Migraine in Children and Adolescents

Migraine is the most common type of headache disorder in children. You may think migraine means a bad headache, but head pain is only one symptom of a migraine attack. Migraine disease is a leading cause of disability and can significantly impact a child's quality of life. Children with migraine may need to skip activities, events, or school until they feel better. Some children may “outgrow” migraine, but more than half of children diagnosed continue to have attacks as adults.1 This is why getting a diagnosis and learning how to manage migraine is vital for a child’s future. 

On this page you’ll learn about what pediatric migraine is, how it affects children of different ages, potential migraine triggers, various treatment options, and common comorbidities. We’ll also share resources for family, teachers, and children.  

What Is Migraine?

Migraine is a complex neurological disease that affects about 11% of children.2

A pediatric migraine attack usually lasts between 2-72 hours. Moderate to severe head pain can be felt on one or both sides of the head. It can also be felt across the forehead. The pain may feel pulsating or pounding. Children may describe the pain feeling like the pain feeling like a hammer, drum, or heartbeat in their head. The head pain may get worse with physical activity. The pain may interfere with or prevent a child from doing normal activities.

Migraine attacks have some other ‘typical’ symptoms in addition to the head pain — like light or sound sensitivity, nausea, vomiting, and/or vision changes. 

Children can also experience other symptoms such as: 

  • Dizziness, lightheadedness or vertigo
  • Loss of appetite
  • Sensitivity to smells
  • Stomach ache
  • Blurred vision
  • Pale skin
  • Irritability or moodiness
  • Difficulty concentrating
  • Diarrhea or constipation
  • Feeling clumsy or losing muscle coordination

Symptoms can change as a child grows, meaning kids at different ages can have new or different migraine symptoms.

Migraine With Aura

Some children may experience migraine with aura. Aura is a sensory disturbance that occurs before or at the same time as the migraine attack. They typically last 5 to 60 minutes and visual aura is most common. An aura can also occur without a headache, which is known as “silent migraine.”

Symptoms of visual aura may include:

  • Flashes of light
  • Blurred vision 
  • Zigzag lines
  • Loss of vision
  • Dark spots 
  • Flashes of colors 
  • Seeing multicolored shapes
  • Double vision
  • Distorted vision

 

Other aura symptoms may include:

  • Numbness or tingling in extremities
  • Tingling or feeling of pins and needles
  • Trouble talking or reading
  • Slowed or slurred speech 
  • Weakness 
  • Trouble paying attention
  • Confusion 
  • Vertigo or dizziness
  • Ringing in the ear(s)

Abdominal Migraine

Abdominal migraine is a type of migraine that occurs mostly in children aged 3-10. Up to 4% of children experience abdominal migraine, but it is often misdiagnosed.3 Adults can also be affected by abdominal migraine, but generally, migraine in adults presents with more typical symptoms like head pain.

To receive a diagnosis of abdominal migraine a person must experience:

  • At least five recurrent episodes of moderate to severe pain in the abdomen usually around the midsection or belly button. 
  • At least two of the following symptoms: nausea, vomiting, paleness, or loss of appetite. 
  • A headache may or may not be present. An aura may occur before the abdominal symptoms. 

Each attack generally lasts from 1 hour to 3 days. A person with abdominal migraine may have complete freedom of symptoms between attacks, meaning that these symptoms do not linger. 

Children with a family history of migraine are more susceptible to this condition. Abdominal migraine may spontaneously resolve for some, but unfortunately, a large number of those with abdominal migraine will develop another form of migraine later in life. A person with abdominal migraine may also have another form of migraine concurrently.

What Should Parents Look For?

When a child complains of a headache, the first step should be to take the complaint seriously.

Migraine attacks can present differently depending on how old the child is.

Babies & Toddlers

Babies and toddlers may bang their heads. Older toddlers may look sick, have stomach pain or vomit. They may be irritable, rock, or cry without an obvious reason. 

Pre-School
5-10 Years Old
Adolescents (10-19 Years Old)

Not only do migraine symptoms vary, so can the frequency of attacks. Some people have more frequent attacks than others. Individuals with episodic migraine have 14 or fewer headache days per month. People with chronic migraine have 15 or more headache days per month with migraine symptoms on eight or more days for at least three months.

About 20% of kids with migraine will have their first attack before the age of 5.4

What Causes Migraine?

We don’t fully understand what causes migraine disease, although there is some evidence that it can be inherited.5 Experts believe migraine could be caused by an imbalance in brain chemicals along with changes in the brainstem that affect the trigeminal nerve.

