Many people experience their first migraine attack during adolescence. From limited treatment options, to social isolation and trouble at school, migraine presents adolescents with a great number of challenges during an already complicated time of their lives.
Early treatment is essential, as it reduces the risk of disease chronification. Yet, many adolescents and their families are often left struggling to navigate the healthcare system in an attempt to find some relief.
We hope the answers to the questions below shed some light on the struggles adolescents with migraine face, and help guide families on how best to support their child and manage treatment.
Many thanks to our pediatric migraine specialists, Dr. Marielle Kabbouche Samaha and Dr. Shalonda Slater, from Cincinnati Children’s Hospital Headache Center, for their help with this project and answers to questions.
Watch this video with Dr. Kabbouche Samaha and Dr. Slater as they talk about how migraine impacts adolescents.
Thanks to our partner, Theranica, for sponsoring this educational project!
Watch Our Adolescents with Migraine Videos
Adolescents with Migraine: Questions + Answers
General Migraine Information
Migraine can happen at any age; even younger kids, one, two, three years old can have it (1-3%), but it's harder to diagnose at this age. Then the percentage increases between ages 8 and 11 to about 10%, and then the rate of migraine goes very high during adolescence. In adolescence it can reach up to 25%, specifically in girls.
—Dr. Kabbouche
The difference depends on the age of the patient. Most of the patients at a very young age are boys, and then during adolescence this totally flips, During adolescence one out of three is a boy, and the rest are girls.
—Dr. Kabbouche
About 85% of our patients have one first degree parent with migraine. The other 15%, we cannot get the family history, or they don't know, or haven’t asked. In general, children with one parent with migraine have a 50% chance of having it also, and with both parents there is a 75% chance.
—Dr. Kabbouche
There is no cure for migraine, but it can be controlled depending on how early you treat it. If we catch it early, we have more control in adulthood and help prevent it from becoming chronic. About 50% of boys can outgrow migraine attacks in their 20s. However, for girls it
is a lifelong disease. We consider migraine to be “controlled” when it is less than one headache a week that goes away quickly with treatment.
—Dr. Kabbouche
At a very young age, children may not complain of a headache at all, but just have other symptoms such as vertigo or abdominal pain or nausea. This is more frequent in younger kids – they may throw up and then nothing for a month. And then they do the same thing episodically. The pediatrician needs to understand, they need to rule out other stuff, but they need to understand that this can be migraine. When the kids grow a little bit, they're more vocal, and they will start complaining of a headache. So at least once that is added to the symptoms that's helpful. Also, for kids they can have a migraine that only lasts an hour.
—Dr. Kabbouche
This is why it is important to train the pediatric neurologist to take care of migraine, and also to bring educational resources to the community because we don't have enough specialists. Even at Cincinnati Children's Hospital, the wait is long and we have the shortest wait compared to any other headache center. Other headache centers have a wait of six months to a year.
—Dr. Kabbouche
Treatment Options
We focus on talking to the patients because this is their migraine. We want them to describe it, and to be involved in the treatment. But the final decision for treatment is on the parents and their involvement is really important too.
—Dr. Kabbouche
The FDA-cleared devices are not medications and so more easily accepted as treatment options. Some of them have been through clinical trials with adolescents, and have less side effects than medications, most of which have not been specifically tested on people under 18.
To take a medication, you have to leave the classroom, go to the nurse to get it. With the devices, you can do it in the classroom. For chronic patients, they cannot take acute medication every day, so using a device is helpful for that also.
Most patients are excited to try a device and want to see if it works. The barrier is usually more about the cost than willingness to use it.
—Dr. Kabbouche
Some of them do, but some don't yet have an adolescent indication. Also, some that are FDA cleared for migraine treatment are also cleared for preventive treatment too. So not just to break an acute attack, but also helping prevent another one from happening.
To be FDA cleared, devices have to show from clinical trials that they are effective and do not have too many side effects. If they're not cleared, it means they did not go through a scientific study to prove efficacy and lack of side effects. To have an adolescent indication means that the device has specifically been tested in clinical trials on that age group.
—Dr. Kabbouche
Yes, the Nerivio is indicated for ages 8 and up.
*Nerivio is indicated for acute and/or preventive treatment of migraine with or without aura in patients 8 years of age or older. It is a prescription use, self-administered device for use in the home environment at the onset of migraine headache or aura for acute treatment, or every other day for preventive treatment.
