Migraine in Children

Timothy C. Hain, MD •Page last modified: August 20, 2020

You may also be interested in our many other pages on migraine on this site

Epidemiology of migraine in children.

Prevalence
Migraine prevalence by age (Stewart et al, 1994) . Dashed line are females, solid line, males. This was a very large study.

As an overview, only about 5% of children younger than 12 have migraine. At puberty, while both genders develop more migraine, the rate of growth is much higher in women. In the figure above, it is clear that migraine increases with age and is far more common in women. The data are not aligned on menarche or menopause. It seems likely that were the female data analyzed this way, there would be a much sharper inflection around 12 years old in women, as well as a second spike at menopause.

Lewis et al. (2004), in a practice parameter for the evaluation of pediatric and adolescent headache, reported a meta-analysis of six prevalence studies involving 13,130 children. Migraine was reported in 1.2% to 3.2% of those aged 3 to 7 years, 4% to 11% of children aged 7 to 11 years, and 8% to 23% of children aged 11 to 15 years or older. There was increasing prevalence with age as well as a shifting from a slight male predominance to a female predominance in adolescents. There were many more children with recurrent headaches than "migraine". Of course, migraine is a diagnosis defined by a commitee (the IHS), and it seems very likely that many of the recurrent headaches have the same mechanism for headaches as the commitee defined patients.

According to Jahn et al (2011), about 5.7% of 10 year olds have "vestibular vertigo", and about 40% of them, vestibular migraine. In other words, they suggest that roughly 2.5% of the 10 year old population has vestibular migraine. We think this is a very high estimate, as only 1% of adults are thought to have vestibular migraine (Neuhauser et al, 2006).

Migraine in children is disruptive of school performance (Arruda, 2012).

Specific migraine disorders in children:

The IHS criteria for diagnosis of migraine are found here. There are many disorders, possibly migranous, that don't "fit" the IHS criteria. Some of those that can cause vertigo are listed below.

Benign Paroxysmal Vertigo of Childhood

This is a disorder of uncertain origin, possibly migrainous. It's initials (BPV) are easily confused with those of Benign Paroxysmal Positional Vertigo (BPPV), but it is not caused by the same mechanisms. This disorder consists of spells of vertigo and disequlibrium without hearing loss or tinnitus (Basser, 1964). The majority of reported cases occur between 1 and 4 years of age, but this syndrome seems indistinguishable from benign recurrent vertigo (BRV, see following) in adults which is presently attributed to migraine, or so-called "vestibular Menieres", which is also attributed to migraine. The differential diagnosis includes Menieres disease, vestibular epilepsy, perilymphatic fistula, posterior fossa tumors, and psychogenic disorders.

Cyclic Vomiting

This is a very disturbing disorder in which persons suddenly develop vomiting, generally without headache or hearing symptoms. It usually responds to migraine prevention medications, as well as some abortives. See this page for more.

Treatment of Migraine in Children.

Acute treatments of migraine in children:

According to Silver et al (2008), only ibuprofen and sumatriptan have been shown to be more effective than placebo. On the other hand, there is a reasonable literature suggesting that dopamine blockers (such as metoclopramide) are useful in the pediatric acute migraine care.

In the ER for treatment of migraine in children includes dopamine antagonists such as prochlorperazine, metoclopramide, or chlorpromazine, as well as analgesics such as acetaminophen and ibuprofen or ketorolac (Richer et al, 2010; Walker and Teach, 2008). Intravenous prochlorperazine has been reported effective in acute confusional migraine (Khatri et al, 2009).

According to Papetti et al (2010), almotriptan was approved for treatment by the FDA of adolescent migraine. Nasal sumatriptan and nasal zolmitriptan were approved for acute treatment of adolescent migraine by the EMEA. Effective doses for Sumatriptan NS are reportedly 10 mg for children weighing < 40 kg, and 20 mg for children > 40 kg. As of 2010, no conclusive data was available regarding use of oral or subcutaneous sumatriptan preparations in children or adolescents, but in general, a positive effect is noted. Berenson et al (2010), reported reasonable responses to oral almotriptan (12.5) in adolescents.

DHE, dihydroergotamine, given intravenously has been reported effective in children and adolescents(Kabbouche et al, 2009).

According to Sheridian et al (2012), subanesthetic doses of propofol are effective. We have also heard that IV midazolam can be effective. While these medications would certainly be effective in calming children down, we think that giving general anesthetics to children is too risky to be practical.

Diet and lifestyle treatment of migraine in children.

Our suggestions for dietary management of migraine in children can be found on this single page migraine-diet handout

As in adults, one starts with behavioral/dietary changes. Diet, good sleep and avoidance of sun was reported by Eidlitz-Markes (2010) as being effective in children younger than 6. Other suggested strategies are to hydrate, and to avoid artificial sweeteners. We do not know of any literature that establishes that this is effective, but on the other hand, lack of evidence is not evidence of lack.

Our suggestions for patients in our clinical practice are confined to diet/sleep. Regarding diet, MSG is often the biggest trigger as it is commonly found in "junk" food such as "Cheetos" and "Pringles" chips. Chocolate can also be a problem. Lots of cheese (such as in pizza) is sometimes a problem. Lots of caffeine (such as in soda) also can be problematic.

Medication for prevention of migraine in children. (there is little evidence that these work)

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In children who are developing their brains and going to school, but who are sometimes old enough to have children of their own, we think it is best to be very conservative about medications. Here we organize treatment of migraine in chilidren in the same categories as treatment of migraine in adults. As an overview, there is little data, and what little there is suggests there is no "magic bullet". Common treatments for prevention of migraine in children, amitriptyline and topiramate, appear to be no different in effect than placebo (Powers et al, 2016). Others that are not clearly better than placebo include sodium valproate, botulinum toxin in jection, nimodipine, and flunarizine. (Szperka et al, 2020). It is possible however that these are effective in subgroups.