Migraines and other Headaches in Children and Adults Discussion

Author: Wake Forest Baptist Health

- Hi everyone, welcome to our Facebook Live session on migraine. I am Dr. Lauren Doyle Strauss and I am a pediatric neurologist here at Wake Forest Baptist Health, and I'm coming up on my three-year anniversary. And so I'm a pediatric neurologist with specialized training in headache medicine. I did most of my training up in the Harvard system, in two different hospitals, Boston Children's Hospital and Brigham and Women's Hospital, and I'm very excited to be down here at Wake Forest. I lead a pediatric program, part of the headache program at Wake Forest Baptist Health, and what we do is, it's an innovative program for children and adults suffering with headaches, providing hope and treatment options, even for the most complex, and our ultimate goal is to help you return to a meaningful life.

I'm very excited that they invited me to talk about migraine, especially during this month, because June is Migraine Awareness Month. That is why I'm wearing purple. I like the color purple, but the reason I'm wearing purple is to bring attention to this special month, and awareness for migraine. I often get asked, what is migraine? Migraine is a neurologic disorder that we know involves both nerve pathways and also brain chemicals. We used to think that migraine was only due to an abnormal blood supply or blood pathology or blood vessel issue, because patients often report pounding in their head that feels like a heart beating, but we now know it's much more complex and it involves both nerve pathways and brain chemicals.

It's very interesting. We haven't fully understood all parts of how a migraine happens, because we've known about migraines for a really long time. Migraines were first described in ancient Egyptian times, written on early papyrus, and then they've been written all throughout history, but yet we're still trying to understand why a migraine happens. What are the symptoms that someone experiences with migraine? Well, everyone kind of hears a little bit about the headache, but actually, there are multiple phases to migraine. So the first one that some patients experience is known as the prodrome, and this is the warning phase.

So a patient or migraine sufferer may describe that they feel weak, tired, dizzy, have neck pain. I had one patient say that he gets a surge in energy, so it can be a lot of different things, but it's something that you may notice before the headache happens. And then there is the aura phase. The aura is a neurologic symptom. The most common aura is actually a visual aura. And this happens in about 20% of patients, and they can see very interesting things. The patients describe all sorts of things. They can see flashes of light, sparkles, colored rainbows, and they can even see cracked glass, or edges, or smudgings.

Migraines and other Headaches in Children and Adults Discussion

So it's really interesting, it usually lasts about, it can be minutes up to hours, and it can happen before the headache, during the headache, after the headache, or sometimes without a headache, so it's pretty fascinating. Then, often, this leads on to a headache. It's important to point out that with migraine, it is not just a headache, okay? This is a severe, very disabling headache associated with migraine, and it's usually unilateral, which means just on one side. And from headache to headache, different headache episodes, it can switch sides. But in kids, they don't often have a unilateral headache, they have a bilateral headache, which can be confusing for some people. But headache is quite severe and that can last hours. So, how common is a migraine? It's actually quite common.

We estimate that it affects about 15% of people around the world. To break that down into what that means in your day-to-day life, that affects about one in four homes. We know it's more common in women, it affects one in five women, and one in 16 men. A lot of people don't realize that this is very common in children as well. It affects one in 11 children. So who is most at risk? Anyone is at risk. We do know it's more common in women, especially related to times where they're affected by hormones.

So puberty, I mentioned, definitely the start of birth control pills, pregnancy, and then actually headaches often improve after they've gone through menopause. And looking at age ranges, we know that it's more common at the onset of puberty, can worsen in frequency and intensity into their 20s and 30s, and then improves later in life. And that's not typical for everyone, but that's generally most patients that are affected. In kids, although it's most common, we say in adults that it's more common in women, we know in kids, before puberty sets in, it's more common in boys, which can be confusing for some people. I'll often get asked, what are the genetic factors that lead to someone developing migraines in their life? That is a really interesting question, and we hope this is something we're going to get an answer to soon, but unfortunately it's very complex. The reason is because it's most likely not just one gene.

