Essential Insights for Navigating Migraine in Teens and Taking Action Today - A Child Neurologist's Guide

Let’s Paint the (Problematic) Migraine Picture

Think migraine is just a bad headache? Think again. Imagine a headache that feels like a full-blown, chaotic neurological thunderstorm in the brain⚡That’s a migraine attack. As a child neurologist, I have seen firsthand how these storms can be tricky and vary greatly amongst each of the millions of adolescents in the US with migraine disease.

Complex, heterogenous, and difficult to diagnose, migraine disease can sometimes be overlooked or misattributed to something else. Especially for adolescents, their migraine attack manifestations can easily be mistaken for school stress, puberty-related physiological changes, or the consequence of irregular sleep patterns (read more: 10 Essential Sleep Habits for Teens with Migraine). While these factors can certainly precipitate or exacerbate a migraine attack, they are not the root cause.

The longer migraine disease goes undiagnosed, the greater the risk it can become chronic and/or uncontrollable. By the time it’s correctly identified, valuable time may have been lost, reinforcing the need for timely treatment intervention (more info later ↓). Sometimes, parents or caregivers might not grasp the severity of a migraine attack – or even recognize it as a migraine. This can lead to inadequate treatment, such as low-dose over-the-counter medication or advice to simply “drink more water!” without consulting a headache specialist.

As your adolescent adjusts to the new school year – whether they have a migraine diagnosis or are showing potential symptoms – it’s essential to understand the intricate reality of migraine disease and how to help them manage their migraine symptoms. If they are experiencing frequent or severe headaches, seek a proper diagnosis from a healthcare provider who understands the distinction between headaches and migraine disease. More on that below ↓

Migraine vs. Headache: The Diagnostic Distinction

On its own, headache can be considered a “non-specific complaint” by healthcare providers and can be indicative of a range of conditions other than migraine disease. It’s important to remember: migraine is a disabling neurological condition, and headache is just one potential symptom of migraine.

So, how can pediatricians, headache specialists and child neurologists make the diagnostic distinction between migraine disease and headache to get adolescents on the right treatment plan?

When diagnosing migraine disease, your adolescent’s healthcare provider will consider their headache characteristics, accompanying symptoms, and results from a physical examination. For a migraine attack without aura, the following diagnostic criteria established by the International Classification of Headache Disorders (ICHD-3) must be met:

• Duration: Headache attack typically lasting 4-72 hours but 2-72 hours in adolescents (untreated or successfully treated)
• Characteristics: Headache has at least 2 of the following characteristics:
  • Usually unilateral location but can also be bilateral in adolescents
  • Pulsating quality
  • Moderate-to-severe pain intensity
  • Aggravation by or causing avoidance of routine physical activity (walking or climbing stairs)
• Accompanying Symptoms: During a headache, at least 1 of the following:
  • Nausea and/or vomiting
  • Photophobia (visual) or phonophobia (sound)

An additional set of criteria are provided to evaluate a migraine attack with aura:

• • At least 1 aura symptom spreads gradually over 5 or more minutes
  • 2 or more aura symptoms occur in succession
  • Each aura symptom lasts 5 to 60 minutes
  • At least 1 aura symptom is unilateral
  • At least 1 aura symptom is positive

• “Positive” aura symptoms include flashing lights, geometric patterns, zig-zag lines
• “Negative” aura symptoms include loss of vision, numbness, weakness

• The aura is accompanied, or followed within 60 minutes, by the headache

• Accompanying Symptoms: At least 1 of the following fully reversible aura symptoms:
  • Visual
  • Sensory
  • Speech and language
  • Motor
  • Brainstem
  • Retina

Even with the ICHD-3 criteria, diagnosing migraine disease can be tricky. For example, a study of nearly 3,000 people who frequently experienced what they thought were sinus headaches found that 88% actually had migraine disease. How could 4-in-5 people have gone undiagnosed? Well, the nerves in the sinuses, eyes, ears, teeth and jaw are the same nerves involved when someone has a migraine attack.

When speaking with your adolescent’s healthcare provider about their headaches, be prepared for questions aimed at understanding how much the headaches disrupt their routine, such as: How disabling are their headaches? Do the headaches interfere with their school, extracurricular and/or social activities? Do their headaches come with nausea or sensitivity to light, sound, or smell?

Notice these questions are connected to the migraine diagnostic criteria above. If your adolescent gets what they think are sinus headaches (this is just one example) and answered “yes” to some or all of these questions, it may actually be migraine disease.

Despite the high prevalence of migraine disease amongst adolescents, suitable therapies for their age are still limited, making an accurate diagnosis even more crucial to ensure appropriate treatment. As parents, advocating for more research and better understanding of adolescent migraine disease is vital. Increased awareness can lead to earlier diagnosis, more effective treatments, and ultimately, better outcomes for your child. Now, let’s dispel some more migraine misconceptions together.

5 Common Myths About Migraine Disease – Debunked

• Migraine Misconception: “I just have migraine disease. There’s nothing I can do to make it better.”
• Moment of Truth: Adolescents are often skeptical when I explain how healthy habits like regular movement, a well-balanced diet, and a structured sleep schedule can help reduce the frequency and severity of their migraine attacks. Beyond this, early intervention with the drug-free, non-invasive, non-sedative Nerivio REN (“remote electrical neuromodulation”) wearable may help relieve their migraine attack. Nerivio is indicated for acute and/or preventive treatment of migraine with or without aura in patients 12 years of age or older.

