When Your Child’s Migraine Is Hard to Manage: Next Steps for Parents

Migraine is a neurological disease that often begins in childhood or adolescence and commonly runs in families. Typical symptoms in children include head pain, light and/or sound sensitivity, nausea, or vision changes. Children may also experience dizziness, irritability, pale skin, difficulty concentrating, stomachache, sensitivity to smells, and more. Attacks may be shorter in children than in adults. 

For most children, migraine is episodic, meaning they have fewer than 15 headache days per month. For others, migraine can become chronic, with headache on 15 or more days each month, at least 8 of which have migraine symptoms such as light or sound sensitivity or nausea.

Unfortunately, there are times when a migraine attack is more severe or prolonged than usual. This is often in response to multiple triggers or stressors happening at the same time, such as weather changes, final exam time, stress, not enough sleep or hydration, menses, or viral illness. For more information about migraine triggers, click here.

Some attacks can be harder to treat and may require a higher level of care. So what can you do if your child’s migraine attacks are hard to manage? In this blog, we’ll walk through potential next steps to discuss with your provider and how to navigate hard-to-treat migraine attacks in kids.

Key Terms to Know

• Episodic migraine: Fewer than 15 headache days per month.¹
• Chronic migraine: 15 or more headache days per month with migraine symptoms on at least 8 days per month for at least 3 months.²
• Status migrainosus: A migraine attack that lasts longer than 72 hours, often with more intense pain and symptoms. Usually responds to higher-level treatments.³
• Refractory migraine: At least 8 debilitating headache days a month for 6 consecutive months or more without response to all available preventive medications.^4,5

In short

• Episodic migraine  → frequency (number of days/month)
• Chronic migraine → frequency (number of days/month)
• Status migrainosus → duration (longer than 72 hours)
• Refractory migraine → response (doesn’t improve with standard preventive treatments)

When to Call a Healthcare Provider

It’s important to know when a migraine attack may need medical attention. Contact your child’s healthcare provider if a migraine attack does not improve with their usual rescue plan, lasts longer than 72 hours, or is accompanied by unusual or concerning symptoms such as confusion, lack of responsiveness, one-sided numbness or weakness, acting unusually ill, or fever. You should also call if your child is vomiting and becoming dehydrated. Remember, it is never wrong to contact your provider if you are worried that something isn’t right.

Develop an Action Plan with Your Child’s Healthcare Provider

Every child with migraine disease should have a personalized rescue or action plan for managing attacks. This plan may include a combination of medications and non-medication strategies tailored to your child’s symptoms and their response to treatment. Having a plan in place helps ensure migraine attacks are treated quickly and effectively, reducing the chance they will become more severe or prolonged. Learn more about creating an action plan here.

In the next section, we’ll review options for acute treatments, preventive treatments, and approaches for managing status migrainosus in kids.

Acute Treatments for Children^6,7

Acute treatments are used at the first sign of a migraine attack to reduce pain, shorten the duration of symptoms, and, ideally, stop the attack altogether. These treatments range from over-the-counter pain relievers to migraine-specific prescription medications and devices, and should be chosen based on your child’s age, symptoms, and medical history. Every child with migraine should be offered an acute treatment to use when an attack occurs. 

• Pain relievers (analgesics): Acetaminophen (Tylenol) and NSAIDs such as ibuprofen (Motrin), naproxen (Aleve), or ketorolac (Toradol). Over-the-counter combination medications like Excedrin Migraine (aspirin, acetaminophen, and caffeine) or Excedrin Tension (acetaminophen and caffeine, without aspirin) may be used when appropriate.
• Triptans: Rizatriptan (Maxalt) is FDA-approved for children 6 years and older. Zolmitriptan (Zomig) and almotriptan (Axert) are FDA-approved for use in children 12 years and older. Sumatriptan (Imitrex) and others are FDA-approved for adults but may be prescribed “off-label” for teens when appropriate.
• Neuromodulation devices: These apply external electrical or magnetic impulses to reduce, eliminate, or prevent migraine attacks. They are worn or held against different parts of the body to stimulate nerves or areas of the brain and nervous system involved in the migraine process.
  • Remote electrical neuromodulation (Nerivio): FDA-cleared for acute treatment in individuals aged 8 and older.
  • Single-pulse transcranial magnetic stimulation (SAVI Dual): FDA-cleared for use in children aged 12 and older.
  • Non-invasive vagus nerve stimulation (gammaCore): FDA-cleared for use in children aged 12 and older.
• Gepants: Ubrogepant (Ubrelvy) and rimegepant (Nurtec) are currently in clinical trials for those under 18, but may be used off-label for older teens with provider guidance and insurance authorization.
• Nausea medications: Options for nausea include ondansetron (Zofran), diphenhydramine (Benadryl), prochlorperazine (Compazine), or metoclopramide (Reglan). Some of these medications may also help reduce the severity of an attack.

