Children

Little is known about the prevalence of migraine in childhood and school age compared to adulthood. A Scandinavian study conducted in the early 1960s reported a migraine prevalence of 2.5% in 7- to 9-year-old children, 4.6% in 10- to 12-year-olds, and 5.3% in 13- to 15-year-olds. These data have been essentially confirmed by more recent studies in other countries. Detailed information on the occurrence of migraine in preschool children is lacking, although migraine attacks can also occur at this early age.

Headaches in children were given little thought in previous centuries. It was generally believed that headaches played a negligible role in infants and school-aged children. At the beginning of the 19th century, the first case of an infant suffering from cyclical vomiting at two weeks old was described; this infant was later diagnosed with migraine. It wasn't until the second half of the 20th century that studies on headaches in young children aged one and older were published. These studies generally showed that headache disorders begin in the second and third years of life. A survey of children in London revealed that 4% of mothers of three-year-old children reported that headaches were currently a problem for their children.

Occurrence of headaches in children

– Eight percent of children report a history of headaches.

Recurrent headaches are present in 3% of children.

– Studies in other countries have also shown that between 3% and 4% of children already suffer from headaches by the age of three.

– A large Finnish study of over 5,000 children showed that by the age of 5, 19.5% of the children already suffered from headaches causing significant distress.

study revealed a high headache frequency of 0.2%, a medium headache frequency of 0.5%, a low headache frequency of 4.3% , and occasional headaches of 14.5%. Interestingly, this study also identified several predictors for the occurrence of headaches in children.

Low housing standards, low family economic status, full-day kindergarten attendance, and a large number of leisure activities are associated with a greater risk of headaches in childhood.

The occurrence of abdominal pain was nine times higher in children who occasionally suffered from headaches, and fourteen times higher in children who suffered from headaches with moderate frequency.

Finnish studies have shown that when children start school . As early as the first grade, 39% of children report suffering from headaches. 1.4% of first-grade children met the criteria for migraine .

These results were obtained in a large study conducted in Uppsala, Sweden, in 1955. While the first study in 1955 showed a migraine prevalence of 1.4%, a comparable study in 1976 revealed a migraine prevalence of 3.2%, and finally, in 1994, a migraine prevalence of 5.7% was found in children aged 7 years.

These figures suggest that the incidence of migraine has apparently increased sharply among schoolchildren over the decades.

, the prevalence of headaches increases with age during school age . Among children aged 7 to 15, the headache prevalence is 58.7%. 3.9% of children in this age group meet the criteria for migraine. Studies in other countries have found very similar data.

A German study conducted in 1994 by Pothmann's research group on over 5,000 schoolchildren revealed that over 52% of schoolchildren suffer from tension-type headaches and 12% from migraines (Pothmann et al. 1994). By the time they start school, over 10% of children already suffer from headaches of significant distress. Over the course of the school years, this prevalence increases to over 90%. 49% suffer from tension-type headaches, 6.8% from migraines with aura, and 4.5% from migraines without aura.

A Finnish study yielded very similar figures: Among Finnish schoolchildren, 71% of girls and 65% of boys experienced significant headaches at age 14. 6.7% of the boys and 13.8% of the girls met the criteria for migraine.

Overall, the migraine prevalence in this sample was 10.2% at age 14.

While children with headaches are in the minority when they start school, this changes dramatically by age 14. At this age, children for whom headaches not a problem are the outliers. Throughout their teenage years, this pattern remains consistent. Approximately one-third of teenagers have no problems with headaches, half suffer from them occasionally, and the remainder frequently experience headaches.

changes in the gender distribution also occur during school age . During the first year of school, there is a slight prevalence of headaches among boys. By age 14, however, this pattern reverses, and there is a slight prevalence of headaches among girls. This prevalence then increases steadily until age 20, and by age 20, approximately twice as many girls as boys report suffering from headaches that cause significant disability.

In addition to this change in relative prevalence, there are also differences in the course of the disease between and within the sex groups . If migraine has already occurred by the age of 7, affected boys are more likely to experience a reduction in migraine attacks. 22% of boys experience partial or complete remission of migraine, while only 9% of girls in whom migraine first appeared by the age of 7 show a corresponding remission. However, the situation is different when considering children in whom migraine first appeared between the ages of 8 and 14. 51% of boys and 62% of girls in this group still have clinically manifest migraine later in life.

Headaches and possible effects on drug abuse

– According to studies conducted in 1995 by the “Glass School” initiative in Schleswig-Holstein (Institute for Addiction Prevention and Applied Psychology, Bremen), headaches are among the main health problems of school-age children.

A representative survey conducted in schools revealed that, depending on the type of school, between 20% and 40% of students reported headaches as a significant and persistent health problem. Alarmingly, this survey also provided clear evidence that headaches are a major contributing factor to the development of addictive behaviors and substance abuse.

– Due to the pressure of disability caused by the headaches, children may become susceptible to trying drugs and attempting to improve their well-being through them.

– Specific knowledge about headache treatment and headache prevention seems to be of great importance in preventing drug addiction in children!

