Myth busters

Though the myth that “children don’t get migraine” was debunked many years ago, it remains a common misperception among the general public, in many schools, and even with healthcare providers. The truth is that migraine in children and adolescents is even more common than asthma, yet a lack of understanding often leads to a delay in diagnosis, ineffective treatment, and needless disability. It is important to teach yourself, your child, and your child’s teachers and coaches about migraine, and help them learn how to prevent and manage your child’s headaches.

Here are some suggestions to help your child or teen:

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  Share your child’s migraine diagnosis with the school nurse. The nurse may have you complete special forms to allow staff to give your child headache medicine while at school.

  
  
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  Share your child’s migraine diagnosis with their teacher(s). This can be done at the beginning of the school year when you first meet their teacher(s) or after a visit to your health provider. Make sure their teacher(s) know the importance of prompt migraine treatment and ask them to allow your child to drink water and use the restroom periodically throughout the day.

  
  
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  Share your child’s migraine diagnosis with all those who will be working with your child after school. This might include their coach, band director, and afterschool care provider.

  
  
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  Make sure your child has a written action plan to tell caregivers what to do to treat their headaches at home, school, and at afterschool activities.

  
  
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  Encourage your child to tell their teacher right when a headache begins.

After the school bell rings…

Parents rely on school staff to be watchful and to care for their children while they are at school. It is the goal of all school nurses to keep students healthy and “ready to learn.” A migraine headache that goes untreated can certainly be a hindrance to learning. Unfortunately, children with migraine miss twice as many school days each year as their healthy peers.

When a migraine strikes, your child needs to take their medication right away. While laws will vary, all states have strict regulations about how medications are to be dispensed to children while attending a public school. Medication administration policies are also created by local school districts or county education boards. The school nurse, school staff, parents, and providers must follow these rules to make sure your child has quick access to their medication when needed. Afterschool programs housed in schools or at other organizations will often require the same written permission to administer medications to your child.

Key players at school include your child’s teacher(s), school nurse, unlicensed assistive personnel (UAP), and other staff such as coaches, trainers, administrative staff, food workers, and bus drivers. Remember these individuals form a team of caring people who want what’s best for your child.

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  The school nurse practices under a license issued by their state’s Board of Nursing. Since the school nurse must often cover more than one school, they may “delegate” the responsibility to treat your child’s headache to a UAP.

  
  
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  UAPs are school staff members who have received some additional training to allow them to give medications and other health-related treatments when the nurse is not physically in the building. The UAP cannot make a diagnosis or medical decision; they are only allowed to follow the instructions the nurse has written in a child’s health plan.

  
  
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  Coaches, extracurricular teachers and support staff should also be aware of the health needs of a child with migraine.

Your child’s health history is considered private, so the information shared with school personnel and extracurricular staff can be limited to the information you want shared. These same individuals are required to keep your child’s health information private, except when that information is necessary to properly care for your child.

Empowering your child

Your child or teen needs to learn how to manage their headaches when you are not around. Teach your child to advocate for themself. Starting with their first headache, your child should be encouraged to alert a parent, teacher, or coach at the very beginning of their headache symptoms. For the younger child who may be shy, a special hand signal or “hall pass” might be a good way for your child to tell their teacher they are getting a headache.

Next, your child will need a plan for treating headaches that start at school or during afterschool activities. This plan needs to be age and developmentally appropriate and tailored to their specific symptoms and individual needs. We recommend using the Pediatric Migraine Action Plan (PedMAP) as a template to create a customized plan for managing your child’s headaches. This tool was designed by pediatric headache specialists from the U.S. and Canada to guide you, your child, their healthcare provider, coaches, and school caregivers in preventing and responding to headaches both within and outside the home. The plan was designed to match the stoplight format of an asthma action plan with a green zone that tells your child what to do to prevent their headaches, a yellow zone that tells them what actions to take when a headache starts and what to do next if that isn’t working, and a red zone with next steps if the treatment plan isn’t working.

Your child should learn more about migraine and what she can do to prevent them. One of our favorite websites for learning about headaches is www.headachereliefguide.com . This website was developed by a multidisciplinary team of headache specialists to help children and their families learn about what causes headaches, what actions can be taken to prevent them, and how to treat headaches more effectively.

The perfect scenario…

Your child reports their headache right away to their teacher, who sends them to the health office. The school nurse or their delegated UAP reviews the PedMAP on file and gives your child their quick-relief medication (that you have provided in a container labeled by the pharmacy). They are allowed some time to rest in a quiet place for 30–45 min (allowing time for the medication to work). Your child soon feels better, their headache has resolved, and they return to the classroom ready to learn.

