Migraine Diagnosis and Management in Children
Diagnostic Approach
Suspect migraine in any child with recurrent headaches that are moderate to severe, especially when accompanied by nausea, vomiting, photophobia, or phonophobia, and strengthen your suspicion with a positive family history. 1
Key Clinical Features to Identify
- Attack duration: In children, migraines last 2-72 hours, which is shorter than the typical adult presentation 1
- Pain characteristics: Attacks are moderate to severe in intensity 1
- Associated symptoms: Look specifically for nausea, vomiting, photophobia (light sensitivity), and phonophobia (sound sensitivity) 1
- Family history: A positive family history of migraine significantly strengthens the diagnosis 1
When Neuroimaging is NOT Needed
- Neuroimaging is NOT routinely indicated for primary headaches in children with a normal neurologic examination 2
- Diagnosis remains predominantly clinical, based on the patient's symptom history 3
Red Flags Requiring Neuroimaging
Order imaging only when these concerning features are present 2:
- Sudden onset "thunderclap" headache
- Rapidly increasing headache frequency or severity
- Headache awakening the child from sleep
- Focal neurologic signs on examination
- Fever accompanying the headache
- Headache worse with Valsalva maneuver
Acute Treatment Strategy
Use ibuprofen at weight-appropriate doses as first-line therapy for mild to moderate migraine attacks. 1
First-Line Acute Treatment
- Ibuprofen is the recommended first-line agent for mild to moderate attacks 1
- NSAIDs are effective for mild-to-moderate attacks 1
- Acetaminophen is also recommended for use in children with acute migraine 4
Critical Medication Overuse Warning
- Limit acute medication use to ≤2 days per week to prevent medication-overuse headache 2
- Medication overuse headache occurs with ≥15 days/month of NSAID use 2
Preventive Therapy
Initiate preventive therapy when migraines adversely affect the child on ≥2 days per month despite optimized acute treatment, or when attacks cause significant school absenteeism or quality of life impairment. 1
First-Line Preventive Options
The following medications are first-line preventive choices 1:
Monitoring Preventive Therapy
- Assess efficacy after 2-3 months at therapeutic dose 2
- Benefits may take several weeks to become apparent 2
- Consider discontinuing preventive medication after 3-6 months of stability to determine if prophylaxis is still needed 2
Non-Pharmacological Management
Implement lifestyle modifications and behavioral interventions as essential components of treatment alongside any pharmacologic therapy. 1
Lifestyle Modifications (All Children Should Receive These)
Behavioral Interventions with Proven Efficacy
Headache Diary
- Maintain a headache diary to identify triggers and monitor treatment effectiveness 5
- Use the diary to track symptomatic days and acute medication use 1
Follow-Up and Monitoring
Schedule follow-up within 2-3 months to assess treatment response using standardized measures. 1
What to Monitor at Follow-Up Visits
- Attack frequency 1
- Attack severity 1
- Migraine-related disability 1
- Adherence to treatment plan 1
- Symptomatic days and acute medication use via headache calendar 1
Assessment Tools
- Use standardized measures to quantify migraine-related disability 1
- The PedMIDAS scale can assess disability in children and adolescents 3
Common Pitfalls to Avoid
- Do not routinely order neuroimaging in children with normal neurologic examinations and typical migraine features 2
- Do not allow frequent acute medication use (>2 days/week), as this leads to medication-overuse headache 2
- Do not delay preventive therapy when the child is adversely affected ≥2 days per month despite optimized acute treatment 1
- Do not expect immediate results from preventive medications—benefits may take several weeks 2
- Do not neglect non-pharmacological interventions—lifestyle modifications and behavioral therapies are essential components, not optional add-ons 1