Paeds · neurology-neurodisability-and-neuromuscular
Headache and migraine in children
Also known as Paediatric migraine · Childhood migraine · Migraine without aura in children · Migraine with aura in children · Tension-type headache in children · Primary headache in children · Chronic migraine in children
Fellowship guide to headache and migraine in children: the ICHD-3 criteria that separate migraine from tension-type headache, the primary-versus-secondary decision driven by the SNNOOP red flags, the acute abortive pathway built around ibuprofen and paracetamol with a triptan for moderate-to-severe attacks, the prophylaxis ladder that begins with lifestyle and cognitive behavioural therapy and confronts the CHAMP trial finding that amitriptyline and topiramate are no better than placebo, and the trap of medication-overuse headache.
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Target exams
Red flags
- A headache that reaches maximum intensity within one minute (thunderclap) is a subarachnoid haemorrhage until proven otherwise - it is never a primary migraine
- An occipital headache in a child is unusual and warrants neuroimaging to exclude a posterior fossa or cervicomedullary lesion
- Focal neurological deficit, papilloedema, ataxia, or a depressed conscious state argues for raised intracranial pressure or a space-occupying lesion, not a primary headache
- A headache that wakes a child from sleep or is worse on waking with early-morning vomiting suggests raised intracranial pressure
- A progressive worsening pattern, a new headache in a child under 5 years, or systemic features such as fever and weight loss demand exclusion of a secondary cause
- Acute medication on two or three days a week or more risks medication-overuse headache - take a careful analgesic diary
Life stages
Care settings
Clinical exam formats
Board mappings
- Applies the ICHD-3 criteria to distinguish migraine from tension-type headache in a child
- Screens every recurrent headache for SNNOOP red flags that point to a secondary cause
- Initiates acute abortive therapy with ibuprofen or paracetamol and recognises when a triptan is indicated
- Confronts the CHAMP trial evidence that amitriptyline and topiramate are no better than placebo and frames prophylaxis around lifestyle and cognitive behavioural therapy
- Distinguishes episodic migraine, chronic migraine, and status migrainosus and adjusts the threshold for prophylaxis accordingly
- Identifies and reverses medication-overuse headache through an analgesic-weaning plan
- ICHD-3 diagnostic criteria for migraine without aura, migraine with aura, and tension-type headache in children
- The acute abortive ladder and the prophylaxis ladder, including the role of triptans and the CHAMP evidence
- Red flags for secondary headache and the indications for neuroimaging
- Takes a focussed headache history and screens for red flags at the bedside
- Communicates the reassuring prognosis of primary headache and the lifestyle and behavioural plan to an anxious family
- Justifies non-imaging for a recurrent headache that meets primary criteria without red flags
- Level 1: Recognition of migraine and tension-type headache and exclusion of secondary causes
- Level 2: Acute management and the stepped introduction of prophylaxis
- Level 3: Long-term management of chronic migraine, disability assessment with PedMIDAS, and prevention of medication-overuse headache
- ICHD-3 criteria for paediatric migraine with and without aura and the features that distinguish it from tension-type headache
- Evidence base for acute treatment (ibuprofen, paracetamol, triptans) and the CHAMP trial for prophylaxis
- Assessment of the child with recurrent headache and the red-flag screen
- Interpretation of headache frequency, disability, and analgesic use for family counselling
- Structured explanation of the acute and preventive plan and the lifestyle foundation
- American Academy of Neurology and American Headache Society 2019 guideline for pharmacologic prevention of pediatric migraine
- Acute treatment with ibuprofen and paracetamol and the role of triptans in adolescents
- Red-flag recognition and the avoidance of medication-overuse headache
- Recognition of headache as a common complaint that needs a structured red-flag screen, not reflex imaging
- Staged acute treatment and the stepped introduction of prophylaxis built on lifestyle and cognitive behavioural therapy
- Family communication around the benign prognosis of primary headache and the plan for disabling migraine
