Migraine is a complex and disabling inherited neurological condition which occurs in 4-10% of children. Nearly half of children with migraine never receive a diagnosis. (1) It can be a cause of undiagnosed abdominal pain or headache in children. Studies suggest that around 60% of children aged between 7 and 15 experience headache but the diagnosis may be delayed because the presentation is not always one of headache. Abdominal pain, cyclical vomiting, travel sickness, limb pain and episodic dizziness can all confuse the picture. Headache may be absent or not follow the pattern more commonly associated with migraine in adults.(2,3)

Migraine can result in severe impact on the life of a child but also on their family, school life and social activities. (4) Missing the diagnosis can result in further harms to the child including poor management of their symptoms, anticipatory anxiety about future attacks, inappropriate/ineffective medication use, a loss of confidence and low self esteem, poor attendance at school or school refusal and even being mislabelled as a malingerer. (3,4) see Factsheet: Advice to schools.

Migraine affects boys and girls equally until puberty, after which migraine is more prevalent in girls (1,2). Severe pain and vomiting which are not treated effectively can mean that children often have to remain at home during attacks and are unable to participate in normal daily activities.

Diagnosing migraine

Migraine in children differs from migraine in adults in several ways:
ā Headache typically affects the forehead and temple areas or the whole head, rather than one side
ā Abdominal pain and/or vomiting are prominent and may be recurrent even without headache (5)
ā Headache may be only a minor symptom and may be absent
ā Attacks are often shorter, sometimes lasting less than an hour

As in adults, children are pale and lethargic. There is no diagnostic test for migraine, so diagnosis depends entirely on the story and pattern of attacks. A simple headache diary is an invaluable aid both for diagnosis and management.

Recurrent bouts of headache or abdominal pain with nausea or vomiting, with complete freedom from symptoms between attacks in an otherwise healthy child, are probably migraine. Sensitivity to light, sounds, smells or touch can also occur and give further clues to the diagnosis. Some children look pale and yawn for a few hours before the headache starts; others are bursting with extra energy.

Some children may experience migraine aura, typically bright visual zig-zags or blind-spots, lasting up to an hour before the headache starts. Attacks may last only a couple of hours especially if the child can rest in a quiet dark room and has simple painkillers quickly.  Note: Girls who get aura should not use contraceptive pills containing oestrogen because of the increased risk of stroke with this medication in aura sufferers.

When should I take my child to the doctor?

It may be obvious, particularly if you have migraine yourself, that your child’s symptoms are typical of migraine. If attacks have obvious causes, symptoms respond to painkillers, and your child is otherwise fit and well, it is probably not necessary to seek a doctor’s advice. However, you should make an appointment for your child to see a doctor if there is any doubt about the nature or cause of the headaches, if your child seems generally unwell, or if the headaches are interfering with daily activities.

In particular, it is very important to see a doctor in the following circumstances:
ā Headaches start under age 7
ā The headache changes
ā An unaccountable increase in frequency, severity and duration of attacks
ā Recent school failure
ā Personality/behavioural changes
ā Fits or blackouts
ā Balance or co-ordination problems
ā Failure to grow/attain normal developmental goals

When do I need to call the doctor urgently?

Increasingly frequent severe headache, particularly if associated with seizures, persistent vomiting, fever, and blacking out, are all symptoms requiring urgent medical attention.

Managing migraine

Migraine in children is essentially managed in a similar way to migraine in adults but as children also spend a lot of time at school we have also included advice specific to schools (see Factsheet: Advice to Schools).

The main concerns that need addressing are:
ā What causes the migraine attacks?
ā What will make the migraine attacks better?

The cause
The brain of a migraine sufferer is sensitive to changes in routine.

Routine is key to minimising the risk of an attack.

Irregular eating times, in particular having long periods between meals or overnight, can be a major trigger in this age group, particularly during the adolescent growth spurt. Migraine in girls may coincide with puberty and the start of menstruation. Sometimes a monthly pattern can be seen due to hormone fluctuations.

