When is a headache not a headache? When it's a childhood migraine, which in some children feels just like a tummy-ache, perhaps with accompanying vomiting and dizziness, but no feeling of headache at all.
The medical assumption used to be that children never had migraines, until studies of adult sufferers revealed that half of them experienced their first migraine before the age of 12.
10 per cent have migraines
Now doctors think 1 in 10 children have regular migraines, including small babies. They affect boys and girls equally until puberty, when the proportion of girls increases to around 15 per cent, while the number of boys who suffer falls to around 1 in 12. By adulthood, roughly a quarter outgrow migraines, another quarter experience a reduction in frequency and intensity, and half find they worsen or remain the same.
Nobody knows why some people get migraines and others do not. The condition undoubtedly runs in families. It may appear for no apparent reason (though often there are triggers - see avoiding attacks below), or can be set off by an accident, perhaps a blow to the head or neck. During a migraine, increased chemical activity in the brain stem causes a rush of blood to the nervous system, and a consequent intense headache, generally lasting between four and 72 hours, with various secondary symptoms.
Fireworks inside my head
Getting children to describe their migraine is difficult, says Iris Tinto, assistant director of the Migraine Action Association (MAA). "Sometimes they don't have the vocabulary to explain what's happening to them, so the whole experience is frightening. Some children have panic or anxiety attacks either after their migraine or at some other time, because of worrying they may have another one."
Although some children will experience their migraine as a pain in the head - usually on one side - others, confusingly, can feel abdominal pain, along with some or all of the other key migraine symptoms: nausea andor vomiting; increased sensitivity to sound, light and smell; drowsiness, numbness or pins and needles in arms and legs; confusion or clumsiness.
Children are also more likely than adults during a migraine to experience what are called "aura" disturbances: seeing flashing lights, black or coloured spots or zigzag lines in front of their eyes. Like Alice in Wonderland they may feel they are getting smaller and smaller, or that they will fall over unless they keep completely still. Descriptions children have given to the MAA include: "There are spiders crawling on the walls,"
"There are snakes around me," and "It's like fireworks inside my head."
Even though children's migraines may last less time than adults' (perhaps only 30 minutes, though sometimes much longer) and their recovery time may be much quicker, too (again perhaps 30 minutes), a true migraine will be recurrent, substantial and, for whatever period of time, enfeebling, says Iris Tinto. "It's very debilitating. If a child goes straight from the medical room to running around at break, it wasn't a migraine."
Early warning system
Adults who know children well may be able to spot their characteristic pattern of migraine early warning signs even before the child is conscious of feeling unwell. The child may seem "spaced out" or complain of feeling sick. She may go pale, with black circles appearing around the eyes, keep still, or seem tense and irritable.
Spotting these signs can be immensely useful, because many migraines can be nipped in the bud if treated quickly. Ordinary headache medication, such as paracetamol or ibuprofen, can remove the pain and prevent further symptoms, if taken in the early stages of a migraine: perhaps in the first 10 minutes after the onset of early warning symptoms. But once a full-blown migraine has taken hold, medication may have little effect on the pain, and the migraine will have to run its course.
This is because once a migraine is established it seems to close down the digestive system, says Ann Turner, director of the MAA. "After that, any medication you take just sits in the stomach and fails to get absorbed into the bloodstream. So then it's much less likely to have any effect."
For this reason, as well as to ensure that children's migraines are not dismissed as "just another headache" or even malingering, good practice for schools means that any child who gets migraines should have a management plan agreed between the child, school and parents. Ideally, say experts, this involves fast access for the child to medication, either by carrying a single dose and administering it under supervision themselves, or being allowed to go straight to an adult who keeps it and has had written permission to administer it.
Nasal Spray medication
Some older children may have specialist migraine medication in the form of a nasal spray, which can be even faster acting, provided the plan allows them to manage it themselves, says Iris Tinto. "The child can leave the lesson, go into a quiet space, use the spray, have a recovery time, and go back into lessons.
"If the child has to pluck up courage to tell the teacher she feels unwell, and the teacher tells her to wait a bit and see if she feels better, and then sends her to the medical room, and the parents are called to give her the medicine, it's too late."
Good practice also requires that the school informs parents on the day, in writing, that headache medication has been taken. Children with migraine are at risk of "medication overuse headache", a reaction to over-frequent painkillers, which occurs if they are used for about 15 days or more in any month, and which, ironically, takes the form of chronic headache.
Once the migraine takes hold, children need a quiet space to sit, and ideally to lie down. They need an adult nearby, and facilities in case they are sick. Many children fall sleep after a migraine; some will then be sufficiently refreshed to go back to the classroom; others may be too drained.
For that reason, says Iris Tinto, schools need to take seriously the educational advantage of having a place for the child to sleep. "Some of these children can miss a lot of school. They become isolated and their academic work suffers. If a management plan enables them to have quick medication and then a rest, they may be able to get back into the classroom. That's much better than just saying, 'We'll send you home.'"
