Q: My 12-year-old daughter recently started menstruating and has been complaining of severe headaches and nausea during her period. OTC pain relief works to subside the pain, but the nausea persists. I am apprehensive to put her on the contraceptive pill due to her young age. I would like to get to the root of the problem, rather than mask it. Is there a more long-term solution?
Dr Grant replies: It sounds like your daughter may be suffering with menstrual migraine (MM) as headaches that occur with nausea is most commonly caused by migraine. Two other simple things to address are ensuring she is well hydrated (drinking 1.5 litres of water per day) and not suffering from low blood sugars from a prolonged fast. As her menstrual period starts, her oestrogen level has already began to fall and this fluctuation in oestrogen level is the trigger for the migraine headache. A migraine headache is often described as ‘dull throbbing’ or ‘severe pulsing’ headache and commonly associated with sensitivity to light, nausea, fatigue or dizziness. It can occur with or without the ‘classic’ aura symptoms of migraine.
Your daughter most likely has ‘pure’ MM headache as it occurs in close relationship to the onset of menstruation. By definition, the headache can start anything from up to two days before, and up to two days after, the first day of menstrual loss. This type of migraine can also affect women who go through a monthly ‘withdrawal bleed’ when taking exogenous oestrogen (e.g. combined contraceptive pill, transdermal patches, vaginal ring, HRT or during IVF treatment).
As with all migraine sufferers, the first treatment approach is to address lifestyle issues that may be contributing to the headache. Lifestyle changes are those that decrease known migraine triggers and are the mainstay of therapy that does not involve taking medication.
Address your daughter’s ability to abide by a healthy, balanced diet, limit screen time as much as possible, limit exposure to artificial light, maintain a normal sleep cycle (that includes going to bed at the same time each day and getting up at the same time each day), and ensure she is getting regular exercise. If you can get the basics right, the frequency and severity of migraine will reduce.
Keeping a symptom diary and documenting what helps relieve the headache can be helpful to track migraine onset and identify potential triggers.
Second line approach to treatment involves OTC medication which thankfully works well for your daughter’s pain associated with her MM but not her nausea.
Has she tried Migraleve pink tablets which can be used in children over 12 years old? This is specifically formulated to help relieve the nausea associated with migraine. It contains three ingredients, namely paracetamol and low dose codeine (both help to relieve pain) and buclizine to help relieve nausea. It is safe to add ibuprofen (e.g. Neurofen) if needed. Sometimes it is worthwhile trying other NSAIDs but you will need a prescription from your doctor.
Third line approach (taken when first and second line fail) includes prescription medication specifically designed to treat migraine known as triptans which are safe and well tolerated in adolescents.
Dr Jennifer Grant is a GP with Beacon HealthCheck