Sporting activities, flickering fluorescent lighting, stress of exams or school work and poor sleep routines can also be major contributory factors. Skipping meals is a common trigger. Encourage children to eat small regular snacks of slow-release energy foods and to keep hydrated throughout the day and in particular around exercise.

Sport can trigger attacks, probably by dehydration and effects on blood sugar. Drinking lots of water and having a snack or possibly sucking glucose tablets before and during sport can help in addition to supplementing meals with mid- morning and mid-afternoon snacks.

Allowing time for rest and relaxation is also important in children, who benefit from a fixed bedtime to ensure sufficient sleep. Avoid screen use for at least an hour before bedtime as the blue light can interfere with sleep quality.

Although a lie-in at the weekend is tempting, this often leads to a migraine attack occuring over the following 24 hours.

People often wonder about food triggers.

For the majority, it is unnecessary to restrict food and much more important to ensure that children have a sensible and regular diet.

Food allergy in children (and adults) is contentious. Missed meals make a child more likely to crave sweets or chocolate, and sweet cravings are a common prodromal symptom of migraine. Chocolate is often wrongly blamed as the migraine trigger because of this. A few susceptible children have established a definite and reproducible temporal relationship between the consumption of certain foods and the onset of migraine but keeping a food diary usually identifies such foods. Alcohol is known to trigger migraine in many people.

Keep simple migraine diaries
Just as in adults, migraine is triggered by a combination of changing events, not just a single event. Encourage your child, if old enough, to keep a daily migraine diary recording any event that is different from the normal routine, or which may be relevant. This can included missed meals, sports activities, stressful lessons, late night study, emotional upsets, etc. A record of migraine attacks and other headaches should be kept too. It can be helpful to score the pain on a range from 0-10 to help the doctor assess the impact.

Look through the diaries with your child, noting patterns of any build-up of triggers, or specific triggers, preceding attacks. This may help for forward planning and managing triggering situations. By minimising the effects of even just one or two aggravating factors, it may be possible to remain below the attack threshold. Treat attacks early to maximise a speedy return to normal activities.

Making the migraine better

Drugs to control the symptoms
Resting in a quiet, darkened room, using a hot or cold pack to ease the pain, and gentle massage, may be sufficient to control mild symptoms. Most children want to lie down during an attack and they can be helped by a short sleep sometimes. Encourage your child to eat or drink something, if possible. If nausea or vomiting is a problem, ask your doctor to prescribe something for this to help the painkillers be absorbed quickly and also minimise these troublesome symptoms. The gut shuts down during migraine and this delays absorption of drugs, reducing their effectiveness.

Treatment should be taken in adequate doses as early in an attack as possible. A migraine attack gathers momentum if left too long and delaying treatment often means it is less effective. Drug treatment should be kept simple. If taken early in an attack, over-the-counter painkillers may be all that is necessary. Syrups or soluble tablets may be preferred as they can be more rapidly absorbed. Soluble or effervescent painkillers can be dissolved in a sweet, fizzy drink to make them more palatable and more effective.

Schools: It is worth informing your child’s school about the problem. If possible, provide staff with specific written instructions for management, stressing the need for early treatment. See our factsheet for guidance (Advice to Schools). In severe cases an individual Health Care plan for your child needs to be drawn up.

Schools have different rules regarding treatment. In some schools, teachers and/or nurses may agree to administer some medication. In other cases, the school will telephone the carer to collect the child. Paracetamol is often considered the drug of choice as it can be given as syrup to even very young children. It is also available as a suppository. Ibuprofen is a more effective alternative. Aspirin is not recommended for children under 16 in the UK.

If these are inadequate to control symptoms, other drugs are available on prescription from your doctor. Some studies have demonstrated the efficacy of triptans in children, but most are still not licensed for patients under the age of 18 years. They have been used widely in children and are generally safe and well-tolerated. Tablets, melts and nasal spray formulations are available.(6,7)

Many combination painkillers available over the counter contain caffeine. These are not advisable in children as caffeine stays in the body for a long time and can reduce sleep quality.