The question of whether headaches have increased in our century remained unresolved until recently. In Finland, a study on migraine prevalence was replicated in almost every detail in 1992, mirroring the original study conducted in the same region in 1974. Seven-year-old schoolchildren were examined.

The data showed that in 1992, 51.5% of children already suffered from headaches, while in 1974 only 14.6% reported such headache problems . The frequency of headaches, meaning at least one or more attacks per month, was answered "yes" by 11.7% of children in 1992, whereas in 1974 only 4.7% reported this frequency. A gender-specific comparison reveals that the increase in headaches is particularly pronounced among boys

The figures document dramatic increases in the prevalence of headaches in childhood. The authors of the Finnish study suggest that an unstable social environment, frequent moves, a lack of autonomy within the social community, feelings of insecurity at home and at school, and a lack of leadership figures are responsible for this rise in headache prevalence.

The conclusion to be drawn from this data is that both pedagogical measures and content requirements in school lessons need to be reconsidered. Just as it was recognized at the beginning of the 20th century that teaching children how to brush their teeth and eat a healthy diet was essential for maintaining dental health, and just as increased attention was paid to physical education at the same time to maintain physical health, so too must the health of the nervous system be given special consideration in schools today.

This includes, at a minimum, early learning of relaxation techniques , which should be practiced regularly; stress management techniques ; information on structuring a regular daily routine ; occupational psychology training ; and health education regarding adequate nutrition and sleep hygiene . These measures would be easy to implement. Given the known pathophysiology of headaches, it can be expected that this would have a positive impact on the steady increase in headache prevalence among school-age children.

Diagnostic criteria

Early prevalence studies in childhood used Vahlquist's diagnostic criteria from 1955 (Vahlquist 1955). Comparative studies using Vahlquist's criteria and the International Headache Society's criteria for diagnosing migraine show that 70% of headache patients meet both the International Headache Society's and Vahlquist's criteria, 80% meet the International Headache Society's criteria, and 90% meet the Vahlquist criteria. This demonstrates a relatively high degree of agreement between the two definition systems. However, the older Vahlquist definition exhibits greater sensitivity for migraine.

According to the classification of the International Headache Society, headache attacks in children lasting less than four hours can be classified as migraine attacks.

Recent studies have shown that the duration of has little impact on the effectiveness of treatment ; that is, regardless of whether the attack lasts four or two hours, the same therapeutic effects can be achieved. Therefore, precisely defining the attack duration in children appears of less therapeutic relevance . Whether this is also true for adults has not yet been investigated.

Assessing headache characteristics in children is more difficult than in adults. This is primarily because accurately express their symptoms than adults. Furthermore, children have only experienced a small, manageable number of attacks and cannot yet precisely describe characteristic pattern with typical symptoms two to 48 hours for children if left untreated or unsuccessfully treated . However, young children also experience attacks lasting even less than two hours.

Since the required number of migraine attacks, namely more than five, is naturally not yet met in the case of newly occurring migraine, a diagnosis of migraine-like disorder can often only be made initially when diagnosed in childhood. Only the subsequent course with the typical occurrence of further attacks then fulfills the required criterion.

Since children often lack clear verbal means of expressing their migraine attacks, it is particularly important during diagnosis to ensure that the headaches are episodic.

The crucial factor is the question posed either to the child or to the parents

– whether there is complete freedom from headaches between the individual attacks and whether the children are otherwise healthy ,

That is, they exhibit neither psychological nor physical problems. In conjunction with a normal general and neurological examination, there is then a high probability that they are indeed migraine attacks

However, in this approach, it is difficult to differentiate between episodic tension-type headache and other types of headache . In early childhood, this type is rare , and the therapeutic approach for both headache types is very similar.

Special features of the clinical characteristics

The same diagnostic criteria apply to migraine in childhood as in adulthood, with the exception of the shorter attack duration already mentioned. In addition to the accompanying disorders that are prominent in adults, there are also additional accompanying disorders in children that can be diagnostically significant:

During an attack, affected children may experience tachycardia, paleness or flushing, changes in general well-being, thirst, appetite , urinary urgency, or fatigue . They may an elevated temperature , yawn , or restless , and may also report pain in other areas of the body Digestive disturbances such as loss of appetite, nausea, vomiting, diarrhea, and increased abdominal guarding are also prominent

Neurological aura symptoms can be just as pronounced and varied as in adults. Similar to adulthood, visual disturbances are particularly prominent . Literature indicates that the frequency of visual aura in childhood migraine attacks ranges from 9% to 50%. Other common aura symptoms include paresis , sensory disturbances , and speech disorders .

Typical types of migraine in childhood

all forms of migraine can be present in childhood , however, some migraine aura processes manifest themselves in particular types of severity.

Besides visual aura, basilar migraine is a particularly common manifestation of migraine aura in childhood . Children with this condition may experience neurological symptoms such as bilateral visual field defects, loss of muscle tone, nystagmus , double vision, dysarthria , and altered consciousness . While attacks typically occur at long intervals, they can last from 24 to 72 hours. Given these accompanying neurological symptoms, a thorough examination by a neurologist essential in childhood.