Parents of children experiencing frequent migraine attacks should avoid administering pain relievers like ibuprofen or acetaminophen on 15 or more days each month for more than three months. They should also refrain from giving triptans and combination medications containing caffeine on 10 or more days per month for over three months. Doing so can cause another type of headache disorder called medication overuse headache to develop.⁸

Preventive Treatments for Children

For children and teens with migraine, a preventive treatment may be prescribed to reduce how often attacks occur and how severe they are. They are typically considered for kids who experience 4 or more headache days per month.⁹ Except for topiramate and fremanezumab, most preventive medications for children are prescribed “off-label”, meaning they are not FDA-approved specifically for migraine in children. When used under the guidance of a healthcare provider, these treatments can be safe and effective.

Preventive Treatment Options Typically Used for Children With Migraine^6,7

• CGRP monoclonal antibodies: Fremanezumab (Ajovy) — FDA-approved for episodic migraine in children ages 6–17 who weigh at least 99 lbs.
• Anticonvulsants: Topiramate (Topamax) (FDA-approved for ages 12–17), zonisamide (Zonegran), gabapentin (Neurontin)
• Neuromodulation devices: FDA-cleared for migraine prevention: Nerivio (aged 8+), gammaCore (aged 12+), and SAVI Dual (aged 12+)
• Nutraceuticals: Magnesium, Riboflavin, Coenzyme Q10
• Antihistamines: Cyproheptadine (Periactin)
• Tricyclic antidepressants: Amitriptyline (Elavil), nortriptyline (Pamelor)
• Beta blockers: Propranolol (Inderal)
• Behavioral Therapies: Cognitive Behavioral Therapy, Acceptance and Commitment Therapy

If your child has chronic or refractory migraine, a referral to a specialty pediatric headache clinic is recommended. These clinics have advanced expertise in migraine care and can offer treatments, off-label medications, and procedures that may not be available in a primary care practice. 

Currently, many of these advanced treatments are FDA-approved only for adults, though clinical trials are underway for younger teens. In certain cases, they may be prescribed off-label for older teens if appropriate and with insurance authorization.

Preventive Treatment For Harder-to-Treat Migraine in Children^6,7

• OnabotulinumtoxinA (Botox): FDA-approved for chronic migraine in adults but not children; used off-label in pediatric patients and administered every 12 weeks.^10,11
• CGRP monoclonal antibodies: Fremanezumab (Ajovy) is FDA-approved for episodic migraine in children ages 6–17 who weigh at least 99 lbs. Three others, erenumab (Aimovig), galcanezumab (Emgality), and eptinezumab (Vyepti), are FDA-approved in adults, but may be used off-label for children.¹²
• Gepants: Atogepant (Qulipta) and rimegepant (Nurtec) are FDA-approved for acute and/or preventive treatment in adults. They may be used off-label in children.
• Peripheral nerve block injections: Given every 6–8 weeks using local anesthetic, with or without steroid medication. Anti-anxiety medication, such as oral diazepam, may be used before the procedure.^11,13
• Sphenopalatine ganglion block: Given every 6–8 weeks; less frequently available for pediatric patients. Anti-anxiety medication, such as oral diazepam, may be used before the procedure.^11,14

Rescue Treatments for Status Migrainosus in Children

Status migrainosus or a migraine attack lasting longer than 72 hours often requires stronger interventions to “break” the episode. Whenever possible, treatment at home is preferred, as it can be less disruptive for the child and family.

Step 1: Home-Based Options

• Steroid taper: A 5–7 day course (e.g., Medrol Dose Pack) can help reduce inflammation and shorten the attack.
• Short course of valproic acid: Taken for 3–4 days (e.g., Depakote), this can be effective in ending prolonged migraine attacks.

Both options are generally safe but may cause gastrointestinal side effects.

Step 2: Facility-Based Treatment

If home treatments are not effective, the next step may involve going to an emergency department, infusion center, or urgent care, ideally in a setting that can provide IV fluids and medications. 

Treatment often includes:

• IV fluids for hydration
• IV ketorolac (Toradol)
• Antinausea medications: Ondansetron (Zofran), diphenhydramine (Benadryl), prochlorperazine (Compazine)
• IV steroids: Dexamethasone (Decadron), methylprednisone (Solu-Medrol)
• IV valproic acid: (Depacon)

The main goals before discharge are to reduce pain, control nausea, and ensure your child can tolerate fluids. Even if the migraine attack is not fully resolved at discharge, continued hydration and rest at home can lead to improvement.

