Many people experience their first migraine attack in childhood. This can be a difficult and scary time for children and their families. From limited treatment options, to missing school and activities with friends and families, migraine presents children with a lot of challenges, and can seem overwhelming..
Early diagnosis and effective treatment is essential, as it reduces the risk of disease chronification. Yet, many children 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 children with migraine face, and help guide families on how best to support their child and manage treatment.
Many thanks to Dr. Sara Pavitt, a board-certified pediatric neurologist and headache specialist, for her help with this project and answers to questions.
Watch this video with Dr. Pavitt as she talks about how migraine impacts children, and best practices to manage it.
Watch Our Videos: Children with Migraine
Frequently Asked Questions
General Migraine Information
10-15% of children have migraine, with chronic migraine occurring in 1-2%.
—Dr. Pavitt
The average age of onset for migraine is around 8 years old for boys and 9 years old for girls. Migraine can be diagnosed as early as age 3, but becomes more common and more frequent around adolescence.
—Dr. Pavitt
The clinical diagnostic criteria for pediatric migraine include:
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At least 5 migraine attacks
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Headache lasting 2-72 hours (shorter than adult criteria)
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At least two of these characteristics:
1. Pulsating pain
2. Moderate to severe intensity (preventing normal activities)
3. Aggravated by physical routine activity -
Associated symptoms like nausea, vomiting, or light/sound sensitivity
There is no need for blood tests or imaging to confirm migraine. The diagnosis is based on a detailed patient history and symptom pattern. The key thing we are looking for is that the attacks significantly impact the child's ability to perform daily activities.
—Dr. Pavitt
Migraine is often misunderstood and under-diagnosed in both children and adults. Stigma is prevalent and many people incorrectly believe migraine doesn't happen in children. Many healthcare providers don't recognize migraine symptoms in children.
It's important that we believe children's symptoms and recognize that migraine can be diagnosed as early as age 3. We must understand that migraine can cause significant disability and advocate for proper diagnosis and treatment.
—Dr. Pavitt
Early intervention is crucial. Migraine is a progressive disease, and early diagnosis can help prevent chronification. Key steps for pediatricians include:
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Recognize early symptoms, even in young children (as early as 3-4 years old)
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Look for signs like:
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Frequent episodes of headache
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Wanting to retreat to dark, quiet spaces
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Abdominal symptoms
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Irritability during attacks
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Missed school or activities
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Create a holistic treatment plan that includes:
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Disease education
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Lifestyle regularity (consistent sleep, meals, hydration)
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Identifying potential triggers
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Considering both pharmacologic and non-pharmacologic strategies
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Exploring behavioral therapies
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Discussing 504 school accommodations
Early intervention can significantly reduce disability and help children build lifelong management strategies. The goal is to empower children and minimize the impact of migraine on their daily life.
—Dr. Pavitt
There are several unique challenges in diagnosing migraine in children:
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Symptom Differences:
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Children's headaches tend to be more bilateral, unlike adult migraines which are often unilateral
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More likely to experience abdominal symptoms rather than head pain
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May have difficulty articulating their symptoms
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Attacks can manifest through irritability or wanting to retreat to quiet spaces
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Detection Challenges:
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Young children may not be able to clearly describe their symptoms
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Requires "detective work" by healthcare providers
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Need to observe behavioral changes during attacks
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Look for patterns like vomiting, nausea, sensory overload
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Age-Related Variations:
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Migraine symptoms change as children grow
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Before puberty, symptoms are different from adolescent presentations
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More abdominal symptoms in younger children
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Classic head pain becomes more prominent after puberty
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Diagnostic Complexity:
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Clinical diagnosis without specific tests
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Requires tracking at least five distinct attacks
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Need to understand how attacks impact daily functioning
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Must differentiate from other childhood headache conditions
Believing children and carefully observing their symptoms is so important.
—Dr. Pavitt
Treatment Options
A holistic approach is key for several critical reasons:
Comprehensive Treatment Rationale:
1. Migraine is a complex neurological disorder
- Affects multiple aspects of a child's life
- Not just a simple headache
- Impacts physical, emotional, and social functioning
2. Disability Prevention
- Migraine is the second leading cause of disability in 15-49 age group
- Early, comprehensive intervention can significantly reduce long-term impact
- Goal is to minimize disability and maintain quality of life
3. Multifaceted Treatment Components:
- Disease education
- Addressing associated health conditions
- Lifestyle regularity
- Acute and preventive treatment strategies
- Behavioral therapies
- School accommodations
- Psychological support
4. Long-Term Management
- Build lifelong coping strategies
- Provide patients with a "treatment toolbox"
- Empower children to manage their condition
- Reduce stigma and improve self-understanding
5. Personalized Care
- Each child's migraine experience is unique
- Treatment must be tailored to individual needs
- Considers physical, emotional, and social factors
The goal is not just treating symptoms, but helping children thrive and achieve their dreams despite living with migraine.