We do know that the migraine brain experiences sensory overload faster than people without migraine. Genetics, environmental factors, hormones, traumatic brain injury, and other factors are thought to play a role.

Migraine usually runs in families.

If one parent has migraine there is a 40-50% chance that their children will inherit it. If both parents live with migraine, their children have a 75% chance of inheriting it.6,7

Migraine Triggers

Overloading the migraine brain with certain stimuli can sometimes contribute to an attack. 

These stimuli, known as “triggers” differ from person to person but may include certain foods, strong smells, weather changes, stress, and lack of sleep. Avoiding or minimizing exposure to certain triggers may help prevent an attack. Unfortunately, some triggers, like changes in weather, are out of our control. 

Some of the most common triggers in children include:

  • Stress (tests/exams, presentations, family life, bullying, etc)
  • Menstruation or other hormonal changes
  • Dehydration
  • Exercise
  • Changes in diet or eating patterns, skipping meals
  • Certain foods with monosodium glutamate (MSG), histamine, chocolate, caffeine, artificial sweeteners, etc.
  • Bright lights, fluorescent lights or flashing lights
  • Weather changes or changes in barometric pressure
  • Travel or time changes
  • Acute illness
  • Poor sleep or changes in sleep schedule
  • Exposure to certain smells or loud noises
  • Some medications including oral contraceptives (birth control), stimulants (ADHD medications), and asthma treatments

 

**As we learn more about the migraine brain, it’s important to understand that for most, no one trigger will “cause” a migraine attack. For example, a poor night's sleep likely will not cause a migraine attack. But, a combination of multiple triggers can increase the risk of an attack. If a child is very stressed, is menstruating, and the barometric pressure drops– that one poor night's sleep may push them over the edge into a migraine attack. It is important to note that triggers are a debatable topic in the migraine community and there is conflicting evidence about their contribution to migraine attacks.

Getting A Diagnosis

If a caretaker or parent begins to notice any migraine symptoms, it’s important to consult a pediatrician or other healthcare provider. Depending on the severity of symptoms, they may refer your child to a pediatric neurologist or headache specialist. 

There is not a specific blood test or brain scan to diagnose migraine.

Instead, the provider may order certain tests to rule out other conditions. 

Preparing For An Appointment

Starting a headache diary can be a good way to log information before an appointment. A diary can help you accurately detail what the child is experiencing. It can also help the healthcare provider find trends, determine a diagnosis, and recommend treatment options.

In a headache diary, you can track:

  • The number of days a child has a headache or stomach ache.
  • The number of days they are impacted by headache or stomach ache (i.e. unable to attend school, event or athletic activity).
  • Any additional symptoms (i.e. nausea, vomiting, visual disturbances or sensitivity to light or sound).
  • If possible, note days when tests, exams, or big events occur. This may help determine if any stressors precede the migraine attack.

What To Expect At An Appointment

At an appointment, the doctor will ask a variety of questions about the headache or stomach ache, such as:

  • Frequency - How often do the attacks occur?
  • Location - Where is the pain or discomfort located? (i.e. Front or back of the head, right or left side of the stomach)
  • Quality - What does the pain or discomfort feel like? (i.e. Stabbing, pulsating, dull, throbbing, etc.) 
  • Time - How long does an attack last?
  • Associated symptoms - Are there any other symptoms like nausea, vomiting, visual disturbances or sensitivity to light or sound? 
  • Is there a family history of migraine?  
  • Are there any external stressors at school or at home?

Treatments

Finding treatments that work is important for improving a child’s quality of life. Treatment should be tailored to the child. Options can vary based on age, disease severity, and other health conditions.

Migraine treatment options include lifestyle changes, acute treatments, preventive treatments, and/or behavioral modifications. 

During an attack, have the child lie down in a cool, dark, and quiet room.

Try applying ice or pressure to the area that hurts. Offer them water and something to eat if they are able to tolerate it.

Lifestyle Changes

Changes in lifestyle are the first step to help children with migraine disease. The migraine brain thrives on routine, so creating and sticking to routine can reduce the number and severity of attacks.
  • Sleep: Most young people need about 8-11 hours of sleep each night. Getting enough rest and keeping a consistent sleep schedule can help. That means going to bed and waking up around the same time every day. Yes, on weekends too.
  • Eat: Healthy foods should be eaten consistently throughout the day. Processed foods, fried foods, and artificial sweeteners should be avoided.
  • Exercise: Regular movement, activity, and exercise may be helpful in preventing migraine but for some people exercise can trigger or worsen an attack.
  • Hydration: Staying hydrated is important but sugary drinks should be avoided.
  • Caffeine: Caffeine use should be minimized. That includes coffee, tea, soda, energy drinks, etc.
  • Electronics: Electronics should be avoided 30-60 minutes before bed.
  • Stress: Manage and minimize stress at home, school, and other places the child spends time.

