- For kids with migraines, a picture can be worth a thousand words | WTOP
- Cluster Headache – NORD (National Organization for Rare Disorders)
- American Migraine Foundation
- Differing symptoms in adults and children
- Piecing the puzzle together
- A family affair
- Other kinds of migraine in children
- Identifying migraine in kids
For kids with migraines, a picture can be worth a thousand words | WTOP
Many of the drawings involve objects hammers, baseball bats and drum sets — things that cause pounding and throbbing pain. (Courtesy Dr. Carl Stafstrom) Some of the pieces depict symptoms directly related to migraines in kids, such as vertigo, and nausea. (Courtesy Dr.
Carl Stafstrom) Dr. Stafstrom says other drawings illustrate sensitivity to sound and light. (Courtesy Dr. Carl Stafstrom)
WASHINGTON — In this day of high tech medicine, an innovative doctor has found a simple way to effectively diagnose migraine headaches in children.
Diagnosing kids has always been tricky because they lack the verbal skills to fully describe their condition. But Dr. Carl Stafstrom, a pediatric neurologist with Johns Hopkins, says this is one case where a picture really is worth a thousand words.
He has been asking his young patients to draw their symptoms and has found over the years that their artwork provides important clinical insight.
“Please draw a picture of yourself having a headache — what does it feel to you?” he asks a child sitting at a low table with paper and crayons. There is no real additional prompting, as the youngster illustrates his or her own symptoms.
A study involving 226 children validated the process. A group of neurologists was shown their drawings and asked to determine whether each child had migraines. Eighty-seven percent of the time, their decisions — based solely on the drawings — matched the clinical diagnosis.
“That’s as high as many tests in medicine that require blood work or scans or things that — and this was a simple art project,” says Stafstrom.
He says the things these children draw fall into several categories. Many of the drawings involve objects, such as hammers, baseball bats and drum sets — things that cause pounding and throbbing pain.
Some depict symptoms directly related to migraines in kids, such as vertigo, and nausea. Stafstrom says others illustrate sensitivity to sound and light, including “a picture of the sun with a line through it.”
The pictures range from a 4-year-old’s stick figures to a drawing by an adolescent worthy of placement in a comic book. All, however, provide vital information.
“If I showed you a picture of a child holding his head, heading to a toilet to throw up — that is worth many, many sentences worth of verbal description. That just says it all,” says Stafstrom.
Parents and children have embraced this new approach to diagnosing migraines, and this pediatric neurologist now has 1,500 “works of art” in his collection.
“It really empowers the children to express themselves,” he says, adding that they appreciate the opportunity to have their own voices in the doctor’s office, instead of leaving all the talking to their parents.
Already there is talk about using art to help diagnose other neurological conditions in kids, such as epilepsy. And drawings by both parent and child could give doctors insight into genetic links in the years to come.
Stafstrom indicates the need for innovation to help kids with various neurological problems is great. He notes 5 percent of children below the age of puberty get migraine headaches. That goes up to 10 percent in the early teen years.
Cluster Headache – NORD (National Organization for Rare Disorders)
NORD gratefully acknowledges Olivia Lanes, NORD Intern and Frederick R. Taylor, MD, Park Nicollet Headache Center, Adjunct Professor of Neurology, University of Minnesota, for assistance in the preparation of this report.
- familial cluster headaches
- histamine cephalalgia
- vasogenic facial pain
Cluster headaches (CH) are an uncommon, severe form of primary neurovascular headaches. CH are the most painful form of headaches, with the pain occurring on one side of the head and behind or above the eye or at the temple most commonly. The pain has been described as searing, burning and stabbing.
The age of onset of CH is most often between 20 and 40, and they are more common in men than women with a ratio of 2:1.
CH attacks also include one or more cranial autonomic symptoms (CAS) on the same side of the head as the pain (ipsilaterally) such as red eye (conjunctival injection), eyelid swelling (edema), forehead and facial sweating, tearing (lacrimation), abnormally small size of the pupil (miosis), nasal congestion, runny nose (rhinorrhea), and drooping eyelid (ptosis). CH is divided into episodic and chronic. Episodic cluster headache patients usually suffer from 1 to 4 short headaches a day that can individually last between 15-120 minutes when they are having a series of attacks. These attacks (cluster periods) last for weeks or months and are separated by months or years of remission periods where the patients are pain-free. Chronic cluster headache patients suffer without remissions for 1 year or more or with remissions so brief they do not even span a month. Less than 20% of cluster headache patients have the chronic form. It is not yet clear what causes CH, but scientists have discovered a lot of recent evidence that links it to the part of the brain called the hypothalamus. There is no cure, and treatment is determined on an individual basis. However, the two most effective types of acute or symptomatic treatment, high-flow inhaled oxygen and injections of subcutaneous sumatriptan, have been proven to be effective in reducing the pain from CH.