—Dr. Pavitt
Medical devices are part of a holistic treatment approach, giving children more options and a sense of agency in managing their migraine. There are three FDA-cleared medical devices for children currently available: Nerivio, gammaCore and SAVI Dual
Not every device works for every child, and devices often require patient willingness and commitment. But devices can be combined with other treatments, can easily be used at school, and can be revisited as the child grows and their needs change.
—Dr. Pavitt
There are currently three FDA-cleared medical devices for children:
1. Nerivio
- FDA-cleared for children as young as 8 years old
- The only FDA-cleared device for children under 12 years old
- Can be used both preventively and during attacks
- Allows child to control stimulation
2. gammaCore & SAVI Dual:
- These two devices are FDA-cleared for children 12 years and older
- Can be used preventively and during attacks
There are several advantages to utilizing medical devices in the migraine treatnent plan for children:
- Alternative to medication
- Potentially less invasive
- Can be integrated with other treatment strategies
- Helps children feel empowered in managing their condition
- Can be used at school during classes
Not every device works for every child, and devices often require patient willingness and commitment. But devices can be combined with other treatments and can be revisited as the child grows and needs change.
—Dr. Pavitt
Currently, we are seeing a large increase in health insurance plans covering the Nerivio device. If you have a child with migraine and want to see if a device is covered, please check the Nerivio website for more information. The company is also happy to work with parents on getting insurance coverage if it is not already available.
There are fewer treatments available to children due to a lack of extensive clinical trials in pediatric populations, combined with ethical challenges in conducting medication studies with children. Therefore, medications are often used "off-label" based on adult research.
However, the landscape of pediatric migraine treatment is rapidly evolving with more research and targeted therapies being developed.
—Dr. Pavitt
There is currently only one FDA-approved medication for migraine prevention in children:
Topiramate (Topamax)
- Approved for children ages 12-17
- Only FDA-approved prescription medication for pediatric migraine
There is an increasing focus on developing migraine-specific treatments for pediatric patientsThere are ongoing clinical trials for CGRP-targeted medications, with the first CGRP medication potentially submitting for FDA approval for children as young as 6.
—Dr. Pavitt
There are several alternatives for managing pediatric migraine:
Behavioral Therapies:
1. Cognitive Behavioral Therapy (CBT)
- Retrains brain's response to pain
- Addresses thoughts, emotions, and behaviors
- Teaches coping strategies
2. Other Behavioral Techniques:
- Biofeedback
- Relaxation therapy
- Hypnosis
- Yoga
- Mindfulness techniques
Lifestyle Strategies:
1. Sleep Management
- Consistent sleep schedule
- Adequate sleep duration
2. Nutrition
- Regular meal timing
- Never skipping breakfast
- Staying hydrated
3. Physical Activity
- Moderate exercise 3-4 days per week
- Can be as effective as preventive medications
Nutraceuticals:
- Riboflavin
- Magnesium
- Coenzyme Q10
- Melatonin
Trigger Management:
- Identifying and mitigating environmental triggers
- Using strategies like wearing sunglasses
- Noise-canceling headphones
- Creating predictable routines
A holistic, personalized approach that combines multiple strategies tailored to the individual child's needs is key.
—Dr. Pavitt
Migraine Attack Symptoms & Triggers in Children
There are several early warning signs parents should watch for:
1. Physical Symptoms:
- Frequent stomachaches
- Wanting to lay down and sleep during activities
- Vomiting
- Sensitivity to light and sound
- Crying and irritability during specific episodes
2. Behavioral Indicators:
- Retreating to darker, quieter environments during attacks
- Wanting to avoid stimulating situations
- Needing to stop normal activities
- Experiencing sensory overload
3. Specific Red Flags Requiring Immediate Medical Attention:
- Rapidly progressive frequency of migraine
- Waking up in the middle of the night with headaches
- Developing a sudden, severe "thunderclap" headache
- Neurologic symptoms like:
* Difficulty using one side of body
* Numbness or tingling
* Unsteadiness while walking
* Trouble grabbing objects
Parents should be "detectives" and observe patterns, and be aware that symptoms can vary widely between children and even between individual attacks.
—Dr. Pavitt
Abdominal migraine is one of the episodic syndromes associated with migraine, particularly common in pediatric patients. Children tend to experience more abdominal symptoms compared to adults.
Characteristics of abdominal migraine include:
- Recurrent gastrointestinal disturbances
- Diffuse abdominal pain
- Nausea
- Vomiting
These symptoms are often more prominent in children before puberty, when headache becomes the primary symptom. Abdominal migraine is part of the early manifestations of a "migrainous nervous system" - indicating a child may be predisposed to developing more classic migraine attacks later in life.