A word about homebound, home-schooled, and online education

If your child has been or will be unable to attend school for an extended period of time, school officials may recommend a homebound education program. Homebound programs are temporary measures to try to ensure that a child does not fall too far behind while recovering from a single period of illness. This is not the scenario for children and adolescents with migraine who will likely experience recurrent headaches for several years. Students on homebound education usually receive instruction from a licensed teacher for about 5–10 h a week. A homebound teacher can only cover a few lessons from a small number of core subjects. High school students using this program for more than a few weeks may find it difficult to earn the credits they need to graduate on time. These short-term solutions are simply insufficient to allow them to keep up with their schoolwork.

Some families consider home-schooling or online education when their child is struggling to attend school. Both options offer some advantages over the traditional school setting (e.g., flexible scheduling, self-pacing, and individualized curriculum). It is important to consider your child’s personality and level of motivation. Parents of highly motivated children often report that online schooling works well for their family; however, other parents describe an ongoing struggle to keep their child engaged and on task. Children in pain can find it hard to find the motivation to get out of bed in the morning and get to work. They may struggle to wake up at their usual time and may find themselves napping throughout the day, staying up later at night, and unintentionally changing their body’s sleep-wake cycle. They often let their pain level dictate their activity level; they become less active, their bodies become deconditioned, and they begin to feel bad every time they try to move. They begin to avoid moving, avoid working, and avoid thinking because all of this makes them feel worse. Obviously, this becomes counterproductive and can produce a downward spiral of increasing disability.

School health plans and 504 accommodations

In a nutshell, students with migraine must learn how to function in spite of their pain. So how are they going to survive and make the best of it? Attending school with some strategic accommodations may be a better answer. For most children and teens with migraine or recurrent headaches, the Pediatric Migraine Action Plan (PedMAP) should be sufficient to assure your child receives their acute medication(s) promptly and that school staff provide some reasonable allowances to keep them functioning at school despite their pain and other symptoms. The PedMAP provides some specific strategies you can review with school officials to tailor an individual health plan that works well for your child and all involved in their care. For example, a health plan for a student with migraine may allow them to eat a snack or drink from a water bottle periodically to prevent migraines. Light- and sound-sensitive students might be allowed to wear dark glasses or work in a quiet spot when their headaches are severe. A student managing a severe headache might be allowed to work in the library or media center for part of the school day or given an alternative PE activity such as yoga, stretching, progressive muscle relaxation, deep breathing, or other relaxation exercises while their headache is severe.

Students whose frequent headaches “substantially limit” their ability to receive an appropriate education may qualify for specific accommodations under Section 504 of the Rehabilitation Act of 1973. A 504 Plan is a formal process that adjusts school services to meet the needs of a child with a mental or physical impairment that is limiting them from full participation at school. Students whose headaches severely limit their ability to concentrate may be given additional time to complete assignments. Students who miss school for doctor appointments or CBT (Cognitive Behavioral Therapy) sessions might be allowed extended time to turn in their assignments. Sometimes, severely affected students who are falling behind can be given a reduced workload or abbreviated schedule to allow them some time to recover. Students returning to school after a prolonged absence might be allowed to turn in a smaller number of key assignments to show that they have mastered the content. Here is how the 504 process works:

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  Any concerned person (e.g., a parent, counselor, or healthcare provider) can refer a student for evaluation

  
  
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  If the school shares their concern, a review committee (often called a 504 team) is assembled

  
  
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  The 504 team will consider information from a variety of sources (e.g., medical diagnosis, school performance, attendance records, teachers’ reports, etc.)

  
  
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  The 504 team will determine which accommodations your child needs in order to have an equal opportunity to compete successfully when compared with their nondisabled peers

  
  
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  If the school refuses to provide a 504 plan or if you disagree with the team’s recommendations, you can request a due process hearing or file a complaint with the Office of Civil Rights

  
  
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  You can learn more about your rights under Section 504 by visiting http://www2.ed.gov/about/offices/list/ocr/index.html .

Private schools are not required to create 504 Plans but may follow a similar process to grant accommodations.

Pace yourself

We have found that many teens with migraines are high-achievers. With so much pressure from school, sports, and extracurricular activities, their busy schedules can lead to late nights with not enough sleep. Lack of sleep can be a potent stressor on the brain and trigger headaches. Daytime headaches can make it more difficult for them to concentrate and take longer to complete their work. With little flexibility in their schedules and a low tolerance for a dip in performance, the high-achiever can quickly become overwhelmed. This added stress makes it even harder for them to sleep, harder to concentrate, and harder to maintain their high level of performance. All of this can trigger even more headaches and lead to more stress. It becomes a vicious cycle. Here is some advice to guide them:

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  Consider scaling back on academic and extracurricular activities

  
  
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  Encourage your child to strive for fulfilling goals, not perfection

  
  
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  Create a realistic schedule and build in some down time

  
  
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  Think about ways to advocate for these changes on a group rather than individual scale—does every teen at your school need to take 8 AP classes and play on multiple travel teams?

