So you have identified one of your patients as having migraine. Now decisions have to be made about management. Important points to consider are: frequency of migraine, intensity of pain and/or associated symptoms, triggers, and lifestyle factors. Unless the patient is presenting with frequent or intractable migraine several times/week, the first things to review with the patient and family are basic headache-healthy lifestyle guidelines.
What are the most important lifestyle factors to consider in migraine (or any headache for that matter)? Hydration, diet, sleep, exercise/activity, and stress management. Helping families understand what they can do to reduce migraine is empowering and creates a sense of partnership. Some families may want to go straight to daily preventive medications, but most would rather start with the basics.
Hydration is probably the most important aspect of preventing migraine in kids and teens. I usually recommend that patients drink the equivalent of their weight in kilograms (50kg = 50 oz), or half their weight in pounds (100lbs = 50 oz). This works for patients up to 80kg; above that weight, I will recommend 80-100oz/day. I have found that families need a real number to aim for, rather than just saying to ‘drink more’, which greatly improves compliance. I strongly encourage bringing a refillable water bottle to school daily, and bringing it home empty. Most bottles are 20-24oz, and kids who drink during school generally meet their hydration requirements. Appropriate hydration includes water, seltzer, electrolyte-rich fluids, milk, juice, and do not include caffeinated beverages or soda. Neither sugary nor sugar-free sodas are great, because both high sugar and artificial sweeteners are migraine triggers. If the kids balk at water, a little juice added can help. Some schools do not allow water bottles, but a note from a provider will help (or it can be a part of a 504 education support plan). I encourage using electrolyte-rich fluids around heavy athletic activity or during migraine, but not as a daily beverage- can lead to obesity or dental caries due to sugar.
Diet is important in a variety of ways. For some migraineurs, there are foods that can trigger migraines and need to be identified and avoided. There are lists of these foods readily available and I will attach a list here (Headache Elimination Diet). I tell kids that as a person with migraine, they have to be a detective for their triggers, again empowering them to have agency in their own health. In addition, ensuring regular meals- breakfast, lunch and dinner plus snacks- is key in preventing migraine. Meal skipping can trigger migraine and many patients have learned this the hard way. Also a diet as varied and nutritious as possible is just good for health. Some children are very selective (‘picky’), and can be lacking in essential nutrients. Kids who eat a ‘beige’ diet, eating few if any vegetables or fruits, probably would benefit from a multivitamin. A common migraine supplement is vitamin B2 (riboflavin) and children with limited diets would benefit from a B complex vitamin.
Getting enough sleep is crucial in the prevention of migraine. Depending on their age, children and teens need between 8-12hours of sleep per night. In addition to getting to bed on time, using good sleep hygiene, including bedtime routines and managing time on electronics, is key to adequate sleep. In our busy, over-scheduled lives, prioritizing sleep can be difficult. Families just need to understand how inadequate sleep can affect the migraineur. This might mean that the tween avoids sleepovers, as she knows that a migraine is likely the next day. Or that strict limits on electronics- using phone, tablet, video games, etc- are consistent and enforced. There are many barriers to getting enough sleep, including heavy homework loads, multiple sports or other activities, as well as early start times for high school. Many communities are beginning to address the start time issue, but families are encouraged to be proactive in setting limits on participation in activities. Inadequate or disrupted sleep is a common migraine trigger.
I’ll continue to review lifestyle factors in the next post. Most of the recommendations apply to all headache types for the most part and are worth a discussion with all families.