eadache is one of the most common conditions seen by neurologists. Physicians in most fields of medicine encounter patients with headache and migraine frequently and there is a significant overlap with other medical conditions. It is estimated that migraine affects one in eleven children and is more prevalent in girls than in boys. Migraine can have a significant effect on the lives of children and their families causing school absences and inability to participate in normal activities during childhood. It is important to recognize and treat early to avoid disability, impact on mental health, medication overuse and progression to chronic migraine.
Specialty Care
Pediatric Migraines
Diagnosis and Treatment
BY Katherine L. Ferguson, MD
A Look at Causes
The cause of migraine is multifactorial. There is a strong genetic predisposition with the risk of migraine being 40% in a child with one parent with a history of migraine and 75% when both parents have a migraine history. Combined with environmental factors and lifestyle habits, this results in migraines in children. Hormones, infection, inflammation, other disease processes, medications and head trauma can influence the age at presentation as well as frequency and severity of migraines. Habits around sleep, hydration, diet, stress and mental health also contribute significantly. The pathophysiology of migraine is not fully understood. It is generally accepted that there is a massive wave of neuronal depolarization across the cortex called the cortical spreading depression, which can result in aura. There is then activation of the trigeminal sensory nerve fibers, resulting in release of proinflammatory and pain molecules including cGRP, substance P and neurokinin A. There is increasing evidence that repeated migraines result in sensitization where neurons become more responsive to these molecules, and this is at least in part responsible for the progression of acute to chronic migraine.
Defining Terms
Migraine is the most common primary headache disorder in children and adolescents. Migraine can start in children as young as toddlers and in children this young may be characterized by periods of irritability and sometimes vomiting before a child is even able to express pain. The International Classification of Headache Disorders 3rd edition defines migraine in children as a recurrent headache disorder manifesting in attacks lasting two to 72 hours. The diagnostic criteria include at least five attacks to be given the diagnosis. They must have at least two of four characteristics including unilateral location, pulsating quality, moderate to severe pain intensity and aggravation by or causing avoidance of routine physical activity. They must also have nausea and/or vomiting or photophobia and phonophobia. This is a lengthy definition, but in practice many headaches that providers may consider tension type actually meet this migraine definition. For example, a headache of moderate severity that causes a child to want to rest and is accompanied by any degree of nausea meets the definition of migraine. Chronic migraine is defined by at least 15 headache days per month with at least eight of those being migrainous.
Patient and family education is a critical part of migraine treatment.
Symptoms
Migraine symptoms can be visual, sensory, speech or language, motor, brainstem or retinal. They can be accompanied by an aura. Auras are fully reversible symptoms that can happen before, during or after the headache. The most common aura in children is visual, this can be flashes of lights, colors or shapes. To be consistent with an aura the symptom must fulfill at least three of the following:
- At least one aura symptom spreads gradually over more than five minutes
- Two or more symptoms occur in succession, each individual aura symptom lasts five to 60 minutes
- At least one aura symptom is unilateral
- At least one aura symptom is an addition to one’s senses, commonly visual perceptions such as flashing lights, zig-zag lines, etc.
- The aura is accompanied or followed within 60 minutes by headache.
- Young children can have difficulty describing an aura so it can be helpful to ask them to draw a picture of it. It is important to determine the presence of an aura so that families can recognize this as the onset of the migraine and treat with medication as early as possible.
Migraines are more commonly bilateral in children than in adults. They often become unilateral after puberty in late adolescence. Young children may not be able to describe the pain quality or location and are unlikely to describe photophobia or phonophobia. We more often have to infer this from their behavior. For example, we can infer photophobia by children asking for sunglasses, burying their head under a pillow or refusing to open their eyes. Phonophobia can manifest as children asking to turn off the television or complaining of their siblings being too loud. Normally active children will want to lie down or will avoid normally desired activities.
Diagnostic Procedure
A thorough history is the first step to diagnosing migraine. Asking about the above diagnostic criteria as well as triggers, relieving factors, medications attempted, habits around sleep, hydration, nutrition and mental health screening are all necessary. A detailed neurologic exam including fundoscopy is important to rule out alternative causes.
