When I evaluate a child that comes in with headaches, my first question is; are the intermittent and have they had them for a while?
I'm much more alarmed when someone comes in with a bad headache and they have never had one before. I can never diagnose that as a migraine right now. I'm always worried at that point that they have an acute illness with something else.
Migraines are intermittent. I need to know the pattern of them; one a week, one a month? Did they use to have one a month and now they have them every week or every day. The temporal pattern of when they start and how long they last and whether or not there is a clear period in there where they don't have a headache. That is the first step in diagnosing migraines.
Also, they need to have a baseline normal exam between the episodes. If they have an abnormal exam, I'm concerned they are not migraines. So given that I've decided that these are probably a migraine, my next question is: What brings them on in this child? A lot of times, its not totally clear to people. So I ask people to bring a fairly detailed calendar, a diary of what they are doing, their activities, their foods. I'm looking for things like, they get a headache after they've been out playing Little League in the hot sun. When they come in, they are dehydrated and they are overly sun exposed. That can precipitate a headache.
I look in teenagers for skipping breakfast, skipping lunch, disturbances in sleep patterns. Interestingly, it's not commonly sleep deprivation that causes the headache, it's the making up for lost sleep that causes the headache. The sad thing is, you work like crazy all week, stay up too late, get up too early, sleep in on Saturday; and you wake up on Saturday afternoon with a horrible headache.
I look for those patterns because it will tell me how to start cutting down on that persons headaches before we even start talking about medicines. Medicines to prevent migraines in some people are somewhat effective. They will cut down headaches by about 50 percent. If I can start off by asking them what starts off their headaches and finding things they can avoid, and cut them by 50 percent first. We're starting from a lower baseline and will have a better overall outcome when I start medicating.