The following are of particular the differential diagnosis : a tumor in the posterior fossa , drug side effects (e.g. antiemetics), mitochondrial disorders and metabolic diseases .

migraine auras are also frequently manifested through changes in affect and cognition .

Particularly well-known is the so-called "Alice in Wonderland syndrome " with acute states of confusion.

Even in such cases, structural lesions carefully ruled out.

Familial hemiplegic migraine is a particularly characteristic form of childhood migraine. Here, too, the episodic nature of the attacks is diagnostically significant. This form of migraine is extremely rare.

Migraine equivalents

Migraine equivalents are defined by the occurrence of autonomic or visceral disturbances characteristic of migraine , but without the headache features. If focal neurological disturbances occur that meet the criteria for migraine aura, but no headache phase is present, it is not referred to as a migraine equivalent, but rather as a migraine aura without headache . The term migraine equivalent thus refers solely to the visceral and autonomic accompanying features of migraine without aura.

Typically, symptoms include nausea , vomiting , malaise, bowel movements, or other nonspecific symptoms . If such disturbances occur periodically , such as cyclical vomiting, they are particularly often associated with migraine attacks. However, empirical data on the relationship between these migraine equivalents and migraine itself are very scarce. As a rule, it is only a diagnosis of exclusion or exclusion when all other investigations have failed to identify a specific cause. In cases of such disturbances, a particularly thorough search should be conducted for gastrointestinal diseases, metabolic disorders, epileptic syndromes, brain tumors, mitochondrial disorders, and especially for mental illnesses .

Possible precursor syndromes in childhood

Benign paroxysmal torticollis in childhood

Repeated episodes of torticollis can occur even in infancy . These movement disorders typically remit in later infancy , hence the classification as "benign." The disorder is very rare. Only a small percentage of affected children experience subsequent episodes of torticollis followed by migraine attacks. Whether there is a direct link between migraine and this movement disorder is not yet fully understood. The pathophysiology of torticollis episodes in infancy is also unclear. It is conceivable that these aura phases within migraine auras. However, no definitive statement can currently be made on this.

Benign paroxysmal vertigo in childhood

In childhood , brief episodes of severe vertigo lasting less than half an hour occur, often accompanied facial pallor , nausea , and vomiting It typically remits by the time a child starts school . The pathophysiology of this disorder remains unclear, but a connection to migraine is likely due to its episodic nature and accompanying symptoms.

Motion sickness

An increased susceptibility to motion sickness in childhood is also associated with migraine. However, empirical data supporting this connection are currently lacking. A predisposition to motion sickness alone cannot justify a migraine diagnosis. Travel-related activities can not only cause motion sickness but also trigger migraine attacks.

Selection of additional instrumental examinations

The indications for additional examinations such as EEG or imaging procedures are similar to those in adulthood . However, since the history often short due , the situation in childhood will frequently arise where a headache diagnosis must be made for the first time and the episodic course of the headache disorder is not yet documented due to its short duration.

For this reason, it is particularly important to carefully rule out the presence of a structural lesion in children with headache. This applies especially to cranial space-occupying lesions. Particular attention is needed in very young children under the age of six. Up to this age, primary headaches are significantly less prevalent than later in life, and the likelihood of headaches associated with structural lesions is therefore considerably higher in preschool children than in later years.

For this reason the rule be observed that in children under the age of 7, an imaging procedure should be performed upon the first occurrence of a headache. Due to the absence of radiation exposure, an MRI scan is preferable . In any case, an imaging procedure should be performed if the children also exhibit noticeable symptoms such as growth retardation, visual disturbances, changes in thirst or appetite, affective or cognitive symptoms, or motor impairments.

The prevalence of primary headache disorders increases rapidly during school age. For this reason, imaging procedures only if there are abnormalities in the general and neurological examination . This applies particularly if the headache disorder has been present in attacks for more than six months.

Indications for the use of imaging procedures in childhood headaches

The same basic principles apply to imaging procedures for diagnosing headaches in children thorough medical history , including a precise recording of the headache characteristics of the presenting headache disorder.

In addition, a detailed description of the child's academic performance be obtained. While imaging routinely in preschool children only recommended for school-aged children in the general or neurological examination. The indication for imaging is also based on the following criteria:

– Changes in the course of the headache with the new occurrence of neurological disorders, increase in headache frequency, increase in headache intensity, increase in headache duration.

–       Lack of response of the headache attacks to the initiated therapy.

–       Delayed growth, increase in head circumference above the age norm.

– Changes in affective and cognitive functions.

– Reduced academic performance, sensorimotor disorders.

Comorbidity

Epilepsy and migraine

Epilepsy and migraine occur in attacks , and a connection between these two disease entities has been discussed very intensively in the literature in the past.

Of particular importance is the fact that the etiological conditions for headaches and epilepsy , such as brain tumors, vascular malformations, etc., can be identical. Parallels have also been drawn regarding therapy, and, for example, anticonvulsants are also used for migraine prophylaxis.

In a number of disorders, both migraine forms and epilepsies be considered in the differential diagnosis. These include, as mentioned above, cyclic vomiting , recurrent paroxysmal abdominal pain , dizziness , and psychiatric disorders EEG plays a particularly important role in diagnosis diagnostically significant in conjunction with epileptiform discharges and clinical phenomena .

