by Sharon Oosthoek
One day when my son, Cole, was six, he suddenly dropped to the floor, pale and trembling, small hands clutching his forehead. While my husband and I didn’t doubt he was in pain, we never imagined Cole might be in the throes of his first migraine. It simply didn’t cross our minds that a six-year-old could suffer from them.

Turns out we weren’t alone in that misconception.

“People tend to think it’s an adult condition, but it’s very common in children,” says Shanna Lindsay, a paediatric neurologist at St. Joseph’s Health Centre in Toronto. While migraines are more pervasive among teens, four to five percent of school-aged children suffer from them, compared with 30 percent of adults. (These estimates include those who have had one or two migraines in their lives, as well as those who suffer daily.)

“Even tiny babies can have migraines. Those are very rare, but it happens,” says Daune MacGregor, a paediatric neurologist with the Headache Clinic at SickKids in Toronto. “Small babies will bang their heads against their crib. Two- and three-year-olds could be unsteady and walk around like a tiny drunk.”

The medical definition of a migraine is a headache with moderate to severe pounding, usually on one side of the head, and often associated with nausea, vomiting and sensitivity to light and noise. A complex pain response, which includes inflammation of the walls of blood vessels in the brain, results in the pounding sensation. Anyone who has had a migraine will tell you it’s not the same as a tension headache, which feels like being squeezed by a cap or band around the head and usually doesn’t cause nausea.

Some people, including children, sense an aura that warns them a migraine is on its way. They may see jagged bright lights that shimmer like the northern lights. Others temporarily lose their vision in one eye about 10 to 15 minutes before the migraine starts. But for most people there’s no aura, no warning. The pain simply begins.

While most migraine symptoms are the same whether you’re a child or an adult, the big difference is how long they last and where the pain occurs. With children, a migraine lasts for one hour or longer; in adults they are longer than four hours. And while adults describe the pain as one-sided, children often say their pain is all over their head, though that’s partly perception. Children are unable to pinpoint the source of their pain, MacGregor explains. “They may have pain on one side, but because they can’t localize it, they say it’s all over. Some of them are quite dramatic in describing it. We get them to draw their headaches, and I have some pictures that show a big knife going through the head.”

The majority of those drawings are done by boys. Until adolescence, boys suffer migraines slightly more frequently than girls. But once their bodies start to change, girls’ monthly hormonal fluctuations put them at greater risk. While boys may outgrow their migraines by their teens, girls are rarely so lucky.

If your child is suffering from migrainE-like symptoms, the first step is to get a diagnosis from a paediatrician or paediatric neurologist. “There is no blood test, X-ray, MRI or any kind of medical test that says this is a migraine,” says MacGregor. “It really is a diagnosis by exclusion.” After ruling out other possibilities, such as sinus infections, vision problems or (in very rare cases) brain tumours, a paediatrician or neurologist will make a diagnosis based on a combination of symptoms and family history (migraines are often inherited).
Migraines have a bewilderingly wide range of triggers. The most common food triggers are caffeine, chocolate, cheese and — especially in kids — processed meats. “You know, hot dogs, salami, pepperoni,” says Lindsay. “Skipping meals is another big one, especially for teens who skip breakfast so they can sleep in.”

Changes in weather, bright lights, dehydration and lack of sleep can also bring on migraines. So can stress, even the good kind of excited stress associated with a birthday party. Of course, there are other kinds of tension or worry in a child’s life. “As adults, we think, ‘How can our kids be stressed? They’re six,’” says Lindsay. “But it could be that somebody said something in the playground a month ago and they’re still thinking about it. I think we forget as adults what can be stressful for a little kid.” She recalls treating an eight-year-old girl who suffered daily migraines at school. “She had incredibly hairy forearms and all the boys were making fun of her. She had the hair removed and the migraines disappeared.”

If your child is diagnosed with migraines, the best way to manage them is to avoid the triggers. Keep a daily diary of what your child eats and drinks, how much she sleeps and what kind of stresses she might be experiencing. MacGregor tells her young patients they must take charge when it comes to avoiding their triggers. “I say, ‘Whose head hurts? Is it Mommy’s head? Is it Daddy’s head? No, it’s yours, and you have to take some responsibility.’”

