One of the hardest things for parents is to see their child in pain. But sadly, children can suffer from migraine too, and it often runs in families. In early childhood there is no gender difference, but after adolescence migraine is more common in girls than boys (see table). Estrogen is particularly active in areas of the brain associated with migraine, which is thought to be one of the reasons that migraine is more common in girls after puberty (6).
Even though migraine isn’t obvious in infants or early childhood, some childhood disorders have been associated with migraine. In infants, colic is thought to be a form of abdominal migraine, particularly because some anti-migraine treatments improve colic (6). Other childhood disorders or symptoms that might be a precursor to migraine are abdominal migraine, cyclic vomiting syndrome, vertigo, or torticollis (6). These disorders aren’t guaranteed to develop into migraine. Parents can keep an eye out for potential signs as their child gets older.
Diagnosis
Diagnosis can be difficult as children may have trouble explaining their symptoms, and even when they can, their symptoms aren’t the same as adults (8). For example, children tend to experience more nausea and gastrointestinal symptoms, and also experience headache on both sides of the head (pain is usually confined to one side for adults). Migraine may even occur without head pain and express primarily as nausea or gut pain. Attacks are also often much shorter for children, lasting as short as 1-2 hours rather than 4-72 hours (5).
Some symptoms might be recognisable through a child’s behaviour, even if they can’t explain it. If a child with a headache asks for the television, lights, or radio to be turned off, or pulls a blanket over their head during attacks, this could point towards sensitivity to light and sound (12).
One study used drawings as a diagnostic tool, so that children could illustrate the symptoms they’re experiencing rather than trying to explain it. The results found that drawings could accurately differentiate migraine or non-migraine headache around 90% of the time (8). Diagnosing migraine in children requires awareness of the symptoms specific to children, and being able to translate this in a way that kids can understand.
Triggers
Just as with adults, migraine in children is triggered by a combination of factors. Many adult triggers are also applicable to children. Children are often aware of relevant triggers themselves. One research group found that the most common triggers were stress, lack of sleep, hot weather, video games, intense noise or light, and over-excitement (7). Foods such as chocolate, cheese, caffeine or citrus fruits are also often reported as dietary triggers, but restrictive elimination diets (i.e. ketogenic or fasting) aren’t recommended for children (7). It’s important to maintain a balanced diet if you’re trying to manage your child’s dietary triggers, to avoid any negative impacts on your child’s growth and development..
Some typically overlooked triggers in children include:
- Stress due to parental conflict or bullying
- Malnutrition during a teenage growth spurt
- Environmental conditions at school
- Undiagnosed allergies
Treatment
Non-drug treatments are usually tried first, to see if migraine can be managed through lifestyle modifications. This might include improving sleep hygiene, drinking lots of water, eating a well-balanced diet, and learning relaxation techniques or cognitive behavioural therapy (CBT). During attacks, some children are able to sleep it off, or treat symptoms by resting in a quiet, darkened room with a hot or cold pack.
However, managing lifestyle triggers shouldn’t prevent your child from participating in school or social activities. Dramatic lifestyle changes can be stressful or confusing for kids, and medication should be used if migraine attacks continue.
The table below outlines the types of medication available (over-the-counter and prescription) and how often they can be used while avoiding medication overuse.
Acute migraine treatment in children (5, 12,13)
| Medication | Frequency | Dosage* | Notes |
| Ibuprofen | Maximum 3 times per week | 7.5-10mg per kg
Max dose 1000mg | Most commonly recommended. Studied in children down to age 4. |
| Paracetamol | 10-20mg per kg
Max dose 1000mg | Less effective - recommended if patient is sensitive to NSAIDs**. Studied in children down to age 4. |
| Naproxen & aspirin | - | Aspirin should be avoided for children under 16. Naproxen studied in 12-17yr olds. |
| Sumatriptan (intranasal) | Maximum 9 times per month | 5-20mg | Some studies include children down to age 6. |
| Zolmitriptan (oral or intranasal) | 2.5-5mg oral, 5mg intranasal | |
| Rizatriptan | 5mg (≤39kg), 10mg (>40kg) | Studied in children down to age 6. |
Other triptans may be recommended on your doctor’s advice
*Actual dosage will be recommended by a GP or medical professional
**Nonsteroidal anti-inflammatory drugs
There are also preventive medications available (14), however some recent studies have found that the placebo effect is very high in children. There is often a small benefit from preventives in the first few months of treatment, but in the long term there was no difference between medication and placebo (8).