Epileptic seizures can be distinguished from migraines, particularly by their temporal course, from a clinical perspective. Epileptic seizures are characterized by a sudden onset, a short duration of minutes or less, altered consciousness before and after the event, and a clearly defined end to the seizure.

– In contrast, migraine is characterized by a slow onset with a gradual spread of symptoms, a longer duration in the range of hours, and a gradual subsiding.

Another connection between migraine and epilepsy is the induction of postictal headaches following an epileptic seizure . Epileptic seizures can trigger migraine attacks and episodic tension -type headaches

clear correlations between the prevalence of various epileptic seizures and migraine . For example, two-thirds of patients exhibiting of Rolandic epilepsy also experience headaches consistent with migraine . Furthermore, so-called benign focal epileptiform discharges are reported to occur in approximately 9% of children with migraine. The characteristic encephalographic features of these disorders are found in only about 2% of the general population.

Syncopal attacks, orthostatic dysregulation

Orthostatic dysregulation, even leading to syncope, can occur during migraine attacks. Systematic studies have shown that orthostatic dysregulation up to three times more frequently than in control groups.

However, the etiology and pathogenesis of these disorders have not yet been clarified and systematically analyzed.

Stroke and migraine

very little information about the frequency of the association between stroke and migraine in childhood . Undoubtedly, migraine strokes can occur at any age.

A Swiss cohort study of 600 children in Bern, which followed an extended period of time, revealed that three of the affected children experienced a stroke between the ages of four and 14. This suggests that, based on these data, the risk of experiencing a migraine-related stroke in childhood for someone suffering from migraines is approximately 0.5% .

However, comprehensive studies are still lacking. The Swiss study shows that, compared to adulthood, the disorders exhibit a good tendency to recover long-term deficits are either very mild or nonexistent . The greatest probability of cerebral ischemia during a migraine attack lies in the territory of the posterior cerebral artery.

The differential diagnosis must include the so-called MELAS syndrome. This is a metabolic encephalopathy associated with lactic acidosis and stroke-like episodes.

MELAS syndrome is characterized by migraine-like headache episodes , which are accompanied by a wide variety of other disorders.

, bilateral neurological disorders develop manifesting prominently as stroke-like episodes and epileptic seizures clinical course . Additional findings on CT or MRI include bilateral occipital necrosis and edema , sometimes with hemorrhage, as well as, in particular, the characteristic lactic and pyruvate acidosis in the cerebrospinal fluid. Muscle biopsies reveal so-called ragged-red fibers .

Other differential diagnostic considerations include Moyamoya disease , alternating hemiplegia in childhood , arteriovenous malformations , cerebral space-occupying lesions and inflammatory diseases , especially isolated cerebral arteritis.

A migraine-induced stroke does not show signs of a cerebral infarction on imaging (CT or MRI). The decisive factor for diagnosis is the persistent clinical deficit , not a corresponding finding in imaging studies.

The question of whether migraine itself increases the risk of stroke has not yet been definitively answered. Studies in adults suggest that migraine increases the risk of stroke by a factor of 1-3.

Differential diagnosis of headaches in childhood

Tension-type headache

Tension-type headaches are rare in children under 10 years of age, but are the most common cause of headaches from the age of 15 onwards . Tension-type headaches manifest across the entire head , but especially in the neck area. tension -type headaches are characterized by fluctuating pain intensity , and headache-free days cannot be reliably distinguished by low headache intensity.

Nausea, vomiting, and accompanying autonomic symptoms, particularly facial pallor, make it relatively easy to distinguish migraine from tension-type headaches. Diagnosis requires precise application of the International Headache Society's classification criteria. Furthermore, a thorough neurological and general examination is necessary.

The etiological factors for tension -type headaches cannot always be identified. Psychological disorders , or stress rarely manifest as tension-type headaches in children under 10 years of age.

In cases of temporomandibular joint dysfunction , pain radiates to the ipsilateral ear . A dental examination may malocclusion , bruxism, other parafunctional habits , or even excessive gum chewing as the cause.

In the case of a temporomandibular joint disorder hot compresses , physical therapy in the form of jaw exercises with conscious slow opening and closing of the mouth, and analgesic therapy can be helpful.

If school-aged children suffer from tension-type headaches , treatment should primarily consist non-pharmacological measures , learning relaxation techniques and examining stress factors within the family and at school.

Headaches due to structural lesions

Even in childhood, headaches associated with structural lesions rare. Recurrent or persistent headaches, excluding acute processes such as infections, in far less than 2% of children . However, the clinical differentiation between primary and secondary headaches is difficult in childhood, as precise clinical features are usually lacking.

Headaches in cases of structural lesions also often manifest themselves through the clinical features of primary headache types, especially migraine and tension-type headache.

Therefore, in children with headaches, great care be taken when assessing headache characteristics, as well as during the general and neurological examination. Headaches due to structural lesions in childhood can be caused by just as many factors entire range of differential diagnoses must be considered. The most common secondary headache disorders are described below.

Cranial space-occupying lesions

The development of a cranial space-occupying lesion is usually manifested by clinical symptoms that increase continuously over time.