These abdominal symptoms can be an early indicator of migraine and should not be dismissed, as they are a legitimate part of the migraine experience, especially in younger children.
—Dr. Pavitt
Triggers are cumulative, not usually single isolated events. Multiple factors can combine to provoke an attack and not every trigger affects every child the same way.
Potential Triggers to Monitor:
1. Sleep Disruption
- Inconsistent sleep schedules
- Not getting adequate sleep
- Irregular bedtime/wake times
2. Nutrition
- Skipping meals (especially breakfast)
- Dehydration
- Irregular meal timing
3. Environmental Factors
- Bright lights
- Loud noises
- Stress
- Physical activity changes
Mitigation Strategies:
- Wear sunglasses/hats in bright environments
- Use noise-canceling headphones
- Carry water bottles
- Eat regular, consistent meals
- Create predictable daily routines
While triggers are important, patients shouldn't become overly anxious about them. The goal is to create manageable lifestyle modifications that support a more stable nervous system.
It's a good idea to track patterns and be creative about managing potential triggers without creating additional stress.
—Dr. Pavitt
There are four distinct phases of a migraine attack:
1. Premonitory Phase (Hours to Days Before Headache):
- Fatigue
- Cognitive slowness
- Mood changes
- Food cravings
Trigger Confusion: Food cravings during this early phase can be mistakenly interpreted as triggers. For example, a person might think a specific food triggers their migraine, when actually the food craving is an early symptom of the impending migraine.
2. Aura Phase (5-60 minutes):
- Neurologic symptoms
- Most common: Visual changes
- Seeing color blobs, zigzag lights, shimmering vision
3. Headache Phase (2-72 hours in children):
- Pain
- Nausea
- Light/sound sensitivity
- Highest disability period
4. Post-drome Phase:
- Feeling tired
- Difficulty thinking
- Potential neck stiffness
Symptoms can vary between individuals and attacks. Understanding these phases helps patients recognize and potentially manage migraine attacks more effectively.
—Dr. Pavitt
There are several strategies for managing trigger "stacking":
Lifestyle Regularity Strategies:
1. Sleep Management
- Maintain consistent sleep schedule
- Ensure adequate sleep duration
- Create predictable bedtime/wake times
2. Nutrition
- Never skip breakfast
- Carry water bottles and stay hydrated
- Eat regular meals
3. Physical Activity
- Moderate exercise 3-4 days per week
- Find activities patient enjoys
- Use exercise as potential migraine prevention
School Accommodations Strategies:
- Develop 504 plan
- Allow water bottle access
- Potential/quiet space
- Flexibility with assignments during attacks
- Understand migraine qualifies for accommodations
Trigger Mitigation Strategies:
- Wear sunglasses/hats in bright environments
- Use noise-canceling headphones
- Identify personal trigger patterns
- Be creative about managing potential triggers
- Don't become overly anxious about triggers
Behavioral Therapy Strategies:
- Cognitive behavioral therapy
- Biofeedback
- Relaxation techniques
- Mindfulness strategies
It's important to create an individualized, holistic approach that empowers the child and provides flexibility in managing their condition.
- Dr. Pavitt
Signs of Progression/Emergency Symptoms
Understanding disease progression matters. Migraine can worsen if it is not appropriately addressed. Early intervention can prevent long-term disability and help parents take proactive management steps.
Migraine can have a significant impact on a child's life. It can affect school performance, cause missed activities and social interactions, and lead to psychological struggles like depression and anxiety.
Addressing symptoms before they become chronic is crucial. Children need comprehensive, evolving treatment strategies and need help building lifelong management "toolboxes."
Signs of migraine progression include:
- Increasing attack frequency
- More school absences
- Dropping out of activities
- Changes in mood/emotional functioning
- Missed family interactions
Migraine is not just a temporary condition. It requires ongoing, adaptive management, with the goal of minimizing disability and helping children achieve their dreams. While there's no current cure, treatment options are continuously improving. Understanding progression empowers parents to be proactive advocates for their children's health, creating supportive environments that help children thrive despite migraine.
—Dr. Pavitt
The most important indicators to look at are:
- How attacks impact daily functioning
- Changes in the child's ability to participate in normal activities
- Overall quality of life modifications
Early recognition and intervention can help prevent further progression and disability.
Progression Warning Signs:
1. Frequency Indicators
- Increasing number of migraine attacks
- More than 4 migraine days per month
- Developing chronic migraine (15+ headache days monthly)
2. Functional Impact Symptoms
- Missing more school
- Dropping out of previously enjoyed activities
- Inability to participate in family activities
- Significant changes in social functioning
3. Psychological Indicators
- Developing mood changes
- Signs of depression or anxiety
- Decreased emotional functioning
- Social withdrawal
4. Physical Progression Symptoms
- More severe attacks
- Longer duration of attacks
- Increasing intensity of pain
- Development of allodynia
- Persistent nausea
5. Treatment Resistance
- Reduced effectiveness of current treatments
- Needing to change strategies frequently
- Increasing difficulty managing symptoms
—Dr. Pavitt
Treatment should be a collaborative, adaptive process between parents, children, and healthcare providers, always focusing on the child's overall quality of life.
