Migraine in children and adolescents

Migraine in children and young people may be more difficult to spot: here’s what to look out for - and what to do

Migraine in children and young people may not always involve the same symptoms as in adulthood, which can mean it’s overlooked.

Stomach migraine in children (abdominal migraine) is a common reason for seeking NHS care from a GP or specialist, but many children are affected by headache too.

About migraine in children and young people

Migraine is a complex and disabling inherited condition that affects around four to ten per cent of children.

Perhaps because migraine in children can involve subtly different symptoms to adult migraine, half of those affected never receive a diagnosis.

With migraines in children and young people, stomach pains are more frequent. Studies suggest that around 60 per cent of children aged between seven and 15 experience headaches, but a diagnosis of migraine may be delayed because tummy pain, vomiting, travel sickness, limb pain and episodic dizziness can all confuse the picture. Children may experience migraine without headache, which is less common in adults.

Migraine can have severe impacts on the life of a child, affecting their family relationships, school life and social activities.

A late or missed diagnosis can result in poor management of their symptoms, anxiety about future attacks, poor school attendance, inappropriate or ineffective medication use, a loss of confidence and low self-esteem. Severe pain and vomiting that aren’t treated effectively can mean that children often have to remain at home during attacks and are unable to participate in normal daily activities.

The pattern of migraines in teenagers starts to change. Migraine affects boys and girls equally until puberty, after which migraine is more common in girls.

Diagnosing migraine in children

Migraine in children can differ from migraine in adults in several key ways:

• Headache typically affects the forehead and temple areas, or the whole head, rather than just one side
• Abdominal pain and/or vomiting are common and may recur even without headache
• Headache may be only a minor symptom or may not feature at all
• Attacks are often shorter, sometimes lasting less than an hour

As in adults, children are often pale and lethargic.

There is no test to identify migraine, so diagnosis depends entirely on the history and pattern of attacks. A simple headache diary is a really useful tool both for diagnosis and management. You can download our headache diary here.

In otherwise healthy children, recurring bouts of headache or stomach pain with nausea or vomiting are probably caused by migraine if the periods between attacks are free of symptoms.

Sensitivity to light, sounds, smells or touch can also occur, giving further clues to the diagnosis. Some children look pale and yawn for a few hours before the headache starts; others are bursting with extra energy.

Some children may experience migraine aura, typically involving bright, visual zig-zags or blind-spots, that can last up to an hour before the headache starts. Attacks may last only an hour or two, especially if the child can rest in a quiet, dark room and takes simple painkillers quickly.

Girls who get aura should not use contraceptive pills containing oestrogen because of the increased risk of stroke with this medication.

When should I take my child to the doctor?

It may be clear to you, particularly if you have migraine yourself, that your child’s symptoms are typical of migraine. If attacks have obvious causes, symptoms respond to painkillers, and your child is otherwise fit and well, it may not always be necessary to seek a doctor’s advice. A pharmacist may be able to help choose the best acute rescue treatments.

However, you should make an appointment for your child to see a doctor if there is any doubt about the nature or cause of the headaches, if your child seems generally unwell, or if the headaches are interfering with daily activities.

In particular, it is very important to see a doctor for suspected childhood migraine in these circumstances:

• Headaches start before the age of seven
• The headache changes
• An unaccountable increase in frequency, severity or duration of attacks
• Recent problems at school
• Personality or behavioural changes
• Fits or blackouts
• Balance or co-ordination problems
• Failure to grow or attain normal developmental goals

When do I need to see a doctor urgently or call 999?

Increasingly frequent, severe headache, particularly if associated with seizures, persistent vomiting, fever, and blacking out, are all symptoms requiring immediate emergency medical attention.

Triggers for migraine in children

The brain of a migraine sufferer is sensitive to changes in routine. It’s essential, then, to avoid those changes that can trigger attacks.