Cluster headaches were first completely described by the London neurologist Wilfred Harris in 1926. At that time, it was believed that nearly 90% of CH patients were men, while women instead suffered with migraine headaches.
Although it has been confirmed that men are more at risk for developing CH, that ratio has decreased significantly. Researchers theorize that this is because women have long been misdiagnosed with migraines instead.
Treatment for migraine headaches differ in several ways from CH, so an accurate diagnosis is important.
In most cases, cluster headaches occur more often at night than during the day, and more often in the spring and fall. Headaches also often occur at the same time every day. The headaches usually last approximately 30 minutes, but can last as long as two hours and uncommonly longer.
The pain of a cluster headache is deep, agonizing, usually non-throbbing and affects only one side of the head (unilateral). The area of the head or face involved is always the same from day to day, but occasionally switches to the other side before a cluster ends entirely.
The cluster can switch sides with the next onset of attacks. The pain usually occurs in the eye socket area (orbit) and spreads to affect the face, temple and/or forehead. Often the headache is tolerated better by moving, pacing, rocking or even banging their head and usually not by remaining still.
They may be irritable and aggressive. When the headache passes, affected individuals may fall into a deep sleep only to be awakened again by another headache. This may continue several times a day, sometimes for weeks or months. Some affected individuals may be unable to continue a normal work schedule.
It is important to note that both drinking alcohol and smoking can act as triggers and can bring on attacks in persons who suffer from CH.
Other symptoms include excessive watering of the eye and nose on the same side of the head as the pain occurs. Facial sweating, nasal congestion, drooping eyelids (ptosis), and eyelid swelling (edema) are also common. Rarely before an attack patients will report seeing an aura or having other visual disturbances.
Chronic and episodic CH patients both experience the same type of severe, unilateral pain, which generally occurs 1 to 4 times a day for about 30 minutes.
However, chronic CH patients do not go through periods of remission or these periods are shorter than 1 month, while cyclic CH patients may experience episodic attacks for weeks or months but are then relieved by symptom-free periods that last months or years.
While the underlying cause of CH is not known, the direct cause of the pain is due to the dilation of blood vessels which creates pressure on the trigeminal nerve.
Recently, position emission tomography (PET) scans have shown activity in the hypothalamus, the part of the brain responsible for circadian rhythms, or the biological clock, during CH attacks.
This reinforces a previous hypothesis that the hypothalamus may be the cluster headache generator.
Although originally not thought to be a genetic disease, researchers now know that genetic factors are involved in approximately 10% of CH cases. It has been suggested that the disorder can be inherited as an autosomal dominant trait that appears to skip generations (incomplete penetrance) or as an autosomal recessive trait.
Dominant genetic disorders occur when only a single copy of an abnormal gene is necessary to cause a particular disease.
The abnormal gene can be inherited from either parent or can be the result of a new mutation (gene change) in the affected individual.
The risk of passing the abnormal gene from affected parent to offspring is 50% for each pregnancy. The risk is the same for males and females.
Recessive genetic disorders occur when an individual inherits two copies of an abnormal gene for the same trait, one from each parent. If an individual receives one normal gene and one gene for the disease, the person will be a carrier for the disease but usually will not show symptoms.
The risk for two carrier parents to both pass the defective gene and have an affected child is 25% with each pregnancy. The risk to have a child who is a carrier the parents is 50% with each pregnancy. The chance for a child to receive normal genes from both parents and be genetically normal for that particular trait is 25%.
The risk is the same for males and females.
All individuals carry 4-5 abnormal genes. Parents who are close relatives (consanguineous) have a higher chance than unrelated parents to both carry the same abnormal gene, which increases the risk to have children with a recessive genetic disorder.
CH has also been associated with tobacco smoking as well as alcohol consumption.
Cluster headaches affect males more often than females with a ratio that is 2:1. Symptoms usually start to appear between the ages of 20-40 with a mean age of onset of 30.
Currently there are no diagnostic tests to confirm CH.
