Migraine in children is frequently misdiagnosed as other causes of headache, or minimised as a functional complaint, particularly when episodes are accompanied by dramatic vomiting and distress but resolve completely between attacks. The child who is well when seen in a clinical setting between attacks, and who describes episodes that can barely be credited in the retelling, can be frustrating to assess.
The fact that migraine in children differs in its typical presentation from adult migraine compounds the difficulty. Understanding the paediatric pattern – shorter episodes, often bilateral pain, prominent nausea and vomiting, dramatic sensitivity to light and noise, and frequently complete symptom resolution with sleep – allows both correct diagnosis and appropriate treatment.
Healthbooq (healthbooq.com) covers childhood neurological conditions and headache.
What Migraine Is in Children
Migraine is a primary headache disorder characterised by recurrent attacks that are typically associated with nausea, vomiting, and sensitivity to light and sound, often with a strong family history. The International Classification of Headache Disorders (ICHD-3) criteria for migraine without aura in children allow for:
Duration of 2-48 hours (shorter than the adult criterion of 4-72 hours). At least two of: unilateral or bilateral location; pulsating quality; moderate or severe intensity; worsening with routine physical activity. At least one of: nausea or vomiting; photophobia and phonophobia. Not attributed to another disorder.
Migraine with aura involves reversible neurological symptoms (most commonly visual – zig-zag lines, scotoma, flickering lights) that precede or accompany the headache. Aura typically lasts 20-60 minutes. Some children have aura without subsequent headache.
Childhood Migraine Variants
Several migraine variants in children may precede or occur without headache:
Abdominal migraine: recurrent episodes of central abdominal pain (typically lasting 1-72 hours), nausea and vomiting, with complete resolution between episodes. More common in children aged 5-9. Frequently evolves into typical migraine with headache as the child grows.
Cyclic vomiting syndrome: episodic, severe vomiting occurring at predictable intervals, with complete wellness between episodes. Associated with migraine and managed similarly.
Benign paroxysmal vertigo of childhood: sudden brief episodes of vertigo in young children (1-5 years) without hearing loss, sometimes with visual disturbance. Resolves spontaneously.
Impact on Children
Migraine has a significant impact on school attendance and academic performance. A survey by the National Migraine Centre found that children with migraine miss an average of 7 school days per year due to migraine, with further impairment on days they attend school during a migrainous prodrome or postdrome. Quality of life is measurably reduced in children with frequent migraine.
Acute Treatment
Analgesics taken early at onset are the first-line treatment. Ibuprofen (10mg/kg per dose) taken at the very start of the attack – ideally before the headache becomes severe – is the most evidence-supported analgesic for paediatric migraine. Paracetamol is also used. Rest in a dark, quiet room and sleep, if achievable, are highly effective.
Anti-emetics (domperidone, prochlorperazine) are used for nausea and vomiting, and may also help absorption of oral analgesics.
Triptans: sumatriptan nasal spray (10mg) is licensed in the UK for adolescents from age 12, and is effective for moderate-to-severe attacks that do not respond adequately to analgesics. Some paediatric neurologists use triptans off-label at younger ages in children with severe, refractory attacks.
Preventive Treatment
When migraine occurs frequently (typically defined as 4 or more headache days per month causing significant disability), preventive treatment is considered. Options include:
Topiramate (licensed for migraine prevention from age 6): reduces attack frequency and severity. Weight loss is a side effect; care is needed in children who are already lean.
Propranolol: widely used in adults, used in children though evidence in children is limited. Monitor blood pressure.
Amitriptyline: effective for migraine prevention; also helps associated sleep difficulties and mood.
CGRP (calcitonin gene-related peptide) monoclonal antibodies (such as erenumab) are now licensed for migraine prevention in adults and are being evaluated in paediatric trials.
Non-pharmacological approaches with evidence in paediatric migraine include: relaxation training, biofeedback, CBT, and regular sleep, exercise, and meal schedules (migraine is triggered by irregularity in these physiological anchors).
Key Takeaways
Migraine is one of the most common recurrent neurological disorders of childhood, affecting approximately 5-10% of school-age children and up to 28% of adolescents. In children under 12, migraine often presents differently from adult migraine: episodes are typically shorter (2-48 hours rather than 4-72 hours), head pain is more often bilateral (both sides) rather than unilateral, and nausea and vomiting are particularly prominent. Paediatric migraine has a significant impact on school attendance, activity participation, and quality of life. First-line acute treatment is ibuprofen or paracetamol taken at onset; triptans (sumatriptan nasal spray is licensed from age 12) are effective for moderate-to-severe episodes that do not respond to analgesics. Preventive treatment (topiramate, amitriptyline, propranolol) is considered when migraines occur frequently enough to affect daily life.