It's most likely more than one gene. But we do know that if a parent has a personal history of migraines, they have a 50% chance of having a child with migraine. And then if both parents have migraines, then you increase that chance to about 75%. So when should you seek out care for your headaches? If the headaches are severe, if there's something concerning about the headaches to you, they're not responding to regular over-the-counter medicines like Tylenol or Motrin, or there is something that you think of a neurologic symptom that is happening with your headaches, these are reasons that you should definitely talk about it with your primary care doctor. Your primary care doctor is always the first place for you to go to to seek out care. And your primary care doctor can definitely start the first steps, look into whether or not you need more testing to look into a cause for these headaches, can we start some treatment options? The question becomes when do you come onto a center like ours, when should they refer? We don't have to refer right away, but I think that if the headaches are becoming troublesome, bothersome, and they are not responding to the medicines that are being prescribed by your primary care doctor, that's a great time to see if referral to our center could be helpful. We are very lucky at the headache program at Wake Forest Baptist because we offer a lot of different treatments. We treat both children and adults.

It's important to point out that we've offered treatments that are non-narcotic options, and why do I point this out? Because in the past, people used to think that narcotic medications were helpful with migraine, and they do temporarily help with migraine, the problem is, is used chronically, they can actually worsen the intensity of pain, it can make pain more frequent and then they can block the effectiveness of medications. Our goal is to definitely offer treatments that do not involve narcotics. If you're on narcotics and you want to come to our center, the best idea would be to try to wean off or wean down the amount of narcotics you're using so that the treatments can be effective. In our program, we have a multi-disciplinary team, so we're very, very lucky. Our team includes several UCNS certified headache specialists. These are people that went on for additional training in headache, and we have a physical therapist who's focused on the head and neck region.

And we have several behavioral medicine specialists, and we have a nutritionist. And so together we see patients and we try to individualize treatment to try to really help you in the best way possible. We focus on promoting a healthy lifestyle, because healthy habits, hydration, sleeping well, reducing stress, these are all really important in helping you cope with your pain, but also to prevent pain. Our program is also really unique because we offer procedural treatments for headache.

A lot of people don't realize that there are procedural treatments for migraine. One of the ones that we use more commonly is called botox. So botox you may have heard of, because it is used or made popular by certain celebrities because they're using it to prevent wrinkles. But botox is a synthetic purified toxin, so it temporarily paralyzes muscles for about two to three months, and they noticed when they were receiving cosmetic treatments that this was helpful for headache and migraine. So there is a research trial known as the Preempt study, that famously showed that this treatment could be helpful in chronic migraine. Chronic migraine is one of our worst types of migraine because migraines can, in this case, they happen more than 15 days a month, for more than three months, and they often don't respond to multiple medicines.

So this is a great treatment option available. So botox is a possibility. Then, we have another treatment option, which are nerve blocks.

One of the nerve blocks that we offer are called occipital nerve blocks. This is really interesting, a lot of patients haven't heard of this, and this is where we take numbing medicine, similar to when you go to the dental office, and we actually inject it in the back of your head, or sometimes in other areas, and we numb down the scalp nerves. This allows your scalp to go numb, put the nerves to sleep, and then the thought is, that when they wake back up again they're not as irritated. And this is a very simple procedure done in our office, you don't need to be sedated for it, and this can really provide relief for patients who are in a really bad headache cycle, someone who has a headache for a few days that doesn't respond to medicine. And then we're very excited that we've offered a new treatment recently, known as SPG blocks. SPG blocks stand for Sphenopalatine Ganglion Blocks. There's a specialized center located in the back of the nose, we use a catheter and we insert it up the nose and we inject lidocaine to be able to hit that area. We don't fully understand why this helps, but it has been helpful in many different types of headache attacks to try to reduce the severity of how long it's going on.

And then our program is also really unique because we launched an urgent care infusion program. This is where we have a patient who's had headache going on for a few days. They call in to our nurse, we know them, because they're one of our patients, and then we bring them in and offer then either an injection into their thigh or the butt or we offer an IV placement to give infusions, and this can be the same kind of medicines that are offered in urgent care setting, or an ED setting, or emergency room setting. And the whole goal for our patients is to give their lives back. To give them back control.