According to the criteria of the International Classification of Headache Disorders, at least 5 attacks meeting the following are required for diagnosis:
- Severe unilateral, orbital (around the eye) and/or temporal (around the temple) pain lasting 15-180 minutes if untreated.
- Headache must be accompanied by at least one of the following:
- Red eye or tearing on the side of the headache
- Nasal congestion or runny nose on the side of the headache
- Eyelid swelling on the side of the headache
- Forehead and facial sweating on the side of the headache
- Small pupil or eyelid droop on the side of the headache
- A sense of restlessness or agitation
- Attacks have a frequency from one every other to 8 per day
Clinical Testing and Work-Up
Brain imaging with MRI with and without contrast is used at presentation of the very first cycle or when CH patients do not respond well to any of the common treatments, in order to exclude an alternative cause. Imaging studies in CH patients are normal most of the time, but lesions responsible for the headache can be seen leading to diagnosis of a secondary cluster headaches.
Treatment for CH varies greatly from patient to patient, depending on what works best to relieve pain for each individual. A common form of acute treatment at the first sign of pain symptoms is pure oxygen inhalation at 7-15 liters per minute by facial mask.
Often this is successful at aborting an attack. Another effective, acute treatment is subcutaneous sumatriptan. When injected or inhaled, this drug acts on several different processes involving blood vessels and pain nerves.
Both of these treatments narrow or constrict blood vessels, but the exact mechanism by which headache is stopped is not known. . Drugs that are used to end the cluster episode are grouped as transitional and chronic prevention. Occipital nerve block may terminate an episode.
Corticosteroids are commonly used transitionally for up to three weeks. Verapamil is the customary chronic preventative, while others include antiepileptic drugs and melatonin.
Transitional rugs are slowly tapered off even with continued headaches, while preventatives discontinued about two weeks after the last headache for episodic cluster. They are continued long term in chronic cluster. In cases of chronic CH only, lithium may be used.
In extreme cases, electrical stimulation of the occipital nerve, deep brain stimulation or surgery to destroy certain facial nerves (radiofrequency retrogasserian rhizotomy) may provide relief.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: [email protected]
For information about clinical trials sponsored by private sources, contact:
Contact for additional information about cluster headache:
Frederick R. Taylor, MD FAAN, FAHS
Park Nicollet Headache Center
Adjunct Professor of Neurology
University of Minnesota
Minneapolis, Minnesota 55426
Sargeant LK, Blanda M. Headache, Cluster. Emedicine. http://emedicine.medscape.com/article/792150-overview. Updated May 20, 2012. Accessed May 25, 2012.
Robert T. Cluster Headache. The American Headache Society. http://www.achenet.org/resources/cluster_headache/. Edited August 14, 2010. Accessed May 25, 2012.
Leroux E, Ducros A. Cluster headache. Orphanet Journal of Rare Diseases.http://www.ojrd.com/content/3/1/20. Published July 23, 2008. Accessed May 25, 2012.
Cluster Headaches. National Headache Foundation. http://www.headaches.org/education/Headache_Topic_Sheets/Cluster_Headaches. Accessed May 25, 2012.
Online Mendelian Inheritance in Man (OMIM). The Johns Hopkins University.
Cluster Headache, Familial. Entry No: 119915. Last Edited October 4, 2007. Available
at: http://www.ncbi.nlm.nih.gov/omim/. Accessed May 25, 2012.
1989, 1997, 1999, 2000, 2002, 2012
The information in NORD’s Rare Disease Database is for educational purposes only and is not intended to replace the advice of a physician or other qualified medical professional.
The content of the website and databases of the National Organization for Rare Disorders (NORD) is copyrighted and may not be reproduced, copied, downloaded or disseminated, in any way, for any commercial or public purpose, without prior written authorization and approval from NORD. Individuals may print one hard copy of an individual disease for personal use, provided that content is unmodified and includes NORD’s copyright.
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American Migraine Foundation
As much as we would to protect our children from pain, the sad reality is that children are not immune to migraine. In fact, up to 10% of school-aged children experience migraine and its debilitating effects.
Despite the numbers, many children are not getting the help they need, either because of improper diagnosis or treatment.
Identifying migraine in kids helps parents become stronger advocates for their children to get them the help and treatment they need.
The real trouble is that kids don’t usually talk about their head pain, generally due to stigma or lack of understanding. Combined with the fact that migraine doesn’t always look the same in children as in adults, the behavior that results from their pain can make them appear undisciplined or anti-social.