- Nerivio is placed on the upper arm halfway between the shoulder and the elbow for a 45 min treatment.
- gammaCore is placed on the side of the neck against the vagus nerve for a 2 min treatment.
- SaviDual is placed on the back of the head for a treatment that takes less than 1 min
Treating adolescents with migraine disease requires a comprehensive approach that addresses physical, biobehavioral and social factors. The high-safety profile and dual-use acute and preventive indication [of the Nerivio REN wearable] make it a compelling first-line intervention for early and effective migraine treatment.
—Dr. Kabbouche
Patients who are younger than 18 don't have all the treatment options that adults have. It takes 10 to 20 years to get something approved for kids after they're approved for adults. For the acute treatment, since migraine includes some inflammation, we use NSAIDs such as ibuprofen and naproxen. If that does not work we have triptans, some of which are now FDA approved for adolescents. One is even approved for as young as 6 years old. The other ones we use are the CGRP inhibitor medications, but they are not approved for younger kids and so it is really hard to get it approved by insurance unless it is “medically necessary.”
—Dr. Kabbouche
Even over-the-counter medications can cause side effects. For example, we use ibuprofen, and that can cause stomach pain. We limit the treatment of that to no more than three times a week because the body can become immune to it, and not only that, one of the side effects is headache – we call that analgesic overuse headache.
As far as medications go, yes, they do all have potential side effects. They’re not that frequent, but you need to know what they are because you may be the one who gets them. We let the parents and the kid decide which medications they prefer based on the information we give them. For prevention, some of them are once a day, some it's twice a day. For adherence, you want the once-a-day ideally. Also, I always like to talk about the side effects of NOT taking medication or not using devices. Migraine will easily chronify.
—Dr. Kabbouche
It is very hard to take medicine every day for any person, and that's why we want the adolescent to be involved in the final decision. We will ask them if they want to be on a daily medicine. If they say no, we will watch it for six weeks then bring them back. Then if the
migraine attacks are still intractable, we may need to be a little bit more aggressive in treatment. This way they feel they are in control in their treatment, rather than just us throwing things at them.
—Dr. Kabbouche
If they've committed to do one of the preventive medications, we try to talk about what barriers there might be. Are there other medications that they take at this time of day? Is there something you always remember to do that we can pair this with? Are there some reminders that we can put on your phone? We try to have that behavioral piece in there to empower them.
—Shalonda Slater, PhD
Generally, they will not have enough medication to treat more than three migraine attacks a week. They also can use one of the medical devices. We tell them that if it is a small attack then still treat it right away, but maybe with ibuprofen or a device. Then as soon as they know it's a bad one, they can add the backup medicine such as a triptan. We usually try to prescribe the medications where they can get 12 per month. The important thing is for them to take it as soon as they know it's bad.
—Dr. Kabbouche
Sometimes there is some hesitance with the nasal sprays because patients may not like the way it tastes. They also don't really like injectables because often people are scared of needles. There’s so many different treatment options, and we offer all of those to them. Sometimes kids don’t know how to swallow pills, or are afraid of doing that. So we talk to them about their concerns.
—Dr. Slater
At our centers there are four vitamins we look into. Vitamin D, because it has shown to be low in any type of pain, not just migraine. Coenzyme Q10 has also been shown in some studies to be low. Then riboflavin (vitamin B2). And now there have been a lot of studies on folic acid that can be low too in migraine. We don't look at magnesium right away.
—Dr. Kabbouche
First, we teach our patients to treat their migraine as soon as it starts. If they don't do that it's going to be harder to stop. When parents call about a really bad migraine, we ask them if they treated it, and if they repeated treatment the way we told them. If they did the right thing and the migraine is continuing, that is called status migrainosus, which is a severe migraine that's not breaking with anything and is very disabling. If they get to that point, then they may need IV treatment. There are infusion centers, which are better than the ER which is loud, bright and has a long wait, so we prefer sending them there. If that is not available they have to go to the ER to have it broken. About 75 % will respond in the infusion center, but there will be some patients who do not respond. If they're not back to zero pain then we offer an admission to the hospital to get a medication called DHE every eight hours until we break it.
—Dr. Kabbouche
Life Impact and Lifestyle Modifications
Migraine can have a pretty big impact on the social functioning of children and adolescents with migraine. It is important for them to know that it is not good for them to be isolated because that can make their mood worse, and even their headaches worse.
