The child who is fine at the GP appointment but spent the previous evening green, vomiting, lying in a dark room with a hand over their eyes, and was back at the breakfast table apparently normal twelve hours later — this is paediatric migraine. It is often missed or dismissed because the child looks well between attacks. Recognising the pattern matters because the right early treatment shortens attacks, and prevention is available for children who get them frequently. Healthbooq (healthbooq.com) covers paediatric neurology and headache.
Migraine in Children Looks Different
Adult migraine is typically pictured as: severe one-sided pulsating headache for 4–72 hours, often with aura, nausea, and sensitivity to light and noise. Paediatric migraine differs:
- Shorter attacks. ICHD-3 paediatric criteria allow 2 hours, not 4. Many children's attacks last 4–8 hours and resolve completely with sleep.
- Bilateral pain in many children. Headache often across both sides of the forehead or temples rather than the classic one-sided pattern. Unilateral pain becomes more common from late teens.
- Prominent nausea and vomiting. Sometimes more dramatic than the headache itself. Some children describe feeling "really sick" before they can articulate "headache."
- Pallor and dark eye circles. Often noticed by parents as the marker that an attack is starting.
- Rapid recovery with sleep. Many children sleep for an hour or two and wake feeling much better. Adult migraine doesn't typically work this way.
- Strong family history. Usually one or both parents have migraine, sometimes diagnosed and sometimes lifelong "bad headaches" never recognised as such.
How Common
About 5–10 per cent of UK school-age children have migraine. The figure rises with age — up to 28 per cent of teenagers, with girls overtaking boys around puberty. Migraine in children under five exists but is less common.
Diagnostic Criteria
The official ICHD-3 criteria for paediatric migraine without aura:
- Attacks lasting 2–48 hours
- At least two of: unilateral OR bilateral location, pulsating quality, moderate or severe intensity, aggravated by routine physical activity
- At least one of: nausea/vomiting OR photophobia AND phonophobia
- Not attributable to another disorder
For migraine with aura, the diagnostic criteria include reversible neurological symptoms — most often visual (zig-zag lines, blind spots, flashing lights) — lasting 5–60 minutes, before or during the headache.
In practice, the diagnosis is usually clinical: a recurrent pattern of episodes that fit the picture above, in a well child between attacks, with no concerning features.
Childhood Migraine Variants Worth Knowing
Several presentations are migraine without prominent headache:
Abdominal migraine. Recurrent episodes of central abdominal pain lasting 1 to 72 hours, with nausea and pallor, with complete recovery between attacks. Most common in 5–9 year olds. Often evolves into classical migraine in later childhood. Diagnosed clinically after exclusion of other causes of recurrent abdominal pain.
Cyclic vomiting syndrome. Episodes of severe vomiting at predictable intervals — sometimes weekly, sometimes monthly — lasting hours to days, with complete wellness between. Strongly linked to migraine biology; often migraines develop later. Triggers include stress, lack of sleep, illness, dietary irregularity.
Benign paroxysmal vertigo of childhood. Sudden brief vertigo episodes in 1–5 year olds; child clings, looks frightened, may be unable to walk for a few minutes; no hearing loss. Resolves spontaneously over years; many later develop migraine.
Hemiplegic migraine. A rare variant with one-sided weakness as part of the aura. Distinguishing from a stroke is critical; first episodes warrant urgent assessment.
Triggers Children's Migraines Respond To
Common identifiable triggers:
- Skipped meals or low blood sugar. A surprisingly common trigger; many children develop migraine after a missed lunch.
- Dehydration. Children who don't drink enough at school.
- Disrupted sleep. Both too little and too much. Lie-ins on weekends are a classic Sunday-migraine setup.
- Stress. School pressure, social conflict, exams. Many children get migraines in school holidays — the come-down after stress is itself a trigger.
- Bright lights. Strip lights, sunlight on snow, flickering screens.
- Strong smells. Some children are particularly affected by perfumes, petrol fumes.
- Hormonal changes. Migraine often worsens around menarche in girls.
- Specific foods (in a minority): chocolate, cheese, citrus, processed meats, MSG, caffeine. Worth keeping a diary if a pattern is suspected.
A simple migraine diary — date, time, what was happening before, what was eaten, sleep the previous night, severity, what helped — kept for a few weeks identifies most modifiable triggers.
Acute Treatment That Works
The single most important principle: treat early. Migraine that has been progressing for an hour is much harder to abort than migraine treated within 30 minutes of onset.
First-line acute treatment:
- Ibuprofen at full weight-based dose (10 mg/kg) at the first sign of attack. Best evidence base of any analgesic for paediatric migraine.