• Migraine Misconception: “Everyone with migraine disease experiences an aura (sensory disturbances).”
• Moment of Truth: Actually, only an estimated 25% of adolescents with migraine disease experience an aura, typically preceding the headache. On the other hand, some adolescents may have a migraine aura even without a headache. If aura is present, visual manifestations like blind spots, blurry or tunnel vision, and zig-zag lines are most common at this age, followed by physical sensations like numbness.2 Still, migraine aura manifestation, duration, and complexity varies significantly amongst adolescents, highlighting the importance of correct recognition to rule out other neurological conditions that can resemble migraine.2

• Migraine Misconception: “I must have a brain tumor that is causing these attacks.”
• Moment of Truth: A population-based study did not find evidence that migraine history was associated with increased risk of a brain tumor. Further, Memorial Sloan Kettering Cancer Center reinforced that “because our brains control everything in our bodies – from our speech to how we walk to our memory and our emotions – a headache from a brain tumor is often accompanied by other neurological symptoms” that aren’t typical of a migraine attack.

• Migraine Misconception: “A mild migraine attack is just a headache and doesn’t need to be treated.”
• Moment of Truth: Wrong! Research has shown that timely treatment intervention results in earlier pain relief, fewer headache frequency, less disability level, and decreased side effects.

• Migraine Misconception: “It’s just allergies. I don’t have migraine disease.”
• Moment of Truth: Migraine is a distinct neurological condition from allergy-related headaches (which are identified by different ICHD-3 criteria) and requires targeted treatment beyond just allergy medication. While they may notice an uptick in migraine days when exposed to more environmental allergens that can push them past their migraine threshold, their migraine attacks are not caused by allergy sensitivities. They still have migraine disease that needs its own treatment plan. That said, if a headache is a common symptom of your adolescent’s allergy flares but typically subsides with allergy medication, this may not be indicative of migraine disease. Remember our earlier distinction between headache and migraine? ↑

Now that we’ve sorted out the migraine myths and paved the way for an accurate diagnosis for your adolescent, it’s time to tackle the next step in their migraine management: finding the right treatment. Let’s dispel some misconceptions about wearables for migraine and see why drug-free treatment can be particularly advantageous for this age group. ↓

Misconceptions About Drug-Free Migraine Treatment – Debunked

When it comes to treating migraine disease, there are several misconceptions about drug-free treatment options. Some parents/caregivers anticipate that drug-free options might be difficult to use, ineffective, inaccessible at school, or draw unwanted attention from their adolescent’s peers.

The moment of truth? The Nerivio REN wearable, for example, is a drug-free treatment for migraine that was designed with adolescents in mind. Let’s explore ↓

Difficult to use? Easy.

Ineffective? See for yourself.

Painful? Nope.

Inaccessible at school? The opposite.

Unwanted attention? It’s discreet.

How Can Adolescents Benefit from Wearable Migraine Treatments?

Many young patients dislike swallowing pills and are even more resistant to shots/injections, while their parents often prefer to avoid pharmacological drugs altogether. Throughout my time as a child neurologist, I have found that wearable treatments like Nerivio offer a valuable alternative or complement to traditional pharmacological options. In particular, the Nerivio REN wearable is not only effective as an abortive treatment during a migraine attack but also serves as a preventive.

What Type of Patient Profile or Characteristics Do I Look for When Considering a Wearable Treatment?

Nerivio is particularly beneficial for patients who experience significant migraine symptoms such as nausea and vomiting, which can make taking oral medications challenging. For adolescents who experience side effects from medications or find that their current treatment provides only partial relief, Nerivio can be used in conjunction with or in lieu of medication. Additionally, it’s an excellent option for adolescents who have contraindications to certain medications, such as those with high blood pressure, gastrointestinal ulcers, or limitations on NSAID use. Adolescents who suffer from rebound headaches may also find Nerivio to be a safer and more effective alternative, allowing them to manage their migraine disease without the risks associated with overuse of medication.

Correcting Migraine Misconceptions: Educating and Empowering Families

In the clinic, educating and empowering both parents and adolescents about migraine disease is a critical part of care. As a child neurologist, it’s essential for me to start by explaining what migraine disease is and why someone experiences migraine attacks. By breaking down the ICHD-3 criteria (above), which outline the specific characteristics of a migraine attack, I help families understand that migraine disease is a complex neurological condition, not just “another headache.”

A key part of this education involves setting realistic goals for treatment. Since migraine is a lifelong condition, the aim isn’t to eliminate migraine attacks entirely but to significantly reduce their frequency and severity. The primary objective is to reduce migraine attacks to fewer than four times per month while minimizing the impact on daily life. We focus on finding the most effective treatment that can lessen the intensity of a migraine attack within two hours for your adolescent, with the fewest possible side effects.

When discussing preventive treatments, I emphasize that these are not meant to be lifelong solutions. Instead, the goal is to manage migraine disease effectively in the short term, with the understanding that treatment plans may evolve as the patient’s needs change. By providing this comprehensive education, I empower parents and adolescents to better understand migraine disease and make informed decisions about their treatment options (read more: How to Create a Comprehensive Migraine Management Plan for Your Teen).

To Sum It Up: Partnering for Better Adolescent Migraine Management

Managing migraine in adolescents is no easy task, and as parents or caregivers, it’s natural to feel overwhelmed by the challenges of moderating and treating this complex condition. It’s important to acknowledge that misconceptions about migraine disease can add to these challenges, making it harder to find the most effective treatments. By working closely with healthcare providers to correct these misconceptions, you can ensure that your child receives the best possible care. Remember, you’re not alone in this journey. There are many resources available (including on Nerivio.com) to help you better understand migraine and support them in managing their migraine disease effectively. Together, with the right information and a strong partnership with your healthcare provider, you can navigate the complexities of adolescent migraine and improve your child’s quality of life.

‍