Lifestyle Advice for Pediatric Migraine: Blaming the Patient, or Evidence Based?

Amy A. Gelfand, MD, MAS; Samantha L. Irwin, MBBS

Disclosures

Semin Neurol. 2020;40(3):277-285. 

In This Article

Abstract and Introduction

Abstract

Children and teenagers with migraine are often advised to live a life of perfect balance—to sleep regularly and well, to eat breakfast each day, to drink plenty of water, and to exercise religiously. The logic is that doing so will decrease their migraine frequency. The corollary that follows is that failing to follow such advice will result in the patient continuing to experience migraine at its current frequency. This opens the door to potentially blaming the patients for their migraine and contributing to migraine stigma. This article reviews the current state of the evidence for each of these behavioral interventions for migraine prevention, and provides the clinician with practical advice for counseling patients.

Introduction

Migraine is common in children and teenagers and can become frequent and disabling, causing students to miss school and negatively impacting school performance.[1,2] Decreasing migraine frequency is an important treatment goal in pediatric migraine. However, pharmacologic strategies that are more effective than placebo for decreasing migraine frequency in this age group have been hard to find.

The Childhood and Adolescent Migraine Prevention (CHAMP) study—which compared the efficacy of amitriptyline versus topiramate versus placebo for migraine prevention in 8- to 17-year-olds—was stopped early for futility. At the first interim analysis, there was no difference in efficacy between the three treatment arms. Approximately 60% of the participants in each group achieved the primary end point of a ≥50% reduction in headache frequency and the trial was stopped.[3] It has been hypothesized that active cointerventions, such as provision of lifestyle advice at every study visit, and the use of evidence-based acute medications for migraine, may have contributed to the high placebo response rate in the CHAMP trial,[4] and limited the ability to separate signal from noise.

The idea that lifestyle interventions have a therapeutic effect on migraine frequency is so ingrained in clinicians' mindsets that it might be considered heresy to question it. Children and teenagers with migraine are pelted with advice from clinicians about how to live their lives in ways that are purported to have the power to decrease their headache frequency. Sometimes called "hygiene" or "healthy habits," or simply "lifestyle,"[5–7] the core belief is that if the patient follows these practices, then migraine frequency will naturally decline. Across all sites, CHAMP study participants were "uniformly instructed on the importance of biobehavioral therapy for headache management including the healthy habits of adequate hydration without caffeine, regular exercise, avoidance of skipping meals with a healthy diet, and maintaining regular sleep."[5]

Is this advice evidence based? On the one hand, one could argue that it is healthy advice and so encouraging young people to follow it is essentially benign. This would be reasonable enough if the reason being given by the clinician for encouraging the young person to follow their advice is that it will support the young person's general health. On the other hand, if the reason being cited is that following this advice will help with migraine, that specific statement requires evidence. Keeping to a regular schedule is hard, particularly for children and teenagers, who enjoy considerably less control over their schedules than the average adult. Young people may not be able to follow all aspects of "healthy habits" advice, all the time.[8] When they do not follow, there may be a tendency for the clinician to blame the patient for their ongoing migraine problem—or for their parents, coaches, or teachers to do so. Worst of all, the patient may come to blame themselves for their migraine.

If we are going to ask children and teenagers to adopt certain lifestyle practices as part of their migraine treatment, they deserve to have those recommendations derived from empiric evidence. We should focus our recommendations on only those lifestyle interventions that actually do have efficacy for migraine prevention, and we should understand what "dose" is therapeutic as well. For example, is it really necessary to drink eight glasses of water per day, or are six glasses just as good?

The goal of this article is to provide a narrative review of the evidence to date on the role of the main "healthy habits" cited in CHAMP for migraine prevention in children and adolescents: (1) adequate hydration, (2) regular exercise, (3) avoidance of skipping meals, and (4) maintaining regular sleep. Whether any of these things might help acutely for migraine in children is beyond the scope of this article. Where there is evidence, practical suggestions for how one might counsel patients, and how to help families implement the recommendations, are also provided. In addition, this article will outline which school accommodations clinicians can recommend for youth with migraine, based on the current evidence. In the U.S. public school system, students can receive accommodations for health-related conditions (i.e., 504 plans), and thus clinicians are often asked to write letters in support of 504 plans. Suggestions for future research are also offered.

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