Initially, intracranial space-occupying lesions can manifest as a phase of gradually increasing headaches lasting two to four months. Over 95% of affected patients exhibit additional neurological deficits, which can be clinically identified through a thorough neurological examination.

If no such neurological disorders are present, but there are indications of psychological or cognitive abnormalities, learning difficulties at school, or developmental delays , close clinical monitoring should be arranged at weekly intervals Increased intracranial pressure typically manifests as headaches upon waking in the early morning or after a midday nap. The occurrence of epileptic seizures in association with headaches is a serious indicator of the development of a brain tumor and must be diagnostically investigated through a thorough neuropediatric examination.

Vascular malformations

Headaches with a fixed lateralization raise suspicion of a vascular lesion , particularly an arteriovenous malformation (AVM). Aside from headaches, such lesions typically present with such as hemorrhage and neurological deficits . Epileptic seizures can also be a typical manifestation of these malformations. Moyamoya disease can be associated with bilateral headaches and alternating hemiplegia.

Hydrocephalus

A key indicator of hydrocephalus in childhood is an enlargement of the head circumference . Obstructive hydrocephalus can occur, for example, in Arnold-Chiari malformations and other causes of aqueductal obstruction. In these cases, symptoms develop relatively quickly, and spontaneous improvement is not observed. In infancy and childhood, intracranial hemorrhages, meningitis, and other inflammatory diseases are common causes of communicating hydrocephalus .

Clinical features include an increased head circumference and fontanelle tension. Later stages reveal prominent venous markings, the sunset sign, and widening of the cranial sutures. In severe cases, additional neurological deficits occur, such as oculomotor paresis, papilledema, optic atrophy, para- or tetraspasticity, and seizures.

Pseudotumor cerebri

A common cause of symptomatic headaches in childhood is benign intracranial hypertension (BPH ). Pathophysiologically, the disorder manifests as cerebral edema , likely caused impaired venous outflow often associated with otitis media , head trauma , or corticosteroid withdrawal.

Phenomenologically, the headache presents with similar characteristics to those of an intracranial space-occupying lesion . The headache may increase continuously over time . However, focal and general neurological deficits are absent. Ophthalmoscopy reveals papilledema , cerebrospinal fluid examination shows elevated CSF pressure be alleviated by CSF drainage and subsequent pressure reduction

Traumatic brain injury

Minor head injuries can trigger migraine attacks in both children and adults. Footballer's migraine is a well-known example, where headers from a ball can trigger attacks. In children, these events can also as vomiting or dizziness . The full spectrum of migraine symptoms can occur.

In severe traumatic brain injuries, disturbances of consciousness and serious neurological deficits are the primary symptoms due to intracranial hemorrhage or malignant cerebral edema . Headaches manifest as a secondary symptom. In the case of a subdural hematoma or hygroma , headaches can the prominent symptom , prompting further diagnostic evaluation. Post-traumatic headaches can also result from traumatic brain injuries.

In childhood, post-traumatic stress disorders in particular by affective and cognitive changes .

Acute inflammatory processes

Acute rhinosinusitis can cause headaches in children. The inflammation can directly responsible for the headache syndrome, but it can also secondarily trigger attacks in susceptible patients. After the inflammation subsides and then flares up again, recurring headaches also be explained by sinusitis.

A characteristic feature of headaches during an acute sinus infection is their location in the forehead, around the eyes , and over the sinuses. Accompanying symptoms include congestion , tenderness to percussion over the sinuses, facial swelling over the sinuses, and an increase in pain intensity when bending the head forward due to movement of secretions in the sinuses.

Contrary to popular belief, headaches are not to chronic sinusitis . Sinus surgery or other manipulations of the nose generally do not alleviate headache symptoms in these chronic conditions. Therefore, in cases of persistent headaches, it is crucial to carefully the specific cause . Often, this involves medication overuse or a chronic tension- type headache .

Other acute inflammatory processes , particularly viral infections or mononucleosis, also frequent causes of acute headaches in childhood. The typical accompanying symptoms of primary headache disorders such as migraine are absent in these conditions.

In cases of meningitis or encephalitis , headaches can be an early and indicative symptom. Neurological examination reveals characteristic abnormalities that prompt further diagnostic testing. Elevated temperature , pleocytosis in the cerebrospinal fluid , and changes in blood count confirm an inflammatory origin.

Finally, arteritis and collagenoses be considered as possible causes of permanent or episodic headaches.

Behavioral medicine therapy measures

Behavioral measures are the primary focus of migraine therapy in childhood .

The same basic principles apply here as in adulthood. Identifying trigger factors is even more difficult in childhood than in adulthood, as children often cannot directly identify which conditions might trigger migraines. A crucial difference is that the information filtered the parents' input , making it very difficult to accurately ascertain the child's individual assessment of stressors through their parents. Counseling on lifestyle , nutrition, leisure activities , and work habits is also of paramount importance.

Dietary measures, such as eliminating cheese, chocolate, citrus fruits, or dairy products, are rarely successful. The data on the link between such factors and the triggering of migraine attacks is very uncertain.

