these medications only cover up the symptoms of headaches. Examples of these are the over-the-counter pain medications. These were never meant to treat frequent headaches and if they are used beyond the recommended dose and/or for prolonged periods of time,they can be quite dangerous, more dangerous than most prescription medications. This is especially true for products that contain acetaminophen. If the headaches respond to these medications and you can get by using them two days a week or less, it is certainly a convenient and cost-effective way to treat the symptom of headaches.
Prescription pain medications, especially narcotics, not only treat the symptoms but can also lead to addiction and a worsening headache condition through what we call Medication Overuse Headache Syndrome. There is only a rare place for these kinds of medications for children or teenagers.
These are medications that actually designed to reverse a headache and get rid of it by going to its source. It does this by mimicking the brain’s own natural system for shutting down a headache. These treatments are superior to pain medications because they actually do treat the root cause. These medications are quite safe. The only problem with them is that they can be expensive and they too can cause Medication Overuse Headache Syndrome if used more than three days per week. This class of medications includes the triptans and derivatives of ergot (a natural fungus). In the near future there will be even much better headache abortive treatments coming.
Because headache disorders have never, until recently, had the respect they deserve, there is not a single medication on the market that was designed to prevent headaches from coming. However, by accident, out of the thousands of prescription medications on the market, a few were found to prevent migraines in sufferers who were taking the medications for other reasons. These findings were often confirmed through large and well-controlled trials which further demonstrated safety and efficacy for headache prevention. We don’t know how most of these work.
At this juncture is where another misunderstanding can easily occur. In the eyes of a well-meaning parent, or patient, it may appear that we are not trying to “get to the bottom” of the headaches but only using the patient, their child, as a “Guinea Pig.” The unfortunate truth is, those patients with stubborn headache disorders and who have failed the simple non-drug treatments, will most likely see great improvement if they stick with medication trials and it could take several.
Some lucky sufferers have become profoundly better with the first preventative medication trial. More often it takes two, three, four or more trials before the most effective treatment is found. We who have decades of experience have some notion of which medications work with which patients, but even for us it is only slightly better than an educated guess. This is what makes headache treatment most challenging because of the complexities of the disease and the fact that each sufferer is unique.
Medications are also real. They do real things in the body. Most of those things are good things which help to prevent headaches, but sometimes they can do irritating things, or have what we call side effects. Most people don’t experience side effects, and those who do, usually have mild ones. We work hard to educate patients about the possible side effects and change the program if side effects do occur.
It is most unfortunate that lawyers and some people within the complimentary and alternative medicine industry have misrepresented medications as being very dangerous. That is absolutely not true. Statistics are often quoted which state very high rates of serious side effects or even death from prescription medications. This frightens people. The vast majority of the situations that generated these statistics are from intentional (suicide) or accidental (child gets an open bottle) overdoses. The rate of serious side effects to medications which are taken as prescribed is so low that the center of disease control can’t even measure it. The FDA has an extremely high standard of approving medications and requires them to be safe and effective. The risk of driving to an appointment is far greater than taking medications that could possibly greatly improve a patient’s quality of life.
When a child or a teenager experiences a side effect, the parent must be rational about it. To have hopes of getting better, they must be willing to take the chance of experiencing an occasional nuisance side effect, knowing that we will quickly and compassionately address that side effect as well. But if the patient or the parent allows their frustration at the disease to be misdirected towards the provider who is trying to help them, simply because a side effect has occurred, then it becomes virtually impossible to help that child get well.