—Dr. Slater
People who don't have migraine can downplay the impact of headaches on school, family, and social functioning. Adolescents with migraine feel that people are not really listening to them or understanding how difficult dealing with this particular chronic condition can be. It is important to give them confidence to know that migraine attacks don't have to control their life.
—Dr. Slater
A lot of patients get frustrated because their teachers don't believe them. It is important for them to know that we believe them; just that is already a step toward coping better.
—Dr. Kabbouche
Migraine can have a really big impact on family relationships. We want to involve their parents so we can teach them ways that they can be supportive, and to help the parents and siblings understand what's going on. What do they need to do? How can they be supportive?
—Dr. Slater
The parents sometimes feel very frustrated that their kid is in pain, and they cannot do anything to help them. That creates a lot of stress for the parents as well as the kids.
—Dr. Kabbouche
Healthy lifestyle recommendations, and any recommendations about counseling or therapy, are equally important to medications. We focus on hydration, eating habits, sleep, and exercise. We'll also go over what the barriers are to doing this. How can their family be supportive? Do they need to put some reminders on their phone? Is there an app that can help by reminding them?
—Dr. Slater
We try to start with figuring out what might be stressing them out. Is it taking lots of challenging courses? Are there some social issues at school going on? Are there family stressors? Do they need accommodations at school? Sometimes it takes some outpatient counseling or therapy such as cognitive behavioral therapy for pain to figure out how they can better manage their emotions.
—Dr. Slater
It definitely is a primary recommended treatment for children, adolescents and adults with migraine. Not only have we had some success in reducing pain frequency, but also increasing functioning and coping. In studies that we’ve done on CBT, more than half of the people were able to reduce their headache days. We try to combine CBT with medications as much as we can.
—Dr. Slater
At our centers there are four vitamins we look into. Vitamin D, because it has shown to be low in any type of pain, not just migraine. Coenzyme Q10 has also been shown in some studies to be low. Then riboflavin (vitamin B2). And now there have been a lot of studies on folic acid that can be low too in migraine. We don't look at magnesium right away.
—Dr. Kabbouche
Other Questions
To make it simple, if we don't catch it, the inflammatory process involved in migraine continues to build up, and you end up not only having migraine attacks but sensitivity all over. When you start going through that process, you're at high risk for what we call chronification. That means the migraine attacks are going to become chronic, and very difficult to control. We really need to catch the attacks when they're not frequent, when they just started. Ideally we need their pediatricians to know how to treat it at that stage.
—Dr. Kabbouche
It's not a matter of whether they have pain or not. It’s more about emphasizing functioning. We want them to treat it and then see what can be done to get them to school.
—Shalonda Slater, PhD
It usually involves basic things like being allowed to take their medication at school, have their sports drink to be able to hydrate, use the bathroom, have snacks. Other accommodations that may be needed are extra time to do tests, extra time on assignments, breaks during the school day when needed.
We try to stay away from blanket excuses for school absences, because we want them to function, and being at home and missing more school creates a negative loop where you miss school, get stressed out about all the work to make up, and then the stress actually can be a trigger for the migraine attacks, so they miss more days. School can become a negative place to be because they always feel like they’re behind, so we focus on how we can make school a more tolerable place versus not being there at all. When their functioning is significantly impacted at school we will suggest a formal plan like a 504 plan.
—Dr. Slater
Don't be afraid of it. It is treatable if controlled from the beginning and parents need to seek help for their adolescents as soon as they notice the symptoms, because then the outcome will be better.
—Dr. Kabbouche
There are so many apps and studies now trying to evaluate different modes of treatment. So it’s good to look at the different options, explore them, and see what they think.
—Dr. Slater
About the Doctors
Dr. Kabbouche is the Director Acute & Inpatient Headache Program, Child Neurologist, Professor UC Dept of Pediatrics. She has been treating children and adolescents with migraine for the last 24 years in the headache center at Cincinnati Children Hospital, and has been the director of the headache center since 2022. Dr. Kabbouche is also involved in different research studies.
Dr. Slater is a Pediatric Psychologist and Professor also at Children’s Hospital Cincinnati where she specializes in the treatment of children and adolescents with chronic pain. She treats children with headaches, abdominal pain, joint pain, sickle cell disease and other conditions. She was inspired to pursue a career in pediatric psychology by her love for working with children, and she wants to help children and adolescents who are dealing with chronic health conditions live full lives and reach their goals.
Cincinnati Children’s Hospital Headache Center
The goal of the headache center is primarily to improve the outcome of pediatric headache, and the disability of the disease.