For this reason, more emphasis should be placed on regular food intake and sufficient food supply, instead of composing burdensome migraine diets for the whole family.

Behavioral medicine and general therapy measures

Especially in children, it is particularly important that headache therapy is not solely focused on treating symptoms and critical illnesses. Rather, therapy must focus on..

– to maintain or restore mental and physical balance,

– to strengthen the body's functions and

– to prevent possible disease mechanisms.

The interplay of mind, spirit, and body must be thoroughly examined in order to prevent and treat headache disorders in children. This includes factors such as..

– Stress,

– Environment, social circumstances,

– Lifestyle habits and diet (detailed information ▶ Section 2.17).

Unhealthy lifestyle habits and behaviors must be identified and abandoned. This requires perseverance and a willingness to change. Behavioral measures are therefore particularly important in the treatment of headaches in childhood.

Physical stress

A major trigger for migraine attacks in children is physical overexertion and stress.

sleep too long or too short a time, for example . Irregular bedtimes and wake-up times should be avoided, especially in children with migraines.

Sudden changes in food intake and eating habits should also be avoided. This includes, for example, eating a rushed breakfast or even skipping breakfast before school because of staying in bed too long. In such situations, children typically get headaches around 9:00 a.m.

However, external factors that are difficult to control can also cause physical stress. These include high humidity in muggy weather, extreme heat, sudden weather changes, poor air quality due to poorly ventilated rooms, overheated living areas, strong odors, sudden changes in lighting conditions, noise, cold, or drafts.

Excessive physical activity can also trigger migraines. On the one hand, it can cause a significant drop in blood sugar levels, and on the other hand, the physical stress can further induce headaches. If children frequently complain of headaches or migraines after physical education classes, efforts should be made to reduce the intensity of these activities. Ideally, children should switch to sports that don't require rapid changes in physical activity. Swimming, running, cycling, or other endurance sports suitable.

Headaches in children can also be triggered by external pressure , such as from hairbands or tight headbands, hats, or swimming goggles. Children prone to headaches should therefore avoid clothing that puts pressure on their head. This also applies to headbands with sharp prongs that irritate the scalp, or to elastic bands used to hold braids or ponytails.

Psychological stress

An irregular lifestyle, tension, anxiety, stress and mental overload are major potent triggers for migraine attacks in children.

Frequent television viewing, often featuring aggressive and stressful content, computer games, prolonged use of Gameboys, loud, stimulating music, and an excessive number of afternoon activities are commonplace for many children. All of these can trigger migraine attacks.

Therefore, children and parents should pay particular attention to a balanced and regular lifestyle. This primarily includes:

– a strict limitation of daily media consumption, with adherence to fixed and limited television viewing times and similarly limited time spent on the computer;

– Limiting leisure or afternoon activities to a few, but regular, activities;

– Regularly scheduled rest periods for relaxation with walks or games in a quiet environment.

Chemical irritants

Many chemical substances can trigger headaches or migraine attacks when exposed to excessive amounts. This applies to the home, school, and other environments.

The following substances are particularly potent headache triggers: car exhaust, cement dust, coal dust, dyes, factory emissions, chlorinated hydrocarbons, formaldehyde, solvents in adhesives, on paints and other materials (especially in many craft glues), flour dust, insecticides, gasoline and oil products, organic phosphate compounds, perfumes, deodorants, wood dust.

Should these or other substances pose a problem, the best solution is to avoid exposure. Adequate ventilation of the rooms and fresh air must also be ensured.

Allergic reactions

Hay fever refers to allergic reactions to pollen from various plants, which occur depending on the respective flowering season. If persistent irritation is present, allergic reactions to other substances must be suspected. This includes, in particular, allergy to house dust mite droppings, the so-called house dust allergy. Other common allergies include those to hair, bird feathers, and mold. In addition to headaches, frequent symptoms include watery eyes, red eyes, a runny or blocked nose, itching, and sneezing fits. If such symptoms occur, an experienced allergist should be consulted to initiate specific testing and treatment.

Whenever possible, the irritant should be avoided. For example, the problems associated with dust mite allergies can be reduced by choosing appropriate furnishings. This includes avoiding dust traps such as curtains, upholstered furniture, carpets, open shelves, and natural bedding. It is better to opt for smooth surfaces that can be wiped clean with a damp cloth, such as wooden or leather-covered furniture, and smooth PVC or parquet floors. Rooms should also be ventilated frequently. For mold allergies, drying out the rooms, proper heating, and ventilation can be particularly helpful. Special cleaning is required for pet allergies. Carpets and upholstery should be vacuumed as often as possible, and the vacuum cleaner should have an allergy filter.

Odors

Children with migraines are particularly sensitive to strong smells. It doesn't matter whether these smells are normally perceived as pleasant or unpleasant. Odors that can be especially potent in triggering headaches are found in tobacco smoke, air fresheners, and especially perfumes. If children experience migraine attacks, it's always important to try to avoid such strong odor sources.

