July 23, 2010

Headache in a 5-year-old

Molly, 5, had an eye problem. It was pretty common, and her eye doctor recommended that she wear a patch on one eye several hours a day. She didn’t mind this, and she and her parents picked out all different designs for the patch that might suit her mood or fashion requirement. Usually, the patch is worn over the stronger eye in order to force the weaker one to get more exercise. 

So when her mother told me that she had a headache, my first guess was eyestrain. It's a common cause of headache at almost any age. But still, 5-year-olds don't often complain of headaches.

Her mother was sympathetic. She told her child that she'd get some medicine for her that would help her feel better, and went to the cabinet where they keep the acetaminophen. It was only a few steps away, but Molly started crying. She said that it was still hurting. Mother repeated that she would give her some medicine that would help. Molly said that it wouldn't help. Mother said, calmly, that she thought it would and that after the medicine they would lie down in the bedroom together until she felt better. Molly said that it wouldn't help and that it was going to get worse and it was getting worse right now and she didn't know what was going to happen and that it was still getting worse and medicine isn't going to help and nothing is going to help and she was really scared. Molly was screaming by now, continuing to express her fear and pain. Mom had picked her up, of course, and was doing her best to settle her.
She did the best thing she could think of, and took her into the bedroom. They lay on the bed together, with Molly in her mother's arms. Soon, Molly fell asleep and was better a few hours later when she awoke. When mom told me the rest of the story, I told her I wanted them to come to the office so I could speak to Molly in person.
Fortunately, Molly is smart and talkative and likes me as much as I adore her. She told me that her eyes didn't hurt when this happened. Her mother told me that there really wasn't a family history of migraine.
Though in my training I received a little exposure to migraines, even now this is generally thought to be uncommon in children. I have a feeling that isn't right. I have diagnosed migraine in children as young as 5, and there is often a family history. Their symptoms are usually just like adult symptoms. I wonder if these kids have headaches or stomach aches from even younger ages, but lack the expressive language to tell us. In this way they suffer without relief, and their doctors never get the clues they need to make the diagnosis. I would guess that a toddler with a headache is pretty cranky. So I wonder if some emotional or behavior problems in these younger kids--who knows? maybe babies, too--could be resulting from this kind of invisible problem.

But Molly didn't fit an identifiable migraine syndrome. She didn't have any problem with her brain that I could find. 

I asked if she would get headaches when she was outside in the bright sun. Her mom said that she didn't have one when they went to the local county fair the previous weekend. They were outside all day. They went to the petting zoo--but she didn't go in. Her brother, just 2, had no hesitation and had fun with the gentle animals. In fact, the closer she got to the fence around the petting zoo, the more upset she had become. She even was scared to see her brother near the animals. I asked her mother about other things she was afraid of. 

The list was long. She was scared of just about any animal that was live, any bug of any kind but especially spiders, snakes, dark places including closets and under the bed. I asked Molly, and she was open with me. She said that she was afraid of being separated from her family, she was afraid that something bad would happen to her mother, to her father, to her brother, to all of them together, and to herself. She was afraid of strange and new places, new foods. She was afraid of snakes. 

Now, with a little more insight, I asked her about the headache. She said it had hurt. This time I asked her more about what she was feeling during the headache. She said that she was very afraid that it wasn't going to get better. She was afraid that her mother wasn't going to be able to help her and that would make her mother feel bad and it would be her fault.

It's always concerning to me when a 5-year-old complains of a headache. I think Molly had a headache, and I'm not sure what caused it. But though it's not in my textbooks, this is what a panic attack looks like in a preschooler. When I told her mother this, she was able to think of a couple of other unusual meltdowns that seemed to come out of nowhere. They weren't for the usual reasons, when a parent says that the child can't have ice cream for dinner or has to turn off the television. They weren't about defiance, they were about worry. And each time, her mother felt powerless to stop them. In many ways, these events might look behavioral. They include crying, perhaps screaming, maybe pounding fists or feet.

It's the panic attack that made her reaction spiral out of control. Her mother had the right treatment for a headache. Some acetaminophen, closing her eyes in a dark quiet room. But I had to give them something that could make the panic attack less traumatic for the child—and maybe for the mother, too.