Acute Treatment Options

Acute treatments are used at the start or onset of a migraine attack. When used early, they can be very effective. Some acute treatment options approved for pediatric migraine include over-the-counter medications, triptans, neuromodulation devices, and nerve blocks. 

Over-the-counter pain medication: Acetaminophen and ibuprofen can offer relief for children 2 years of age and older. Naproxen can be used for children 12 years and older.

Anti-nausea medication: Anti-nausea medications like prochlorperazine or metoclopramide may be prescribed for children aged 4 and older.

Triptans: A class of medication known as triptans can be effective for children. Medications may come in the form of tablets or nasal sprays. Certain triptans are FDA-approved for different ages. They include:

  • Sumatriptan/naproxen combination for children aged 12 years and older
  • Rizatriptan for children aged 6-17 years and older
  • Almotriptan for children aged 12 years and older
  • Zolmitriptan nasal spray for children aged 12 years and older

*CAUTION* Avoid taking acute medications more than two times per week. Taking more than this could lead to another type of headache called medication overuse headache or rebound headache.

Neuromodulation devices: Neuromodulation is a treatment option that does not involve medication or drugs. The devices 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.The FDA cleared three devices for the acute and/or preventive treatment of migraine in children aged 12 and older.

Nerve Blocks: Nerve blocks (i.e. sphenopalatine ganglion blocks or occipital nerve blocks) are injections of a numbing medication given around the nerves that contribute to a migraine attack. Sometimes they include steroids for longer-lasting effects. They may also be used preventively.

A child might need to trial several treatments before finding the right one.

Preventive Treatment Options

Preventive treatments are used regularly to reduce the number and severity of migraine attacks. Preventive options include supplements, neuromodulation devcies, medications, and/or behavioral therapies.

Vitamins and Supplements

Studies are limited, but some dietary supplements may help migraine in young people. These include:

  • Magnesium
  • Riboflavin
  • Coenzyme Q10

Make sure to speak with the child’s doctor before trying any supplements.

Prescription Medications

There are limited FDA-approved migraine preventive drugs for children. Unfortunately, in clinical trials, no medications have been shown to be more effective than placebo for preventing migraine.8

  • Topiramate is the only FDA-approved medication for children aged 12 and older.

Some doctors will prescribe certain medications for “off-label” use. These drugs include:

  • Propranolol
  • Sodium valproate
  • Divalproex
  • Cyproheptadine
  • Amitriptyline *Note: Amitriptyline is an antidepressant and nerve pain medication. The FDA issued a black box warning for amitriptyline due to risk of suicidal thoughts and behavior in kids and teenagers.

It is important to work with the child’s doctor to monitor drug effectiveness and side effects. Be sure to discuss risks, benefits, and treatment length. As of now, there is no clear guidance on how long these treatments should be used in children.9

Neuromodulation: Nerivio, gammaCore, SAVI Dual are FDA-cleared devices for the acute and preventive treatment of migraine in children aged 12 and older.

OnabotulinumtoxinA: OnabotulinumtoxinA (commonly known as Botox) injections are not FDA-approved in children. A doctor might try it “off-label” for chronic pediatric migraine.

CGRP Medications (Anti-CGRP monoclonal antibodies and gepants) : Clinical studies are underway to see if migraine-specific medications like anti-CGRP monoclonal antibodies and CGRP receptor antagonists (gepants) are safe and effective in children. Some headache specialists may use them off-label for children because of their proven efficacy in adults.

Behavioral Therapies

Living with pain from migraine or another headache disorder can be extremely stressful. Behavioral therapies help to teach children about their disease, understand the thoughts and feelings they have, and how to cope with the pain. Behavioral therapies can also help treat comorbid conditions like anxiety, depression, ADHD, or sleep disorders.

Complementary and Alternative Medicine (CAM)

Natural, complementary, and alternative medicine approaches may help children with migraine. Talk to a pediatrician about approaches that may benefit your child.

Childhood conditions that may be associated with migraine

There is some evidence to suggest that certain childhood conditions may be linked to migraine later in life.