Changes in light

Constantly changing light conditions are also a potent trigger for migraine attacks. Often, with the best of intentions, desks are placed in front of a window to have as much natural light as possible for doing homework. When children look up from their desks, they are looking out the window into the bright light. This constant adjustment to the light-dark situation is a persistent stress factor for the nervous system. Furthermore, a child's brain has to repeatedly adjust its focus from near to far. Passing clouds also dim the sunlight, and when breaks in the clouds, the eye has to adjust to the bright, glaring light again. This constant change, combined with the mental exertion of doing homework, is an extremely potent trigger for headaches and migraine attacks. For this reason, desks should always be placed against a wall, and direct sunlight should be avoided. This, of course, also applies to adult workspaces.

If children frequently suffer from migraines at school, their seating arrangement should be examined to see if potentially unfavorable, fluctuating lighting conditions can be identified as a trigger. Moving the child to a different seat in the classroom can then significantly reduce the problem.

Similar problems occur when looking at glittering water from the beach or when snow glitter constantly enters the eye. Driving with your eyes facing direct sunlight also produces similar effects.

For teenagers, flickering lights in discotheques combined with noise can also be a potent migraine trigger.

www.kopfschmerz-schule.de – Stop headaches in children

Approximately half of all children experience headaches and migraines at school, at home, or during leisure activities. Six percent of them suffer from headaches once a week or more frequently. Without early intervention, many of these children experience headaches more often or even chronically. New approaches to treatment and prevention, such as "Stop the Headache" and "Headache School," demonstrate that there is an alternative to chronic pain and suffering. These programs are implemented in cooperation with the Techniker Krankenkasse (a German health insurance company), the Kiel Pain Clinic, teachers, and independent therapists. The goal is to alleviate headaches in children while simultaneously reducing or even eliminating the need for medication.

Stop the headache

"Stop the Headache" is aimed at children and teenagers between the ages of eight and fourteen who already suffer from headaches or migraines. They will be offered modern advice and treatment. Participation requires a doctor's certificate confirming that the child has been suffering from tension headaches or migraines for more than six months. The program's effectiveness has been demonstrated in a study by the University of Göttingen: the number of headache days in participating children can be significantly reduced through treatment. Medication use also decreased. Courses are started as needed and take place in cooperating specialist practices. Further information is available from the course instructors. Addresses and additional information can be found online at www.kopfschmerz-schule.de

"Stop the Headache" uses modern psychological methods and experienced instructors to help children and teenagers between the ages of eight and fourteen reduce or eliminate chronic tension headaches or migraines. The eight-week training program aims to effectively treat the pain before it becomes chronic and to empower students to become experts in managing their own headaches. The program fosters the children's ability to help themselves. At the same time, in cooperation with the statewide treatment network, professional medical diagnosis, consultation, and treatment are provided.

The course program is based on the findings of a two-year study conducted by Techniker Krankenkasse in collaboration with the Universities of Göttingen and Düsseldorf. The study results clearly demonstrate that many affected children can be helped: approximately 60 percent of participants, who previously suffered from headaches frequently throughout the week, experienced a significant improvement in their condition. Medication use also decreased by about 40 percent.

Training overview

– Week 1: The Headache Expert – Information about the pain

– Week 2: The Relaxation Chief – Learning a relaxation exercise

– Week 3: The Stress Manager – Identifying Headache Triggers

– Week 4: The Thought Specialist – Pessimism and Clairvoyance

– Week 5: The Attention Checker – Attention and Headache

– Week 6: The I'm OK Master – Confident interaction with friends and family

– Week 7: The Problem Fighter – Problem Solving

– Week 8: The headache expert – Review of what has been learned and future planning

– Week 9: Final meeting – Child – Parents – Therapist

TK provides all course materials to participants and covers treatment costs for insured children and adolescents as part of its reimbursement policy. You can find course locations online at www.kopfschmerz-schule.de

Three school hours against headaches and migraines

Currently, there are no measures or programs specifically targeting teachers and students to prevent headaches in schools. This is all the more surprising given that, according to research from the "Transparent School in Schleswig-Holstein" initiative (Institute for Addiction Prevention and Applied Psychology, Bremen), headaches are now among the most common health problems of school-aged children. A representative survey of schools in Schleswig-Holstein revealed that, depending on the type of school, between 20 and 50% of students reported headaches as a significant and persistent health problem. The frequency of headaches has increased by approximately 300% in the last 20 years!

In light of these facts, Frisch K. and Göbel H. (2009) developed a teaching unit that is available for free download to all teachers via the internet. Currently, there are no measures or concepts specifically aimed at teachers and students for the prevention of headaches in schools. Teachers, students, and parents should be comprehensively informed to raise awareness of headache disorders in school-age children. Knowledge about headache disorders, the ability to recognize different types, and the dissemination of various coping strategies can lead to the early detection of headaches and the initiation of specific measures (parent consultations, involvement of specialists and doctors).

The school has a special responsibility to promote health in this area. This includes:

– Information on structuring a regular daily routine;

– occupational psychology training;

– Health education regarding adequate nutrition and sleep hygiene;

– Learning relaxation techniques in physical education classes as well as

– Stress management techniques.

These measures are easy to implement. Due to the known mechanisms underlying headaches, it is possible to positively influence the steady increase in headache prevalence among school-age children.