When a child does get a migraine, MacGregor recommends putting her in a quiet, darkened room — no TV or iPods! Some children find relief from either a cool or warm cloth on the head or neck. Pain therapists, such as those at the Headache Clinic, can also help children to use relaxation techniques to control the pounding.

In the case of a severe migraine, both MacGregor and Lindsay recommend non-prescription drugs such as ibuprofen (sold as Motrin and Advil) or acetaminophen (Tylenol and Tempra). “Most children do quite well with over-the-counter medications, as long as they’re given a good dose,” says Lindsay. She says that because drug manufacturers err on the side of caution when suggesting doses, kids should get the OK from their doctor for a higher dose. “The key is, they need one good dose as soon as they get the headache. If you wait, you’ve missed the boat and [the pain] is bad.”

If you’ve tried Motrin and that doesn’t do the trick, you can also try giving your child Tylenol, or vice versa. Lindsay says that since these drugs act on different pathways in the brain, you can use both at the same time. Lindsay and MacGregor caution, however, against using non-prescription drugs more than three times a week. “You can get a rebound headache,” says Lindsay. “Your body is saying, ‘Where is my Tylenol?’ In this situation, we need to consider a preventive medication.”

With migraines that hit once every couple weeks, Cole is lucky enough not to require preventive drugs, but we do often resort to over-the-counter medication. And having discovered that lack of sleep is his major trigger, we’ve become, much to his dismay, militant about bedtime.

Can migraines be prevented?

Doctors are reluctant to prescribe preventive medication — drugs taken daily to ward off migraines — to children. They have side effects such as weight gain, kidney damage and drowsiness, and none has been properly tested on children. In severe cases, though, after all other options have failed, doctors will consider prescribing drugs such as amitriptyline, pizotyline and gabapentin.

As a last resort for young patients, Daune MacGregor, a paediatric neuro-logist at Toronto’s SickKids, will even use Botox (yes, the treatment best known for temporarily removing wrinkles when injected into the face). The botulinum toxin blocks nerve impulses and temporarily relaxes muscles when used in high doses for cosmetic purposes. In smaller doses, used for migraines, it blocks pain pathways in the brain. “It has to be redone every three months, but some of these kids haven’t been to school in a year,” says MacGregor.

Published August, 2006

by Sharon Oosthoek
Andrew Heubner vividly recalls the day he sat in a Toronto allergist’s office anxiously watching his eight-year-old son Jesse eat peanut butter.

For years, he and his wife Katharine had carefully kept their boy away from peanuts, knowing it could mean the difference between life and death. But on that day three years ago, they had good reason to suspect Jesse was one of the roughly 20 per cent of children who outgrow their peanut allergy.

“The glimpse of freedom was so exciting. If they’d fed him pins and razor blades, that would have been alright,” jokes Andrew.
Over the course of three hours, a nurse, with a shot of adrenalin nearby in case of an anaphylactic reaction, fed Jesse increasing amounts of peanut butter. By the time it was over, he was able to eat a tablespoon without reacting.

“We went back to the car and Andrew had bought a Mr. Big chocolate bar with peanuts. He had it in his pocket and gave it to Jesse in the car. That was too much for me,” recalls Katharine. It was hard for her to stop thinking about peanuts as the enemy.

Indeed, only in the last decade have allergists dared attempt such “peanut challenges,” offering new hope to families struggling to lead normal lives after their child is diagnosed.

“It’s life-altering. Nothing is as satisfying as taking someone who has been afraid they’ll die if they eat peanuts and showing them they’re fine,” says Dr. Stuart Carr, a pediatric allergist in Edmonton. “That’s the kind of thing that will make Mom cry in the office.”

Dr. Rhoda Kagan, a pediatric allergist at the McGill University Health Centre in Montreal, says only recently have studies shown some children can leave their allergy behind.
“Ten years ago, we never would have thought children could outgrow their peanut allergy,” says Kagan.

According the Anaphylaxis Canada, roughly 0.8 per cent of children in this country are allergic. That compares to 0.6 per cent of adults. Clearly, somewhere along the way, some children lose their sensitivity.

Medical advances mean it’s now possible to predict which children may have outgrown it before allowing them to try a peanut challenge.
“The gold standard test for any allergy is the challenge – actually eating it. Every other test is to guess the outcome of the challenge,” says Carr.