Irregular eating times, in particular skipping meals or having long periods between meals or overnight, can be a major trigger in this age group, especially during the adolescent growth spurt. Encourage children to eat small, regular snacks of slow-release energy foods and to keep hydrated throughout the day.

Sport and exercise can trigger attacks, probably due to dehydration and their effects on blood sugar. Drinking lots of water and having a snack can help, as can sucking glucose tablets before and during sport, in addition to supplementing meals with mid-morning and mid-afternoon snacks.

Migraine in girls may coincide with puberty and the start of menstruation. Sometimes a monthly pattern can be seen due to hormone fluctuations.

Flickering fluorescent lighting, colds and viruses, working on a computer screen for too long, the stress of exams and schoolwork or poor sleep routines can all contribute to triggering migraine.

Allowing time for rest and relaxation is important in children, who will benefit from a fixed bedtime to ensure sufficient sleep. Avoid screen use for at least an hour before bedtime as the blue light can interfere with sleep quality.

Although a lie-in at the weekend is tempting, this can lead to a migraine attack occurring over the following 24 hours.

People often wonder about food triggers. For the majority of children, it isn’t necessary to restrict foods. Instead, focus on making sure that children have a sensible and regular diet.

Sweet cravings can also be common in the early stages of migraine – so sweets, and chocolate in particular, are often wrongly blamed for triggering migraine.

A few susceptible children have an established link between certain foods and the onset of migraine, but keeping a food diary usually identifies such foods.

Keep a simple migraine diary

Just as in adults, migraine is triggered by a combination of events, rather than one single factor. Encourage your child, if they’re old enough, to keep a daily migraine diary recording any event that is different from the normal routine or which may be relevant.

A migraine diary can help keep track of missed meals, sports activities, stressful lessons, late night study, emotional upsets or other possible triggers. A record of migraine attacks and other headaches should be included, scoring the pain on a range to help the doctor assess the impact.

Look through the diaries with your child, noting patterns of any build-up of triggers, or specific triggers, preceding attacks. This may help for forward planning and managing triggering situations. By minimising the effects of even just one or two aggravating factors, it may be possible to remain below the attack threshold. Treat attacks early to maximise a speedy return to normal activities.

You can download our simple headache diary here.

Treating migraine in children

Resting in a quiet, darkened room, using a hot or cold pack to ease the pain, and gentle massage, may be sufficient to control mild symptoms.

Most children will want to lie down during an attack, and they can be helped by a short sleep sometimes. Encourage your child to eat or drink something, if possible.

If nausea or vomiting is a problem, ask your doctor to prescribe something for this to help the painkillers be absorbed quickly and also minimise these troublesome symptoms. The gut shuts down during migraine, delaying absorption of drugs and reducing their effectiveness.

Medication should be taken in adequate doses as early in an attack as possible. A migraine attack gathers momentum if left too long and delaying treatment often means it is less effective.

Drug treatment should be kept simple. If taken early in an attack, over-the-counter painkillers may be all that is necessary. Syrups or soluble tablets may be preferred as they can be more rapidly absorbed. Soluble or effervescent painkillers can be dissolved in a sweet, fizzy drink to make them more palatable and more effective.

Paracetamol is often considered the drug of choice as it can be given as syrup to even very young children. It is also available as a suppository. Ibuprofen is a more effective alternative. In the UK, aspirin is not recommended for children under the age of 16.

If these aren’t enough to control symptoms, other drugs are available on prescription from your doctor. Some studies have demonstrated the efficacy of triptans in children, but most are still not licensed for children. However, they have been used widely in children and are generally considered safe and well-tolerated. Tablets, melts and nasal spray formulations are available.

It’s worth noting that many over-the-counter combination painkillers contain caffeine, which is not advisable as it stays in children’s bodies for a long time and can reduce sleep quality.

As with adults, children with migraine should completely avoid drugs containing codeine. Migraine is easily aggravated by codeine which can transform episodic headache into chronic daily headaches.