So what does this mean for treatment? Doctors aren’t able to prescribe placebo, but some have suggested that children take supplements such as riboflavin, magnesium and coenzyme Q10. These have essentially no risk and might help on their own or through the pill-taking effect (8).
Given that the benefit of placebo is psychological, cognitive behavioural therapy (CBT) can also be effective in managing migraine. CBT is a type of therapy that helps patients to recognise psychological patterns and unhelpful behaviours/ways of thinking. Clinicians then give strategies to improve problem solving, make realistic assessments about the behaviour of yourself and others, and develop confidence in your own abilities (9). For children with migraine, strategies can help to manage the stress and negative self-image surrounding migraine attacks. CBT can also help with common triggers for children, such as stress or lack of sleep. By providing strategies to control these triggers, migraine attacks can be quite effectively reduced (12).
While migraine is very much a medical disorder involving biochemical changes in the brain, CBT appears to alter brain function in areas that control emotion and pain (8). Your child could combine medication with CBT, then gradually try to reduce medication if they are still free from attacks.
Other ways to reduce the impact of migraine include:
- Ensuring child’s school and teachers are aware of condition and treatment plan
- Encouraging a positive self-image despite headache – not letting parental anxiety and concern lead the child to identify themselves as an impaired patient unable to live a normal life
- Talking to counsellors or other children with migraines to assist the child to understand the headaches and make them feel more comfortable in dealing with them and explaining them to friends
- Keeping a headache diary where the child can record times and places the headaches occur (as well as any potential emotional, environmental or dietary triggers)
Tension-type Headache (TTH)
Tension-type headache (TTH) is the most widespread headache disorder, and while it is most common in adults, it is more common than migraine at all ages (10). It can either be chronic (occurring on 15 days/month or more) or episodic (less than 15 days/month). Generally TTH causes less severe pain than migraine, and the headache is not accompanied by nausea or sensitivity to light and noise. However, there are still a number of symptoms that overlap.
Some researchers have suggested that TTH and migraine should be viewed on a ‘sliding scale’ of headache disorders, given that some children transition from TTH to migraine (or vice versa) (11). Despite the physiological differences between the two conditions, most strategies for treatment and lifestyle management can be applied to both headache types – with the exception of migraine-specific medication.
References
- M Valeriani et al, 2019, Editorial: Clinical and Pathophysiological Peculiarities of Headache in Children and Adolescents. https://doi.org/10.3389/fneur.2019.01280
- S Seshia, 2012, Chronic Daily Headache in Children and Adolescents. https://doi.org/10.1007/s11916-011-0228-9
- J Gassman, 2009, Risk factors for headache in children. https://doi.org/10.3238/arztebl.2009.0509
- Deloitte Access Economics, 2018, Migraine in Australia Whitepaper. Retrieved from: https://www2.deloitte.com/au/en/pages/economics/articles/migraine-australia-whitepaper.html
- J Kacperski et al, 2016, The optimal management of headaches in children and adolescents. https://doi.org/10.1177%2F1756285615616586
- D Borsook et al, 2014, Sex and the migraine brain. https://doi.org/10.1016/j.nbd.2014.03.008
- G Yamanaka et al, 2020, A Review on the Triggers of Pediatric Migraine with the Aim of Improving Headache Education. https://doi.org/10.3390/jcm9113717
- E Sohn, 2020, The unique demands of childhood migraine. https://doi.org/10.1038/d41586-020-02869-2
- APA Div. 12 (Society of Clinical Psychology), 2017, What Is Cognitive Behavioral Therapy?. Retrieved from: https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral
- CP White, 2019, Headache in children and young people. https://doi.org/10.1016/j.paed.2019.07.011
- R Torriero et al, 2017, Diagnosis of primary headache in children younger than 6 years: A clinical challenge. https://doi.org/10.1177%2F0333102416660533
- Migraine World Summit, 2017, Best Therapies that are Safe for Kids [Dr. Amy Gelfand Interview]. Retrieved from: https://migraineworldsummit.com/talk/best-therapies-that-are-safe-for-kids/
- M Oskoui et al, 2019, Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention. https://doi.org/10.1212/WNL.0000000000008105
- M Oskoui et al, 2019, Practice guideline update summary: Acute treatment of migraine in children and adolescents. https://doi.org/10.1212/WNL.0000000000008095