While the fundamental cause of migraine is unknown, the reason children have particular attacks is often very clear. All migraine sufferers have triggers: tiredness, physical over-exertion, bright light, dehydration, unusual smells, certain foods, and stress. Some of these cannot be avoided: experts agree, for example, that it is much better for a child's overall health to be accustomed to regular exercise and achieve physical fitness, which may then make exercise less of a trigger, than to drop out for fear of a migraine.
However, schools can make a big difference by allowing a child to have access to drinking water throughout the day, and even small snacks or glucose drinks; by letting the child sit where bright light is not a problem and away from strong-smelling glue, paint or chemicals; and by being sensitive to a child's stress levels.
"If a child is sitting in the classroom and the sun is streaming through the window and they ask for the blind to be closed, it's important that the teacher doesn't say, 'But it's so lovely,'" says Ann Turner.
Doctors will often ask the child and parents to keep a migraine diary, noting what happens before an attack to try and identify that child's triggers. Schools have a substantial contribution to make here, since they see the child for large parts of the day. But it is important not to assume cause and effect too directly, says Louise Raisbeck of the Migraine Trust.
Eating chocolate, for example, once pointed out as a major cause of migraines, is now thought to be an innocent response to the body's demand for blood sugar in the run-up to a migraine already on its way.
Reassure and watch
"Reassure, record, watch, encourage" is the guidance for parents and teachers written by specialists for the Migraine Trust's information pack.
(The MAA also produces a primary school's pack, and is working on materials for 12-18s. See resources). Remember, these children can become extremely fearful, avoiding anything that might bring on an attack, but in the process greatly narrowing their daily lives.
For schools there is a tricky balance to be found, says Ann Turner. Staff need to be sympathetic to, and understanding of children's fears. They need to reassure them that if they miss a crucial test because of a migraine they will not be moved down a set; that if they are ill on an exam day their medical condition will be acknowledged. At the same time, they need to help keep their horizons wide. "We need to emphasise that it's possible to live a full and active life and be a migraine sufferer; that you can't let it restrict your life unnecessarily."
Is this headache A migraine?
Schools must bear in mind that a particular headache on a particular day may not be migraine at all. Teachers should be aware that if a headache continues to worsen, rather than stabilising; or if it occurs early in the morning, it could be a sign of another, serious condition. If any child's headache is accompanied by a fever andor a rash, it could be a symptom of meningitis or septicaemia, and the child will require immediate medical attention.
The overall point, says Louise Raisbeck, is that adults need to take children's headaches seriously. "The Migraine Trust produced its pack because we kept hearing of children who were trying to keep their condition secret. They felt people would single them out."
In addition, it can take a long time before migraine is diagnosed: doctors may suspect a child has sinus or eyesight problems, or allergies, or anxiety, before they settle on a diagnosis of migraines.
"There's no doubt there is a stigma about migraines," says Raisbeck.
"People think it's just a headache, just an excuse adults use when they phone in sick. So some people don't take it seriously, and children worry they won't get much sympathy."
* Migraine Action Association: www.migraine.org.uk; helpline 0870 0505898.
It also runs www.migraine4kids.org.uk, and publishes fact sheets, including a sample lesson (literacyPSHE) for primary children.
* Migraine Trust: www.migrainetrust.org; helpline 0207 436 1336. It also publishes a pack with guidance for children, parents and teachers.
I SLEEP AND THEN I'M SICK
IN MY EXPERIENCE
Callan Stone, 9, is in Year 4 at Copplestone school, in Crediton, Devon, and wants to be a footballer. His migraines, which he has most weeks, began after he hurt his neck and was briefly unconscious when he was 5. Doctors initially told him that children don't get migraines.
I can tell when I'm going to get a migraine because I get a little pain in my head. It goes and then it comes back really strong. Just in my forehead.
When it's really strong it feels like I can't get up or do anything, I just have to lie down and sleep.
After I've slept I wake up. Then I get a tummy ache and I'm sick, and then I'm better. That lasts about two hours; but recently when I had one it lasted from lunchtime to 10 o'clock at night.
When I get a migraine I put up my hand to tell the teacher, and they tell me to go and sit in a comfy chair outside the classroom. Sometimes they give me Calpol. My mum usually comes to pick me up. It's difficult having migraine in the classroom because it's quite noisy and every time people talk to me it's more painful. Light doesn't help; I normally sit right at the back of the classroom where it isn't too light.
I worry a little bit about getting migraines because it really hurts when you have one. I don't eat oranges or drink orange juice in case I get one.
I don't think it affects my work. It means I can't play football at lunch.
I'm not really sure if my friends understand what it's like. When I'm sitting down where it's quiet they come up and say, "Hope you get better soon."