Red flag symptoms in children with headaches include waking from sleep due to a headache or vomiting, headache caused by valsalva, associated neurologic symptoms that do not meet criteria for aura or abnormalities on neurologic exam. Many children will endorse waking from sleep with headache when asked, but to be a red flag this needs to be a headache that started during the night and is the cause of their waking. It is less concerning if the headache was present before sleep or they woke up for another reason and realized they had a headache. Headaches that are daily at onset, rapidly worsening, or headaches unresponsive to medication are also more concerning for an alternative etiology.
Workup for migraine can include laboratory testing and imaging, most likely an MRI. Labs to consider include CBC, CMP, vitamin D, vitamin B12, ferritin, hemoglobin A1C, TSH and celiac antibodies. A child with headaches that meet diagnostic criteria for migraine and who has a normal neurologic exam with no red flags on history or exam likely does not need imaging studies. If the pattern of headache has been stable for more than six months this is also reassuring as is a strong family history of migraine. Other diagnostic testing can include EEG, for example if atypical aura are present, or vessel imaging or sleep studies.
Treatment Options
The first step for treatment of migraine in children and adolescents should be optimizing lifestyle factors and healthy habits. This includes maintaining a consistent bedtime and wake time with sufficient sleep for the child’s age. Many teenagers with migraine need to be counseled to avoid screen time of all varieties for at least 30 to 60 minutes before bed. This often requires buy-in from parents to enforce. Additionally, children should eat a healthy and varied diet and avoid skipping meals, especially breakfast. Obesity can be a risk factor for worsening migraines. We should promote regular activity and exercise as well as sufficient and consistent hydration. Finally, children should avoid caffeine, especially the high caffeine energy drinks that are popular with teenagers. Stress, mental health and the demanding schedules of activities common in children today can also contribute to migraines.
When considering further treatment of migraine there are options for both acute and preventive treatment. Acute migraine treatment is used to end a migraine attack in an attempt to stop the pain and other associated symptoms. The goal is to find a regimen that allows children to continue with their normal activities, but often this is a challenge given the side effects associated with medication treatment of migraine. In general, the earlier we treat a migraine the better it will respond to medication treatment.
Most patients will start with over-the-counter analgesics including acetaminophen, ibuprofen and naproxen. NSAIDs are generally more effective in migraine treatment, but acetaminophen can help especially in younger children. The next most common class of acute treatment medications is the triptans, which cause serotonin receptor activation. Only four of the seven triptans are FDA approved for patients under the age of 18, which include rizatriptan, almatriptan, zolmitriptan and sumatriptan with naproxen. Rizatriptan is the only one approved for patients under the age of 12. Nasal sprays, oral dissolving tablets and subcutaneous injections are available for patients with significant vomiting or young children unable to swallow tablets. Triptans can be more efficacious when used in conjunction with an NSAID. Patients will also frequently use medications to target associated symptoms, for example, using ondansetron for treatment of nausea.
The pathophysiology of migraine is not fully understood.
If first-line acute treatment is ineffective, some patients with migraine should be given a second-line plan. This most often is one or more medications that the child will take scheduled for 24 to 48 hours to attempt to stop the attack. This is especially important in children with a pattern of prolonged migraines or those who have previously needed treatment with IV medications to terminate a migraine. Medications most commonly include over-the-counter NSAIDs or prescription NSAIDs including ketorolac or diclofenac, anti-emetics including ondansetron or prochlorperazine and diphenhydramine.
Migraine Prevention
Excessive use of these acute treament medications can result in medication overuse headaches. Using over-the-counter medications more than 15 days per month or triptans more than 10 days per month are the most common situations in which patients can develop overuse headaches. When patients are using their acute treatments excessively or do not have an effective acute treatment option, then preventive medications are the next step in treatment. Preventive treatment is used routinely even in the absence of an acute migraine to attempt to improve the frequency or severity of migraine over time. This should be considered in patients with more than two migraines per week or in whom migraines are significantly impacting their life, for example, children missing school routinely because of migraine.