Children (and adult migraineurs) should completely avoid drugs containing codeine. Migraine is easily aggravated by codeine which can transform episodic headache into Chronic daily headaches.

Preventing migraine

Identification and management of trigger factors are the mainstay of treatment. Children also respond well to biofeedback and relaxation techniques, which should be considered before instigating drug therapy. Unless the headaches are really disabling, it is rarely necessary to give children daily drugs to prevent attacks.

If the attacks are coming more than 5-6 times per month, a preventer may be helpful.

A course of preventative drugs may be indicated when there is concern that attacks are interfering with normal school work – often around exam time. The child should try them out before the critical time to ensure that the drug can be tolerated and side- effects do not compromise performance. Once the migraine attacks have settled, the preventer can be weaned down and stopped.

When treatment fails

If children are experiencing frequent attacks of migraine or headache, particularly if these are not responding to simple management strategies, there may be other underlying problems such as depression, bullying at school, or other emotional problems. Overuse of acute medication should be considered as this can itself be a cause of frequent headache. Drugs to treat the symptoms of migraine should not be used regularly on more than two to three days a week.

Case study: Mary

Mary is 12 and has had migraine since she was nine. Attacks used to be infrequent but for the last couple of months she has been having attacks most weeks, often starting late afternoon when she gets home from school. She gets really bad stomach pains, looks pale, and goes straight to bed. A couple of hours into the attack, she vomits and then feels much better. By the next morning, she is fine. Her mother is concerned that these attacks are affecting her schoolwork, as her homework doesn’t get finished when she is ill. Her mother takes her to the doctor, who asks if Mary has needed new shoes or outgrown her clothes recently. Her mother replies that she has been growing rapidly over the last few months and her periods started last year. The doctor explains that growth spurts are common time for migraine to worsen. The doctor asks Mary what she eats for lunch and which sports she enjoys. Mary replies that she takes a packed lunch but doesn’t always eat it. Her mother answers that Mary often wakes up too late for a decent breakfast and comments that the migraines are often after Mary has had a swimming lesson. The doctor recommends that Mary tries to eat more sensibly, particularly on swimming days, making time for a more substantial breakfast and with a snack to eat as soon as she comes home from school. Mary and her mother return a few weeks later to report that his simple advice has been very effective. Mary also comments that she has much more energy after school.

Summary points

ā Migraine can occur in children and adolescents and is more common that many people realise
ā Recurrent attacks of ‘sick’ headaches or bilious attacks in an otherwise well child is likely to be migraine
ā Abdominal pain is often more prominent -headache may not be a feature of migraine in children
ā Migraine is more common in children who have one or both parents who suffer from migraine

References

1. Ishaq Abu-Arefeh, George Russell (1994) Prevalence of headache and migraine in schoolchildren BMJ Vol. 309 765-769
2. R B Lipton, M E Bigal (2007) Ten lessons on the epidemiology of migraine Headache Vol 47 Suppl 1:S2-9
3. Li Bu. Cyclic vomiting syndrome: age-old syndrome and new insights. Semin Pediat Neurol 2001;8:13-21.
3. Marco Arruda, Marcelo E Bigal (2012) Migraine and migraine subtypes in preadolescent children Neurology Vol. 79 no 18 1881-1888
4.Daniel Kantor (2012) The Impact of Migraine on school performance Neurology Vol. 79 e168-e169
5. Heather Angus Le-ppan et al (2018) Abdominal migraine BMJ 360:k179
6. Lea Eiland, Melissa Hunt (2010) The Use of Triptans for paediatric migraines Pediatric Drugs Dec Vol 12 (6) 379-389
7. S L Linder, N T Mathew, R K Cady et al (2008) Efficacy and tolerability of Almotriptan in adolescents: a randomised, double blind, placebo controlled trial. Headache Oct 48(9) 1326-36

 

This information is provided as a general guide only and is not a comprehensive overview of prescribing information. If you have any queries or concerns about your headaches or medications please discuss them with your GP or the doctor you see at the National Migraine Centre.