- Paracetamol at full dose if ibuprofen unavailable or contraindicated. Less effective but useful.
- Dark, quiet room, lie down. Often as effective as medication for many children.
- Sleep if possible. Often resolves the attack in 1–2 hours.
- Cold compress on the forehead helps some children.
- Fluids. Particularly if the child is vomiting or has not been drinking.
For nausea and vomiting:
- Domperidone or prochlorperazine can reduce nausea and help analgesics absorb. Prescription needed; ask the GP.
For attacks not responding to analgesics:
- Sumatriptan nasal spray (10 mg) — licensed in UK from age 12 for moderate-severe migraine that doesn't respond to analgesics. Effective; well-tolerated. Some paediatric neurologists use other triptans off-licence in younger children with refractory migraine.
What doesn't usually help:
- Codeine and other opioids — not recommended for paediatric migraine; can worsen with regular use
- Caffeine in large doses — though small amounts in over-the-counter painkillers (for older children) can help
- Sustained painkiller use across many days — leads to medication overuse headache
When to Consider Prevention
NICE and the British Association for the Study of Headache recommend considering preventive treatment when migraine causes:
- 4 or more headache days per month, OR
- Significant disability or school absence
- Failure of acute treatments to abort attacks reliably
- Severe attacks that disrupt life
Options:
- Topiramate (licensed for migraine prevention from age 6) — reduces frequency and severity. Side effects: weight loss (concerning in lean children), pins and needles, cognitive slowing in some. Start low, build up.
- Propranolol — widely used; check blood pressure; avoid in asthma.
- Amitriptyline — useful where sleep and mood also need support; sedating, given at bedtime.
- Magnesium and riboflavin (vitamin B2) — supplements with some evidence in adolescents; modest effect; low harm.
- CGRP monoclonal antibodies (erenumab, fremanezumab) — newer adult medications, paediatric trials underway, not currently routine in children.
Non-medication approaches with real evidence:
- Regular sleep and meal schedules — migraine biology rewards predictability
- CBT, biofeedback, relaxation training — particularly useful in adolescents and where stress is a trigger
- Regular exercise — moderate, regular
- Hydration — chronic mild dehydration is a common contributor
- Reducing screen time — particularly screens in the hour before bed
Most children with frequent migraine respond to a combination: reducing modifiable triggers + early acute treatment + sometimes a preventer.
When to Worry About a Headache (Not Migraine)
Migraine is benign. A few patterns warrant urgent assessment because they suggest something else:
- A new severe headache, particularly the worst headache the child has ever had ("thunderclap")
- Headache woken from sleep
- Morning headaches with vomiting
- Progressively worsening over weeks
- Associated neurological symptoms — weakness, change in vision, balance problems, change in personality
- New seizures
- Headache after a head injury
- Fever with severe headache, neck stiffness, or rash
- Worsening after coughing, straining, or lying flat
- Personality or cognitive change
- Significant gait change
Same-day GP appointment, or 999/A&E if more concerning. The HeadSmart campaign (in the cancer signs article) lists the patterns suggestive of brain tumour. The vast majority of headaches are not anything sinister; the small minority that are need to be picked up.
Talking to School
Schools that understand migraine accommodate it well. Worth providing:
- A written care plan describing the typical attack and what to do
- Permission for early ibuprofen at the school office (with parental consent)
- Permission to lie down in a dark room rather than going home if appropriate
- Permission to wear sunglasses indoors during attacks
- Some flexibility around exams falling on attack days
Many UK schools work well with this; some need an explicit conversation. The school nurse and SENCO can help.
Living With Childhood Migraine
Most children's migraine improves through adolescence and into adulthood, particularly with consistent management. Some children grow out of it entirely. The bulk of the work is in:
- Recognising the pattern early — both within an attack and across patterns of triggers
- Treating early with the right dose
- Protecting the regular life — sleep, meals, hydration, stress
- Knowing when to step up to preventer treatment
- Knowing when a headache is not just migraine
A child whose family understands their migraine and treats it well lives a full, normal childhood. The goal is not no migraines; it is migraines that are infrequent, brief, and well-managed when they happen.
Key Takeaways
Migraine in children looks different from adult migraine — shorter attacks, often bilateral pain, dramatic nausea and vomiting, and rapid recovery after sleep. About 5–10% of school-age children and up to 28% of teenagers have it. Treating early with ibuprofen, dark and quiet, and sleep handles most attacks. Frequent migraine is worth a GP appointment for prevention.