Overuse of acute medication can also itself be a cause of frequent headache. Drugs to treat the symptoms of migraine should not be used regularly on more than two to three days a week.

If children are experiencing frequent attacks of migraine or headache, particularly if these are not responding to simple management strategies, there may be other underlying problems such as depression, bullying at school, or other emotional problems.

Preventing migraine in children

Identifying and then managing triggers is crucial for successful prevention of migraine.

Children also respond well to biofeedback and relaxation techniques, which should be considered before drugs.

Unless the headaches are really disabling, it’s usually not necessary to give children daily drugs to prevent attacks. If your child is suffering more than five or six attacks each month, it’s worth discussing preventative medication with your GP or headache specialist.

Preventative drugs may also be considered where there is concern that attacks are interfering with schoolwork. Children should try new medications before critical periods (such as exam times) to ensure that any drug can be tolerated and that side effects won’t affect their performance. Once the migraine attacks have settled, the preventer can be reduced and then stopped.

Migraine and schools

To make sure your child’s progress at school doesn’t suffer and they are properly supported, it’s worth informing the school. If possible, provide staff with specific written instructions for the management of migraine, stressing the need for early treatment.

In severe cases, an individual Health Care Plan for your child should be drawn up.

Each school will have its own rules regarding treatment. In some schools, teachers or nurses may agree to administer some medication, while elsewhere a parent or guardian may be called to collect the child.

You can help the school to properly control your child’s migraine by sharing this factsheet with them. In particular, draw their attention to the following:

• Two to three children in each class can be affected and, since there is significant under-diagnosis, the real figure could be higher
• Migraine in children can be quite different, and is more likely to involve stomach pain and less likely to include headache
• Attacks can be shorter, so schools should provide opportunities to recover in quiet, appropriate spaces, rather than always sending children home to miss a whole day
• Make sure treatments offered are appropriate for migraine in children, as outlined in this factsheet – and that treatment is always provided early
• Also, make the school aware of common triggers (see this factsheet), or the specific triggers you have identified that affect your child

Remember, timing of medication is essential to be effective in migraine.  If the attack is not treated early, it is much less likely to be effective.  Waiting to see if the attack becomes severe or waiting for parents to arrive may mean the opportunity for effective treatment is lost.

Simple painkillers in adequate doses given at the earliest stage of the attack, followed by an hour’s quiet rest (and preferably sleep) will often mean a child recovers enough to complete the school day.

Education and your rights

Should your child be unfortunate enough to either miss or under-perform in a public exam because of a migraine attack at the time of the assessment, they may be eligible for a post-examination adjustment to their mark. You should ask the school to check the current Joint Council for Qualifications guidance.

Your child may also qualify for additional legal rights if their migraine reoccurs over a period of at least a year and has an adverse effect on their ability to continue normal day-to-day activities. In such cases, their condition could be categorised a disability under the Equality Act 2010, meaning schools have a duty to make reasonable adjustments to avoid any disadvantage. These adjustments could include:

• Devising a Health Care Plan
• Allowing opportunities to drink frequently
• Permitting breaks from working too intensively on computer screens
• Providing opportunities for healthy snacks or a breakfast club, if required
• Substituting yoga or other low-energy activities for team games or sports
• Taking glucose tablets before games, with plenty of fluid and a snack at half-time
• Giving extended timescales for the completion of coursework
• Providing additional time in exams (subject to the agreement of the examination body)
• Allowing opportunities to self-medicate (subject to medical advice) within school or college
• Giving access to a quiet, dark room (a medical room) to lie down during a migraine attack

Section 100 of the Children and Family Act 2014 also places further duties on schools to support children who have medical conditions, with government guidance issued to schools that can be found online.

Find out more

Find out more about migraine in children and adolescents by checking out our special Heads Up podcast episode 10 in series 1 on the subject here.

Book an appointment with the experts: review the best treatment options for you or your child with a leading headache specialist. Beat the misery of migraine and get back to living. Book your consultation through the National Migraine Centre now.