A few childhood conditions that may be associated with migraine include:

  • Infantile colic occurs when a baby cries three or more hours a day, three or more days a week for three or more weeks.
  • Benign paroxysmal torticollis is a rare condition characterized by recurring episodes of abnormal head tilting or rotation, often with vomiting and impaired balance. The episodes last from a few hours to days. It typically resolves by age 3.
  • Alternating hemiplegia of childhood is an extremely rare condition that is characterized by recurrent episodes of muscle weakness, often affecting one side of the body that lasts from minutes to days.
  • Abdominal migraine is characterized by recurrent attacks of moderate to severe stomach pain, with or without vomiting, that lasts from 2 hours to 3 days, typically without symptoms in between episodes. Often, there is no headache with the attacks. 
  • Benign paroxysmal vertigo of childhood is characterized by sudden onset of spinning that can last minutes to hours. During these attacks, children may also vomit or have difficulty balancing or walking.10
  • Cyclic vomiting syndrome (CVS) is characterized by unexplained episodes of severe nausea and vomiting. Episodes typically occur around the same time of day with similar levels of intensity, symptoms and duration. CVS often develops in children between 3 to 7 years of age, although this disorder may also occur in adolescents and adults. 11
  • Pediatric vestibular migraine is characterized by episodes of vertigo, dizziness, nausea, vomiting, sensitivity to light and/or sounds, loss of balance and more. A headache may or may not be present. The symptoms can last between a few minutes to 72 hours and often recur.

Comorbidities

Children with migraine can have other health conditions too. Children with migraine may be more susceptible to developing certain medical conditions and similarly, children with certain medical conditions may be more prone to developing migraine. Those conditions are called comorbidities. Migraine in children can be exacerbated or worsened by comorbidities. Determining the best migraine treatment plan should include consideration of other health conditions.

Common childhood comorbidities include:12

  • Depression
  • Anxiety disorders 
  • Epilepsy 
  • Sleep disorders
  • Attention-deficit/hyperactivity disorder (ADHD)
  • Tourette syndrome
  • Cardiovascular disease
  • Anemia
  • Obesity
  • Atopic disorders like asthma, rhinitis, and eczema.

Concussion and Migraine

A concussion is a brain injury caused by a blow, bump, or a hit to the head or body. Some concussions result in loss of consciousness, but the majority do not. Some children may experience migraine-like symptoms after a head injury or concussion. These symptoms usually improve within 10 days, but some young people may take more time to heal. 

Talk to your healthcare provider if your child experiences a head injury.

If it occurs during a sport or activity, they should be cleared by a medical professional before resuming physical activity. 

How Does Migraine Impact a Child’s Life?

Migraine can be disruptive and disabling which may severely affecting a child’s quality of life. Migraine can greatly impact a child’s routine, education, social life, and family life. 

The challenges of migraine can also impact mental health. Research shows that children and adolescents who experience migraine are more likely to have anxiety and depression compared with children who don’t have migraine.13 Young people living with migraine should be routinely screened for anxiety and depression by their healthcare provider.

Children and adolescents with migraine are more likely to have anxiety and depression compared to their peers without migraine.

Because migraine can impact schooling, activities, and overall quality of life, it’s vital for caregivers to inform and educate those involved in the child's life. Educating others about migraine can help to reduce migraine stigma, foster greater empathy and provide alternative arrangements to support a child's success.

Some strategies may include:

  • Utilizing resources provided by Migraine At School.
  • Involving a school nurse with a Migraine Action Plan. 
  • Determining if your child needs a 504 plan or an Individualized Education Plan (IEP). You can learn about the differences here.
  • Discussing a child’s needs with teachers. Working to find suitable accommodations where children can succeed in school and stay healthy. This may include assignments given in advance, a permission note to keep a water bottle with them, permission to carry medication, access to a dark room, etc. 
  • Talking to teachers, school nurses, activity advisors, coaches, mentors, and other parents about the child’s symptoms, triggers, and what to do if an attack strikes. 
  • Involving a school counselor, therapist, or mental health professional to help your child manage migraine and its impact.

Migraine at School

Migraine at School envisions a world where children understand and are able to treat their migraine and headache disease, and are able to get the education they deserve.

Migraine at School will take the lead in making this happen through migraine and headache screening, an education curriculum for schools, and resources for students, parents, and educators.

Migraine-at-School

This page has been medically reviewed by: Deanna Duggan, DNP, APRN, CPNP-PC, PMHS, AQH

Caution: This information is NOT intended to endorse drugs or recommend therapy. Only your doctor can decide which medications are right for you. Never stop, start or change the way you use a prescription medicine without first consulting your doctor. Not all side effects are described. Call your doctor or consult your pharmacist for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

The contents of this page are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The dosages provided are all stating what is typical for an individual but it is important to always consult with a medical professional to determine what dose is best for you. The list of side effects for each medication is not exhaustive. AMD does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.