Step 3: Dihydroergotamine Protocol¹⁵

For attacks unresponsive to standard emergency care, dihydroergotamine (DHE) may be considered. Typically given as 4–6 doses via IV over 2–3 days, it requires pre-treatment for nausea and close monitoring due to possible side effects. DHE is a potent medication often administered in an emergency department, infusion center, or inpatient hospital setting. While it requires close monitoring and can have significant side effects, it can be highly effective for breaking status migrainosus and managing severe attacks refractory to migraine treatments.

Tip: If your child is treated at an emergency department or infusion center, keep a record of the exact treatments they received, especially those that worked well. This information can help guide future care, be added to their migraine action plan, and potentially be used earlier during a future attack that may require a higher level of care.

Conclusion

If your child is struggling with frequent or severe migraine attacks, be sure not to overlook the “headache-healthy” lifestyle habits that can help reduce the frequency and severity of attacks. The goal for children and teens is to prevent and, when possible, reverse chronic or refractory migraine before adulthood. Focus on the basics, such as consistent hydration, regular nutritious meals, adequate sleep, and regular physical activity. Pay attention to their stress level and coping skills. Living with chronic head pain while managing school and activities is challenging. Your child may need additional support. Be sure to advocate for accommodations at school, talk to the school nurse about their migraine action plan, and when necessary, connect them with a therapist who can help them navigate the emotional toll. Living with migraine is challenging for both children and parents. It’s important to find trustworthy sources of support to help your family through the process. View our Migraine in Children page for more information, or visit Migraine at School, which provides educational information for children, parents, and teachers.

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References

1. https://ichd-3.org/1-migraine/1-1-migraine-without-aura/
2. https://ichd-3.org/1-migraine/1-3-chronic-migraine/
3. https://ichd-3.org/1-migraine/1-4-complications-of-migraine/1-4-1-status-migrainosus/
4. https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-020-01130-5
5. Robblee, J., 2023. Breaking the cycle: unraveling the diagnostic, pathophysiological and treatment challenges of refractory migraine. Frontiers in Neurology, 14, p.1263535.
6. Gibler, R.C., Knestrick, K.E., Reidy, B.L., Lax, D.N. and Powers, S.W., 2022. Management of chronic migraine in children and adolescents: where are we in 2022?. Pediatric health, medicine and therapeutics, pp.309-323.
7. Marshall, A., Lindsay, R., Clementi, M.A., Gelfand, A.A. and Orr, S.L., 2022. Outpatient approach to resistant and refractory migraine in children and adolescents: A narrative review. Current Neurology and Neuroscience Reports, 22(10), pp.611-624.
8. https://ichd-3.org/8-headache-attributed-to-a-substance-or-its-withdrawal/8-2-medication-overuse-headache-moh/
9. Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021 Jul;61(7):1021-1039. doi: 10.1111/head.14153. Epub 2021 Jun 23. PMID: 34160823.
10. Lindsay, R., Kalifa, A., Kuziek, J., Kabbouche, M., Hershey, A.D. and Orr, S.L., 2024. The safety and efficacy of onabotulinumtoxinA injections for children and adolescents with chronic migraine: A systematic review and meta‐analysis. Headache: The Journal of Head and Face Pain, 64(10), pp.1200-1216.
11. Peck, J., Zeien, J., Patel, M., Cornett, E.M., Berger, A.A., Hasoon, J., Kassem, H., Jung, J.W., Ramírez, G.F., Fugueroa, P.C. and Singhal, N.R., 2023. Review of interventional therapies for refractory pediatric migraine. Health Psychology Research, 10(5), p.67853.
12. Greene, K.A., Gentile, C.P., Szperka, C.L., Yonker, M., Gelfand, A.A., Grimes, B. and Irwin, S.L., 2021. Calcitonin gene–related peptide monoclonal antibody use for the preventive treatment of refractory headache disorders in adolescents. Pediatric neurology, 114, pp.62-67.
13. Hassan, R., Gudiwala, V., Dawn, P. and Jeynes, L., 2023. Greater Occipital Nerve Block as an Effective Intervention for Medically Refractory Pediatric Migraine: A Retrospective Study. Cureus, 15(2).
14. Mousa, M.A., Aria, D.J., Mousa, A.A., Schaefer, C.M., M’hamed, H.T. and Towbin, R.B., 2021. Sphenopalatine ganglion nerve block for the treatment of migraine headaches in the pediatric population. Pain Physician, 24(1), p.E111.
15. Srouji, R., Schenkel, S.R., Forbes, P. and Cahill, J.E., 2021. Dihydroergotamine infusion for pediatric refractory headache: A retrospective chart review. Headache: The Journal of Head and Face Pain, 61(5), pp.777-789.

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