A message to kids about returning to school…

This is hard, but you can do it. Because you have been brave, you will find that you will be stronger and better-equipped for handling hard things that come up in the future. Pace yourself. Don’t let how you feel dictate your schedule; but be realistic about the limitations your headaches impose on you. Going to school for part of the day is better than not going at all. Reduce your workload. Build in break periods. Wear sunglasses or polarized lenses when light is bothering you. You may be able to use ear plugs or wear headphones when noise is really bothering you. Find quiet areas to eat and to work. Sometimes the school library or media center is a good option for quiet self-paced study. Though being overly active can worsen your headaches, a lack of activity will decondition your body and make you feel even worse. Try to find a balance in rest, school, work, friends, and activities. Be sure you are doing something in each of these areas of your life. Don’t let your headaches define you. They aren’t the boss of you—you are. Be a fair boss. Be kind to yourself. Don’t expect more than you can do, but don’t accept anything less than your best from you. This is hard, but you can do it. You are brave.

Summary

Migraines are common in children and adolescents and it should not be surprising that children commonly experience migraines at school. The Pediatric Migraine Action Plan (PedMAP) is a great tool to give school nurses, teachers, and coaches the instructions they need to help your child properly manage their headaches at school and on the ball field. Homebound programs cannot provide an adequate education for students with recurrent headaches. Online programs can offer more flexibility, but parents should be careful not to let how their child feels dictate their schedule. Creating a health plan with your child’s school nurse is usually the best option to reduce some of the headache-related challenges they face at school. A 504 plan may be needed when frequent migraines “severely limit” your child’s ability to function properly at school. With a good plan and reasonable accommodations, your child can learn to manage their headaches outside your home and be better prepared to handle other challenges in life.

For primary care and specialty providers

Migraine is among the world’s most disabling conditions, and youth with migraine are at risk for developing lifelong disability. A primary goal of headache care is to enable youth with migraine to attend school regularly and to function optimally despite their headaches and associated symptoms. While fewer than 50% of youth with headache report having seen a primary care provider or specialist in the past year, children with headaches commonly visit the school nurse or health office. In fact, data collected from a large suburban school district found that 33% of all students had at least one visit to the school nurse for headache, and 7% of students made at least eight headache-related visits during the school year. Students lacking a management plan are often sent back to class with a lowered ability to function or sent home from school. Students who miss as few as two days of school a month are at risk for chronic absenteeism which has been linked to poor school performance, high school dropout, and adverse economic and health outcomes in adulthood.

As such, it is essential that youth with migraine are identified quickly and given the necessary tools to effectively manage their headaches at school. School nurses are well-positioned to identify and refer students with migraine before they become disabled by the condition. The Pediatric and Adolescent Migraine Screen (PAMS) is a three-item screening tool with excellent sensitivity that can be used in school settings to identify students with migraine. ^{, a}

a The Pediatric and Adolescent Migraine Screen (PAMS) is available to download at https://www.cincinnatichildrens.org/service/h/headache-center/pams .

Students with recurring headaches should be counseled to avoid missing school as this leads directly to increased disability. Instead, they should be equipped and encouraged to manage their headaches at school. An Individualized Health Plan or a 504 Plan can be used to allow a student with migraine the accommodations needed to enable them to stay at school while managing their headaches. Not only is an acute medication strategy essential, but nonmedical interventions can also increase their functional capacity. Relaxation strategies such as mindfulness, diaphragmatic breathing, and progressive muscle relaxation can improve their ability to cope with pain. Permitting a child experiencing migraine to wear dark glasses or work in a quiet room might enable them to continue their schoolwork. Allowing an alternative PE activity or additional time to make up missed work may mitigate some of the physical and psychological stress that can perpetuate headaches. Prevention strategies such as increased water intake, scheduled snack breaks, and wearing light-filtering lenses in brightly lit classrooms or while working on a computer can also be included in such a plan. A sample 504 plan request letter is included in the appendix.

Appendix: Supplementary material

Supplementary material related to this chapter can be found on the accompanying CD or online at https://doi.org/10.1016/B978-0-323-83005-8.00001-X .

Appendix: Supplementary material

The following is the Supplementary material related to this chapter.

Related posts:

The “episodic syndromes”: I.e., what migraine looks like before it “looks like” migraine POTS and dysautonomia Acute medications Devices Advocacy for children with migraine Growing up: Transitioning to adult care

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