Migraine in children and adolescents

What it is

Migraine in children is the same neurobiological process as in adults — a primary brain disorder, not a vascular problem, with cortical-spreading-depression-related events and trigeminovascular activation — but it presents differently. Younger children often have a much shorter attack (1–4 hours rather than the adult 4–72 hours), the pain is more often bilateral and bifrontal, and the gastrointestinal and autonomic features (nausea, vomiting, abdominal pain, pallor, light and sound sensitivity) are often more prominent than the head pain itself.

Pre-school children may experience the 'periodic syndromes of childhood' that are now classified as migraine equivalents: cyclical vomiting, abdominal migraine, benign paroxysmal vertigo and benign paroxysmal torticollis.

Diagnosis

Diagnosis is clinical, using the International Classification of Headache Disorders (ICHD-3) with the paediatric modification that attacks can be as short as 1 hour. A headache diary kept by the child or parent — date, time, duration, pain side, severity, triggers, what helped — is the most useful diagnostic tool, and far outperforms imaging.

Brain MRI (without contrast) is reserved for atypical features: a sudden 'thunderclap' headache, headache that wakes the child consistently in the early morning, an abnormal neurological examination, a child under 5 with severe headache, or significant worsening over weeks. Routine MRI for typical paediatric migraine is unnecessary, expensive, and often causes incidental-finding-related anxiety.

Lifestyle — the foundation

Lifestyle modification — captured by the SEEDS mnemonic — works as well as most medications and is the foundation of paediatric migraine care:

• Sleep — regular bedtimes; teenagers need 8–10 hours, school-age 9–11 hours, pre-schoolers 10–13 hours. Migraine is exquisitely sensitive to sleep deprivation and sleep excess
• Exercise — at least 60 minutes of moderate activity most days. Aerobic exercise has direct preventive effect on migraine
• Eat — three meals plus snacks; never skip breakfast; adequate hydration. Hypoglycaemia is a powerful trigger
• Diary — a 2–4 week headache diary identifies trigger patterns specific to the individual child (often sleep, certain foods, screens, stress, menstruation)
• Stress — open conversations about school, friendships and family; consider cognitive behavioural therapy (CBT), which has strong evidence in adolescent migraine

Acute treatment

The goal is to abort the attack within 1–2 hours, return to normal activity, and avoid medication-overuse headache. Modern paediatric acute treatment is:

• Mild-moderate attacks: ibuprofen 10 mg/kg (max 400 mg) at the first sign of headache, with food and a drink. Repeat at 4–6 hours if needed
• Paracetamol 15 mg/kg is a less effective alternative
• Anti-emetic: ondansetron 4 mg if vomiting is prominent (especially abdominal migraine)
• Moderate-severe attacks not responding to ibuprofen within 2 hours: a triptan. Paediatric-licensed options (NICE / EMA):
• Rizatriptan 5 mg orodispersible (age 6+) — the most-studied paediatric triptan
• Zolmitriptan nasal spray 5 mg (age 12+) — fastest-acting, useful when vomiting prevents oral medication
• Almotriptan 12.5 mg oral (age 12+)
• Sumatriptan nasal spray (age 12+) is also licensed in some regions
• Combination therapy (ibuprofen + triptan) is more effective than either alone in moderate-severe attacks
• Avoid opioids and butalbital combinations in children — they have a high risk of rebound headache and dependency
• Limit acute medication to no more than 2–3 days per week to avoid medication-overuse headache, which is a major and under-recognised cause of worsening migraine in teenagers

Preventive treatment

Preventive treatment is considered when a child has 4 or more migraine days per month, significant impact on school attendance, or attacks that respond poorly to acute treatment.

The 2017 CHAMP trial (Childhood and Adolescent Migraine Prevention) was a major shift: it found that topiramate, amitriptyline and placebo all produced similar 50% reductions in attack frequency. This means placebo response is large in paediatric migraine and the absolute pharmacological advantage of these older agents is small. CHAMP was widely interpreted as 'lifestyle, biofeedback and CBT first; medication only when these fail'.

• Lifestyle + CBT + biofeedback — the strongest evidence-based 'first prevention', and effective in most adolescents
• Riboflavin (vitamin B2) 200–400 mg/day — evidence-based, low-cost, low-risk preventive in paediatric and adolescent migraine; usually given for 3 months at a time
• Magnesium oxide 9 mg/kg/day — modest evidence, low-risk
• Coenzyme Q10 1–3 mg/kg/day — small studies suggest benefit, low-risk
• Topiramate, amitriptyline, propranolol, flunarizine — used when lifestyle and nutraceuticals fail; effectiveness modest (CHAMP) and individual
• Onabotulinum toxin A — paediatric data from PREEMPT-derivative trials emerging, used off-label in chronic migraine (≥15 headache days/month) in adolescents
• CGRP-pathway therapies — rimegepant 75 mg orally dissolving tablet has paediatric (age 12+) trial data from 2024 with positive results in both acute and preventive use; atogepant adolescent Phase 3 trials reading out 2025–2026; CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) are licensed adult-only in most regions but adolescent trials are ongoing. This is the most promising area in paediatric migraine care

Prognosis

Most children with migraine continue to have migraine into adulthood — but with a long lifestyle-based plan, the great majority lead full lives with manageable attack frequency. About a third of paediatric-onset migraine remits spontaneously by mid-twenties, particularly in boys. School absence and academic impact are common in the most affected children, and a coordinated approach with the school nurse and teachers is part of comprehensive care.

How an educational review can help

Many families arrive at clinic after years of repeated 'gastroenteritis' diagnoses, unnecessary MRIs, or generic 'just take paracetamol' advice. An educational review can place the diagnosis on the modern ICHD-3 criteria, plot the right acute and preventive ladder, and pull together the rapidly-changing CGRP-pathway evidence in paediatric and adolescent migraine.

It is an educational second opinion — not a diagnosis, treatment or prescription — and it does not replace the care of your child's own clinicians.