So we want them to be able to come to us, get treatment fast and go right back to work or back to school. That's a great option for a lot of our patients. We're just so lucky at Wake Forest Baptist Health, because being part of a university setting like this, it really gives us the academic advantage. I really would like to highlight a few of our ongoing clinical trials that are targeted towards migraine, and the first one which is currently recruiting for headache patients who have episodic migraine is run by Dr. Rebecca Wells, and this is a study looking at stress reduction.

You take eight weekly classes, and it is a study that is a great option if you're looking for an opportunity to try something that doesn't involve using a new medicine or trying something that's medicine based. This could be really helpful for you. We're currently recruiting patients. You have to be 18 years older, and we'll include the link in the posting, so if you're interested you can contact Dr. Wells. The second study, we don't fully have all the details, but it's very exciting, we're about to announce that we were accepted as a clinical trial site to look at one of the new therapies that is coming out called CGRP. CGRP is in clinical trials across the country, this is a new target site for migraine that has got exciting promise.

It's received a lot of national attention, and this could be the next big treatment in headache. Really, in the early studies that have come out, we have seen results in refractory patients that never found response before. So this is really exciting, and Dr. Bryson will have further details coming out soon, but it will most likely focused on episodic migraines, so a few headaches a month. If you're interested in that, I would direct you to the clinicaltrials.gov site, because there are multiple trials ongoing for that. So at this time, we're going to pause for questions and see if you have anything to pick my brain with. I can't read it.

Oh, okay. Are migraines genetic? Yeah, we kind of touched upon that. The answer to that is, yes. Nationally, everyone is wondering this question, and if you can sort out what the genetics are, then that would open up lots of treatment options because if you find where exactly to target, we would be able to treat migraine more effectively. And in the past, most of our medicine choices that we use in migraine treatment have been borrowed from other fields or other classes, so we borrow blood pressure meds, we borrow psychiatric meds, we borrow seizure meds, and if we could figure out where the exact genetic cause is, it would really advance the field. So it isn't a race to try to understand this, the problem is it's so complicated because it's multiple sites that we think are involved, and there is a movement to create a repository where basically if you went to an academic center like ours, part of your appointment would be you would draw blood and then they would store it, and eventually we could try to cumulatively understand nationally, where is the target site for migraine? Okay, so what would a child typically experiencing migraines, what would that look like? It looks very similar to when an adult has migraine, the problem is, children can't always express what they're feeling, so we have this international headache classification system, and it actually says specifically for children, that you can infer from behavior. And so during a headache, which I didn't mention before, you can have some associative features, so you can be light sensitive, sound sensitive, we use the fancy terms of photophobic or phonophobic.

And so you may see a child dive under the blankets or ask to put a pillow over their head, or turn out the lights and close the door. And then they don't want their baby sister screaming because it really bothers them, or no tv, even though they love watching tv. So there may be some extra behaviors that you're gonna notice.

They may not come out and say. There are times that we'll look back and we have a four or five-year-old who can finally express what was happening and we realize there were times they were yelling or holding their head and look back and say wow, they may have even been having migraines when they were two or three years old. Now the thing I want to point out which is really interesting about children, is that there are some migraine variant syndromes, which we call childhood periodic syndromes, which happen in childhood or in adolescence that don't have headache part of them.

And these are very different. They're kind of a unique group of disorders, but one is cyclic vomiting, where you can have bouts of vomiting, sometimes up to 15 times a day, that happen in cycles every few months. So that's really interesting and it definitely deserves a work up. Then there are abdominal migraines where you can have bouts of belly pain centered around the belly button, and sometimes get worked up like they're in apendicitis. And then we'll realize with a big workup being normal, that it might be this migraine variant. And then there's a third, well there's several, but there's another one of interest, where you can have bouts of torticollis, which is twisting of the neck, kind of stuck in one position and they can have that for hours to days, and they can do cycles where they have episodes of that. So we notice kids sometimes don't manifest the migraines, they sometimes have some of these other symptoms.

