Migraine in Children

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.

Thanks to our partner, Theranica, for sponsoring this educational project! You can learn more about the Nerivio medical device for children on their website HERE.

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“Children who have migraine tend to miss more school, they tend to perform more poorly in school, and... the more frequently you have migraine, that tends to predict more poor school performance over time. We want to do everything we can to improve the quality of life."

—Sara Pavitt, MD

Children with Migraine

General Migraine Information

Young girl laying in bed holding stomach in pain

Symptoms & Triggers

Devices, Medications & More

Signs of Disease Progression

General Migraine Information

Treatment Options

Symptoms & Triggers

Signs of Progression

Final Thoughts from Dr. Pavitt

General Migraine Information

How many children in the US have migraine disease?

What’s the average age of children who are diagnosed with migraine?

What are the guidelines for diagnosing children with migraine?

The clinical diagnostic criteria for pediatric migraine include:

At least 5 migraine attacks
Headache lasting 2-72 hours (shorter than adult criteria)
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

How widespread is under-diagnosis, misdiagnosis and mistreatment found with children who live with migraine?

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

How important is early diagnosis in preventing chroniﬁcation, and what can pediatricians do to help intervene before children end up needing to see a specialist?

Early intervention is crucial. Migraine is a progressive disease, and early diagnosis can help prevent chronification. Key steps for pediatricians include:

Recognize early symptoms, even in young children (as early as 3-4 years old)
Look for signs like:

Frequent episodes of headache
Wanting to retreat to dark, quiet spaces
Abdominal symptoms
Irritability during attacks
Missed school or activities

Create a holistic treatment plan that includes:

Disease education
Lifestyle regularity (consistent sleep, meals, hydration)
Identifying potential triggers
Considering both pharmacologic and non-pharmacologic strategies
Exploring behavioral therapies
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

What unique challenges are there in diagnosing migraine in children? E.g. differences in symptoms, etc.

There are several unique challenges in diagnosing migraine in children:

Symptom Differences:

Children's headaches tend to be more bilateral, unlike adult migraines which are often unilateral
More likely to experience abdominal symptoms rather than head pain
May have difficulty articulating their symptoms
Attacks can manifest through irritability or wanting to retreat to quiet spaces

Detection Challenges:

Young children may not be able to clearly describe their symptoms
Requires "detective work" by healthcare providers
Need to observe behavioral changes during attacks
Look for patterns like vomiting, nausea, sensory overload

Age-Related Variations:

Migraine symptoms change as children grow
Before puberty, symptoms are different from adolescent presentations
More abdominal symptoms in younger children
Classic head pain becomes more prominent after puberty

Diagnostic Complexity:

Clinical diagnosis without specific tests
Requires tracking at least five distinct attacks
Need to understand how attacks impact daily functioning
Must differentiate from other childhood headache conditions

Believing children and carefully observing their symptoms is so important.

—Dr. Pavitt

Treatment Options

Why is it important to have a comprehensive holistic approach when treating migraine in children?

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

How can non-invasive medical devices fit into a treatment plan early on?

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

What medical devices are available that are FDA-cleared for children?

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

Are any of the medical devices covered by insurance?

Why are there fewer FDA-approved medications for children?

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

Are there any FDA-approved medications for children?

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

What are some of the other alternatives that can be used for migraine in children?

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

What are some of the earliest warning signs that a child may be having migraine attacks and a parent should talk to their child’s doctor?

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

What is an abdominal migraine, and what are the symptoms to look for?

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

What potential triggers should parents look out for, and ultimately help their children recognize and manage?

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

What are the different phases of migraine attacks and can triggers sometimes be confused with prodrome symptoms?

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

What are some strategies to reduce these triggers or address days when triggers may “stack?” (e.g. school accommodations)

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

Why is it important for parents to know that migraine is a progressive disease?

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

Should parents look for specific symptoms to see if migraine is progressing/ chronifying? (e.g. Allodynia, depression, severe nausea, more frequent or severe attacks, resistance to treatment, etc.)

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

How can parents navigate changes in their children in regards to migraine treatment as their children grow and develop?

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

How can parents, and children themselves, advocate to receive age-appropriate and effective care, and necessary accommodations?

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

What are some "red flag" symptoms in a child's headache that should prompt immediate medical attention beyond a typical migraine attack?

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 parent, seeing your kid in pain is one of the worst things that can happen. But I want you to recognize 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 is important. When you're starting to wonder, does my child have migraine? Do not be 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.

Migraine in Children

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 Our Videos: Children with Migraine

“Children who have migraine tend to miss more school, they tend to perform more poorly in school, and... the more frequently you have migraine, that tends to predict more poor school performance over time. We want to do everything we can to improve the quality of life."

—Sara Pavitt, MD

Children with Migraine

General Migraine Information

How many children in the US have migraine disease?

What’s the average age of children who are diagnosed with migraine?

What are the guidelines for diagnosing children with migraine?

How widespread is under-diagnosis, misdiagnosis and mistreatment found with children who live with migraine?

How important is early diagnosis in preventing chroniﬁcation, and what can pediatricians do to help intervene before children end up needing to see a specialist?

What unique challenges are there in diagnosing migraine in children? E.g. differences in symptoms, etc.

Treatment Options

Why is it important to have a comprehensive holistic approach when treating migraine in children?

How can non-invasive medical devices fit into a treatment plan early on?

What medical devices are available that are FDA-cleared for children?

Are any of the medical devices covered by insurance?

Why are there fewer FDA-approved medications for children?

Are there any FDA-approved medications for children?

What are some of the other alternatives that can be used for migraine in children?

Migraine Attack Symptoms & Triggers in Children

What are some of the earliest warning signs that a child may be having migraine attacks and a parent should talk to their child’s doctor?

What is an abdominal migraine, and what are the symptoms to look for?

What potential triggers should parents look out for, and ultimately help their children recognize and manage?

What are the different phases of migraine attacks and can triggers sometimes be confused with prodrome symptoms?

What are some strategies to reduce these triggers or address days when triggers may “stack?” (e.g. school accommodations)

Signs of Progression/Emergency Symptoms

Why is it important for parents to know that migraine is a progressive disease?

Should parents look for specific symptoms to see if migraine is progressing/ chronifying? (e.g. Allodynia, depression, severe nausea, more frequent or severe attacks, resistance to treatment, etc.)

How can parents navigate changes in their children in regards to migraine treatment as their children grow and develop?

How can parents, and children themselves, advocate to receive age-appropriate and effective care, and necessary accommodations?

What are some "red flag" symptoms in a child's headache that should prompt immediate medical attention beyond a typical migraine attack?

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?

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