But as any parent who has watched their child take the challenge can tell you, it’s a nerve-wracking experience. If their child is in fact still allergic, even trace amounts of peanut can lead to anaphylaxis, an “explosive overreaction” of the body’s immune system. It can cause hives, swelling, difficulty breathing, abdominal cramps, vomiting, diarrhea, circulatory collapse, and in the worst case, coma and death.
Both Kagan and Carr, part of a small group of Canadian allergists who perform peanut challenges, say that’s why they will only attempt it if they are reasonably sure the allergy has passed.

So how do allergists satisfy themselves that a child is a good risk for a peanut challenge?
The first thing to know is that only an allergist can make that call. In fact, Dr. Peter Vadas, director of allergy and clinical immunology at Toronto’s St. Michael’s Hospital, is so worried about parents attempting the challenge themselves that he was reluctant to speak about the test with Today’s Parent.

“I don’t want even a single parent to walk away and say, ‘Maybe my allergist is wrong and maybe I should give my child peanuts.’ Even though you put the caveat (about leaving the test to allergists) across the page in huge letters, people will ignore it,” says Vadas.
The difficulty is that even your allergist is making an educated guess. The tests that determine the likelihood that a child has outgrown their allergy are fallible – that’s why peanut challenges are done with a medical team standing by.

There are two tests necessary before attempting the challenge. The first involves pricking the surface of the skin with peanut extract and watching for a hive-type reaction.

“The skin test is very, very good at ruling out allergies. The problem with skin testing is its positive predictive value. That is, if you test positive, are you actually allergic? ” says Carr.

He says that if you randomly test people, only 30 to 40 per cent of those who show a positive result are truly allergic. If on the other hand, you test only people who have had allergic reactions in the past, a positive result is more reliable.

“If you have a strong history, that is, if you ate peanuts three times in a row and threw up every time and broke out in hives, then the probability is 60 to 70 per cent that the positive skin test is correct,” he says.

This has implications for children whose allergist or family doctor diagnoses a peanut allergy based on the skin prick test alone.
“I know that people are walking around with a diagnosis of peanut allergy who aren’t allergic and probably never were,” says Carr.

He says that if the skin test is positive, the doctor should order a follow-up blood test known as ImmunoCap which measures a patient’s level of IgE antibodies. It’s these antibodies that trigger a reaction when they come in contact with peanut protein.

If the blood test shows low levels of antibodies, the child is likely no longer allergic and is a good risk for a peanut challenge.
In Jesse’s case, it took a year of regular blood tests before his allergist was satisfied levels were finally low enough to proceed with a challenge.

Unfortunately, Jesse’s story didn’t end there. He is one of the very rare number of children who become resensitized to peanuts after passing the challenge.

His family tasted two months of freedom before he began complaining of a “scratchy” feeling in his throat when eating peanuts.
He had been eating small amounts of peanut butter or peanuts once every couple weeks, just as his allergist recommended. Recent research suggests eating peanuts a couple times a month can help stave off a relapse after a child has passed the challenge. “It teaches the immune system that peanuts are ok,” says Kagan.

But when Katharine insisted Jesse receive another ImmunoCap test, it confirmed her fears. His IgE antibodies had risen again.
“We had peanuts in our cupboards, our fridge,” recalls Katharine. “I felt like our house was contaminated. I threw it all out and scrubbed everything.”

Jesse went back to carrying his epi-pen and forgoing treats at birthday parties. “It’s very frightening for that to happen,” says Kagan. “Today they’re not allergic, but we don’t have a crystal ball that says they never will be.”

Over the next two years, Katharine brought Jesse regularly for ImmunoCap tests, which eventually showed receding levels of the IgE antibody. By March, just shy of his 11th birthday, Jesse was again deemed a good risk for a peanut challenge, and again, he passed.
This time, Katharine refuses to feed him peanuts and she insists Jesse continue to wear his epi-pen. Still, she allows treats that may contain peanuts and doesn’t worry if a food doesn’t come with a list of ingredients.

Despite their back-and-forth experience, Katharine says medical advances in dealing with peanut allergies mean the world to families such as hers. “I’m just so grateful. We’re going on holidays and I don’t have to worry. Food is not an issue any more. I find I’m getting much more relaxed,” she says.

Published January, 2006