First line prevention for migraine are the neutraceuticals. These are low risk and have few side effects. They include riboflavin (B2), magnesium and coenzyme Q10. Riboflavin is used at a dose of 100mg twice daily for children weighing less than 40kg or 200mg twice daily for those weighing over 40kg. Side effects include yellow urine. Magnesium dosing is approximately 9mg/kg/day to a max of 500mg dosed at night due to side effects of sedation. Additionally magnesium can cause GI upset, which appears to be less significant with magnesium glycinate. Finally, coenzyme Q10 can be given 50mg twice daily for children weighing less than 40kg and 100mg twice daily for those weighing over 40kg. There is not evidence to suggest that combining these is more effective than choosing one. Neutraceuticals can take at least three months of regular use to see benefit.
If migraine persists after neutraceuticals, first-generation medication options for prevention are topiramate and amitriptyline. The CHAMP trial in 2017 was a randomized controlled trial studying amitriptyline versus topiramate versus placebo for migraine prevention. This study showed equal efficacy among all three arms and decreased headache days in 70% of patients. Choosing between amitriptyline and topiramate is largely based on side effects for the specific child. Amitriptyline can commonly cause sedation, increased appetite, dry mouth, GI upset, dizziness and rarely arrhythmias. Topiramate side effects include decreased appetite, paresthesias, sedation, cognitive fogging and kidney stones. Other options with less evidence include gabapentin and beta blockers, most commonly propranolol. Cyproheptadine can be helpful especially for younger children up to approximately age 10.
It is an exciting time for children with migraine, largely due to the development of the cGRP inhibitors. This is a class of migraine medications used for both acute and preventive treatment. They are the first medications for migraine that specifically target a molecule involved in the pathophysiology of migraine. They include the small molecule inhibitors, or Gepants and cGRP monoclonal antibodies. Calcitonin gene-related peptide (cGRP) is expressed in pain fibers that innervate the meningeal and cerebral arteries. cGRP causes vasodilation and inflammation and ultimately cortical spreading depression resulting in migraine symptoms. The cGRP inhibitors are so effective, safe and well-tolerated that the American Headache Society published a position paper in March 2025 to say that cGRP inhibitors should be considered first-line therapy in patients over age 18. The only side effects are injection site reaction and constipation. Many of the cGRP inhibitors are currently in studies in children, and the first, fremanezumab, was recently approved by the FDA for children ages 6 older, weighing at least 45 kg. This is an injection done at home every four weeks with an auto-injector. Many others are currently in trials and we hope they will be available for children in the future.
Non-medication Options
More and more children and their families are looking for non-medication options for treatment of migraine. These can also be useful in children with significant side effects or concerns for polypharmacy. There are other injection options for children with difficult to treat migraines, but these can be limited by insurance coverage. They include botox for chronic migraine and peripheral nerve blocks or trigger point injections most often for acute treatment. Additionally there are three FDA approved neuromodulation devices for use in children. The Nerivio or Remote Electrical Neuromodulation (REN), gammaCore non-invasive vagus nerve stimulator (nVNS) and SAVI Dual or single pulse trancranial magnesic stimulation (sTMS). These can both be used for acute and preventative treatment of migraine. They are less likely to have side effects, but unfortunately can be costly and are often not covered by insurance.
Other Considerations
Many children will outgrow migraine as they get older. Predicting which patients will outgrow them is challenging, but often they can improve after puberty as hormones begin to regulate. A strong family history of migraine can mean that a child is more likely to have migraines into adulthood, as is a young age at migraine presentation.
Patient and family education is a critical part of migraine treatment. Families need to understand the difference between their acute and preventive treatments. Children need to learn what the beginning of their migraine feels like so it can be treated early. They have to be comfortable telling a teacher or an adult when a migraine starts and be able to access their acute treatment quickly. This may mean working with the school nurse and classroom teacher to ensure the child can keep the medication at school. Giving specific and concrete suggestions for lifestyle interventions results in the most success.
Finally, our language around migraine can affect our patients greatly and how they are perceived by others including health care providers. Referring to migraine in the singular state rather than plural “migraines” indicates that this is a chronic neurological disease. There is disease burden even between acute attacks. Using the word attack instead of headache to refer to a migraine occurrence helps account for the many symptoms other than headache that can accompany a migraine. Lastly, avoid using the phrase migraine cocktail as this is vague and can refer to a number of different medications. It also minimizes the severity of the migraine and can stigmatize the child as medication or pleasure-seeking.
Katherine L. Ferguson, MD, is a pediatric neurologist at Noran Neurology.
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