The website provides the following materials:

– Information and involvement of parents (letter to parents, possibly a parents' evening);

– specific information about headache disorders in children for the teacher;

– Implementation of the teaching series;

– Interdisciplinary learning with balancing and relaxation techniques in physical education.

The lesson series comprises three double lessons. The overall goal is to address unhealthy behaviors in the everyday lives of young people and to provide strategies for avoiding them. Moralizing instruction is strictly prohibited; rather, the aim is to empower young people to recognize problems in their lives that can trigger headaches and, with an understanding of the benefits of a balanced lifestyle, to develop long-term behavioral modifications. They must not be made to feel they have to justify their daily routines and thus bear some responsibility for their headaches.

To ensure students accept the subject matter, the lesson content is explored using the comic character "Mütze" (Cap). This allows the students to actively participate and complete the assigned tasks individually. The knowledge gained in this way is thus anchored in their long-term memory. At the end of each unit, the results achieved should be recorded in writing.

To present the most important results of the lesson series, a poster can be hung in the classroom. This will serve as a constant reminder of what has been learned. All materials can be downloaded from the website www.kopfschmerz-schule.de . The materials may be copied for use in the school.

Acute drug therapy

There are significant differences drug therapy compared . Especially in childhood migraines, it is essential that medication is taken as early as possible

One begins by giving the

– Antiemetic domperidone (10 mg orally or as a suppository),

to improve absorption and effect of the analgesic and to initiate therapy for nausea and vomiting.

Dosage must be very careful, as severe dystonia can occur as an undesirable side effect, especially in children. Even at low doses ocular crises , opisthotonus , dysarthria , and trismus occur. This is even more true when metoclopramide .

An analgesic can be administered 15 minutes after the administration of domperidone. For young children under 12 years of age, paracetamol or ibuprofen are suitable options.

Attention! Due to new study results, the previous general recommendation to administer paracetamol to children for pain or fever without special concerns can no longer be upheld. Please also read – Paracetamol: Current warning against taking it during pregnancy

Due to the potential risk of Reye's syndrome, acetylsalicylic acid should not be administered. For schoolchildren whose migraine attacks can occur at any time, especially in the mornings at school, the teachers be informed. Ideally, the doctor should provide the student with written instructions on how to manage migraine attacks, to be given to the teacher.

To treat attacks in children whose attacks do not respond sufficiently to paracetamol and ibuprofen, dihydroergotamine in tablet form (2 mg orally) can also be used.

In cases of severe nausea and vomiting, antiemetics and analgesics can also be administered suppositories

Ergotamine tartrate and triptans are not indicated for children under 12 years of age. For use in adolescents aged 12 years and older, Imigran (sumatriptan) as a 10 mg nasal spray or AscoTop (zolmitriptan) as a 5 mg nasal spray may be used. The use of sumatriptan or zolmitriptan in adolescents should only be undertaken after a prescription from a specialist or a physician with extensive experience in migraine treatment and in accordance with local guidelines.

Drug prophylaxis

Drug-based prophylactic therapy in childhood is even more difficult and complicated than in adulthood.

Given the potentially high frequency of analgesic use required and the significant suffering involved, prophylactic medication should also be considered in children with frequent migraine attacks. However, it must be borne in mind that side effects of prophylactic medications are more frequent and severe in children than in adults.

In prophylactic therapy, the same principle applies to children as to adults: only monotherapy should be used and different medications should not be given in combination.

Primarily, this can occur in childhood

– a beta blocker,

such as metoprolol or propranolol.

Alternatives include flunarizine or pizotifen (no longer available in Germany, but can be ordered from abroad).

– It must be understood that drug prophylaxis cannot replace behavioral medicine prophylaxis

– As a rule, behavioral measures produce the same or even better results.

Regarding the effectiveness of medication for migraine prophylaxis in children, the literature presents highly contradictory findings. Some studies show significant effects, while others fail to demonstrate such substantial results.

When considering prophylactic medication for children, it is important briefly assess whether the medication is effective and how any initial side effects can be managed. This monitoring the effectiveness of the medication every two weeks . Only if the medication is effective should it be continued. Potential side effects must be discussed with the parents and children and carefully documented if necessary. The therapy may need to be adjusted.

All these precautions show that prophylactic drug therapy for migraine in childhood avoided as much as possible , and that medications for migraine prophylaxis only offer a solution to the problem for a certain period of time in exceptional cases.

However, especially in children very severe and debilitating attacks , " individual case experiments " may be necessary. Occasionally, surprisingly effective prophylactic therapies are observed. However, these are exceptions. In such complex cases, treatment should ideally be carried out by an experienced neuropediatrician.

Even if a rapid improvement in migraine symptoms is not achievable, it is necessary that patients and their parents receive repeated counseling and hope , spontaneous remission can occur repeatedly .

Sometimes it only becomes apparent later which trigger factors are particularly potent, and a continuous recording and inquiry into possible trigger factors can achieve a decisive improvement.

However, it is completely unsatisfactory and frustrating for children and parents when patients are discharged from the consultation without specific advice on current treatment options, with the explanation that migraine is incurable and nothing can be found.