Panic_in_year_zero_1962_poster I gave the mother a pair of questionnaires I give to parents to help me evaluate anxiety disorders in children. The responses were convincing.

Though Molly had a clear anxiety disorder, she had some big potential advantages as I considered her treatment options. She was smart, she was verbal, and she wasn't afraid of me. The first two points would enable her to cooperate in her treatment in important ways. The last one would, I hoped, enable her to accept my guidance without her anxiety interfering. I discussed treatment options with her mother. She, too, thought that Molly's particular trust in me was worth exploiting to help her. 

Often, with generalized anxiety that includes aspects of the diagnostic subcategories (such as social anxiety disorder, separation anxiety, phobias, and so on) medication is a reasonable approach. But we had these advantages, and her mom and I wanted to try and take advantage of them. We could always revisit a medication option if other approaches didn't work.

I could have sent her to someone really good at Cognitive Behavioral Therapy. In 5-year-olds.
This approach is designed to help patients recognize their dysfunctional thoughts, and manage them in a rational way. Though the technique is well-known in adult psychotherapeutic circles, it's not so well developed for kids. And certainly not with preschoolers. 

In the bigger picture, however, the effects of Cognitive Behavioral Therapy, I think, can be thought of in the same general pool with meditation, yoga, prayer, and clinical hypnosis. They all help people (nothing works for everybody—each helps some people) get relief from thoughts and feelings that are painful or harmful.

What her mother decided was to let me try to teach her self-hypnosis. 

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  1. my daughter is 5-1/2 yo and complained of headache during morning when she wakes up, for a week now. i had her checked with an opthalmologist and all tests are normal. i also brought her to a pediatric neurologist. again the tests are normal. so the pedia neuro is worried because of her unusual headache during mornings when she woke up. as for now, we're observing her for another week and if the headache persists, said the pedia neuro, my daughter has to go for CT scan next week.

  2. I was diagnosed w/migraines at 5 back when a migraine diagnoses was very uncommon at all. I experienced migraines before that...light and sound sensativity, nausia and also vomitting....but my migraines have always had an unusual symptom...bloody noses....my migraine gets so bad that both nostrils just pouring blood so fast that even gauze packs at the ER were insufficient,...shortly after the bleeding started I would pass out from the pain, my nose would bleed a while longer, then I would feel better. ...the blood was always a good sign...like its my bodies way of relieving the pain. I've never found a doctor who could explain the bloody noses, but my mom used to have to take me to the ER and they would give me morphine (starting at age 7)...once, after blacking out, in addition to the bloody noses, blood started pouring from my ears. My mother and doctors both thought they were going to lose me...no CT scan or MRI or anything else has ever been able to explain the blood loss...my mother worked in the medical field my whole childhoood and the pedi she worked for spent months and months trying to figure it out, as has my adult best friend who is a pharmacist and is baffled by my rx reactions...but answers have never been found. Drugs like immatrex and topamax do NOTHING for my migraines, even if caught early. Pregnancy stopped my migraines, both times. Midrin would knock out my migraine w/in 15-20 mins EVERY TIME W/O FAIL!!! (In my opinion that's a miracle drug, idk why it got pulled from the shelves). I was given darvocet at age 8. ...that made the migraines worse....much much worse, a terrible trigger! Things would get better but the backlash migraine would hit and be terrrribly worse! I have tons of food triggersOnions, Garlic, MSG, Ginger, and artificial sweeteners, like vanillan and vanillin found in cheap chocolate, equal, sweet n low, etc., any alcohol, most anything aged (cheese)....the list goes on and on, and ON!! Furthermore,...the other day my 20 month old was screaming and holding her head and stumbling around like she's dizzy. Tylenol has NEVER worked on my migraines, nsaids are the only OTC to touch them so I immediately gave her childrens motrin, took her to my room, turned the fan on, and laid down with her. She had been very fussy all day but after waking she was MUCH better. This isn't the first time this has happened and she has had bloody noses also...I do, whole heartedly, believe my 20 month old is suffering from migraines.


Please let me know what you think. Do you know a child or situation like this?