Key Developmental Considerations:
1. Changing Symptoms
- Symptoms differ before and after puberty
- Early childhood: More abdominal symptoms
- Adolescence: More classic head pain
- Migraine presentation evolves with nervous system development
2. Treatment Adaptation Strategies:
- Regularly reassess treatment plan
- Be flexible and open to trying new approaches
- Understand that what works now might not work later
- Continuously build "migraine toolbox"
3. Treatment Approach Evolution:
- Start with non-invasive options
- Incorporate behavioral therapies
- Consider devices/medications as child grows
- Personalize treatment to child's changing needs and interests
4. Holistic Management
- Address physical symptoms
- Support psychological/emotional aspects
- Maintain open communication
- Empower child to understand and manage their condition
5. Long-Term Perspective
- Treatment is about building lifelong management skills
- Help child develop resilience
- Focus on achieving dreams despite migraine
—Dr. Pavitt
I recommend several key advocacy strategies, with the ultimate goal of helping children feel supported, understood, and capable of managing their condition.
School Accommodations:
- Migraine qualifies for 504 accommodations
- Request specific supports like:
* Water bottle access
* Potential rest/quiet spaces
* Flexible assignment deadlines
* Understanding migraine's impact on learning
Medical Advocacy:
- Be a "squeaky wheel"
- Ask for referrals to specialists
- Request comprehensive, holistic treatment plans
- Don't accept "nothing can be done"
Empowerment Strategies:
- Educate child about their condition
- Help them understand migraine is a legitimate neurological disorder
- Teach them to articulate their symptoms and needs
- Build confidence in discussing their health
Specific Advocacy Steps:
- Document migraine frequency and impact
- Bring detailed medical history to appointments
- Ask about all treatment options
- Request explanations of diagnosis and treatment
- Explore both pharmacologic and non-pharmacologic strategies
We must believe a child's experience, and create supportive environments that focus on helping them to achieve life goals despite migraine.
—Dr. Pavitt
There are some specific red flag symptoms requiring immediate medical attention.
Urgent Medical Evaluation Needed If Child Experiences:
1. Headache Progression Symptoms
- Rapidly increasing migraine frequency
- Continuous daily headache that suddenly appears
- Headache that doesn't resolve
2. Nighttime Warning Signs
- Waking up repeatedly in the night with headaches
- Headaches that interrupt sleep
3. Severe Pain Indicators
- "Thunderclap" headache (10/10 pain within one minute)
- Sudden, extremely intense pain
4. Neurological Red Flags
- Difficulty using one side of body
- Numbness or tingling sensations
- Unsteadiness while walking
- Trouble grabbing objects
- Unexpected neurological changes
5. Additional Concerning Symptoms
- Significant changes in headache pattern
- Headaches accompanied by unusual neurological symptoms
- Persistent vomiting
- Changes in consciousness or mental status
These symptoms warrant immediate professional medical evaluation to rule out potentially serious underlying conditions. Parents should trust their instincts and seek medical attention if something seems significantly different or concerning.
—Dr. Pavitt
Final Thoughts from Dr. Pavitt
What is the most important piece of advice you would give to parents and family members who are feeling overwhelmed or frustrated while still trying to support their child with migraine?
"I think it's important to hear that there are so many treatment options for your children. And I know in the moment, being a mom, seeing your kid in pain is one of the worst things that can happen. But recognizing that we have treatment options, that the future is really bright for this condition, that your child is really resilient, and so making sure that we make those connections with the healthcare providers. When you're starting to wonder, does my child have migraine? Not being afraid to advocate for a referral to a neurologist or a pediatric headache specialist. If you feel like you're running into a barrier, I never want a family to feel like there's nothing else that can be done, because there is always something else that can be done. Your child's future is bright, and our goal as healthcare providers and headache specialists is to make sure that your child is able to do and achieve the dreams that they have."
Sara Pavitt, MD, is a board-certified pediatric neurologist and headache specialist and serves as both the Chief of the Dell Children’s Pediatric Headache Center within UT Health Austin Pediatric Neurosciences at Dell Children’s, a clinical partnership between Dell Children’s Medical Center and UT Health Austin, and the Associate Chief of Pediatric Neurology. She specializes in pediatric headaches.
Additionally, Dr. Pavitt is an assistant professor in the Dell Medical School Department of Neurology at The University of Texas at Austin.