- Canadian approach to recurrent paediatric headache and the restrained use of neuroimaging
- Acute treatment and the CHAMP-informed approach to preventive drugs
- Counselling on lifestyle, cognitive behavioural therapy, and the avoidance of medication-overuse headache
Overview & Definition
Picture the 11-year-old who has missed a day of school each fortnight for a year with a throbbing headache, nausea, and a need to lie in a dark room, and whose mother is now asking whether she needs a brain scan. That child carries the whole teaching point of paediatric headache: the diagnosis is almost always clinical, the workup is selective, and the management is built on lifestyle and behavioural medicine more than on drugs. The single most important first question is not which drug to give but whether the headache is primary or secondary, because missing a secondary cause is the catastrophic error and over-investigating a primary headache is the common one. [1] [2]
A headache is primary when it is the disease itself, and migraine and tension-type headache together account for the overwhelming majority of recurrent paediatric headache. Migraine is defined by the ICHD-3 as at least five attacks of headache lasting two to 72 hours with characteristic features, while tension-type headache is bilateral, pressing, mild to moderate, and lacks the nausea and aggravation that define migraine. A headache is secondary when it is a symptom of another disorder, whether infection, raised intracranial pressure, a vascular event, or a tumour, and the red-flag screen exists to separate these two worlds. [1]
Recurrent headache is common. The systematic review by Abu-Arafeh and colleagues put the overall prevalence of headache in children and adolescents at around 60 per cent over the preceding year and the prevalence of migraine at between 5 and 15 per cent, rising steeply through adolescence. Girls overtake boys after puberty, and the burden falls disproportionately on adolescents, who lose school days and quality of life to attacks that are often untreated. The challenge for the clinician is to make the diagnosis confidently, to exclude the dangerous minority, and to resist the reflex to scan every head that hurts. [2]
References12ShowHide
- [1]Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia, 2018.PMID 29368949
- [2]Abu-Arafeh I, Razak S, Sivaraman B, Graham C Prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies. Dev Med Child Neurol, 2010.PMID 20875042
- [3]Lewis D, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein S Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology, 2004.PMID 15623677
- [4]Oskoui M, Pringsheim T, Billinghurst L, et al. Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology, 2019.PMID 31413170
- [5]El-Chammas K, Keyes J, Thompson N, et al. Pharmacologic treatment of pediatric headaches: a meta-analysis. JAMA Pediatr, 2013.PMID 23358935
- [6]Powers SW, Coffey CS, Chamberlin LA, et al. Trial of Amitriptyline, Topiramate, and Placebo for Pediatric Migraine. N Engl J Med, 2017.PMID 27788026
- [7]Powers SW, Kashikar-Zuck SM, Allen JR, LeCates SL, Slater SK, Zafar M, Kabbouche MA, O'Brien HL, Shenk CE, Rausch JR, Hershey AD Cognitive behavioral therapy plus amitriptyline for chronic migraine in children and adolescents: a randomized clinical trial. JAMA, 2013.PMID 24368463
- [8]Richer L, Billinghurst L, Linsdell MA, et al. Drugs for the acute treatment of migraine in children and adolescents. Cochrane Database Syst Rev, 2016.PMID 27091010
- [9]Ho TW, Pearlman E, Lewis D, et al. Efficacy and tolerability of rizatriptan in pediatric migraineurs: results from a randomized, double-blind, placebo-controlled trial using a novel adaptive enrichment design. Cephalalgia, 2012.PMID 22711898
- [10]McDonald SA, Hershey AD, Pearlman E, et al. Long-term evaluation of sumatriptan and naproxen sodium for the acute treatment of migraine in adolescents. Headache, 2011.PMID 21797863
- [11]Linder SL, Mathew NT, Cady RK, Finlayson G, Ishkanian G, Lewis DW Efficacy and tolerability of almotriptan in adolescents: a randomized, double-blind, placebo-controlled trial. Headache, 2008.PMID 18484981
- [12]Casanova A, Vives-Mestres M, Donoghue S, et al. The role of avoiding known triggers, embracing protectors, and adhering to healthy lifestyle recommendations in migraine prophylaxis: Insights from a prospective cohort of 1125 people with episodic migraine. Headache, 2023.PMID 36651502