Parents need to be on the lookout for any potential signs of migraine in their child. By understanding what migraine is, learning to identify the symptoms and knowing when to take them to their doctor, parents can start their children down the road to treatment.
Differing symptoms in adults and children
When it comes to identifying migraine in kids, it can be challenging to determine if a child is suffering from migraine or another ailment because their symptoms and the way they react to them often differ from those of adults. Further complicating the diagnosis, children may have trouble communicating the symptoms they experience before, during or after a migraine attack.
While children may experience many of the same symptoms as adults—dizziness, fatigue, nausea and sensitivity to light or sound—they are also more ly than adults to experience abdominal migraine, which can cause pain in their abdomen, nausea and vomiting.
These migraine attacks are most common in children between the ages of 5 and 9, and can last less than an hour to several days. Colic in infants has also been linked to migraine later in life, indicating that it may be the earliest sign of the disease.
There are some noticeable differences in pediatric migraine when comparing symptoms between children and adults. Specifically, in children:
- The headaches may be shorter than in adults, lasting only an hour or two. Frequently, they last less than twelve hours.
- The episodes don’t occur as often as in adults. For example, they may happen only once a month or every few months.
- The headaches may go away after a few months or years.
- The pain tends to be more bi-frontal (across the forehead) than unilateral (on one side of the head). As children get older, the pain tends to be more unilateral.
Piecing the puzzle together
Children experiencing migraine may not always be able to describe what they are feeling, so it’s important for parents to help provide information. With careful observation and insightful questioning, you can get a clearer understanding of your child’s headaches and help get the right diagnosis.
It’s important to ask questions in a way that your child is able to comprehend. For instance, if you ask direct questions such as, “Are you sensitive to light or sound?” younger children may not understand what you mean.
Sometimes rephrasing the question or watching their behavior may provide a better view of potential headache symptoms. For example, a child with light sensitivity may not want to play outside or watch TV because “the light is so bright.
” Asking your child to draw a picture of what they are feeling can sometimes help express what they are unable to put into words.
Nausea is another symptom that’s difficult for a younger person to identify or explain. Ask your child, “Are you nauseated?” and there’s a good chance they won’t understand your question.
Even if you ask, “Are you sick to your stomach?” they might not know what you mean. You may notice, however, that they simply do not want to eat or say that their stomach feels bad.
By watching their behavior, you also can help identify what your child may be experiencing when they have a migraine attack. For instance:
- Watch to see if they go into a quiet place to rest or even nap.
- Notice if they talk to you less than usual or have a mood swing.
- Watch for a change in their daily routine. They may not engage in their usual reading or television activities because their eyes hurt or focusing is more challenging.
- Be aware of when they resume their normal activities.
A family affair
Migraine is a genetic disease, so if you’re a parent with migraine, it’s especially important to be mindful of signs that your children may be exhibiting similar symptoms. An overwhelming majority (about 70%) of children and adolescents who experience migraine have an immediate family member who also has migraine or had it when they were children.
Many adults, however, don’t realize that their headache is actually a migraine. Only 48% of adults receive a migraine diagnosis—so it’s very possible that a parent might not realize when a child’s “regular” headache is actually a migraine.
Other kinds of migraine in children
When they’re fairly young (2 to 8 years old) and before they complain of headache, children may get other childhood migraine syndromes/variants. The two most common are abdominal migraine and cyclic vomiting syndrome.
Abdominal migraine is similar to migraine, except instead of headache, children complain of stomachaches. The location of the pain can range from being a general discomfort to presenting as cramping around the belly button or all over the stomach.
Cyclic vomiting syndrome consists of episodes of vomiting with predictable repeat episodes weeks later. These can be very dramatic, can lead to dehydration and may/may not be associated with headache.
While these conditions are very real and can affect children, episodic abdominal pain or vomiting may be due to a gastroenterological problem and be unrelated to migraine. It’s a good idea to have a gastroenterologist assess your child before initiating migraine therapies.
Identifying migraine in kids
If you have a child who experiences bad headaches that you suspect might be migraine, make an appointment with a migraine specialist for a proper diagnosis. It may make all the difference.
For help finding a doctor experienced in identifying migraine in kids in your area, check out the American Migraine Foundation’s Find a Doctor tool.
For more information about pediatric migraine, visit the AMF Resource Library.
This blog was updated in March 2020.