Residency · Residency · Pediatrics

Pediatric Headache and Migraine

Overview

Headache is one of the most common complaints in pediatric practice, with prevalence increasing with age. By age 18, approximately 75% of children have experienced significant headache. Migraine is the most common primary headache disorder in children, affecting about 10% of adolescents. Tension-type headache is common but less frequently brought to medical attention. The critical clinical skill is identifying red flags for secondary headache (tumor, infection, increased intracranial pressure) while avoiding unnecessary neuroimaging.

Classification (ICHD-3)

Primary Headaches

Primary headaches include migraine (with or without aura), tension-type headache, and trigeminal autonomic cephalalgias (cluster headache, which is rare in pediatrics).

Secondary Headaches

Secondary headaches arise from infection (meningitis, sinusitis), increased ICP (tumor, hydrocephalus, idiopathic intracranial hypertension), trauma (concussion, subdural hematoma), vascular causes (AVM, stroke, venous sinus thrombosis), medication overuse, and systemic illness (hypertension, carbon monoxide poisoning).

Migraine in Children and Adolescents

Diagnostic Criteria (ICHD-3, Pediatric Modifications)

Diagnosis requires 5 or more attacks fulfilling criteria. The duration is 1-72 hours (shorter than in adults; can be as brief as 2 hours in children). At least 2 of 4 headache features must be present: unilateral location (may be bilateral in children), pulsating quality, moderate-to-severe intensity, or aggravation by activity. At least 1 of 2 associated features is required: nausea or vomiting, or photophobia and phonophobia. Aura, when present, involves visual phenomena (scotoma, zigzag lines, fortification spectra), sensory symptoms (tingling), or speech disturbance and precedes the headache by 5-60 minutes.

Pediatric-Specific Features

Pediatric migraine is often bilateral (frontal or temporal) rather than unilateral, which differs from the adult pattern. Duration is shorter than in adults. Prominent associated symptoms include nausea and vomiting (which may be more prominent than the headache itself) and abdominal pain. Pallor and a desire to sleep are common. Childhood periodic syndromes, considered migraine equivalents, include cyclic vomiting syndrome, abdominal migraine, benign paroxysmal vertigo of childhood, and benign paroxysmal torticollis of infancy.

Red Flags for Secondary Headache (Mnemonic: SNOOP)

The SNOOP mnemonic identifies warning signs: Systemic symptoms (fever, weight loss, immunocompromised status), Neurologic signs (papilledema, focal deficits, ataxia, altered consciousness), Onset that is sudden or thunderclap (subarachnoid hemorrhage until proven otherwise), Older child with new onset progressive headache, and Positional quality, Papilledema, or Progressive worsening.

Additional Red Flags Specific to Children

Additional concerning features include headache awakening the child from sleep or present immediately upon waking, progressive increase in frequency and severity, new headache in a child under 5 years, change in personality or school performance, occipital headache in young children (which raises concern for posterior fossa tumor), and headache worsened by Valsalva maneuvers (coughing, straining).

<image>Red flag assessment checklist for pediatric headache showing warning signs requiring urgent neuroimaging (sudden thunderclap onset, papilledema, focal neurologic deficits, headache awakening from sleep, progressive worsening, age under 5 years) versus reassuring features suggesting primary headache disorder (family history of migraine, episodic with symptom-free intervals, normal neurologic exam)</image>

Neuroimaging Indications

MRI is preferred over CT (no radiation) and is indicated when red flag features are present. Emergent CT is indicated for thunderclap headache (to rule out subarachnoid hemorrhage), acute focal neurologic deficit, altered mental status, or post-traumatic headache. Neuroimaging is not indicated for a typical migraine pattern with normal neurological examination or for tension-type headache. The AAN/AHS Practice Parameter states that neuroimaging is not recommended for recurrent headaches with normal neurological exam and no red flags.

Acute Migraine Treatment

Principles

Treatment should begin early, as medications work best at headache onset (within 1 hour). A stratified approach based on severity is appropriate, combining pharmacotherapy with rest in a dark, quiet room.

First-Line Medications

Ibuprofen at 10 mg/kg (maximum 400-600 mg) is the most effective over-the-counter option and is superior to acetaminophen in trials. Acetaminophen at 15 mg/kg (maximum 1000 mg) is an alternative when NSAIDs are contraindicated. Triptans are used for moderate-to-severe migraine not responding to NSAIDs: almotriptan is FDA-approved for ages 12 and older, rizatriptan is FDA-approved for ages 6 and older (with a useful ODT formulation), sumatriptan nasal spray is FDA-approved for ages 12 and older and is useful when vomiting prevents oral administration, and zolmitriptan nasal spray is approved for ages 12 and older. Safety in adolescents is well established, though data in young children remain limited. Antiemetics include ondansetron at 0.15 mg/kg IV or PO, and prochlorperazine at 0.15 mg/kg IV, which also has headache-aborting properties.

ED Management of Severe/Refractory Migraine

Emergency department management includes IV fluids (patients are often dehydrated from vomiting), ketorolac at 0.5 mg/kg IV (maximum 30 mg) as an effective parenteral NSAID, prochlorperazine at 0.15 mg/kg IV (maximum 10 mg) given with diphenhydramine to prevent dystonia, metoclopramide at 0.1-0.2 mg/kg IV (maximum 10 mg) for antiemetic and headache-aborting effects, magnesium sulfate at 25-50 mg/kg IV (maximum 2 g) especially for migraine with aura, and dexamethasone at 0.5 mg/kg IV (maximum 10 mg) to reduce 24-72 hour recurrence. Opioids should be avoided due to poor efficacy, risk of medication overuse headache, and rebound.