So any symptoms that you're concerned about and if they're happening on a regular basis, you would talk to your doctor and they can help you sort it out. Oh, okay, this is a really interesting question. Does the aura beforehand have implications to migraine being more severe? The struggle is when someone experiences their first aura, you have to take it really seriously. You don't want to just say oh yeah, this might be a migraine, someone in my family has migraine, because if it's just a loss in your vision or even some things that can look like a migraine aura, sometimes it can be a sign of something more serious, and so it's very good to talk about your symptoms to a doctor. There are so many different ways that someone can have an aura, sometimes people can have tingling in an arm or leg, you don't want to miss a stroke. So if you have a new episode of a neurologic symptom, even if it comes and goes, if it's the first time you've experienced that, I would definitely mention it to your doctor. Now, once they've determined that you have migraine, - [Hospital Announcer] Your attention please, will Amanda Cooper - Sorry, we'll pause (laughs) - [Hospital Announcer] call security at 63305, Amanda Cooper call security at 63305, thank you.

- Well, hopefully Amanda Cooper gets in touch with them, I don't know if you could hear the overhead, that's why we were pausing, but so once they've determined that your symptoms are related to migraine with aura, and they think okay, you've got either episodic migraine with aura or chronic migraine with aura, if it's visual or sensory, but if they've made that determination and you've had the same sort of neurologic symptom every time, we become less and less concerned. And the type of aura, whether or not it's a sensory aura versus a visual aura, that doesn't necessarily make us more worried about your headaches and it doesn't necessarily change the prognosis, meaning we can't tell if someone has a certain type of aura that they're not gonna respond to certain medicines. Oh, okay, and this is one of the first comments that we got, so I'm glad they reminded us, there was a question related to someone who may have migraines and who may have sustained a brain injury of some sort and was having issues with smell. The question was whether or not migraines can cause loss in smell, and is there a treatment for olfactory damage? It's very interesting because we mentioned light sensitivity, sound sensitivity, patients with migraine can also experience sensitivity to smell. So actually, their smells are usually enhanced. We have to be very careful in the headache program, we can't wear perfume, we don't wear fancy shampoos, because our patients can really notice it, so the fact that the person who sent it in their comment is having difficulties with smell, I would suspect that's more related to the brain injury or what might have happened to the olfactory bulb, rather than related to migraines. If that is a concern, I would definitely mention it to your primary care doctor or your rehab doctor to see if there are some ways that you can rehab from that, or testing, if any testing is needed.

Okay, so if there are any further questions related to that, you can always make an appointment with us in the headache center and see if we can help. Okay, so I think we're gonna be wrapping up, and I really, really appreciate your time, and coming and logging in and listening to our session, and definitely spread the migraine awareness. I wanted to list a few places you can go if you want more information. One would be the American Migraine Foundation.

We call this AMF. This is a wonderful resource, it's on a website, and you can go and there's a lot of information about all different types of headache. We only spent most of the time talking about migraine, but there's a lot of different types of headaches that are on that website. And AMF is very involved, and right now, because of migraine awareness month, they have a hashtag that you can follow on Twitter, called hashtag moveagainstmigraine, and they've also launched a Facebook picture that has a purple ribbon, purple because of migraine awareness, so you may notice some people are doing that on Facebook. And the AMF is hosting a tweet chat, which is on Twitter, which is gonna be on Wednesday at 5 p.m.

As part of our national conference, and I'll participate in it, and several other headache specialists around the country are gonna answer questions about migraine and other types of headache, and what advances are coming out in headache research. So definitely check that out if you're on Twitter. And so I'm very involved in the national scene as part of the American Headache Society, and I write a monthly column looking or trying to share what is fascinating and new in headache research, so if that's something that you want to follow, you can go to the American Headache Society webpage, Headache and then News, and you can search under my name.

And then thirdly, I want to point out the patient organization, which is called AHMA, it's A-H-M-A, it's American Headache and Migraine Association. This is a patient run group, and they are very active, they're active in fundraising, and they're active in education and support groups. So if that's something that you need, I would encourage you to reach out to AHMA. They're even organizing now at this point national conferences for their patients. So I really want to thank you. Thank you so much, and definitely let us know if any comments or questions come up.

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