Preventive Therapy

Non-Pharmacologic (First-Line)

Lifestyle modifications include maintaining a regular sleep schedule, adequate hydration, regular meals, and exercise. Triggers should be identified and avoided, including stress, sleep disruption, skipped meals, caffeine, and screen time. A headache diary should track frequency, duration, triggers, and medication use. Biofeedback and cognitive behavioral therapy have evidence supporting their efficacy and should be offered as part of comprehensive management. The CHAMP trial showed that CBT plus amitriptyline was superior to amitriptyline alone.

Pharmacologic Prevention (When Needed)

Pharmacologic prevention should be considered when there are 4-6 or more headache days per month, significant disability, frequent school absences, or acute medications are failing. The landmark CHAMP trial (2017) showed that amitriptyline and topiramate were not superior to placebo for pediatric and adolescent migraine prevention. The high placebo response rate (approximately 60%) in pediatric migraine trials complicates interpretation. Despite this result, these medications are still used in practice when non-pharmacologic approaches fail.

Options

Amitriptyline is given at 0.25-1 mg/kg/day at bedtime, with side effects including sedation, weight gain, and dry mouth; an ECG is recommended due to QT prolongation risk. Topiramate is given at 1-3 mg/kg/day, with side effects including weight loss, cognitive dulling, paresthesias, and nephrolithiasis; it is teratogenic. Propranolol at 1-3 mg/kg/day should be avoided in asthma and may cause fatigue and exercise intolerance. Cyproheptadine at 0.25-0.5 mg/kg/day is useful in young children under 6 years, with sedation and weight gain as side effects. Valproate is rarely used due to teratogenicity and side effects and should be avoided in adolescent females. Nutraceuticals include magnesium (400 mg/day), riboflavin (200-400 mg/day), and CoQ10 (100-300 mg/day), which have modest evidence and are generally safe.

CGRP Inhibitors

Anti-CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are FDA-approved for adults, with emerging data in adolescents. Some adolescents receive these off-label when standard preventives fail. Limited pediatric safety and efficacy data exist, and clinical trials are ongoing.

Medication Overuse Headache (MOH)

Regular analgesic use of 10-15 or more days per month can paradoxically worsen headache frequency. The thresholds are 15 or more days per month for NSAIDs, 10 or more days for triptans, and 10 or more days for combination analgesics. Treatment involves gradual withdrawal of the overused medication with bridge therapy and initiation of preventive medication. Patients should be educated to limit acute medication use to 2 or fewer days per week.

<image>Comprehensive management approach to pediatric migraine showing acute treatment ladder (ibuprofen first, triptans second, IV rescue in ED), non-pharmacologic prevention strategies (sleep hygiene, hydration, CBT, biofeedback), and pharmacologic prevention options with CHAMP trial results demonstrating high placebo response rate and implications for treatment decisions</image>

Clinical Pearls

Pediatric migraine is often bilateral and shorter in duration than adult migraine, so the ICHD-3 pediatric modifications should be used for diagnosis. A normal neurological examination in a child with recurrent episodic headaches is highly reassuring, and neuroimaging is almost never needed. Ibuprofen at adequate dose (10 mg/kg) given early is the most effective acute treatment; timing matters more than medication choice. The CHAMP trial showed amitriptyline and topiramate were not superior to placebo, underscoring the importance of non-pharmacologic strategies (lifestyle modification, CBT, biofeedback) before reaching for medications. Medication overuse headache is increasingly recognized in adolescents, and frequency of analgesic use should be screened at every headache visit. Cyclic vomiting syndrome, abdominal migraine, and benign paroxysmal vertigo are migraine equivalents, and a family history of migraine supports the diagnosis.

Key Controversy: CGRP Inhibitors in Adolescent Migraine

Anti-CGRP monoclonal antibodies have revolutionized adult migraine prevention. Off-label use in adolescents is increasing, especially for refractory cases. Concerns include limited pediatric safety data and unknown effects on the developing brain (CGRP plays roles in neurodevelopment, cardiovascular regulation, and bone metabolism). Cost is approximately $600-700 per month, and insurance coverage for adolescents is inconsistent. Ongoing clinical trials with fremanezumab and galcanezumab in adolescents will inform future guidelines. The current recommendation is to reserve these agents for adolescents with refractory migraine who have failed two or more standard preventives and non-pharmacologic approaches.

References

• Powers SW, et al. Trial of Amitriptyline, Topiramate, and Placebo for Pediatric Migraine (CHAMP). N Engl J Med. 2017;376(2):115-124.
• Oskoui M, et al. Practice Guideline Update: Pharmacologic Treatment for Pediatric Migraine Prevention (AAN/AHS). Neurology. 2019;93(11):500-509.
• Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd Edition. Cephalalgia. 2018;38(1):1-211.
• Kacperski J, et al. The Optimal Management of Headaches in Children and Adolescents. Ther Adv Neurol Disord. 2016;9(1):53-68.
• Richer L, et al. Drugs for the Acute Treatment of Migraine in Children and Adolescents. Cochrane Database Syst Rev. 2016;(4):CD005220.

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